P. Madhavan

Duplex ultrasound in aneurysm surveillance following endovascular aneurysm repair: a comparison with computed tomography aortography

OBJECTIVES Cumulative radiation dose, cost, and increased demand for computed tomography aortography (CTA) suggest that duplex ultrasonography (DU) may be an alternative to CTA-based surveillance. We compared CTA with DU during endovascular aneurysm repair (EVAR) follow-up. METHODS Patients undergoing EVAR had clinical and radiological follow-up data entered in a prospectively maintained database. For the purpose of this study, the gold standard test for endoleak detection was CTA, and an endoleak detected on DU alone was assumed to be a false positive result. DU interpretation was performed independently of CTA and vice versa. RESULTS One hundred thirty-two patients underwent EVAR, of whom 117 attended for follow-up ranging from six months to nine years (mean, 32 months). Adequate aneurysm sac visualisation on DU was not possible in 1.7% of patients, predominantly due to obesity. Twenty-eight endoleaks were detected in 28 patients during follow-up. Of these, 24 were initially identified on DU (four false negative DU examinations), and eight had at least one negative CTA with a positive DU prior to diagnosis. Twenty-three endoleaks were type II in nature and three of these patients had increased sac size. There was one type I and four type III endoleaks. Two of these (both type III) had an increased sac size. Of 12 patients with increased aneurysm size of 5 mm or more at follow-up, five had an endoleak visible on DU, yet negative CTA and a further five had endoleak visualisation on both DU and CTA. Of six endoleaks which underwent re-intervention, all were initially picked up on DU. One of these endoleaks was never demonstrated on CTA and a further two had at least one negative CTA prior to endoleak confirmation. Positive predictive value for DU was 45% and negative predictive value 94%. Specificity of DU for endoleak detection was 67% when compared with CTA, because of the large number of false positive DU results. Sensitivity for DU was 86%, with all clinically significant endoleaks demonstrated on CTA also detected on DU. CONCLUSION Despite its low positive predictive value, we found DU to be a sensitive test for the detection of clinically significant endoleaks. Given concerns about cumulative radiation exposure and cost, and the surprisingly low sensitivity of CTA for endoleak detection in this series, selective CTA based on DU surveillance may be a more appropriate long-term strategy.

A comparative study of the bell-bottom technique vs hypogastric exclusion for the treatment of aneurysmal extension to the iliac bifurcation

INTRODUCTION A significant proportion of patients undergoing endovascular aneurysm repair (EVAR) have common iliac artery aneurysms (CIAA). Aneurysmal involvement at the iliac bifurcation potentially undermines long-term durability. METHODS Patients with CIAA who underwent EVAR were identified in two teaching hospitals. Bell-bottom technique (BBT; iliac limb ≥20 mm) or internal iliac artery embolization and limb extension to the external iliac artery (IIE + EE) were used. Outcome between these two approaches was compared. RESULTS We identified 185 patients. Indication for EVAR included asymptomatic abdominal aortic aneurysm (AAA) in 157, symptomatic or ruptured aneurysm in 19, and CIAA in nine. Mean AAA diameter was 59 mm. Among 260 large CIAAs that were treated, BBT was used to treat 166 CIAA limbs, and 94 limbs underwent IIE + EE. Total reintervention rates were 11% for BBT (n = 19) and 19.1% for IIE + EE (n = 18; P = .149). Rates of reintervention for type Ib or III endoleak were 4% for BBT (n = 7) and 4% for IIE + EE (n = 4; P > .99). The difference in limb patency rates was not significant. The 30-day mortality rate was 1%. Median follow-up was 22 months. Complications did not differ significantly between the two groups; however, the combined incidence of perioperative complications and reinterventions was higher in the IIE + EE group (49% vs 22%; P = .002). CONCLUSIONS The combined incidence of perioperative complications and reinterventions is significantly higher with IIE + EE than with BBT; therefore, when feasible, BBT is desirable.

Suprarenal mycotic aneurysm exclusion using a stent with a partial autologous covering.

Purpose: To report a combined endovascular and open technique to manage a suprarenal mycotic aortic aneurysm using a stent-graft partially covered with a section of autologous artery. Methods and Results: A 50-year-old was hospitalized for staphylococcal septicemia and severe back pain. A previously diagnosed 3-cm abdominal aortic aneurysm was found to have expanded 2 cm in 3 weeks. Aortography documented some periaortic thickening and 2 mycotic aneurysms, one posterior at the level of the superior mesenteric artery and the second at the aortic bifurcation. After intensive antibiotic therapy, an endovascular approach to exclude the suprarenal mycotic aneurysm was undertaken in tandem with surgical excision of the infrarenal aneurysm. The harvested right common iliac artery was used to partially cover a Palmaz stent, which was deployed under direct vision just above the renal artery ostia so that the covered portion of the stent excluded the aneurysm. A right axillofemoral bypass with a femorofemoral bypass completed the revascularization. Postoperatively, the patient developed renal failure, ischemic colitis necessitating a left hemicolectomy, and paraplegia. Although the patient is paralyzed, the aneurysm remains excluded with patent visceral vessels at 12 months following surgery. No organisms were grown from excised aortic tissue, and no signs of recurrent infection have been seen. Conclusions: Stent-graft repair may be able to lessen the invasiveness and reduce the morbidity associated with treatment of mycotic aortic aneurysms.

