RNF213 c.14576G>A Is Associated with Intracranial Internal Carotid Artery Saccular Aneurysms

A mutation in RNF213 (c.14576G>A), a gene associated with moyamoya disease (>80%), plays a role in terminal internal carotid artery (ICA) stenosis (>15%) (ICS). Studies on RNF213 and cerebral aneurysms (AN), which did not focus on the site of origin or morphology, could not elucidate the relationship between the two. However, a report suggested a relationship between RNF213 and AN in French-Canadians. Here, we investigated the relationship between ICA saccular aneurysm (ICA-AN) and RNF213. We analyzed RNF213 expression in subjects with ICA-AN and atherosclerotic ICS. Cases with a family history of moyamoya disease were excluded. AN smaller than 4 mm were confirmed as AN only by surgical or angiographic findings. RNF213 was detected in 12.2% of patients with ICA-AN and 13.6% of patients with ICS; patients with ICA-AN and ICS had a similar risk of RNF213 mutation expression (odds ratio, 0.884; 95% confidence interval, 0.199-3.91; p = 0.871). The relationship between ICA-AN and RNF213 (c.14576G>A) was not correlated with the location of the ICA and bifurcation, presence of rupture, or multiplicity. When the etiology and location of AN were more restricted, the incidence of RNF213 mutations in ICA-AN was higher than that reported in previous studies. Our results suggest that strict maternal vessel selection and pathological selection of AN morphology may reveal an association between genetic mutations and ICA-AN development. The results of this study may form a basis for further research on systemic vascular diseases, in which the RNF213 (c.14576G>A) mutation has been implicated.

Poor runoff and distal coverage below the knee are associated with poor long-term outcomes following endovascular popliteal aneurysm repair

OBJECTIVE

Reports of good short-term outcomes for endovascular repair of popliteal artery aneurysms have led to an increased use of the technique. However, data are lacking on long-term limb-related outcomes and factors associated with the failure of endovascular repair.

METHODS

All patients who underwent endovascular popliteal aneurysm repair (EPAR) at a single institution from January 2006 to December 2018 were included in the study. Demographics, indications, anatomic and operative details, and outcomes were reviewed. Long-term patency, major adverse limb event-free survival (MALE-FS) and graft loss/occlusion were analyzed with multivariable cox regression analysis and Kaplan-Meier curves.

RESULTS

We included 117 limbs from 101 patients with a mean follow-up of 55.6 months (range, 0.43-158 months). The average age was 73 ± 9.3 years. Thirty-two patients (29.1%) were symptomatic (claudication, rest pain, tissue loss, or rupture). The stent grafts crossed the knee joint in 91.4% of cases. In all, 36.8% of procedures used one stent graft, 41.0% used two stent grafts, and 22.2% of procedures used more than two stent grafts. The median arterial length covered was 100 mm, with an average length of stent overlap of 25 mm. Tapered configurations were used in 43.8% of cases. The majority of limbs (62.8%) had a three-vessel runoff, 20.2% had a two-vessel runoff, and 17% has a one-vessel runoff. The Kaplan-Meier estimates of graft occlusion at 1 and 3 years were 6.3% and 16.2%, respectively. The 1- and 3-year primary patency rates were 88.2% and 72.6%, and the 1- and 3-year major adverse limb event-free survival (MALE-FS) rates were 82% and 57.4%. The 1- and 3-year survival rates were 92.9% and 76.2%, respectively. On multivariable Cox regression, aneurysm size, one-vessel runoff, and coverage below the knee were associated with a lower 3-year MALE-FS. Coverage below the knee was also associated with a lower 3-year MALE-FS. Other anatomic or technical details were not associated with limb-related events or patency.

CONCLUSIONS

This study is the largest single center analysis to describe the predictors of poor outcomes after EPAR. EPAR is a safe and effective way to treat popliteal artery aneurysms. Factors associated with poor MALE-FS after EPAR include single-vessel tibial runoff and coverage below the knee.

