Incidence, risk factors, and management following cardiac catheterization via carotid and axillary artery approaches: A single-center experience on pseudoaneurysms in young infants

BACKGROUND

Use of alternate access for complex neonatal interventions has gained acceptance with carotid and axillary artery access being used for ductal and aortic interventions.

METHODS

This study was a retrospective, single-center study at Cincinnati Children's Hospital Medical Center. The study included infants, aged ≤90 days, who underwent cardiac catheterization with either carotid or axillary artery access between 2013 and 2022. Data encompassing demographics, clinical information, catheterization data, and the incidence of pseudoaneurysm as a procedural complication were collected.

RESULTS

Among 29 young infants (20 males, 69%), 4 out of 15 patients (27%) who underwent the carotid approach developed pseudoaneurysms, while 1 out of 14 patients (7.1%) who underwent the axillary approach developed one. Two patients required transcatheter intervention due to enlargement of pseudoaneurysms, involving the placement of transarterial flow-diverting stent and occlusion of left common carotid artery. Longer sheath in-to-out time (135 vs. 77 min, p = 0.001), and higher closing activated clotting times (ACT) (268 vs. 197 s, p = 0.021) were observed among patients with pseudoaneurysms compared to those without.

CONCLUSIONS

Young infants with alternative access via the carotid and axillary arteries may be at risk of pseudoaneurysm formation during longer procedures and with higher ACTs for closure. Ultrasound-guided compression can be employed to prevent the progression and in resolution of these lesions.

Risk of pseudoaneurysm and bleeding complications after partial nephrectomy: comparison of tumor enucleation to standard margin technique

Partial nephrectomy (PN) is the gold standard for the resection of amenable small renal masses. Some surgeons have adopted tumor enucleation (TE) over the standard margin PN (SPN) technique based on preservation of healthy renal parenchyma by following the tumor pseudocapsule. However, TE may also confer additional advantages due to avoidance of sharp incision including reduction in perioperative and bleeding complications. Therefore, we evaluated the rate of pseudoaneurysms and other complications following TE vs. SPN. A retrospective cohort study of patients undergoing PN (TE and SPN) between 2008 and 2020 was conducted. Baseline characteristics were compared between the TE and SPN cohorts with univariable and multivariable logistic regression models. A total of 534 patients were included, 195 (36.5%) receiving TE and 339 (63.5%) SPN. There were no differences in baseline patient demographics. There was no difference in RENAL nephrometry scores between the two groups (p = 0.47). TE had lower rates of postoperative complications (11.3 vs. 21.5%, p = 0.002). TE had less bleeding complications (2.1 vs. 8.0%, p = 0.002) with no pseudoaneurysm events following TE compared to 12 following SPN (0.0 vs. 3.5%, p = 0.008). Need for interventional radiology largely reflected pseudoaneurysm differences (0 (0.0%) TE vs. 13 (3.8%) SPN, p = 0.006. Readmission occurred less often after TE vs. SPN (4.1 vs. 8.3%, p = 0.07). Patients receiving TE experienced no clinically significant pseudoaneurysm formation and were less likely to have any bleeding complication or major complication postoperatively. TE may be preferred when minimizing morbidity aligns with patient selection and preferences.

Open Radial Artery Study

Radial artery occlusion (RAO) has been the most common postprocedural complication of transradial artery access. The optimal method of prevention of RAO is still lacking. In our study, we aimed to evaluate the effect of patent hemostasis on early (24 hours) and late (2 weeks) RAO prevention. The Open Radial Artery Study was a single-arm, prospective, and multicenter study. The primary end points were early and late RAO at the vascular access site after transradial coronary procedures. Secondary end points were access site hematoma, pseudoaneurysm formation, arteriovenous fistula, and nerve injury. A total of 2,181 patients were analyzed (67% male, mean age 68 years). The mean interventional duration and hemostatic times were 75.6 ± 55.6 and 60 ± 5.6 minutes, respectively. Radial artery spasm occurred in 10% of patients (n = 218). Catheter kinking, radial artery rupture, or dissection were not observed during the procedure. RAO, hematoma, pseudoaneurysm, arteriovenous fistula, or nerve damage was not observed in any of the patients in the early or late period. In patients who undergo coronary diagnostic or interventional procedures through transradial artery access, the patent hemostasis method seems a critical step in the prevention of early and late RAO.

Abdominal Pseudoaneurysms in Patients With High-Grade Traumatic Injuries

Utilization of CT scans in the work-up of trauma patients has led to increasing diagnosis of traumatic pseudoaneurysms (PSAs). While rare, PSAs have devastating consequences if ruptured. Evidence for the benefit of early detection of PSAs is lacking. The objective of this case series was to determine the incidence of solid organ PSAs after trauma. A retrospective chart review of patients with AAST grade 3-5 traumatic solid organ injuries was performed. 47 patients were identified with PSAs. PSAs were most common in the spleen. A CT finding of contrast blush or extravasation was found in 33 patients. 36 patients underwent embolization. 12 patients had an abdominal CTA prior to discharge. Re-admission was required for 3 patients. 1 patient presented with PSA rupture. During the study, there was no consistency in surveillance for PSAs. Future studies are needed to develop evidence-based practice guidelines for PSA surveillance in high risk populations.

Incidence of and predisposing factors for pseudoaneurysm formation in a high-volume cardiovascular center

Purpose

To evaluate factors associated with pseudoaneurysm (PSA) development.

Methods

Between January 2016 and May 2020, 30,196 patients had invasive vascular radiological or cardiac endovascular procedures that required arterial puncture. All patients with PSA were identified. A matched (age, gender, and type of the procedure) control group of 134 patients was created to reveal predictors of PSA formation.

Results

Single PSAs were found in 134 patients. Fifty-three PSAs developed after radiological procedures (53/6555 [0.8%]), 31 after coronary artery procedures (31/18038 [0.2%]), 25 after non-coronary artery cardiac procedures (25/5603 [0.4%]), and 25 due to procedures in which the arterial puncture was unintended. Thirty-four PSAs (25.4%) were localized to the upper extremity arteries (vascular closure device [VCD], N = 0), while 100 (74.6%) arose from the lower extremity arteries (VCD, N = 37). The PSA prevalence was 0.05% (10/20478) in the radial artery, 0.1% (2/1818) in the ulnar artery, 1.2% (22/1897) in the brachial artery, and 0.4% (99/22202) in the femoral artery. Treatments for upper and lower limb PSAs were as follows: bandage replacement (32.4% and 14%, respectively), ultrasound-guided compression (11.8% and 1%, respectively), ultrasound-guided thrombin injection (38.2% and 78%, respectively), and open surgery (17.6% and 12%, respectively). Reintervention was necessary in 19 patients (14.2%). The prevalence of PSA for the punctured artery with and without VCD use was 37/3555 (1%) and 97/27204 (0.4%), respectively (OR, 2.94; 95% CI, 1.95–4.34; P<0.001). The effect of red blood cell (RBC) count (P<0.001), hematocrit value (P<0.001), hemoglobin value (P<0.001), international normalized ratio (INR; P<0.001), RBC count—INR interaction (P = 0.003), and RBC count—VCD use interaction (P = 0.036) on PSA formation was significant.

Conclusion

Patients in whom the puncture site is closed with a VCD require increased observation. Preprocedural laboratory findings are useful for the identification of patients at high risk of PSA formation.

