William M. Stone

Hepatic artery aneurysm: factors that predict complications

OBJECTIVE We reviewed the Mayo Clinic experience with management and outcome of hepatic artery aneurysms (HAA). METHODS Retrospective review of charts for 306 patients with true visceral aneurysm diagnosed from 1980 to 1998 enabled identification of 36 patients (12%) with HAA. RESULTS Patients with HAA included 23 men and 13 women, with mean age of 62.2 years (range, 20-85 years). Most aneurysms were extrahepatic (78%) and single (92%). Mean aneurysm diameter at presentation was 3.6 cm (range, 1.5-14 cm). Five aneurysms had ruptured (14%), and four were symptomatic (11%). Mortality from rupture was 40%. Of the 9 patients with ruptured or symptomatic aneurysms, 2 patients had multiple HAA, 3 patients had fibromuscular dysplasia, and 2 patients had polyarteritis nodosa. All five HAAs that ruptured were of nonatherosclerotic origin (P =.001). Fourteen patients (39%) underwent elective procedures, including excision with vein graft (n = 7), excision with dacron graft (n = 3), excision alone (n = 2), and percutaneous embolization (n = 2). Two vein grafts and one dacron graft became occluded within 1 year. Nonoperative management was elected in 22 patients (61%) with mean aneurysm diameter 2.3 cm (range, 1.5-5 cm). No complications related to the aneurysm occurred during mean follow-up of 68.4 months (range, 1-372 months). Aneurysm growth was identified in 27%, the greatest being 0.8 cm over 34 months. CONCLUSIONS HAA are at definite risk for rupture (14%). Risk factors for rupture include multiple HAA and nonatherosclerotic origin. Patients with symptomatic aneurysms or any of these risk factors should be considered for intervention.

Clinical features and management of splenic artery pseudoaneurysm: case series and cumulative review of literature

INTRODUCTION Splenic artery pseudoaneurysm is uncommon. We report our institutions recent 18-year experience with these aneurysms and review the literature. METHODS We reviewed the records for 37 patients with visceral artery pseudoaneurysm evaluated at our institution from 1980 to 1998. From this group we found only 10 patients (27%) with splenic artery pseudoaneurysm. We also reviewed 147 cases of splenic artery pseudoaneurysm reported in the English literature. RESULTS In this series of 10 patients, 5 were men. Mean age was 51.2 years (range, 35-78 years). Causes of aneurysm included chronic pancreatitis in 4 patients, trauma in 2 patients, iatrogenic cause in 1 patient, and unknown cause in 3. The most common symptom was bleeding in 7 patients and abdominal or flank pain in 5 patients; 2 patients had no symptoms. Aneurysm diameter was known for four pseudoaneurysms, and ranged from 0.3 to 3 cm (mean, 1.7 cm). Splenectomy and distal pancreatectomy were performed in 4 patients, splenectomy alone in 2 patients, endovascular transcatheter embolization in 2 patients, and simple ligation in 1 patient. One patient with a ruptured pseudoaneurysm died before any intervention could be performed; there were no postoperative deaths. Follow-up data were available for 7 patients, with a mean of 46.3 months (range, 4.5-120 months). CONCLUSIONS Splenic artery pseudoaneurysm is rare and usually is a complication of pancreatitis or trauma. Average aneurysm diameter in our series of 10 patients was smaller than previously reported (1.7 cm vs 5.0 cm). Although conservative management has produced excellent results in some reports, from our experience and the literature, we recommend repair of all splenic artery pseudoaneurysms.