Aortic Aneurysms, Chronic Kidney Disease and Metalloproteinases

Metalloproteinases (MPs) are proteolytic enzymes involved in extracellular matrix deposition, regulation of cellular signals of inflammation, proliferation, and apoptosis. Metalloproteinases are classified into three families: Matrix-MPs (MMPs), A-Disintegrin-and-Metalloprotease (ADAMs), and the A-Disintegrin-and-Metalloproteinase-with-Thrombospondin-1-like-Domains (ADAMTS). Previous studies showed that MPs are involved in the development of aortic aneurysms (AA) and, concomitantly, in the onset of chronic kidney disease (CKD). CKD has been, per se, associated with an increased risk for AA. The aim of this review is to examine the pathways that may associate MPs with CKD and AA. Several MMPs, such as MMP-2, -8, -9, and TIMP-1 have been shown to damage the AA wall and to have a toxic effect on renal tubular cells, leading to fibrosis. Similarly, ADAM10 and 17 have been shown to degrade collagen in the AA wall and to worsen kidney function via pro-inflammatory stimuli, the impairment of the Renin-Angiotensin-Aldosterone System, and the degradation of structural proteins. Moreover, MMP-2 and -9 inhibitors reduced aneurysm growth and albuminuria in experimental and human studies. It would be important, in the future, to expand research on MPs from both a prognostic, namely, to refine risk stratification in CKD patients, and a predictive perspective, likely to improve prognosis in response to targeted treatments.

Hypothenar Hammer Syndrome with Ulnar Nerve Neuropathy

Hypothenar hammer syndrome is a rare medical condition that is usually associated with repetitive hand trauma. In this article, we delineate the importance of the nerve conduction velocity study to help determine objectively whether neuropathy is significant to the point that surgical means should be considered in absence of obvious ischemic change.

A review study on blood in human coronary artery: Numerical approach

Computational fluid dynamics (CFD) study of blood flow in human coronary artery is one of the emerging fields of Biomed- ical engineering. In present review paper, Finite Volume Method with governing equations and boundary conditions are briefly discussed for different coronary models. Many researchers have come up with astonishing results related to the various factors (blood viscosity, rate of blood flow, shear stress on the arterial wall, Reynolds number, etc.) affecting the hemodynamic of blood in the right/left coronary artery. The aim of this paper is to present an overview of all those work done by the researchers to justify their work related to factors which hampers proper functioning of heart and lead to Coronary Artery Disease (CAD). Governing equations like Navier-stokes equations, continuity equations etc. are widely used and are solved using CFD solver to get a clearer view of coronary artery blockage. Different boundary conditions and blood properties published in the last ten years are summarized in the tabulated form. This table will help new researchers to work on this area.

Left Ventricular Noncompaction with Multiple Thrombi in Apical Aneurysm

A 44-year-old man was admitted to our hospital due to heart failure. Transthoracic echocardiography demonstrated global hypokinesis with an ejection fraction of 25%, prominent trabeculation and deep intertrabecular recesses, and apical aneurysm with multiple thrombi (10×13 mm in the inferior wall, 15×8 mm in the anterior wall). Cardiac magnetic resonance imaging showed an increased ratio of noncompacted (NC) to compacted (C) myocardium (NC/C ratio >2.3) and apical aneurysm. Coronary angiography revealed no significant stenosis. He was therefore diagnosed with left ventricular noncompaction complicated by apical aneurysm. Four weeks after starting anticoagulation, the multiple apical thrombi disappeared without clinical signs of embolism.

Population-specific modelling of between/within-subject flow variability in the carotid arteries of the elderly

Computational fluid dynamics models are increasingly proposed for assisting the diagnosis and management of vascular diseases. Ideally, patient-specific flow measurements are used to impose flow boundary conditions. When patient-specific flow measurements are unavailable, mean values of flow measurements across small cohorts are used as normative values. In reality, both the between-subjects and within-subject flow variabilities are large. Consequently, neither one-shot flow measurements nor mean values across a cohort are truly indicative of the flow regime in a given person. We develop models for both the between-subjects and within-subject variability of internal carotid flow. A log-linear mixed effects model is combined with a Gaussian process to model the between-subjects flow variability, while a lumped parameter model of cerebral autoregulation is used to model the within-subject flow variability in response to heart rate and blood pressure changes. The model parameters are identified from carotid ultrasound measurements in a cohort of 103 elderly volunteers. We use the models to study intracranial aneurysm flow in 54 subjects under rest and exercise and conclude that OSI, a common wall shear-stress derived quantity in vascular CFD studies, may be too sensitive to flow fluctuations to be a reliable biomarker.