Mortality following severe liver trauma is declining at Auckland City Hospital: a 14-year experience, 2006-2020

INTRODUCTION

Liver injuries sustained in blunt and penetrating abdominal trauma may cause serious patient morbidity and even mortality.

AIM

To review the recent experience of liver trauma at Auckland City Hospital, describing the mechanism of injury, patient management, outcomes and complications.

METHODS

A retrospective cohort study was performed, including all patients admitted to Auckland City Hospital with liver trauma identified from the trauma registry. Patient clinical records and radiology were systematically examined.

RESULTS

Between 2006-2020, 450 patients were admitted with liver trauma, of whom 92 patients (20%) were transferred from other hospitals. Blunt injury mechanisms, most commonly motor-vehicle crashes, predominated (87%). Stabbings were the most common penetrating mechanism. Over half of liver injuries were low risk American Association for the Surgery of Trauma (AAST) grade I and II (56%), whereas 20% were severe grade IV and V. Non-operative management was undertaken in 72% of patients with blunt liver trauma and 92% of patients with penetrating liver trauma underwent surgery. Liver complications occurred in 11% of patients, most commonly bile leaks (7%), followed by delayed haemorrhage (2%). Thirty-two patients died (7%), with co-existing severe traumatic brain injury as the leading cause of death. There was a significant reduction in death from haemorrhage in patients with grade IV and V liver trauma between the first and second half of the study period (p=0.0091).

CONCLUSION

Although the incidence and severity of liver trauma at Auckland City Hospital remained stable, there was a reduction in mortality, particularly death as a result of haemorrhage.

Patches of different types for carotid patch angioplasty

BACKGROUND

Extracranial carotid artery stenosis is the major cause of stroke, which can lead to disability and mortality. Carotid endarterectomy (CEA) with carotid patch angioplasty is the most popular technique for reducing the risk of stroke. Patch material may be made from an autologous vein, bovine pericardium, or synthetic material including polytetrafluoroethylene (PTFE), Dacron, polyurethane, and polyester. This is an update of a review that was first published in 1996 and was last updated in 2010.

OBJECTIVES

To assess the safety and efficacy of different types of patch materials used in carotid patch angioplasty. The primary hypothesis was that a synthetic material was associated with lower risk of patch rupture versus venous patches, but that venous patches were associated with lower risk of perioperative stroke and early or late infection, or both.

SEARCH METHODS

We searched the Cochrane Stroke Group trials register (last searched 25 May 2020); the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 4), in the Cochrane Library; MEDLINE (1966 to 25 May 2020); Embase (1980 to 25 May 2020); the Index to Scientific and Technical Proceedings (1980 to 2019); the Web of Science Core Collection; ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) portal. We handsearched relevant journals and conference proceedings, checked reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised and quasi-randomised trials (RCTs) comparing one type of carotid patch with another for CEA.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility, risk of bias, and trial quality; extracted data; and determined the quality of evidence using the GRADE approach. Outcomes, for example, perioperative ipsilateral stroke and long-term ipsilateral stroke (at least one year), were collected and analysed.

MAIN RESULTS

We included 14 trials involving a total of 2278 CEAs with patch closure operations: seven trials compared vein closure with PTFE closure, five compared Dacron grafts with other synthetic materials, and two compared bovine pericardium with other synthetic materials. In most trials, a patient could be randomised twice and could have each carotid artery randomised to different treatment groups. Synthetic patch compared with vein patch angioplasty Vein patch may have little to no difference in effect on perioperative ipsilateral stroke between synthetic versus vein materials, but the evidence is very uncertain (odds ratio (OR) 2.05, 95% confidence interval (CI) 0.66 to 6.38; 5 studies, 797 participants; very low-quality evidence). Vein patch may have little to no difference in effect on long-term ipsilateral stroke between synthetic versus vein materials, but the evidence is very uncertain (OR 1.45, 95% CI 0.69 to 3.07; P = 0.33; 4 studies, 776 participants; very low-quality evidence). Vein patch may increase pseudoaneurysm formation when compared with synthetic patch, but the evidence is very uncertain (OR 0.09, 95% CI 0.02 to 0.49; 4 studies, 776 participants; very low-quality evidence). However, the numbers involved were small. Dacron patch compared with other synthetic patch angioplasty Dacron versus PTFE patch materials  PTFE patch may reduce the risk of perioperative ipsilateral stroke (OR 3.35, 95% CI 0.19 to 59.06; 2 studies, 400 participants; very low-quality evidence). PTFE patch may reduce the risk of long-term ipsilateral stroke (OR 1.52, 95% CI 0.25 to 9.27; 1 study, 200 participants; very low-quality evidence). Dacron may result in an increase in perioperative combined stroke and transient ischaemic attack (TIA) (OR 4.41 95% CI 1.20 to 16.14; 1 study, 200 participants; low-quality evidence) when compared with PTFE. Early arterial re-stenosis or occlusion (within 30 days) was also higher for Dacron patches. During follow-up for longer than one year, more 'any strokes' (OR 10.58, 95% CI 1.34 to 83.43; 2 studies, 304 participants; low-quality evidence) and stroke/death (OR 6.06, 95% CI 1.31 to 28.07; 1 study, 200 participants; low-quality evidence) were reported with Dacron patch closure, although numbers of outcome events were small. Dacron patch may increase the risk of re-stenosis when compared with other synthetic materials (especially with PTFE), but the evidence is very uncertain (OR 3.73, 95% CI 0.71 to 19.65; 3 studies, 490 participants; low-quality evidence). Bovine pericardium patch compared with other synthetic patch angioplasty Bovine pericardium versus PTFE patch materials  Evidence suggests that bovine pericardium patch results in a reduction in long-term ipsilateral stroke (OR 4.17, 95% CI 0.46 to 38.02; 1 study, 195 participants; low-quality evidence). Bovine pericardial patch may reduce the risk of perioperative fatal stroke, death, and infection compared to synthetic material (OR 5.16, 95% CI 0.24 to 108.83; 2 studies, 290 participants; low-quality evidence for PTFE, and low-quality evidence for Dacron; OR 4.39, 95% CI 0.48 to 39.95; 2 studies, 290 participants; low-quality evidence for PTFE, and low-quality evidence for Dacron; OR 7.30, 95% CI 0.37 to 143.16; 1 study, 195 participants; low-quality evidence, respectively), but the numbers of outcomes were small. The evidence is very uncertain about effects of the patch on infection outcomes.

AUTHORS' CONCLUSIONS

The number of outcome events is too small to allow conclusions, and more trial data are required to establish whether any differences do exist. Nevertheless, there is little to no difference in effect on perioperative and long-term ipsilateral stroke between vein and any synthetic patch material. Some evidence indicates that other synthetic patches (e.g. PTFE) may be superior to Dacron grafts in terms of perioperative stroke and TIA rates, and both early and late arterial re-stenosis and occlusion. Pseudoaneurysm formation may be more common after use of a vein patch than after use of a synthetic patch. Bovine pericardial patch, which is an acellular xenograft material, may reduce the risk of perioperative fatal stroke, death, and infection compared to other synthetic patches. Further large RCTs are required before definitive conclusions can be reached.