The minimally invasive management of visceral artery aneurysms and pseudoaneurysms

OBJECTIVE Minimally invasive methods (MIMs) are now available for the management of visceral artery aneurysms and pseudoaneurysms (visceral artery aneurysms [VAA]). The purpose of this study was to review our 10-year experience with the MIM of treating VAA. METHODS All patients evaluated from June 1999 to June 2009 with VAAs were reviewed. Demographics, therapy, and results were analyzed. RESULTS MIM was attempted in 185 aneurysms in 176 patients. Initial intervention was successful in 98% ofaneurysms. Sixty-three (34%) aneurysms were located in the splenic artery, 56 (30%) in the hepatic, 28 (15%) in the gastroduodenal, 16 (8.6%) in the pancreaticoduodenal, six (3.2%) in the superior mesenteric, four (2.1%) in the gastric, four (2.1%) in the celiac, four (2.1%) in the gastroepiploic, two (1%) in the inferior mesenteric, and one (0.5%) in the middle colic artery. Pseudoaneurysms were more common than true aneurysms (64% vs 36%). Bleeding was the indication for intervention in 86 aneurysms (46%). Initial treatment was successful in 177 aneurysms (98%). Reintervention was required in five (3%) aneurysms within 30 days. Coiling was used alone in 139 aneurysms (75%) and in combination with at least one other technique in 20 (11%) cases. Thirty-day aneurysm-related mortality was 3.4% (six deaths). Five additional deaths occurred during 30-day follow-up, although none was related to complications of the aneurysms (2.8%). CONCLUSIONS MIM for visceral artery aneurysms can be used alone or in combination to effectively treat VAAs in elective or emergent conditions.

Stroke Prevention by Cilostazol in Patients with Atherothrombosis: Meta-analysis of Placebo-controlled Randomized Trials

BACKGROUND Cilostazol is an antiplatelet agent that inhibits phosphodiesterase III in platelets and vascular endothelium. Previous randomized controlled trials of cilostazol for prevention of cerebrovascular events have garnered mixed results. We performed a systematic review and meta-analysis of the randomized clinical trials in patients with atherothrombotic diseases to determine the effects of cilostazol on cerebrovascular, cardiac, and all vascular events, and on all major hemorrhagic events. METHODS Relevant trials were identified by searching MEDLINE, EMBASE, and the Cochrane Controlled Trial Registry for titles and abstracts. Data from 12 randomized controlled trials, involving 5674 patients, were analyzed for end points of cerebrovascular, cardiac, and major bleeding events. Searching, determination of eligibility, data extraction, and meta-analyses were conducted by multiple independent investigators. RESULTS Data were available in 3782, 1187, and 705 patients with peripheral arterial disease, cerebrovascular disease, and coronary stenting, respectively. Incidence of total vascular events was significantly lower in the cilostazol group compared with the placebo group (relative risk [RR], 0.86; 95% confidence interval [CI], 0.74-0.99; P=.038). This was particularly influenced by a significant decrease of incidence of cerebrovascular events in the cilostazol group (RR, 0.58; 95% CI, 0.43-0.78; P < .001). There was no significant intergroup difference in incidence of cardiac events (RR, 0.99; 95% CI, 0.83-1.17; P=.908) and serious bleeding complications (RR, 1.00; 95% CI, 0.66-1.51; P=.996). CONCLUSIONS This first meta-analysis of cilostazol in patients with atherothrombosis demonstrated a significant risk reduction for cerebrovascular events, with no associated increase of bleeding risk.

Aberrant right subclavian artery: Varied presentations and management options

Although an aberrant right subclavian artery arising from the proximal portion of the descending thoracic aorta is the most common aortic arch anomaly, few patients have clinical symptoms directly attributable to it. When symptoms do occur they are usually causally related to aneurysmal or occlusive sequelae of atherosclerotic disease of the anomalous vessel. More unusual manifestations peculiar to the anomalous artery include aneurysmal degeneration of the origin of the vessel from the aortic arch, with its inherent risk of rupture, or symptoms of compression of the trachea or more commonly the esophagus by the anomalous vessel as it traverses the superior mediastinum. In patients with symptoms a variety of operative approaches and management strategies have been used. Our recent experience with treatment of two patients with clinical symptoms caused by an aberrant right subclavian artery illustrate the varied surgical options and prompted a review of the surgical management of this unusual anomaly.