[Conservative aneurysmorrhaphy for hemodialysis arteriovenous fistula]

The aim of this study was to evaluate the results of conservative surgical treatment of the aneurysmal complications of arteriovenous hemodialysis fistulae and to determine the factors predictive of long- and mid-term patency of treated fistulae. The surgical treatment was mainly based on caliber reduction and reconstruction.

METHODS

This was a descriptive retrospective study with a five-year duration, going from January 2013 to December 2018. This study included 40 patients presenting aneurysmal complications of their hemodialysis vascular access who were treated with aneurysmorrhaphy.

RESULTS

The mean age of the aneurysmal-complicated hemodialysis vascular access was 42 months. The indications for treatment were puncture-related difficulties in 42.5% of cases, rapid increase of the aneurysmal diameter in 27.5%, skin thinning in 25% and aneurysmal rupture in 5%. The mean aneurysmal course was 6.6 months with an average diameter of 3.25cm at the moment of management. The initial technical success rate was 100%. Twenty patients had complications in the postoperative period. Patency rates at 3, 6, 12 and 24 months were 89.5%, 81.6%, 71% and 63.1%, respectively. Factors predictive of thrombosis were diabetes (P=0.001), peripheral arterial disease (P=0.003), number of punctures per week (P=0.003) and context of emergency presentation (P=0.001).

CONCLUSION

Aneurysmorrhaphy seems to be the best conservative surgical treatment for aneurysmal complications of hemodialysis vascular access fistulae. This surgical approach allows us to conserve the native autologous vascular access and spare the patient's venous network.

Endovascular stent repair of celiac arterial aneurysm

The aim of this study was to evaluate the safety and clinical effectiveness of endovascular stent repair of celiac arterial aneurysm (CAA).From January 2015 to December 2018, 11 patients (7 males, 4 females with a mean age of 52.2 ± 7.9 years) underwent endovascular stent repair of CAA in our center. A covered stent was used to occlude the CAA neck. Follow-up was performed 2 weeks and 1, 3, 6, and 12 months following surgery and yearly thereafter. Rates of technical success, treatment-related complications, and long-term outcome were analyzed.Each patient was placed with 1 stent for repair of CAA. Stent was placed in the celiac and common hepatic arteries for 10 patients and was placed in the celiac artery for 1 patient. The duration of the procedure ranged from 50 to 75 minutes (mean 63.2 ± 7.2 minutes). The rate of technical success of the endovascular stent repair was 100%. No patient experienced CAA rupture or instant endoleak during or after stent insertion. Abdominal pain was relieved progressively after stent insertion. All patients were followed-up for 6 to 48 months (mean 22.4 ± 10.8 months). All patients were alive during the follow-up. No endoleaks were experienced during follow-up with 100% stent patency rate. No patient suffered splenic, hepatic, or bowel infarction during follow-up.Endovascular stent repair is a safe, simple, and effective treatment for patients with CAA.

The Epidemiology, Pathophysiology, and Novel Treatment of Calcific Arterial Disease

Endovascular treatment of arterial diseases has become first-line in most cases due to improved technology. However, until recently, excessive atherosclerotic calcification has been a major limiting factor in the endovascular management of peripheral arterial disease, as well as vascular access for endovascular aneurysm repair (EVAR) and transcatheter aortic valve replacement (TAVR). The Peripheral Intravascular Lithotripsy (IVL) System (Shockwave Medical, Inc., Fremont California) applies pulsatile mechanical energy under fluoroscopic guidance to disrupt calcified lesions. The purpose of this paper is to introduce IVL in the treatment of calcific access vessels in preparation for EVAR and TAVR, as well as peripheral arterial disease applications to enhance luminal gain. Using the IVL System, angioplasty can be performed with lower pressures, which may minimize arterial dissection. Further, the lithotripsy effect on calcium will enhance vessel compliance. We describe several cases where IVL was applied successfully and present additional cases that may have benefitted from the use of this technology.