Femoral Pseudoaneurysm in IV Drug Abusers: Single-center Study Experience

BACKGROUND

Pseudoaneurysm of the femoral artery is the most common complication among IV drug abusers who inject drugs in groin. These are usually infective and potentially fatal so it requires astute clinical recognition and prompt treatment, possessing a significant challenge to vascular surgeons.

METHODS

We present a retrospective descriptive study and the prevalent practice of their management covering the period from 2013 July- December 2019 at our center. Data regarding demography, presentation, surgical management, and the outcome was analyzed.

RESULTS

Among 368 femoral pseudoaneurysm operated during the period, groin swelling with pulsatile mass was the most frequent presentation accounting 304 (82.61%) patients. About 67.12% (247 patients) of the pseudoaneurysm has purulent discharge and 60.07% (221 patients) had bleeding at presentation out of which 211patients had hepatitis C (HCV), hepatitis B (HBsAg) and/or Human Immunodeficiency virus (HIV) status positive.  Thirty six patients (9.78%) presented with femoral pseudoaneurysm in both groins. Ligation and excision of the pseudoaneurysm were done in all cases while delayed revascularization was done in eight patients with expanded Polytetrafluoroethylene (ePTFE) graft in one patient and venous bypass grafts in other 7 cases. All patients after bypass had no major limb loss and two patients had a patent graft at five years follow up. There were nine mortalities and thirty two patients underwent amputation.  Conclusions: Infected femoral pseudoaneurysm can be managed by ligation of the involved artery with delayed revascularization if required without major limb and life loss.

Association between contrast extravasation on computed tomography scans and pseudoaneurysm formation in pediatric blunt splenic and hepatic injury: A multi-institutional observational study

PURPOSE

We aimed to examine the association between contrast extravasation (CE) on initial computed tomography (CT) scan and pseudoaneurysm (PSA) development in pediatric blunt splenic and/or liver injury.

METHODS

We conducted a multi-institutional retrospective study in cases of blunt splenic and/or hepatic injury who underwent an initial attempt of nonoperative management. A logistic regression model was used to compare PSA formation and CE on initial CT scan, and the area under the receiver operating characteristic curve (AUC) with and without CE was used to assess the predictive performance of CE for PSA formation.

RESULTS

Of 236 cases enrolled from 10 institutions, PSA formation was observed in 17 (7.2%). Multivariate analysis showed a significant association between CE on initial CT scan and increased incidence of PSA formation (odds ratio, 4.96; 95% confidence interval, 1.37-18.0). There was no statistically significant association between the grade of injury and PSA formation. The AUC improved from 0.75 (0.64-0.87) to 0.80 (0.70-0.91) with CE.

CONCLUSION

Active CE on initial CT scan was an independent predictor of PSA formation. Selective use of follow-up CT in children who showed CE on initial CT may provide early identification of PSA formation, regardless of injury grade.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.

Transcatheter arterial embolization for advanced gastric cancer bleeding: A single-center experience with 58 patients

To investigate computed tomography and angiography findings and clinical outcomes after transcatheter arterial embolization for acute upper gastrointestinal bleeding from advanced gastric cancers.From January 2005 to December 2014, 58 patients with pathologically proven gastric cancer were treated at our institution with transcatheter arterial embolization due to acute upper gastrointestinal bleeding recalcitrant to endoscopic treatment. The electronic medical records for each patient were reviewed for clinical presentation, endoscopy history, computed tomography and angiographic findings, blood transfusion requirements, and follow-up results.Angiography findings were positive in 13 patients (22.4%): contrast extravasation was found in 9 patients and pseudoaneurysm in 4 patients. All patients with positive angiograms underwent selective embolization treatment. Those with negative angiography findings underwent empirical embolization. Gelfoam, n-butyl cyanoacrylate, coils, or a combination of these were used as embolic agents. The overall clinical success rate was 72.4% (42/58), and the success rate for patients with positive angiography was 53.8% (7/13). The median survival was 97.5 days (range, 7-1415 days), and the 1-month survival rate was 89.6% (52/58). The 1-month survival rate of the clinical success group was 95.2% (40/42), which was significantly higher than that of the clinical failure group (P = .04). The clinical success group also required significantly fewer transfusions (2.43 units, range 0-24 units) (P = .02).Transcatheter arterial embolization is a highly effective treatment for advanced gastric cancer with active bleeding. It should be considered as an additional treatment, especially when endoscopic or surgical treatment fails or when these approaches are difficult.

Emergency management of iatrogenic arterial injuries with a low-profile balloon-expandable stent-graft: Preliminary results

Endovascular treatment of arterial injuries with stent-graft is a reliable alternative approach in patients not suitable for embolization or at high risk for surgery. The aim of our study was to evaluate the efficacy and the safety of the BeGraft stent-graft, a low-profile balloon expandable covered stent, for emergency endovascular treatment of iatrogenic arterial injuries.Between August 2015 and September 2018, 34 consecutive patients (mean age 71 ± 12 years, 9 females) underwent implantation of BeGraft stent-grafts for iatrogenic arterial injuries (22 active bleedings, 11 pseudoaneurysms, and 1 enteric-iliac fistula). The primary endpoints were technical and clinical success and rates of major and minor complications. The secondary endpoint was the patency of the device during the follow-up. Imaging follow-up was performed by duplex ultrasound and/or computed tomography angiography (according to lesion site/target vessel), at 1-6-12-15 and 24 months.In all 34 patients (100%), the lesion or the defect was effectively excluded with a cumulative amount of 42 stent-grafts. The clinical success was documented in 30/34 patients (88.2%). Neither device- or procedure-related deaths, or major complications occurred. A minor complication was reported in 1 patient (2.9%), successfully treated during the same procedure. Thirty (88.2%) patients were available for a mean follow-up time of 390 ± 168 days (minimum 184, maximum 770), with no observed loss of patency, yielding a 100% Kaplan-Meier cumulative survival patency function. The percentage of patent patients was 30/30 at 6 months, 22/22 at 12 months, and 5/5 at 15 months.Endovascular treatment of iatrogenic arterial injuries with the BeGraft stent-graft is minimally invasive and effective, with good patency rate at midterm follow-up.

Systemic review of global case reports on ankle pseudo aneurysm: Analysis of epidemiology, clinical presentation, diagnosis and treatment

INTRODUCTION

Pseudo aneurysm of the ankle is a rare presentation and the management is complex due to the complex anatomy. The aim of this review is to examine the epidemiology, etiology, diagnostic modalities used and management. This is the first systematic review of this topic in literature.

METHODS

We performed a systematic review in multiple databases (including PubMed, MEDLINE, EMBASE, and Scopus) from 1966 to May 18, 2019, to identify all case reports and case series describing patients with ankle pseudo aneurysm. This systematic review was performed in accordance with the Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA). Our inclusion criteria included patients with ankle pseudo aneurysm of any age. We excluded reports in which the individual level data is not available. Patients demographic (gender, age), clinical characteristics (precipitating event, duration), diagnostic modality and treatment were recorded.

