Aleksander Falkowski

Stent-Graft Implantation to Treat an Inferior Vena Cava Aneurysm:

Purpose To present a patient with a primary inferior vena cava aneurysm who was subjected to endovascular treatment. Case Report A 60-year-old man, suffering from pulmonary embolism, was diagnosed with a vena cava aneurysm located below the renal veins. Through the right common femoral vein, a custom-made stent-graft was implanted. Proximal and distal barbs were incorporated in the frame to assist fixation and avoid caudal or cephalad migration. The procedure was performed without any technical or clinical complications, and the aneurysm was completely excluded from the circulation. During the 6-month follow-up, imaging verified the correct position of the stent-graft and exclusion of the aneurysm without endoleak or any other complication Conclusion In patients with inferior vena cava aneurysm, stent-graft implantation may be an alternative to open surgery.

The blood flow channel index as novel predictor of abdominal aortic aneurysm impending rupture based on the intraluminal thrombus angio-CT study

OBJECTIVE In this study the hypothesis that the thickness of the thinnest part of the thrombus, combined with bleeding into the intraluminal thrombus (ILT), is associated with a possible higher risk of abdominal aortic aneurysm (AAA) rupture was investigated, independently of aneurysm diameter, by using angio-CT. This article describes blood flow channel index based on the CT imaging findings that may help identify impending rupture prior to complete rupture. METHODS Computed tomographic images of 310 hospitalized patients with infrarenal AAA, were collected over a three-year period. They were divided into two main groups: 125 with bleeding into the ILT and control group 185 without the presence of blood in the thrombus. Patients were also analyzed in subgroups with ruptured, symptomatic and asymptomatic AAAs. A blood flow channel index was formulated as: maximal/minimal thickness ratio of thrombus from the same CT scan. RESULTS In dissected ILT group blood flow channel index was over a twofold higher than in group with intact ILT (19.0 [1.2-89.3] vs. (9.7 [1.3-38.9]; p<0.001), respectively. Median thickness at the thinnest part of the ILT in dissected thrombus group was lower (1.3mm [0.3-16.0]) than in group with intact ILT (1.7 mm [0.2-23.4]; p<0.003). CONCLUSION An association between a high blood flow channel index and bleeding into the ILT based on angio-CT study was demonstrated, and can suggest the aneurysm propensity for rupture.

Pseudo-allergic symptoms as a rare manifestation of an ascending aortic aneurysm.

A 79-year-old man was admitted early in the morning to the emergency department (ED) due to oedema of the lips, tongue and dyspnoea. The symptoms awoke the patient from sleep in a supine position. On admission, heart rate was irregular about 80/min, blood pressure 150/80 mm Hg, respiratory rate 23/min, and temperature 36.8°C. Abnormal findings included visible, painless swelling of the lower part of the face, lips, mucous membranes of the mouth and throat, tongue and hoarseness. No itching was present. There were no obvious respiratory or cardiovascular abnormalities on physical examination. Medical history revealed ischaemic heart disease and myocardial infarct of the inferior wall 12 years ago and persistent atrial fibrillation. Aortic dilatation had been found on echocardiography ten years ago without follow up since that time. There was no history of exposure to chemicals or allergies but due to the swelling of the lips and tongue of unknown cause, the patient had twice attended the emergency department (in 2004 and 2005). The last episode of similar symptoms had occurred a year earlier during a long train trip and the symptoms subsided spontaneously. First line therapy at ED included oxygen mask and semi-supine position with some relief of symptoms. Chest X-ray (Fig. 1) detected the enlargement of the mediastinal shadow on the right side. Echocardiography revealed the extension of ascending aorta to the diameter of 56–57 mm at the height of 5 cm above the aortic valve (Figs. 2, 3). Acute superior vena cava syndrome (SVCS) was diagnosed based on the medical history and clinical picture, confirmed by echocardiography. The patient did not agree to further diagnostics and potential surgical intervention. Symptoms and signs of vena cava obstruction regressed within 4 hours of the observation. The patient left the ED in a stable general condition, without symptoms reported on admission. Currently, thrombosis caused by the presence of an intravascular device is the most common cause of nonmalignant SVCS. In most cases, thrombotic complications are revealed within 100 days from device introduction. The second major cause of SVCS is ascending aorta abnormality. The length of superior vena cava varies between 6 cm and 8 cm. It runs along the right edge of the sternum and then forms an arch whose concave margin is adjacent to the ascending aorta. The distension of aortic diameter is mainly due to degenerative changes of the aortic wall. The significantly dilated aorta (> 55 mm) may compress superior vena cava. In the case described above, swelling of the facial soft tissues was the main symptom and had to be differentiated from an allergic reaction which is present in 40% of patients admitted to ED with vasomotor response and urticaria. Demographic changes with increasing numbers of older patients will result in the more frequent occurrence of similar cases, and a differential diagnosis of obscure oedema located in the upper part of the body should involve the exclusion of an ascending aortic aneurysm as a possible cause.

Emergency Use of Stent and rtPA with Mechanical Cloth Defragmentation for a Thromboembolic Complication during GDC Coil Treatment of an Acutely Ruptured Basilar Tip Aneurysm

Thrombotic occlusion of both posterior cerebral arteries occurred during embolization of an acutely ruptured basilar tip aneurysm. Intracranial stenting and continuous superselective infusion of rtPA was administered combined with mechanical clot fragmentation to reestablish normal vessel flow. DSA disclosed that normal vessel patency was achieved within 30 min. There were no adverse events related to rtPA administration and the patient recovered from the embolization with minor neurologic deficit as present before the procedure.