Endovascular Re-routing the Errant Aortic Endoprosthesis

The anatomic complexity of aortic dissection remains a challenge in endovascular treatment. The dissection flap may contain defects allowing accidental guidewire passage from one lumen into the other, and inadvertent device placement into the false lumen can occur. The description of this complication and its bail-out maneuvers are sparse in the literature. Herein, we describe seven patients with errant endoprosthesis re-routed with minimally invasive intervention into the true lumen.

Endovascular Fenestration/Stenting First Followed by Delayed Open Aortic Repair for Acute Type A Aortic Dissection With Malperfusion Syndrome

BACKGROUND

Immediate open repair of acute type A aortic dissection is traditionally recommended to prevent death from aortic rupture. However, organ failure because of malperfusion syndrome (MPS) might be the most imminent life-threatening problem for a subset of patients.

METHODS

From 1996 to 2017, among 597 patients with acute type A aortic dissection, 135 patients with MPS were treated with upfront endovascular reperfusion (fenestration/stenting) followed by delayed open repair (OR). We compared outcomes between the first and second decades and observed mortalities with those expected with an "upfront OR for every patient" approach, determined using prognostic models from the literature (Verona, Leipzig-Halifax, Stockholm, Penn, and GERAADA [German Registry for Acute Aortic Dissection Type A] models).

RESULTS

Overall, in-hospital mortality improved between the 2 decades (21.0% versus 10.7%, P<0.001). In the second decade, for patients with MPS initially treated with fenestration/stenting, mortality from aortic rupture decreased from 16% to 4% ( P=0.05), the risk of dying from organ failure was 6.6 times higher than dying from aortic rupture (hazard ratio=6.63; 95% CI, 1.5-29; P=0.01), and 30-day mortality after OR for MPS patients was 3.7%. Compared to the expected mortalities with the upfront OR for every patient models, our observed 30-day and in-hospital mortalities (9% and 11%, respectively) of all patients with acute type A aortic dissection were significantly lower ( P≤0.03).

CONCLUSIONS

Immediate OR is the strategy to prevent death from aortic rupture for the majority of patients with acute type A aortic dissection. However, relatively stable (no rupture, no tamponade) patients with MPS benefit from a staged approach: upfront endovascular reperfusion followed by aortic OR at resolution of organ failure.

Intra-arterial ampicillin and gentamicin and the incidence of splenic abscesses following splenic artery embolization: A 20-year case control study

PURPOSE

Splenic abscesses represent a major complication following splenic artery embolization. The purpose of this study was to assess the effectiveness of intra-arterial antibiotics administered during splenic artery embolization in reducing splenic abscess formation.

MATERIALS AND METHODS

406 patients were screened. 313 (77.1%) patients who underwent splenic artery embolization and were >18 years old were included. Mean age of the cohort was 58 ± 15 years (range: 18-88 years). There were 205 (65.5%) male patients and 108 (34.5%) female patients. 197 (62.9%) patients underwent embolization without intra-arterial antibiotics and 116 (37.1%) patients underwent embolization with 1 g ampicillin and 80 mg gentamicin administered in an intra-arterial fashion. Primary outcome was splenic abscess formation. Secondary outcomes included type of splenic artery embolization, embolic agent, and technical success.

RESULTS

Partial splenic embolization was performed in 229 (73.1%) patients. Total splenic embolization was performed in 84 (26.8%) patients. Platinum coils were the most commonly used embolic agent overall (n = 178; 56.9%) followed by particulates (n = 114; 36.4%). Embolization technical success was achieved in 312 (99.7%) patients. 7 (3.6%) splenic abscesses were detected in the non-intra-arterial antibiotic group and 1 (0.9%) in the intra-arterial antibiotic cohort (P = 0.27). Coils were found to be statistically more likely to result in splenic abscesses than any other embolic agent (P = 0.03). Mean time to abscess identification was 74 days ±120 days (range: 9-1353 days).