Hemodynamic Analysis to Assist Treatment Strategies in Complex Visceral Arterial Pathologies: Case Reports and discussion from Pancreaticoduodenal Artery Aneurysm with Superior Mesenteric Artery Occlusion

BACKGROUND

Pancreaticoduodenal artery aneurysms (PDAAs) with occlusion of the superior mesenteric artery (SMA) are extremely rare. In the present study, we used computational fluid dynamics (CFD) to analyze the hemodynamics of a patient-specific PDAA with occlusion of the SMA preoperatively and then decide the treatment strategy in terms of the potential postoperative hemodynamics.

METHODS

A 3D model of a 69-old-year female with PDAA was reconstructed based on CT images. The virtual postoperative models of the aneurysmectomy with or without revascularization were numerically simulated in terms of hemodynamics including the flow field and wall shear stress (WSS).

RESULTS

Aneurysmectomy with revascularization would result in the original aneurysm site experiencing abnormally high WSS and pressure, which may possibly lead to the recurrence of PDAA. However, aneurysmectomy without revascularization would lead to stagnant flow in the blocked posterior-inferior pancreaticoduodenal artery (PIPDA). As a result, the PIPDA may soon be completely occluded after surgery and the SMA perfusion would be guaranteed. Finally, aneurysmectomy without revascularization was performed in this patient. The postoperative six-month computed tomography angiography result finely matched to the preoperative CFD simulation result.

CONCLUSIONS

This study gained insights into hemodynamics of PDAA. In addition, it demonstrated that utilization of CFD analysis also possibly helps assist the operation strategies for vascular diseases.

Mathematical modelling of cardiac pulse wave reflections due to arterial irregularities

This research aims to model cardiac pulse wave reflections due to the presence of arterial irregularities such as bifurcations, stiff arteries, stenoses or aneurysms. When an arterial pressure wave encounters an irregularity, a backward reflected wave travels upstream in the artery and a forward wave is transmitted downstream. The same process occurs at each subsequent irregularity, leading to the generation of multiple waves. An iterative algorithm is developed and applied to pathological scenarios to predict the pressure waveform of the reflected wave due to the presence of successive arterial irregularities. For an isolated stenosis, analysing the reflected pressure waveform gives information on its severity. The presence of a bifurcation after a stenosis tends do diminish the amplitude of the reflected wave, as bifurcations' reflection coefficients are relatively small compared to the ones of stenoses or aneurysms. In the case of two stenoses in series, local extrema are observed in the reflected pressure waveform which appears to be a characteristic of stenoses in series along an individual artery. Finally, we model a progressive change in stiffness in the vessel's wall and observe that the less the gradient stiffness is important, the weaker is the reflected wave.

Popliteal Angiosarcoma after Bypass with Autologous Saphenous Vein

Angiosarcoma (AS) is a type of malignancy within sarcomas affecting soft tissue and bone. It presents a very heterogeneous distribution in the human body, and it can appear in multiple locations, from breast to liver or skin. The incidence of this type of tumor is low; however, it is aggressive and requires an early diagnosis to initiate the treatment as soon as possible. In the present article, we report the case of a male patient who was diagnosed with epithelioid AS of popliteal artery after an aneurysm popliteal surgery, as well as its treatment and evolution. This kind of tumors has controversial treatment and poor survival rates in the early years.

A bilharzial pulmonary artery aneurysm with a large calcified mural thrombus

Although very rarely encountered nowadays, bilharziasis should still be considered as one of the main causes of pulmonary artery aneurysms (PAA) and core-pulmonale in endemic areas. The ideal treatment of PAA remains uncertain because there is no clear consensus about the best therapeutic approach, due to limited experience because of the rarity of the disease. Still the management of pulmonary artery thrombus is only through proper anticoagulation and follow-up with a very limited role for surgery.

Hybrid approach with endovascular and open surgical techniques for challenging aneurysms

This study is a case series describing the management of complex aneurysmal disease using the principles of both open and endovascular techniques.

[Extracranial aneurysms of carotid arteries in the practice of a vascular surgeon]

The present study was aimed at retrospectively analysing the results of examination and open surgical treatment of patients diagnosed with extracranial aneurysms of carotid arteries.