RESULT

There were in total 23 case reports identified on ankle pseudo aneurysm from 1966 until 2018. Among these twenty-three reports, 16 (70%) were male and seven (30%) patients were female. Age distribution showed higher number of reports among young adults, 15 patients (65%). Based on our systematic review trauma (48%), arthroscope (48%) and arthrodesis (4%) were the etiologies described in all these case reports. Ultrasound duplex and CT Angiogram has been used as a single modality in three reports each. In fifteen patients (65%) combination of imaging has been used for diagnosis. Anterior tibial artery is the most commonly injured vessel among the reported cases, comprised of 14 (61%) patients. Among these arthroscopes were the highest reported precipitating events, 9 (64%), followed by trauma in four patients (29%) and arthrodesis in one patient (7%). Treatment modalities described in all previous reports were excision and ligation, 10 (42%); excision of sac and primary repair, 4 (17%); excision of sac followed by reversed saphenous venous graft repair, 2 (8%); US guided compression, 2 (8%); US guided thrombin injection, 4 (17%); stenting, 1 (4%) and coiling, 1 (4%).

CONCLUSION

Ankle pseudoaneurysm is mostly preventable by detailed initial assessment following trauma or careful approach during arthroscope. Evolving diagnostic modality and treatment has shed some light into noninvasive management of pseudo aneurysm of ankle.

Prevalence and natural history of and risk factors for subaneurysmal aorta among 65-year-old men

Background: The aims of this study were to determine the prevalence of screening-detected subaneurysmal aorta (SAA), i.e. an aortic diameter of 2.5-2.9 cm, its associated risk factors, and natural history among 65-year-old men. Methods: A total of 14,620 men had their abdominal aortas screened with ultrasound and completed a health questionnaire containing information on smoking habits and medical history. They were categorized based on the aortic diameter: normal aorta (<2.5 cm; n = 14,129), SAA (2.5-2.9 cm; n = 258), and abdominal aortic aneurysm (AAA) (≥3.0 cm; n = 233). The SAA-group was rescanned after 5 years. Associated risk factors were analyzed. Results: The SAA-prevalence was 1.9% (95% confidence interval 1.7%-2.1%), with 57.0% (50.7%-63.3%) expanding to ≥3.0 cm within 5 years. Frequency of smoking, coronary artery disease, hypertension, hyperlipidemia, and claudication were significantly higher in those with SAA and AAA compared to those with normal aortic diameter. Current smoking was the strongest risk factor for SAA (odds ratio [OR] 2.8; P < 0.001) and even stronger for AAA (OR 3.6; P < 0.001). Men with SAA expanding to AAA within 5 years presented pronounced similarities to AAA at baseline. Conclusions: Men with SAA and AAA presented marked similarities in the risk factor profile. Smoking was the strongest risk factor with an incremental association with disease severity, and disease progression. This indicates that SAA and AAA may have the same pathophysiological origin and that SAA should be considered as an early stage of aneurysm formation. Further research on the cost-effectiveness and potential benefits of surveillance as well as smoking cessation and secondary cardiovascular prevention in this subgroup is warranted.

Clinical course of abdominal aortic aneurysms in Behçet disease: a retrospective analysis

Arterial aneurysms are rare manifestations of Behçet Disease (BD) with high morbidity and mortality. This study aimed to investigate the clinical course of BD patients with abdominal aortic aneurysms (AAA). We retrospectively searched charts of BD patients, followed up between 1988 and 2011, to identify those with AAA with at least 6-month clinical and radiological follow-up data. Chart review revealed 12 patients (11 males) with AAA amongst 1224 patients; follow-up data from 11 patients were available. The most common symptoms were lower back and abdominal pain. The only pre-treatment complication was a spontaneous rupture. All but one patient received corticosteroid and cyclophosphamide pulses for the induction, and corticosteroid and azathioprine for the maintenance treatment; one patient received only the maintenance treatment. Two patients had surgical graft interposition, without postoperative complications. Seven patients had endovascular stenting; five of them (71.4%) showed radiological regression after 32.5 (13.4-53.8) months, while four (57%) had clinical improvement after 11.8 (0.2-29.4) months. However, one non-responsive patient developed stent infection and exsanguinated during percutaneous drainage, and one patient developed femoral artery pseudo-aneurysm at the catheter insertion site. Another patient developed a new aneurysm under the maintenance treatment. Medical treatment alone yielded radiological regression in one of two patients. Current immunosuppressive, surgical or endovascular approaches can provide clinical and radiological improvements lately in BD patients with AAA. Furthermore, complication rates seem to be high with interventional approaches. These findings suggest an unmet need for safer alternative treatments.

[Complications in the conservative managemennt of splenic rupture]

INTRODUCTION

Management of splenic rupture in haemodynamically stable children is non-surgical treatment. However, complications can occur during follow-up. Objective: to study the frequency, evolution and treatment of complications of conservative treatment of splenic rupture. Secondary objective: to evaluate the results of the American Pediatric Surgical Association (APSA) clinical guideline in conservative treatment.

MATERIAL AND METHODS

Retrospective study of patients with abdominal trauma between 2010-2016. We included children under 15 years of age with splenic injury after blunt abdominal trauma. Demographic variables, mechanism and degree of injury of American Association for the Surgery of Trauma were studied in the sample. The complications, the time of onset and their treatment were analyzed. The treatment was based on the recommendations of the APSA with the exception of ultrasound follow-up. In case of complications and according to the clinical and characteristics, embolization was indicated.

RESULTS

Twenty-eight patients were attended, 21 males (75%). The median age was 8.35 years (6.28-11.35). Seven patients (25%) presented complications: two arteriovenous fistula (AVF), three pseudo-aneurysms and two hemorrhages. The median time to diagnosis of complications was 5.67 days (P25 4- P75 5.75). Embolization was performed in two patients with pseudo-aneurysm. Another patient underwent emergency splenectomy for rebleeding. The rest of the complications resolved spontaneously.

CONCLUSIONS

In splenic rupture, unlike APSA, ultrasound monitoring is useful to rule out early complications.

Femoral Pseudoaneurysms

Iatrogenic pseudoaneurysms will continue to be a problem associated with arterial cannulation procedures. With the increasing trend toward minimally invasive procedures, vascular surgeons, as well as interventionalists will be performing more cannulation procedures; hence we will be more involved in the management of this complication more frequently. Treatment trends and efforts aimed at preventing iatrogenic pseudoaneurysms have evolved over the past decade. This article reviews the history and available literature on the subject, in conjunction with the experience of a center that performs over 10,000 cannulation procedures annually.

[Femoral artery pseudoaneurysms encountered in orthopedics and traumatology]

BACKGROUND AND PURPOSE

Most published articles regarding orthopedic- and trauma-related femoral artery pseudoaneurysms (FAPs) are case reports in English. Reported cases are often associated with a literature review but actually provide little robust data. We wanted to summarize the current knowledge on diagnostic and therapeutic features of these FAPs.

METHODS

A new case of superficial FAP is described followed by a review of the literature. A bibliographic search was performed online (PubMed, ScinceDirect) from 1964 to 2015 using the descriptors "traumatic femoral pseudoaneurysm, orthopedic surgery, osteochondroma".

RESULTS

A total of 64 cases of FAPs was analyzed. There were 50 men with an average age of 40.72±26.45 years old. The most common clinical presentation was painful swelling (34%). Arteriography was the commonest radiological investigation used (63%). The main etiologies were orthopedic injuries (47%), surgery of the upper thigh (30%) and femoral osteochondromas (23%). Arterial injuries included superficial femoral (47%) and profunda femoris artery (50%). The treatment was open surgery (56%) or endovascular repair (36%). Deep femoral artery and its branches were embolized (47%) or ligated (38%). Endovascular stenting was performed in 30% of posttraumatic FAPs. All FAPs relating to osteochondromas were repaired surgically. Postoperative courses were uneventful in 95% of patients.