CONCLUSION

Splenic abscesses occurred more frequently in patients who did not receive intra-arterial antibiotics during splenic embolization; however, this did not reach statistical significance.

Distal arterial splenic embolization via collaterals: report of two cases

Two patients were treated for bleeding gastric varices, developed due to splenic vein occlusion. In one patient with occlusion of the main splenic artery, splenic embolization performed via collaterals facilitated open splenectomy with minimal blood loss. In another patient, bleeding from the gastric varices stopped after partial arterial splenic embolization performed via the accessory left gastric and inferior phrenic arteries. No complications were encountered.

Aortic Branch Artery Pseudoaneurysms Accompanying Aortic Dissection. Part I. Pseudoaneurysm Anatomy

PURPOSE

Small areas of blood flow are sometimes seen within an otherwise thrombosed false lumen on computed tomography (CT) scans of intramural hematomas of the aorta. These are blood-filled spaces that, although they have no apparent communication with the true lumen, appear isodense with the aorta on contrast-enhanced CT scans. The purpose of this report is to describe angiographic and autopsy studies that establish the nature of this entity and describe the principal CT features distinguishing it from a penetrating ulcer.

MATERIALS AND METHODS

Conventional angiographic and CT aorta findings in two cases with small collections of contrast material within an otherwise thrombosed false lumen of an aortic dissection are discussed. Also examined is another case with pathologic and histologic findings in addition to those of small collections of contrast material within an otherwise thrombosed false lumen of an aortic dissection, which illustrate the pathoanatomy of these lesions.

RESULTS

Angiographic and necropsy evidence shows that some of these lesions represent branch artery pseudoaneurysms and, as such, are secondary to an intramural hematoma, not the primary cause of it.

CONCLUSIONS

Difficulty in demonstrating communication between these collections of contrast material and the adjacent true lumen of the aorta on helical CT examinations and the characteristic location of these lesions along the nonpleural portion of the aortic circumference distinguish them from penetrating ulcers and should suggest the diagnosis of branch artery pseudoaneurysm. Demonstration of a branch artery originating from the contrast collection confirms the diagnosis. These branch artery pseudoaneurysms should be distinguished from penetrating atherosclerotic ulcers.

Aortic Branch Artery Pseudoaneurysms Accompanying Aortic Dissection. Part II. Distinction from Penetrating Atherosclerotic Ulcers

PURPOSE

Small collections of contrast material are frequently seen within the otherwise thrombosed false lumen of an aortic dissection (AD). These collections can be divided into those without apparent communication with the aortic lumen (ie, pseudoaneurysms) and those with obvious communications (ie, ulcers). The present study was performed to test the hypotheses that pseudoaneurysms and ulcers differ in their distribution around the aorta and that the distribution of pseudoaneurysms is similar to that of small aortic branch arteries.

MATERIALS AND METHODS

Computed tomography (CT) scans in 187 patients with AD and thrombosed false lumens showed 335 intramural contrast medium collections, including 128 pseudoaneurysms and 207 ulcers. CT scans in 40 control individuals without AD were reviewed to localize small aortic branch arteries. The angular distributions around the circumference of the aorta of pseudoaneurysms and ulcers and the branch artery origins were tabulated and compared. The frequency of detection of small branch arteries arising from the contrast material collections was noted.

RESULTS

The angular distribution of pseudoaneurysms did not differ significantly from that of branch artery origins but did differ from that of ulcers. Pseudoaneurysms were found along the posterior, medial, and anterior walls of the aorta in the chest, sparing the lateral wall abutting the pleura. Ulcers tended to spare the arc containing branch artery origins. The composite distribution of ulcers and pseudoaneurysms appears uniform around the circumference of the aorta except at the T10-T12 levels.