Contemporary management of aberrant right subclavian arteries

BACKGROUND Aberrant origin of right subclavian arteries represents the most common of the aortic arch anomalies. This variant has few published series to guide management. Our goal was to review treatment options and results for these potentially complex reconstructions. METHODS A retrospective review was performed on all patients with a diagnosis of aberrant right subclavian artery at our institution between January 2003 and July 2009. RESULTS A total of 24 patients, which comprises one of the largest series reported, including 10 males and 14 females (mean age: 46.6 years, range: 7-77), were diagnosed with an aberrant right subclavian artery. Sixteen (66%) were diagnosed incidentally, but eight (33%) had symptoms of either dysphagia, upper extremity ischemia, or both. Computed tomography was most commonly used to establish the diagnosis (19 patients, 79%). Magnetic resonance imaging established the diagnosis in three patients (12%), upper gastrointestinal barium study in one (4%), and standard angiography in one (4%). A Kommerells diverticulum (KD) was the most common associated anomaly (seven patients, 29%). All seven patients (100%) with a KD required intervention for either symptoms or aneurysmal degeneration. Intervention was performed in 10 patients (42%), including carotid subclavian bypass in five (50%), carotid subclavian transposition in three (30%), and ascending aorta to subclavian bypass in two (20%). Four patients (40%) had additional intervention for management of aneurysmal disease of the aorta or KD, with open aortic replacement in two (20%) and aortic endografting in two (20%). There was one perioperative death (10%) in a patient undergoing aortic arch debranching with placement of an aortic endograft. In all, 18 patients survived without symptoms after a mean follow-up of 38 months. CONCLUSIONS Aberrant right subclavian arteries are most commonly found incidentally with computed tomography. The presence of a KD seemed to correlate with the need for intervention. Patients with no symptoms with the absence of a KD can safely be followed.

Impact of a computerized physician order-entry system.

BACKGROUND The Institute of Medicine has urged the adoption of electronic prescribing systems in all health-care organizations by 2010. Accordingly, computerized physician order entry (CPOE) warrants detailed evaluation. Mixed results have been reported about the benefit of this system. No review of its application in surgical patients has been reported to date. We present the implementation of CPOE in the management of surgical patients within an academic multispecialty practice. STUDY DESIGN Retrospective and prospective analyses of patient-safety measures were done pre- and post-CPOE institution, respectively. Other metrics evaluated included medication errors, order-implementation times, efficiencies, personnel requirements, and physician time. Sampling of time span for the order placement process was assessed with direct hidden observation of the provider. RESULTS A total of 15 (0.22%) medication errors were discovered in 6,815 surgical procedures performed during the 6 months before CPOE use. After implementation, 10 medication errors were found (5,963 surgical procedures [0.16%]) in the initial 6 months and 13 (0.21%) in the second 6 months (6,106 surgical procedures) (p = NS). Mean total time from placement of order to nurse receipt before implementation was 41.2 minutes per order (2.05 minutes finding chart, 0.72 minutes writing order, 38.4 minutes for unit secretary transcription) compared with 27 seconds per order using CPOE (p < 0.01). Four additional informational technology specialists were temporarily required for assistance in implementing CPOE. After CPOE adoption, 11 of 56 (19.6%) ancillary personnel positions were eliminated related to order-entry efficiencies. CONCLUSIONS Present CPOE technology can allow major efficiency gains, but refinements will be required for improvements in patient safety.