PATIENTS AND METHODS

We analysed the results of examination and outcomes of surgical treatment in a total of 11 patients (6 men and 5 women) presenting with an aneurysm of the extracranial portion of the carotid artery and undergoing treatment at the Department of Vascular and CAD Surgery of the Moscow Regional Research Clinical Institute from 2005 to 2016. The mean age of the patients amounted to 56.5±13.9 years (ranging from 33 to 73 years). The diagnosis of an aneurysm was made based upon the findings of duplex scanning with colour mapping (DS+CM), four patients were additionally subjected to computed tomography (CT) and one to magnetic resonance tomography (MRT). 8 aneurysms turned out to be true aneurysms and 3 appeared to be pseudoaneurysms. 8 aneurysms were localized in the internal carotid artery (ICA) and 3 - in the common carotid artery (CCA).

RESULTS

Eight cases were treated by resection of the aneurysm followed by prosthetic repair (5 with an autovenous graft and 3 with a synthetic graft), a further two cases were managed by resection of the aneurysm and an 'end-to-end' anastomosis made, and in one case a false aneurysm was removed, with the arterial defect sutured. The check-up examinations were carried out at 2 and 6 months of the postoperative period. Neither lethal outcomes nor acute cerebral circulation impairments (ACCIs) were registered within the time frame the follow up period. Two patients were found to suffer from cranial nerve injury having disappeared during follow-up.

CONCLUSION

An open reconstructive operation is a safe and effective method of preventing complications of aneurysms of the extracranial portion of the carotid artery.

[Splenic artery aneurysm masked by postcholecystectomy syndrome]

Visceral artery aneurysms appear to belong to uncommon and potentially lethal vascular diseases. They are usually revealed accidentally during an ultrasonographic examination, magnetic resonance imaging, or computed tomography. Described in the article is a clinical case report concerning a sacciform aneurysm of the splenic artery, detected in a 53-year-old woman presenting with postcholecystectomy syndrome and followed up for abdominalgia by therapeutists and gastroenterologists. Timely performed radiodiagnosis (including multispiral computed tomography and angiography of the abdominal vessels) made it possible not only to detect the aneurysm, having thus verified the volumetric formation previously found on ultrasonographic examination, but to take adequate measures aimed at preventing rupture of the aneurysm and consisting in endovascular occlusion of the aneurysmatic cavity with metal spirals. Lack of complete clarity in the understanding of the mechanisms of the origin of and no distinctly defined therapeutic-and-diagnostic algorithm for visceral artery aneurysms dictate the necessity to continue collecting and generalizing clinical case reports regarding this rarely encountered vascular pathology.

Multiple aneurysms and gastrointestinal involvement in Behcet's disease: A case report

RATIONALE

Behcet's disease (BD) is a rare systemic vasculitis disorder that can involve vessels of any size.

PATIENT CONCERNS

A 60-year-old female had recurrent painful mouth ulcers about 30 years ago and recently presented with abdominal distension, conjunctival congestion, and chest pain in sequence.

DIAGNOSES

The patient was diagnosed with BD according to the International Criteria for Behcet's Disease (ICBD).

INTERVENTIONS

A therapy of glucocorticoids and cyclophosphamide was administered.

OUTCOMES

After a 3-month treatment, follow-up examination showed a depression of the inflammation and a slight decrease of the arterial aneurysms.

LESSONS

BD patients may get a delayed diagnosis because of the long duration between the first and subsequent manifestations. Suspect patients should be followed-up and the diagnosis of BD should be considered when multiple tissues or organs are involved.

The diagnosis and endovascular therapy of renal artery aneurysm: A 32-patient case report

RATIONALE

Renal aneurysm is a rare disease with the atypical symptoms and mostly diagnosed by imaging modalities. Endovascular therapy is a one of treatment methods.

PATIENT CONCERNS

A retrospective analysis of 32 patients with renal artery aneurysm, from June 2010 to May 2016 in our hospital, was made in our study. All of them underwent therapy, and the effects and perioperative characteristics of it were analyzed.

DIAGNOSIS

32 patients were taken contrast-enhanced CT and diuretic renal dynamic imaging to evaluate the state of illness.

INTERVENTIONS

The preoperative blood creatinine, perioperative hemoglobin and relief of hypertension were performed.