CONCLUSION

Endovascular embolization is preferred in management of postsurgical FAPs which have usually involved the deep femoral artery. Endovascular stenting graft may be proposed for posttraumatic FAPs, for which the superficial femoral trunk is the most often involved vessel. Surgical repair should be performed when endovascular stenting graft is not feasible. Surgical repair is mandatory for all FAPs secondary to traumatic exostoses.

Femoral pseudoaneurysm in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction: incidence, clinical course and risk factors

AIM

Various peripheral vascular complications may be observed after cardiac catheterization. However, no data are available about femoral pseudoaneurysm (FPA) after urgent primary percutaneous coronary intervention (PCI). We sought to determine the in-hospital incidence, clinical course and predictors of FPA in patients with ST elevation myocardial infarction (STEMI) undergoing primary PCI.

METHODS

Two thousand six hundred consecutive STEMI patients (mean age: 56.5 ± 11.7 years; 2158 men) undergoing primary PCI were retrospectively enrolled into this study. Patients were evaluated with Doppler ultrasonography following PCI and categorized into two groups according to whether FPA developed or not. All the parameters were compared between FPA and non-FPA groups.

RESULTS

The incidence of FPA after primary PCI was determined to be 2.3%. The mean age was higher in the FPA group compared to the non-FPA group (mean age: 60.6 ± 11.6 vs. 56.5 ± 11.8, respectively, P=0.007). Furthermore, the FPA developing group experienced prolonged hospitalizations compared to the non-FPA group, but no differences in in-hospital or long term mortality were noticed. In the multivariate analysis of this study, female gender and age (>75 years), after primary PCI, were found to be independent predictors of FPA.

CONCLUSION

High incidence of FPA was noticed in STEMI patients undergoing primary PCI, which prolonged in-hospital stay. Extra care must be given, especially to women and those who are >75 years of age, for this complication.

Bleeding and vascular complications at the femoral access site following percutaneous coronary intervention (PCI): an evaluation of hemostasis strategies

BACKGROUND

Previous research found at least one vascular closure device (VCD) to be associated with excess vascular complications, compared to manual compression (MC) controls, following cardiac catheterization. Since that time, several more VCDs have been approved by the Food and Drug Administration (FDA). This research evaluates the safety profiles of current frequently used VCDs and other hemostasis strategies.

METHODS

Of 1089 sites that submitted data to the CathPCI Registry from 2005 through the second quarter of 2009, a total of 1,819,611 percutaneous coronary intervention (PCI) procedures performed via femoral access site were analyzed. Assessed outcomes included bleeding, femoral artery occlusion, embolization, artery dissection, pseudoaneurysm, and arteriovenous fistula. Seven types of hemostasis strategy were evaluated for rate of "any bleeding or vascular complication" compared to MC controls, using hierarchical multiple logistic regression analysis, controlling for demographic factors, type of hemostasis, several indices of co-morbidity, and other potential confounding variables. Rates for different types of hemostasis strategy were plotted over time, using linear regression analysis.

RESULTS

Four of the VCDs and hemostasis patches demonstrated significantly lower bleeding or vascular complication rates than MC controls: Angio-Seal (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.65-0.70); Perclose (OR, 0.54; CI, 0.51-0.57); StarClose (OR, 0.77; CI, 0.72-0.82); Boomerang Closure Wire (OR, 0.63; CI, 0.53-0.75); and hemostasis patches (OR, 0.70; CI, 0.67-0.74). All types of hemostasis strategy, including MC, exhibited reduced complication rates over time. All trends were statistically significant except one.

CONCLUSIONS

This large, nationally representative observational study demonstrated better safety profiles for most of the frequently used VCDs, compared to MC controls.

Different spectrum of vascular complications after angio-seal deployment or manual compression

BACKGROUND

Reported complication rates after vascular closure device deployment or femoral manual compression (MC) are similar. However, the features and severity of such complications have never been thoroughly evaluated.

METHODS AND RESULTS

A consecutive series of 1241 patients treated from 2008 to 2010 with Angio-Seal (AS) was prospectively evaluated for vascular complications (VC). As control group, we used a consecutive series of 672 patients treated with MC in the 7 months preceding AS adoption at our institution. VC were observed in 88 patients, 55 with AS and 33 with MC (relative risk, 0.90; 95% confidence interval, 0.59-1.38; P=.63). The clinical profile of complications observed in the 2 groups was different. Groin hematomas were more frequent with MC (100% vs 65.5%; P=.0005) and retroperitoneal bleedings were more common with AS (41.8% vs 6.1%; P=.0005). AS complications required more frequently transfusions (49.1% vs 18.2%; P=.006), while MC complications significantly delayed hospital discharge, in comparison to AS (4.3 ± 4.0 days vs 2.7 ± 1.9 days; P=.01). Differences in groin hematoma and retroperitoneal bleeding rates were confirmed after propensity score matching. Finally, a different allocation of diagnostic/therapeutic resources was observed in the 2 groups.

CONCLUSION

AS and MC were associated with similar incidences of VC, with a higher prevalence of severe complications (retroperitoneal hemorrhages and transfusions) after using AS. However, complications after MC were associated with significantly prolonged hospital stay. Comparison between different hemostatic strategies should consider the logistic burden imposed by different vascular complications.

Vascular complications after percutaneous coronary intervention following hemostasis with the Mynx vascular closure device versus the AngioSeal vascular closure device

We investigated the prevalence of vascular complications after PCI following hemostasis in 190 patients (67% men and 33% women, mean age 64 years) treated with the AngioSeal vascular closure device (St. Jude Medical, Austin, Texas) versus 238 patients (67% men and 33% women, mean age 64 years) treated with the Mynx vascular closure device (AccessClosure, Mountain View, California).

RESULTS

Death, myocardial infarction or stroke occurred in none of the 190 patients (0%) treated with the AngioSeal versus none of 238 patients (0%) treated with the Mynx. Major vascular complications occurred in 4 of 190 patients (2.1%) treated with the AngioSeal versus 5 of 238 patients (2.1%) treated with the Mynx (p not significant). Major vascular complications in patients treated with the AngioSeal included removal of a malfunctioning device (1.1%), hemorrhage requiring intervention (0.5%) and hemorrhage with a loss of > 3g Hgb (0.5%). The major vascular complications in patients treated with the Mynx included retroperitoneal bleeding requiring surgical intervention (0.8%), pseudoaneurysm with surgical repair (0.8%) and hemorrhage with a loss of > 3g Hgb (0.4%). These complications were not significantly different between the two vascular closure devices (p = 0.77). Minor complications included hematoma > 5 cm (0.5%, n = 1) within the AngioSeal group, as well as procedure failure requiring > 30 minutes of manual compression after device deployment, which occurred in 7 out of 190 patients (3.7%) treated with the AngioSeal versus 22 of 238 patients with the Mynx (9.2%) (p = 0.033).

