Abdominal Aortic Aneurysm With Ectopic Renal Artery Origins: A Case Report

The coexistense of an abdominal aortic aneurysm with ectopic main renal vasculature complicates aortic surgery and mandates a focused imaging evaluation and a carefully planned operation to minimize renal ischemia. We present the case of a 75-year-old man with an abdominal aortic aneurysm and a right kidney with two ectopic main renal arteries, one originating from the aneurysmal distal aorta and the other from the right common iliac artery; the patient underwent a surgical repair and followed an uneventful course with no deterioration of renal function. The preoperative and intraoperative details are reported, along with a review of the literature.

Experimental surgery in infrarenal aorta and sigmoid ischemia

AIM

Colon ischemia is a rare but serious complication in surgery of the infrarenal aorta, due to ligation of the inferior mesenteric artery and the ischemia-reperfusion syndrome. In order to investigate the degree of intestinal damage, we employed experimental surgery in pigs, applying the usual protocol for elective repair of the infrarenal aorta (AAA or Y graft).

METHODS

Three groups of pigs were operated on. In Group A (n=4, 21-25 kg, mean 22.6) a sham operation was performed. In Group B (n=6, 21-26 kg, mean 24) the infrarenal aorta was cross-clamped along with the internal and external iliac arteries and a longitudinal incision was performed in the aorta, while in Group C (n=5, 20-27 kg, mean 23.8) a Pruitt-Inahara shunt was used to allow flow from the infrarenal aorta towards the iliac arteries and the inferior mesenteric artery during cross-clamping. The duration of cross-clamping was two hours (Group B and C). In all groups we evaluated sigmoid histology after reperfusion under light microscopy.

RESULTS

The pathologic examination of the sigmoid revealed increased postischemic injuries in Group B, while the protective effect of the shunt was obvious in Group C. The tissue samples of Group B presented hyperemia, submucosal edema, dilatation of the lymph vessels and severe inflammatory infiltration of the mucosa, muscularis propria and serosa, with cells showing acute and chronic inflammatory responses. In Group C all specimens presented hyperemic vessels and a slight inflammatory reaction of mucosa. In conclusion, Group B, presented the most severe inflammatory changes, involving all layers, while in Group C congestion and slight inflammatory reactions of the mucosa were observed. In Group A, no significant changes in normal histology were observed.

CONCLUSION

The importance of these findings is evident, because in the clinical situation patients have variable degrees of arteriopathy, thus even short periods of ischemia might prove disastrous and this could occur in repair of the infarenal aorta as well as in other cases of inevitable risk, such as in surgery of the thoraco-abdominal aorta.

Abdominal aortic aneurysm and renal artery stenosis: renal function and blood pressure before and after endovascular treatment

We describe three patients with abdominal aortic aneurysm (AAA) and renal artery stenosis (RAS). These patients were treated by placement of an aortic endograft and angioplasty or stenting of the renal artery. After the procedure renal function improved or remained stable in two patients and deteriorated slightly in one. Blood pressure was reduced in one hypertensive patient and remained normal in the other two normotensive patients. In conclusion, simultaneous treatment of AAA and RAS with aortic endograft placement and renal artery angioplasty with or without stent, is a safe and effective technique for selected high-risk patients.

Renal artery stenting for renal insufficiency in solitary kidney in 26 patients

OBJECTIVE

to present our experience with stent placement in renal arteries in solitary kidneys for treating renal insufficiency.

DESIGN

retrospective analysis.

MATERIALS

in 26 patients with solitary kidney (17 men, 9 women, mean age: 63 years), presented with renal insufficiency (se-creat >0.144 mmol/l), stent was placed in a stenosed renal artery. We analysed the clinical outcome, based on the level of creatinine at 3 months following the procedure. Clinical benefit was considered when there was a decrease compared to the baseline creatinine by >20% or a stabilisation of the creatinine value (+/-20% of the baseline).

RESULTS

in 16 of the 26 patients (62%), clinical benefit was achieved. However, 38% of the study population, renal function continued to deteriorate. Baseline creatinine value was the single best predictor for clinical benefit achievement (odds ratio: 13; 95% confidence intervals: 1.6-107, p=0.01).

CONCLUSION

renal stenting results in improvement or stabilisation of renal function in the majority of the patients with solitary kidneys and renal artery stenosis, presenting with renal insufficiency. Because best outcome was observed mainly in those patients with not progressed renal insufficiency, intervention should be focused on that group.