Comparison of open and endovascular repair of inflammatory aortic aneurysms

OBJECTIVE Inflammatory abdominal aortic aneurysms (IAAAs) have been traditionally managed with open repair. Endovascular aneurysm repair (EVAR) was approved September of 1999. Some authors have suggested that EVAR is not an acceptable option for management of an IAAA. However, several recent reports have suggested EVAR is a reasonable management option in these patients. The purpose of our study was to review our experience with the contemporary management of IAAA involving both open and endovascular approaches. METHODS A retrospective review of all patients undergoing repair of IAAAs from 1999 to 2011 was conducted at three geographically separate institutions. Basic demographics, diagnostic workup, treatment, and outcomes were reviewed. RESULTS Between 1999 and 2011, 69 patients underwent surgical repair of IAAAs, 59 by open repair and 10 by EVAR. Eighty-three percent of patients were men with a mean age of 67. Aneurysm size was similar in both groups (6.3 cm open repair vs 5.9 cm EVAR). Follow-up for the open group was a mean of 42.6 months and 33.6 months for the EVAR group. Periaortic fibrosis decreased from a mean of 5.4 mm to 2.7 mm after EVAR. Hydronephrosis was present preoperatively in one patient and did not change after EVAR. Aneurysm size decreased in seven patients (70%) who underwent EVAR. Two patients had no change with one lost to follow-up. Mean aneurysm size decrease after EVAR was 1.12 cm (17.8%). There were no aneurysm-related deaths or major morbidities in the EVAR group. Twenty-two patients (37%) in the open surgical group suffered major complications, including myocardial infarction, renal failure, lower extremity amputation, sepsis, and prolonged ventilation. CONCLUSIONS Endovascular repair for IAAA results in successful management with improvement of periaortic inflammation. EVAR should be considered as first-line therapy in which anatomic parameters are favorable.

Popliteal vascular entrapment syndrome caused by a rare anomalous slip of the lateral head of the gastrocnemius muscle

Popliteal vascular entrapment syndrome can result in calf claudication, aneurysm formation, distal arterial emboli, or popliteal vessel thrombosis. The most commonly reported causes of this syndrome have been anomalies of the medial head of the gastrocnemius muscle as it relates to the course of the popliteal artery. We report two cases of rare anomalous slips of the lateral head of the gastrocnemius muscle causing popliteal vascular entrapment syndrome.

Surgical and medical management of extracranial carotid artery aneurysms

OBJECTIVE Extracranial carotid artery aneurysms (ECCAs) are extremely rare with limited information about management options. Our purpose was to review our institutions experience with ECCAs during 15 years and to discuss the presentation and treatment of these aneurysms. METHODS A retrospective review of patients diagnosed with ECCAs from 1998 to 2012 was performed. Symptoms, risk factors, etiology, diagnostic methods, treatments, and outcomes were reviewed. RESULTS During the study period, 141 aneurysms were diagnosed in 132 patients (mean age, 61 years; 69 men). There were 116 (82%) pseudoaneurysms and 25 (18%) true aneurysms; 69 (49%) aneurysms were asymptomatic, whereas 72 (52%) had symptoms (28 painless masses; 10 transient ischemic attacks; 10 vision symptoms; 9 ruptures; 8 strokes; 4 painful mass; 1 dysphagia; 1 tongue weakness; 1 bruit). Causes of true aneurysms included fibromuscular dysplasia in 15 patients, Ehlers-Danlos syndrome in three, Marfan syndrome in one, and uncharacterized connective tissue diseases in two. Of 25 true aneurysms, 11 (44%) were symptomatic; 15 (60%) true aneurysms underwent open surgical treatment, whereas 10 (40%) were managed nonoperatively. Postoperative complications included one stroke during a mean follow-up of 31 months (range, 0-166 months). No aneurysms managed nonoperatively required intervention during a mean follow-up of 77 months (range, 1-115 months). Of 116 pseudoaneurysms, 60 (52%) were symptomatic; 33 (29%) pseudoaneurysms underwent open surgery, 18 (15%) underwent endovascular intervention, and 65 (56%) were managed medically. Pseudoaneurysm after endarterectomy (28 patients; 24%) presented at a mean of 82 months from the surgical procedure. Mean follow-up for all aneurysms was 33.9 months. One (0.7%) aneurysm-related death occurred (rupture treated palliatively). No patient undergoing nonoperative management suffered death or major morbidity related to the aneurysm. Nonoperative management was more common in asymptomatic patients (71%) than in symptomatic patients (31%). CONCLUSIONS ECCAs are uncommon and may be manifested with varying symptoms. All segments of the carotid artery are susceptible, although the internal is most commonly affected. Open surgical intervention was more common in patients with symptoms and with true aneurysms. Patients with pseudoaneurysms were more likely to undergo endovascular intervention. Nonoperative treatment is safe in selected patients.