CONCLUSIONS

Major vascular complications after PCI following hemostasis with vascular closure devices occurred in 2.1% of 190 patients treated with the AngioSeal vascular closure device versus 2.1% of 238 patients treated with the Mynx vascular closure device (p not significant). The Mynx vascular closure device appears to have a higher rate of device failure.

Gender disparity in patients undergoing percutaneous coronary intervention for acute coronary syndromes - does it still exist in contemporary practice?

INTRODUCTION

Prior studies have demonstrated evidence of a disparity in the treatment and outcome of male compared to female patients undergoing percutaneous coronary intervention (PCI).

MATERIALS AND METHODS

From a dedicated database, we retrospectively analysed all consecutive patients with acute coronary syndrome (ACS) admitted to our institution for PCI in 2008. Baseline and procedural characteristics as well as complications were then evaluated for male patients (n = 331) as compared with female patients (n = 137).

RESULTS

Women were noted to be older at the time of presentation (66.1 +/- 10.0 vs 60.7 +/- 11.6 years, P <0.00001), the groups were otherwise well matched in terms of baseline characteristics. Female patients were treated with significantly smaller diameter stents (2.86 +/- 0.44 vs 2.96 +/- 0.50 mm, P = 0.04), though the proportion of drug-eluting stents was similar (53.7% vs 50.5%, P = 0.5). Female patients were significantly less likely to receive optimal medical therapy with lesser use of glycoprotein IIb/IIIa inhibitor (26.3% vs 55.3%, P <0.0000001), and beta-blockers (83.9% vs 90.9%, P = 0.04). At 30 days, there were no differences in the rate of major adverse cerebrovascular or cardiac events (2.9% vs 3.9%, P = 0.8), though females had a significantly higher rate of femoral access site pseudoaneurysm (4.4% vs 0.9%, P = 0.02).

CONCLUSIONS

There remains evidence for continued gender disparity in contemporary practice; despite evidence for efficacy in ACS patients, females received a notably lower use of glycoprotein IIb/IIIa inhibitors and beta-blockers. Women are also significantly more likely to develop femoral access site complications with pseudoaneurysm development; it is important therefore to optimise procedures for sheath removal in female patients or give strong consideration to the use of radial access site.

Initial experience of removal of 10-French sheaths using the 8-French Angio-Seal vascular closure device

OBJECTIVES

We studied the use of 8 Fr Angio-Seal in closure of access sites up to 10 Fr.

BACKGROUND

The use of larger French catheters for procedures such as valvuloplasty and percutaneous valve replacement has required the use of better methods for arterial closure. The use of 6 and 8 Fr Angio-Seal hemostatic devices (St. Jude Medical, St. Paul, Minnesota) has been well described and are routinely used for diagnostic and interventional procedures up to 8 Fr in size. However, no data are available for the use of an 8 Fr Angio-Seal device in the closure of access sites up to 10 Fr.

METHODS

In our center, we evaluate the incidence of vascular complications following the use of an 8 Fr Angio-Seal device with 10 Fr sheaths in patients undergoing aortic valvuloplasty.

RESULTS

Of 53 procedures, there was only 1 vascular complication, a ruptured pseudoaneurysm, which required vascular repair.

CONCLUSIONS

Our data suggest that an 8 Fr Angio-Seal device can be utilized effectively and safely in procedures requiring larger access sites up to 10 Fr.

[Strategy and results of pneumatic compression following transfemoral catheterization]

BACKGROUND AND OBJECTIVE

Transfemoral arterial access of catheterization requires a method of hemostasis that is always easily and quickly applicable, but also safe, inexpensive and comfortable for the patient. Current methods meet these requirements only in part. The pneumatic pressure-controlled FemoStop system has been described as straightforward and safe. But the conventional procedure has been to achieve primary hemostasis with FemoStop and then switch to a pressure bandage. We here present our method of using FemoStop alone for the entire duration of the compression and compare the results with those of manual compression.

PATIENTS AND METHODS

The preferred methods of managing the arterial puncture site in our center were compared for two different periods. Group MC (manual compression) comprised 1,085 patients (mean age 63.310.5 years, 29.8% females) in whom manual compression had been applied followed by a pressure bandage. Group FS (pneumatic compression) comprised 1,087 consecutive patients (mean age 64.610.7%, 35.1% females) in whom pneumatic compression only had been applied. The incidence of pseudoaneurysms, a-v fistulas and bleeding requiring transfusion were compared.

RESULTS

The incidence of pseudoaneurysms after diagnostic cardiac catheterization in the FS group was lower than in the MC group. In patients after an angioplasty the results were similar other than the time the patient has to remain in bed. The incidence of a-v fistulas was similar in the two groups. There was only one episode pf bleeding that required transfusion (MC group). A multivariate analysis indicated that female gender is an independent risk factor for the occurrence of pseudoaneurysms and a-v fistulas.

CONCLUSIONS

The FemoStop system used by itself took less time than manual compression and was associated with a slightly lower risk of complications.

The Utility of Serial Computed Tomography Imaging of Blunt Splenic Injury: Still Worth a Second Look?

BACKGROUND

Serial computed tomography (CT) imaging of blunt splenic injury (BSI) can identify the latent formation of splenic artery pseudoaneurysms (PSAs), contributing to improved success in splenic salvage. The practice of serial CT imaging, however, has not been embraced. The purpose of this study was to reevaluate the clinical practice of serial CT imaging within the context of an institutional protocol for the nonoperative management (NOM) of BSI.

METHOD

Consecutive patients with BSI selected for NOM were identified from our trauma registry. Patients were managed according to protocol, whereby hemodynamically stable patients with PSA on initial or follow-up CT imaging were referred for angiography. Follow-up CT was performed 24 to 48 hours after the initial CT. Data were abstracted from hospital, clinic, and radiology records, and included age, Injury Severity Score, splenic injury grade (SIG), and CT findings. The incidence and timing of PSA identification with respect to subsequent management and outcome were reviewed.

RESULTS

Of 426 BSI admissions during a 2.5-year period, 341 (80%) were selected for NOM. Mean follow-up was 39 days, with 76% followed for >or=7 days. Serial CT imaging resulted in the angiographic detection of 14 (4%) early PSAs and 11 (3%) latent PSAs. PSAs were associated with increasing SIG (p<0.001); however, 24% of PSAs were observed in SIG 1 and 2. Embolization was successful in 13 of 14 (93%) patients with early PSAs and 10 of 11 (91%) with latent PSAs. The splenic salvage rate for all patients selected for NOM during the study period was 329 of 341 (97%).

CONCLUSIONS

Adherence to a NOM protocol guided by serial CT imaging has resulted in one of the highest splenic salvage rates reported to date. Identification and embolization of latent PSA likely contributes to NOM success, given the unfavorable natural history of these lesions. Although PSA formation is correlated with increasing SIG, PSAs are not exclusive to higher-grade injury, warranting serial CT surveillance regardless of SIG.

Hybrid Treatment of Ascending Aortic Pseudoaneurysm: Endovascular Stent-graft Placement and Extraanatomic Reconstruction without Sternotomy

Conventional surgical repair of ascending aortic pseudoaneurysms following prior cardiac operations is performed with a high operative mortality. We report a 67 year old female patient with an ascending aortic pseudoaneurysm detected 3 years after coronary bypass surgery. The patient was treated with ascending aortic endovascular stent graft placement and extraanatomic reconstruction of supraaortic branches without using sternotomy.