The significance of Chlamydia pneumoniae in symptomatic carotid stenosis

An association between symptomatic carotid stenosis and recent infection with Chlamydia pneumoniae is reported. Thirty-five patients (20 symptomatic and 15 asymptomatic) with carotid stenosis of 70% to 90% underwent carotid endarterectomy. Endarterectomy was performed without patch and shunt; the average occlusion time of the internal carotid artery was 14 +/- 3 min. The atheromatic plaque and a portion of the thyroid artery were examined with polymerase chain reaction and peripheral vein blood was obtained for serologic detection of systematic infection, and IgG and IgM antibodies to C. pneumoniae by enzyme-linked immunosorbent assay. Twenty of 35 patients (57.1%) had increased titers of IgG antibodies to C. pneumoniae. Eight patients revealed IgG plus IgM antibodies; two of the eight had IgG, IgM, and positive findings on polymerase chain reaction. No C. pneumoniae was detected on the thyroid arteries. Sixty-five percent (13/20) of the patients with increased IgG antibodies to C. pneumoniae, 87.5% (7/8) with IgG + IgM, and 100% with IgG + IgM + positive polymerase chain reaction were symptomatic. Plaque morphology in association with symptoms did not reveal a significant correlation between soft plaques and symptoms, whereas the majority of the symptomatic patients had plaques of type III-V. Patients having recent contamination and positive polymerase chain reaction had a significant relationship between C. pneumoniae infection and symptomatic carotid disease. This supports the hypothesis that C. pneumoniae infection can produce a kind of instability of the carotid plaque. The results of this study demonstrate that patients with advanced atherosclerotic carotid disease have an increased incidence of C. pneumoniae infection. Recent infection could be responsible for instability of the carotid plaque, causing cerebral ischemic episodes.

Ischemia of spinal cord following elective operative procedures of the infrarenal abdominal aorta

OBJECTIVE

Ischemia of the spinal cord following procedures of the infrarenal abdominal aorta and the iliac arteries due to aneurysmatic or occlusive disease.

DESIGN

Retrospective study, duration of follow up: two years.

SETTINGS

Vascular Department of the 2nd Surgical Clinic of the University of Athens, Medical School.

PATIENTS

1,112 operative procedures to the infrarenal abdominal aorta and iliac arteries, carried out from January 1, 1976 to June 30, 1994; 665 cases were aneurysms, electively operated, to which a tube graft was placed in 390 and a bifurcated graft in the remaining 265. Similarly 457 bifurcated prostheses were placed due to stenotic disease.

INTERVENTIONS

Aneurysmectomy, graft insertion.

MEASURES

Death, severe disability.

RESULTS

Ischemic damage to the spinal cord was noted in two cases postoperatively. The first case following placement of bifurcated prosthesis due to high occlusion of the abdominal aorta and the second case following resection of an aneurysm and placement of a tube graft. One of the patients passed away on the 43rd postoperative day, and the other 18 months after was able to stand but, however, could not walk easily without the help of another person.

CONCLUSIONS

The complication seems to be multicausal, carrying a bad prognosis and cannot be foreseen. The stable hemodynamic condition of the patient during the operative and postoperative period with revascularisation of at least one hypogastric artery, reduces the time of aortic occlusion and securing collateral circulation might reduce these complications. Also preopeorative angiography of the spinal cord with more sophisticated techniques, might constitute the most reliable prognosis in the future.

Surgery of varicose veins on ambulatory basis. Early and late results

Varicose veins resection on a day-case basis has the advantage of the early return of the patient to his usual activities, thus also reducing the cost and occupation of hospital beds. Between 1980-1992, 1710 patients (2325 extremities) were operated on as outpatients. The preoperative management included: clinical examination, Doppler ultrasounds, Duplex scanning, ambulatory venous pressure and phlebography. The surgical method was based on two axioms: resection of affected segments only, and functional operation according to the hemodynamic parameters. At the end of the first trimester, 1.572 (91.9%) patients showed satisfactory results. One to twelve years later 72.1% with surgical therapy alone and 82% in combination with sclerotherapy. The serious complications were injury in 2 cases, one of the common peroneal nerve and the other of the posterior tibial artery. In conclusion, patients with varicose veins may be operated as outpatients with good results.