CONCLUSIONS

Branch artery pseudoaneurysms spare the pleural surface of the aorta and have nearly the same distribution around the circumference of the aorta as the origins of small aortic branch arteries. In contrast, ulcers tend to spare branch artery origins. The characteristic appearance and distribution of pseudoaneurysms on CT can help differentiate them from ulcers.

Endograft repair of partially anomalous pulmonary venous connection with dual drainage

A 73-year-old woman with dyspnea and fatigue was found to have a partially anomalous pulmonary venous connection with communication between the right upper lobe pulmonary vein and the superior vena cava, as well as a normal pulmonary vein confluence with the left atrium. She was successfully treated with an endograft implanted in the superior vena cava, covering the defect. The unique dual drainage of the pulmonary vein allowed percutaneous treatment of a condition that ordinarily requires complex caval and intracardiac reconstruction. Except for several episodes of arrhythmias, she has been doing well, with exercise tolerance improving from New York Heart Association class III at baseline to class I after treatment. Follow-up imaging and clinical findings at 36 months showed no migration of the stents and significant improvement of quality of life.

A novel approach to the management of late-onset liver failure in biliary atresia

PURPOSE

Late-onset hyperbilirubinemia in patients who have undergone a successful portoenterostomy (PE) for biliary atresia (BA) is usually considered evidence of ongoing severe liver failure. The authors recently have treated 2 patients who had acute hyperbilirubinemia years and months after a successful PE and had dilated intrahepatic cysts. A combined operative and percutaneous approach reestablished drainage and a reduction in their bilirubin levels.

METHODS

Data from 2 cases of BA and late-onset hyperbilirubinemia from obstruction were reviewed and analyzed.

RESULTS

Two patients (15-year-old boy and a 2.5-year-old girl) presented with increasing serum bilirubin after a PE for BA in infancy. Both had extensive preoperative workup, which showed intrahepatic biliary dilatation in one and a large bile lake in the other. They underwent attempted percutaneous transhepatic cholangiography and stenting, followed by an intraoperative transhepatic approach in which the dilated ducts were connected to the PE. A rapid and sustained reduction in the serum bilirubin level was noted in these patients.

CONCLUSIONS

When patients with BA after a successful PE present with sudden onset of hyperbilirubinemia, imaging for biliary obstruction should be carried out. If biliary dilatation is found, then a combined radiologic and operative approach may help improve the bile flow and delay the need for liver transplant.

Successful Angioplasty of a Superficial Femoral Artery Stenosis Caused by a Suture-Mediated Closure Device

We report the successful angioplasty of an acute arterial narrowing after suture-mediated closure (SMC) of a femoral arterial puncture. A 75-year-old woman underwent a cerebral arteriogram via a right common femoral artery puncture. The arteriotomy site was closed with a SMC device. Four days after placement the patient complained of pain in her right calf after walking. An arteriogram 7 days after SMC showed a severe focal stenosis at the origin of the superficial femoral artery involving the presumed puncture site. The lesion was successfully treated with balloon angioplasty. The patient at 6 months was asymptomatic.

Focal hyperemia on RBC blood-flow imaging. A scintigraphic marker of arterioportal venous shunting in hepatic cavernous hemangiomas?

PURPOSE

To investigate the significance of increased perfusion associated with some hepatic hemangiomata during radionuclide blood volume imaging.

METHODS

Immediate dynamic planar projections and delayed SPECT imaging of a hepatic lesion were obtained after the administration of Tc-99m-labeled RBC. Scintigraphic data were compared with X-ray CT, contrast angiography and postresection histopathology.

RESULTS

A surgically proven, cavernous hemangioma with typical findings on delayed radionuclide blood-pool imaging showed markedly increased perfusion by scintigraphy. This correlated with arterioportal venous shunting (AVPS) on contrast angiography.

CONCLUSION

Increased perfusion on radionuclide blood-volume imaging of hepatic hemangiomata may be a scintigraphic marker of AVPS. This may serve to identify patients with increased risk for spontaneous rupture or may identify them for the development of portal hypertension.