[Peripheral vascular complications after the cardiac catheterization]

OBJECTIVE

To explore the cause, the clinical manifestation and the management of peripheral vascular complications after cardiac catheterization.

METHODS

Clinical data of patients with peripheral vascular complications were analyzed retrospectively.

RESULTS

Of the 4,531 patients, 122 (2.7%) had peripheral vascular complications, including local hematoma (86 cases, 1.90%), pseudoaneurysm (15 cases, 0.33%), arteriovenous fistula (8 cases, 0.18%), femoral venous thrombosis (5 cases, 0.11%), excessive hemorrhage (5 cases, 0.11%), femoral arterial thrombosis (2 cases, 0.04%), and femoral nerve malfunction (1 case, 0.02%). All complications were relieved after conservative therapy except that one case needed surgery.

CONCLUSION

Peripheral vascular complications are associated with anticoagulation, diabetes, and hypertension. Prognosis of overwhelming complications is good, as long as patients are treated timely and appropriately.

Endovascular repair of the descending thoracic aorta: mid-term results and evaluation of magnetic resonance angiography

AIM

The endoluminal stent-grafting represents an alternative to surgery in the treatment of lesions of the descending thoracic aorta. The purpose of the present study was to evaluate the mid-term results of the Talent stent-graft in the different indications of aortic disease and the use of magnetic resonance angiography (MRA) in the diagnosis of complications.

METHODS

Over a 3-year period, 23 patients with a high surgical risk and presenting a localized lesion of the descending thoracic aorta had an implantation of a Talent stent-graft. Indications were degenerative aneurysm (n=13), false aneurysm (n=7) and penetrating atherosclerotic ulcer (n=3). The feasibility of the endovascular treatment and sizing of the aorta and stent-grafts were determined pre-operatively by MRA and intraoperative angiography. Immediate and mid-term technical and clinical success were assessed by clinical and MRA follow-up.

RESULTS

Endovascular treatment was completed successfully in all patients with no conversion to open repair. There was no intraoperative mortality. The mean operative time was 38+/-7 min. Primary success rate was 100%. We didn't have perioperative mortality. The mean follow-up period was 15+/-5 months. The survival rate was 97% (n=22). Regression of the aneurysmal size was observed in 70% (n=16). MRA diagnosed 3 over 4 postoperative endoleaks that were not diagnosed with the CT-scan, and did not interfere with the nitinol structure of the stent-graft.

CONCLUSIONS

Endovascular treatment of the various localized diseases of the descending thoracic aorta is a promising, feasible, alternative technique to open surgery in well selected patients. MRA is well adapted to diagnose postoperative endoleaks.

Devastating late complication for repair of type A acute aortic dissection with usage of gelatin-resorcinol-formalin glue

OBJECTIVES

We review cases of pseudoaneurysm formation of the graft anastomosis sites following repair of type A acute aortic dissection by our original leak-proof technique for dissected aortic wall reinforcement with xenopericardium and gelatin-resorcinol-formalin (GRF) glue.

CASES

A 47-year-old male presented inferior acute myocardial infarction with bradycardia and cardiogenic shock 34 months after the initial total arch replacement for acute aortic dissection. The patient underwent reoperation with total arch replacement and coronary artery bypass grafting to the right coronary artery. There was rupture of the proximal anastomosis with clotted pseudoaneurysm formation extending over the right ventricle. The right coronary artery was compressed by the pseudoaneurysm. The distal anastomosis also ruptured with localized pseudoaneurysm formation. Twenty-two patients with type A acute aortic dissection underwent aortic repair by our original leak-proof technique for dissected aortic wall reinforcement with xenopericardium and gelatin-resorcinol-formalin glue between 1997-2003. Four patients developed redissection of the anastomosis sites, which required reoperation, including the current case.

DISCUSSION

The cause of redissection was unclear, however, use of GRF glue itself might develop tissue damage and redissection of the aorta, and also glued xenopericardium strip reinforcement in our original technique might accelerate damage to the aortic wall.

CONCLUSION

Follow-up examination is mandatory for the patient of aortic repair with the use of GRF glue.

Pseudoaneurysm of the Hepatic Artery Following Liver Transplantation

We report 12 cases of pseudoaneurysm hepatic artery (PA) among 825 liver transplantations (OLT) performed between January 1985 and December 2005. In the early period (1985 to 1995), the incidence was 2.6% and in the later period (1996 to 2005), 0.9%. Median time to onset was 39.5 days post-OLT (range 14 days to 5 years). Six patients presented with rupture into the peritoneum (n = 4) or gastrointestinal tract (n = 2), while five patients presented with gastrointestinal bleed due arteriobiliary fistulation with hemobilia. The twelfth PA was found incidentally during retransplantation. PAs were detected with radiological imaging (n = 4), exploratory laparotomy (n = 6), at autopsy (n = 1) or at retransplantation (n = 1). We performed immediate revascularization, after surgical excision was performed in three and endovascular embolization in one patient. In six patients hepatic artery ligation without revascularization was inevitable with subsequent successful retransplantation in four patients. No PA-specific treatment was attempted in two cases due to the poor prognosis or diagnostic ambiguity. In 10 cases microbial pathogens were cultured in the blood, subhepatic abscesses, or from the wall of the hepatic artery. A hepaticojejunostomy was performed for biliary reconstruction in six patients and two had a hepaticojejunostomy conversion due to biliary leak. Survival in the early period (1985 to 1995) was 14%, whereas during the later period (1996 to 2005), the survival increased to 100% with a 4.2-year median follow-up (range 7.4 months to 6.9 years). Infrequently PA complicates OLT, becoming evident primarily after rupture with hemoperitoneum or a gastrointestinal bleed. Early recognition with angiography is important but acute hemorrhage often requires immediate exploration with ligation of the PA, although surgical or endovascular exclusion of the PA followed by revascularization provides a feasible treatment option.

Spontaneous false aneurysm of the gastroduodenal artery in a hemophilic patient ruptured into the duodenum: case report

Pseudoaneurysms of the splanchnic arteries are rare causes of gastrointestinal bleeding. We report a case of a spontaneous gastroduodenal artery false aneurysm ruptured into the duodenum in a patient with hemophilia. The diagnosis was confirmed by spiral computed tomography and magnetic resonance angiography. The patient died from massive gastrointestinal bleeding.

Femoral pseudoaneurysm due to diagnostic or interventional angiographic procedures

The authors investigated the incidence of, diagnostic methods for, and treatment strategies for iatrogenic femoral pseudoaneurysms in their hospital and compared the results with those in the literature. The hospital records of 25,273 patients who had coronary or peripheral angiography and angioplasty in Sani Konukoglu Medical Center from September 1997 to December 2002 were collected retrospectively. All the complications were detected and femoral pseudoaneurysm cases were selected. Diagnostic criteria and treatment strategy were documented. All results were compared with the literature. Femoral pseudoaneurysm was the second in number of complications and bleeding the first. Twenty-eight patients with pseudoaneurysm were diagnosed with color Doppler ultrasound (US) imaging (0.11%). Eleven of these closed spontaneously within 3-7 days. Image-guided compression therapy was applied to the remaining 17 and was effective in 10. The remaining 7 patients were operated on successfully. In this series the incidence of iatrogenic femoral pseudoaneurysm was comparable with the literature (0.02%-2%). Color Doppler US is the best diagnostic tool for this complication, and no other method was necessary. Eleven cases of spontaneous closure may show a rather benign prognosis, but close follow-up is advised. Image-guided compression is also an effective and noninvasive method of therapy for this complication. In late cases with a thick neck, surgery should be done immediately. It is easy to prevent rather than treat this complication. The similar incidence in the literature and in this series shows that a number of complications are to be expected, and so prompt and early diagnosis and effective treatment are very important. Application of good external compression after catheterization, selecting the thinnest introducer, use of B-mode and color Doppler US imaging for suspected cases, and image-guided compression therapy are also effective in early cases with a thin neck of the aneurysm.