The clinical significance of carotid plaque haemorrhage

The clinical picture with the pathology findings of 89 atheromatic plaques which were removed following endarterectomy of the internal carotid artery, for the purpose of determining the clinical significance of the haemorrhagic atheromatic plaque were correlated. Intraplaque haemorrhage was determined in 44 of the 57 plaques (72.2%) of symptomatic patients while in the asymptomatic patients haemorrhage was noted in 12 of the 32 plaques (37.5%) p < 0.001. The extent of haemorrhage was > 25% of the plaque thickness in 21 of 44 symptomatic plaques (47.72%) and in the asymptomatic plaques in 3 out of 12 (25%) p > 0.05. The incidence of ulceration of the intima, with or without the presence of thrombus, was more frequent in the haemorrhagic plaques (68.42%) as compared with the non-haemorrhagic (31.57%), without any significant difference between the symptomatic and asymptomatic plaques. Communication of haemorrhage with the lumen was observed in 8 of 24 plaques (33.33%), 7 of which (29.16%) were symptomatic. The presence of haemorrhage in the atheromatic plaque of the internal carotid artery does not seem to play any direct role in the pathogenesis of the symptoms but, nevertheless, it constitutes a significant indication of instability of the atheromatic plaque.

Digital subtraction angiography in the evaluation of chemodectomas

During the last 2 years eleven patients with surgically confirmed chemodectomas have been investigated by means of digital subtraction angiography (DSA). Seven patients underwent i.v. DSA, which revealed eight carotid body tumours, and in the remaining four with jugulotympanic chemodectomas intra-arterial (i.a.) DSA was performed. We found i.V. DSA an easy and satisfactory method for the investigation of carotid body tumours but when glomus intravagale, tympanicum or jugulare is suspected an i.a. selective injection is required.

Comparative study between iohexol and iopromide for aortofemoral arteriography

A double-blind clinical trial was performed on 50 patients in order to compare omnipague (iohexol) and Ultravist-300 (iopromide) for peripheral arteriography. Both contrast media were well tolerated, but there was less body heat and pain in the Ultravist group. There were no idiosyncratic reactions or significant changes in blood pressure before and after the injection.

Spontaneous aorto-cisterna chyli anastomosis

A case of a spontaneous aorto-cisterna chyli communication is presented in a 65 year old patient who was admitted to the Hospital with severe abdominal pain simulating a dissecting aneurysm of the aorta. The diagnosis was suspected on a CT examination and established by a free flow aortogram and selective catheterization of the cisterna chyli through the aorta.

A comparative study of the degree of arterial recanalization in kidneys of dogs following transcatheter embolization with eight different materials

41 dogs were subjected to percutaneous arterial embolization of branches or the main trunk of the renal artery with or without prior injury to the kidney. 8 materials were used: homologous blood clot, muscle, fat, fascia, barium sulfate, plain catgut, gelfoam and polyvinyl alcohol (Ivalon). From the angiographic investigation over a relatively long period, it was observed that complete recanalization of the embolized vessels occurred only with blood clot and gelfoam; partial recanalization, with muscle fat and plain catgut; and no recanalization at all with fat, barium sulfate and Ivalon.

[Selective catheterization of peripheral arteries for the monitoring of patients in intensive care units]

In critical ill patients, determination of blood gases is a crucial part of patient evaluation and management. In intensive care situations many blood-gas determinations are required in a single day. The introduction of an arterial catheter into a small peripheral artery is an invaluable technique that allows continuous blood-sampling. During the past three years we had catheterized either the radial, ulnar or the pedal artery in 450 instances. The arterial catheter was left in place from 1 to 15 days. There were no serious complication. Haemorrhage due to accidental opening of the catheter occurred in three occasions. No case of ischaemia was encountered after a single artery catheterization. Temporary ischaemia of the upper limb appeared in three patients after simultaneous catheterization of both ulnar and radial arteries. The infection rate was nil. Arterial catheterization and maintenance of indwelling catheter for repeated blood-samples is a simple and safe procedure with minimal complications, invaluable in the management of critical ill patients.

[Valve of plastic repair of the deep femoral artery in chronic circulatory disease of the lower extremities]

It is reported about indication, surgical technique, early and late postoperative results of the plastic of the profunda femoris artery. On 17, mainly old patients with chronic circulatory disease of the lower limbs was this operation carried out, because a longer angioplastic operative procedure would have been a great risk. The statement, that 47% of our patients were practically without symptoms after four years is promising for the plastic of the profunda femoris artery with chronic ischemia syndrome of the lower limbs.