Endovascular Management of Rare Sciatic Artery Aneurysm

Purpose: To present a rare case of complete persistent sciatic artery aneurysm successfully treated by coil embolization and to suggest a new classification for this anomaly that encompasses both clinical and pathological factors. Methods and Results: A 77-year-old female presented with sudden onset of sharp, throbbing left thigh and foot pain. A nontender 10.0- × 7.0-cm pulsatile mass was found over the inferolateral aspect of the left buttock on examination in the right lateral decubitus position. Angiography demonstrated a 6.9-cm sciatic artery aneurysm with the distal sciatic artery completely thrombosed. Before planned bypass grafting, the aneurysm and distal segment of the internal iliac artery were successfully embolized with coils through a left percutaneous approach. The patients symptoms resolved with no deterioration in limb perfusion, and further revascularization was unnecessary. Postembolization imaging showed complete occlusion of the aneurysm, which has continued for 19 months. Conclusions: The application of endovascular techniques and surgical revascularization procedures provides numerous management options for the treatment of an aneurysmal persistent sciatic artery. This case demonstrates that clinical evaluation between staged procedures may obviate the need for further intervention.

Operative and endovascular management of extracranial vertebral artery aneurysm in Ehlers-Danlos syndrome:a clinical dilemma--case report and literature review.

The most prevalent lesion of the vertebral artery is an atheromatous plaque located at its origin from the subclavian artery. A case of successful management of a symptomatic vertebral artery aneurysm due to Ehlers-Danlos syndrome is reported. The patient had asymptomatic posterior intracerebral artery dissection on the contralateral side. A common carotid artery to V-3 segment bypass using reversed saphenous vein graft was carried out. Avulsion of the V-2 segment occurred peroperatively and endovascular coil embolization of the vertebral artery aneurysm was performed. Endovascular equipment and training must be in the armamentarium of vascular surgeons as more complex cases are being treated, which demands new approaches for ultimate clinical success. This unique case outlines what might unexpectedly occur. Endovascular intervention as an adjuvant procedure provides a satisfactory outcome in what could have been a catastrophe.

Aorto—Left Renal Vein Fistula: Is There a Place for Endovascular Management?

Purpose: To describe the endovascular treatment of an aorto-left renal vein fistula. Methods and Results: A 77-year-old man with multiple comorbidities presented with low back pain, hematuria, cyanosis, and a pulsatile abdominal mass. Imaging confirmed a 7-cm abdominal aortic aneurysm with a contained rupture into the left renal vein. Owing to the patients high surgical risk, a Talent Endoluminal Stent-Graft was implanted to satisfactorily exclude the aneurysm. Hemodynamic stability and normal renal function were restored; however, continued perfusion of the sac prompted an attempt to percutaneously repair the renal vein defect. This effort failed, so open laparotomy was necessary. Conclusions: Although total endovascular management was not successful in this case, the initial use of a minimally invasive approach allowed the patients clinical status to improve and lower the risk of subsequent surgery.

Increased platelet activation in early symptomatic vs. asymptomatic carotid stenosis and relationship with microembolic status: results from the Platelets and Carotid Stenosis Study

Cerebral microembolic signals (MES) may predict increased stroke risk in carotid stenosis. However, the relationship between platelet counts or platelet activation status and MES in symptomatic vs. asymptomatic carotid stenosis has not been comprehensively assessed.

Hybrid management of a spontaneous ilio-iliac arteriovenous fistula: a case report

IntroductionSpontaneous iliac arteriovenous fistulae are a rare clinical entity. Such localized fistulation is usually a result of penetrating traumatic or iatrogenic injury. Clinical presentation can vary greatly but commonly includes back pain, high-output congestive cardiac failure and the presence of an abdominal bruit. Diagnosis, therefore, is often incidental or delayed.Case presentationWe report a case of a spontaneous ilio-iliac arteriovenous fistula in a 68-year-old Caucasian man detected following presentation with unilateral claudication and congestive cardiac failure. Following computed tomography evaluation, the fistula was successfully treated with a combined endovascular (aorto-uni-iliac device) and open (femoro-femoral crossover) approach.ConclusionEndovascular surgery has revolutionized the management of such fistulae and we report an interesting case of a high-output iliac arteriovenous fistulae successfully treated with a hybrid vascular approach.

Endovascular Management of a Pancreaticoduodenal Aneurysm: A Clinical Dilemma

PURPOSE To report the successful endovascular embolization of a pancreaticoduodenal aneurysm (PDA). CASE REPORT A 56-year-old man with a history of pancreatitis presented with insidious, progressive epigastric pain for the preceding 6 months. Contrast-enhanced computed tomography (CT) and selective hepatic digital subtraction angiography identified a 7.7-cm aneurysm that arose from the pancreaticoduodenal branch of the gastroduodenal artery. Through a percutaneous common femoral approach, 10 stainless steel coils were delivered to occlude the aneurysm. A single coil detached and became lodged in a small branch of the right hepatic artery without sequelae. At 26 months, duplex and CT scans show continued occlusion of the aneurysm. CONCLUSIONS Transcatheter coil embolization should be the first choice treatment for aneurysms of the pancreaticoduodenal artery.

Increased endothelial activation in recently symptomatic versus asymptomatic carotid artery stenosis and in cerebral microembolic-signal-negative patient subgroups

von Willebrand factor propeptide (VWF:Ag II) is potentially a more sensitive marker of acute endothelial activation than von Willebrand factor antigen (VWF:Ag). These biomarkers have not been simultaneously assessed in asymptomatic versus symptomatic carotid stenosis patients. The relationship between endothelial activation and cerebral microembolic signals (MESs) detected on transcranial Doppler ultrasound is unknown.