Hemorrhage From Ruptured Hepatic Artery Pseudoaneurysm Co-occurring With Pancreatic Head Tumor and Portal Vein Thrombosis

We report a case of 50-year-old man with a hepatic artery pseudoaneurysm, pancreatic head tumor, and portal vein thrombosis. The patient was operated on due to acute bleeding into duodenum. The pancreatic tumor was unresectable, which is why the ruptured pseudoaneurysm was only sutured. The second therapeutic step was to protect the hepatic artery against rupture. Therefore, a stent graft and then a wall graft endoprosthesis were placed across the pseudoaneurysm neck. The final angiogram demonstrated total exclusion of the pseudoaneurysm with preservation of the arterial lumen.

Complicaciones vasculares de la pancreatitis

Vascular complications of pancreatitis are infrequent but important clinical problems because of their higher mortality. Pseudocysts that appear in 5%-50% patients with pancreatitis can erode adjacent vessels with hemorrhage, venous thrombosis and pseudoaneurysms. Increase in pressure within pseudoaneurysm can give rise to its rupture, that is the most serious complication of pancreatitis. Intracystic and intraperitoneal or retroperitoneal hemorrhage are the other arterial complications that can occur in the natural history of pancreatitis. Most frequent venous complications are splenic thrombosis, splenoportal thrombosis, and mesenteric thrombosis.

Successful coaxial double-vein graft for infrarenal aortic pseudoaneurysm due to Salmonella infection associated with hepatic resection for hepatocarcinoma

This is a case of aortic pseudoaneurysm due to Salmonella aortitis successfully treated by coaxial double-vein graft replacement (femoral vein and internal jugular vein) associated with hepatic resection for hepatocarcinoma. The aim of the technique is to improve the solidness of the vascular anastomosis and the tensile strength of the autologous vein graft, thus preventing long-term degeneration. Simultaneous hepatic resection did not affect clinical outcome. At 5-year follow-up, neither morphological alteration of the double-vein graft nor neoplastic relapse of the hepatocellular carcinoma was observed. This surgical technique could potentially improve long-term outcome and could therefore be considered a useful modification of the classic femoral vein graft for substitution of the septic infrarenal aorta when an extension to the iliac or femoral artery is not necessary.

Presentation and management of pseudoaneurysms of femoral artery

OBJECTIVE

This study reports our experience of presentation, diagnosis and management of femoral pseudoaneurysms (PSAs).

DESIGN

Descriptive study.

PLACE AND DURATION OF STUDY

This study was carried out at South Surgical Unit, Mayo Hospital, Lahore over a 3-year period from January 2001 to December 2003.

PATIENTS AND METHODS

Data was collected noting patient's demographic characteristics, etiology of aneurysms, modes of presentation, management and outcome.

RESULTS

Thirteen patients presented with femoral artery PSAs. All except 2 were young males. Nine patients had aneurysms following IV drug abuse. Three occurred following accidental trauma and one followed angiography access. Ten presented with overt external bleeding (leaking) while 3 had closed rupture. Two PSAs were initially mistaken as an abscess and incised resulting in sudden hemorrhage. All IV drug abusers (n=9) had initial proximal / distal ligation to stop bleeding. Five had no further symptoms of ischemia, one had mild claudication, one developed rest pain and had had extra-anatomical ileo-popliteal bypass through the obturator foramen. One further patient had crossover femoral grafting because of critical ischemia. Four non-infected cases were reconstructed using direct repair, 2 reversed vein grafts and one polytetrafluoroethylene (PTFE) graft respectively. One patient (11%) each had a major and a minor limb amputation respectively. One patient left against medical advice after proximal /distal ligation. There was no mortality. There was one documented instance of recurrent drug abuse of PTFE graft.

CONCLUSION

Femoral PSAs in our study was mostly due to IV drug abuse. All PSAs were either leaking or had frankly ruptured on presentation. If significant ischemia develops on ligation, bypass through the obturator foramen, placing the graft in depth away from recurrent abuse, is a useful option. These patients also need dedicated psychiatric rehabilitation to prevent further IV drug abuse.

Peripheral Pulmonary Artery Pseudoaneurysms and Massive Hemoptysis

OBJECTIVE

The aim of this study was to determine the incidence and etiology of pulmonary artery pseudoaneurysms in patients undergoing bronchial angiography for massive hemoptysis and to assess patient outcome after the embolization of these pseudoaneurysms.

CONCLUSION

Peripheral pulmonary artery pseudoaneurysms occur in up to 11% of patients undergoing bronchial angiography for hemoptysis. These are often most easily appreciated on bronchial and/or nonbronchial systemic arterial angiograms because of complete reversal of flow in pulmonary artery branches in the diseased lung. Embolization of bronchial and nonbronchial systemic arteries alone may not be sufficient therapy to control hemoptysis, and occlusion of the pseudoaneurysm itself via a pulmonary artery approach is recommended.

Pseudoaneurysm of the popliteal artery. Surgical management of 3 cases

Pseudoaneurysm of the popliteal artery is much less common than true aneurysm in this location. We report 3 cases of popliteal artery pseudoaneurysms, each of differing etiopathology, one presenting 3 months after trauma, one following aortic valve replacement for aortic regurgitation with suspected endocarditis, with no organism detected, and the 3rd of infective etiology. The clinical presentation and surgical management are discussed with a review of the literature.

[Arterial false aneurysm after total hip arthroplasty. A case report]

Vessel damage during implantation of a total hip arthroplasty is exceptional (0.2-0.3% incidence). We observed a case of false aneurysm of the common femoral artery diagnosed in a pauci-symptomatic patient seven months after total hip arthroplasty. The vessel was damaged by a fragment of cement in contact with the artery. Treatment consisted in extraction of the cement fragment and insertion of a vascular prosthesis after dissection and ligature of the pseudoaneurysm. A review of the literature of vascular complications after prosthetic hip surgery was undertaken. Early complications include acute bleeding or ischemia while late complications include pseudoaneurysm or arteriovenous fistulization. Predisposing factors are: infection, repeated contact between the implants and arterial walls, overly medial reaming of the acetabulum, intrapelvic cement spikes, and use of Hohmann retractor. We detail here the clinical signs, diagnostic approach, and natural course of arterial false aneurysm resulting from intra-pelvic cement leakage.

Pseudoaneurysm of the Dorsalis Pedis Artery Causing Neurological Deficit

Pseudoaneurysm of the dorsalis pedis artery is very rare. This case report describes a 71-year-old man with an idiopathic aneurysm of the dorsalis pedis artery that caused neurological deficit. Surgical resection was performed and his symptoms improved.