OUTCOMES

The preoperative blood creatinine was slightly increasing, while the perioperative hemoglobin was slightly decreasing. The relieving hypertension was performed in 9 of patients.

LESSONS

Endovascular therapy is a mature and feasible treatment method. There is little effect on hemoglobin and renal function in postoperation, while it can also decrease the blood pressure.

Handle With Care: A Ductus Arteriosus Aneurysm in an Elderly Patient

A ductus arteriosus aneurysm (DAA) was corrected with an 18 mm Amplatzer patent foramen ovale occluder. DAA is a rare finding, with sporadic cases reported (the vast majority in children and infants). In the elderly, it poses serious therapeutic challenges, as the risk of rupture is counterbalanced by the high risk of its correction, which requires surgery or placement of an endovascular prosthesis in a critical region such as the aortic arch.

The Management of Superior Mesenteric Artery Aneurysm: Experience with 16 Cases in a Single Center

BACKGROUND

Superior mesenteric artery aneurysm (SMAA) represents a rare but potentially fatal condition. This study aimed to present the individual management protocol of SMAA in our center and to discuss a potential preliminary treatment algorithm.

METHODS

SMAA patients treated in our center between January 2007 and December 2014 were retrospectively reviewed on January 2015.

RESULTS

Sixteen patients with SMAA were identified, including 1 female and 15 males, with a mean age of 48.9 ± 12.9 years. Three patients (3/16, 18.8%) were treated by multiple overlapping bare stents and one (1/16, 6.3%) initially by a single bare stent. Two cases (2/16, 12.5%) were treated by a covered stent implantation, but one of those suffered from SMAA rupture 7 days later, whereas the other had inner-stent thrombosis one month after discharge and died from multiple organ-dysfunction syndrome. Nine patients (9/16, 56.2%) received conservative therapy, one of who received multiple overlapping bare stents implantations for persistent abdominal pain. One patient underwent open surgery. There were 2 major complications, with no death during hospitalization and 1 death during follow-up.

CONCLUSIONS

SMAA treatment needs to be individually prescribed, based on clinical manifestation, anatomy, and etiology. Multiple overlapping bare stents are safe and effective in selective patients with SMAA, and covered stents should be used with caution to avoid covering proximal branches; open surgery should be reserved for patients with suspected intestinal necrosis.

Stent-Assisted Coil Embolization of a Symptomatic Renal Artery Aneurysm at a Bifurcation Point

BACKGROUND

Symptomatic renal artery aneurysms at bifurcation points present challenging clinical scenarios rarely amenable to endovascular repair due to concerns regarding parenchymal loss following intervention. Herein, we add to the scant body of literature describing successful endovascular repair of a saccular, symptomatic renal artery aneurysm situated at a bifurcation point.

METHODS

A 52-year-old woman with a 2.5-cm extraparenchymal, saccular, symptomatic left renal artery aneurysm underwent self-expanding stent-assisted detachable platinum microcoil embolization.

RESULTS

Complete aneurysm exclusion was achieved with minimal parenchymal loss. There were no perioperative complications, and no evidence of acute kidney injury perioperatively or at 3-month follow-up. Sustained symptomatic relief was achieved.

CONCLUSIONS

Endovascular therapy can provide safe and effective aneurysm treatment within challenging bifurcated renal artery anatomy.

[Aneurysm of the extracranial portion of the internal carotid artery combined with kinking of its distal segment]

Presented herein is a clinical case report regarding successful operation for an aneurysm of the left internal carotid artery (measuring 4.5*8.3 cm) combined with pathological tortuosity in its distal portion. The patient was subjected to aneurysmectomy of the left internal carotid artery with prosthetic repair. Kinking in the distal portion of the aneurysm made it possible with minimal technical difficulties to establish a distal anastomosis during prosthetic repair. The diagnosis of an atherosclerotic-aetiology aneurysm was morphologically confirmed.

[Aneurysm of the gastroduodenal artery in a female patient with the postcholecystectomy syndrome (a clinical case report)]

Aneurysms of visceral arteries appear to belong to rare and potentially lethal vascular diseases. The most important role in the aetiology of aneurysms of the gastroduodenal artery is plaid by either acute or chronic pancreatitis. The article deals with a clinical case report concerning a saccular partially thrombosed aneurysm having developed in a 77-year-old woman presenting with the postcholecystectomic syndrome and detected on ultrasonographic examination of the abdominal-cavity vessels. Timely radiodiagnosis (SCT angiography of abdominal cavity vessels), adequate and timely performed endovascular occlusion of the cavity of the aneurysm with metal spirals performed in a timely manner made it possible to attain a favourable outcome. Little is known regarding the understanding of the aetiology and lack of full clarity in therapeutic approaches to aneurysms of visceral arteries predetermine the necessity to continue collecting clinical case reports concerning this rarely encountered vascular pathology in order to generalize and work out an appropriate therapeutic-and-diagnostic algorithm.

[Aneurysmal lesions of the extracranial segment of the internal carotid artery]

The article contains a review of the literature devoted to the state-of-the-art data concerning management of patients presenting with an aneurysmal lesion of the extracranial segment of the internal carotid artery. This is followed by describing two clinical case reports regarding aneurysms of the extracranial segment of the internal carotid artery and the outcomes of endovascular treatment.

Endovascular Exclusion of Popliteal Artery Aneurysms With Expanded Polytetrafluoroethylene Stent-Grafts: Early Results

There is increasing interest in using endovascular methods instead of surgical reconstruction to treat popliteal artery aneurysms. Exclusive use of the Viabahn stentgraft, a nitinol stent covered with expanded polytetrafluoroethylene, was assessed in the treatment of patients who presented with popliteal artery aneurysms in the absence of acute limb ischemia. Technical success, endoleaks, graft patency, freedom from amputation, and aneurysm sac flow and size changes were assessed by duplex ultrasound. From June 2004 to March 2006, 16 men (mean age, 76 years; range, 65-83) underwent endovascular exclusion of 23 popliteal artery aneurysms (mean diameter, 2.5 cm; range, 1.3-6.7 cm). Nine lesions had partial thrombus on preprocedural duplex imaging. Nineteen of the 23 limbs treated had at least 2-vessel tibial artery runoff. Procedures were performed under local anesthesia using ipsilateral percutaneous antegrade arterial access. All patients received 75 mg/day of clopidogrel afterward. Follow-up assessments included direct clinical examinations and duplex ultrasonography performed 1, 3, 6, and 12 months after the procedure. Primary patency and amputation-free survival were calculated using Kaplan-Meier analysis. Complete aneurysm exclusion (technical success) was achieved in all cases. During the mean follow-up of 7 months (range, 1-21 months), 22 of 23 treated limbs remained asymptomatic. One stent-graft thrombosis occurred 6 months after the procedure and was successfully treated with percutaneous mechanical thrombectomy, balloon angioplasty of a stent-graft stenosis, and insertion of an uncovered nitinol stent. No popliteal artery aneurysm sac size enlargements or endoleaks were detected. At 12 months, the treated limb mean anklebrachial index was 1.0 (range, 0.82-1.31) and the primary and secondary patency rates were 93% and 100%, respectively. Early results with Viabahn endovascular stent-graft exclusion of asymptomatic popliteal artery aneurysms are promising. Patient selection for endovascular repair depends on suitable popliteal artery anatomy, extent of aneurysmal degeneration, and quality of tibial arterial runoff.

Magnetic Particle Imaging for High Temporal Resolution Assessment of Aneurysm Hemodynamics

Purpose

The purpose of this work was to demonstrate the capability of magnetic particle imaging (MPI) to assess the hemodynamics in a realistic 3D aneurysm model obtained by additive manufacturing. MPI was compared with magnetic resonance imaging (MRI) and dynamic digital subtraction angiography (DSA).

Materials and Methods

The aneurysm model was of saccular morphology (7 mm dome height, 5 mm cross-section, 3–4 mm neck, 3.5 mm parent artery diameter) and connected to a peristaltic pump delivering a physiological flow (250 mL/min) and pulsation rate (70/min). High-resolution (4 h long) 4D phase contrast flow quantification (4D pc-fq) MRI was used to directly assess the hemodynamics of the model. Dynamic MPI, MRI, and DSA were performed with contrast agent injections (3 mL volume in 3 s) through a proximally placed catheter.

Results and Discussion

4D pc-fq measurements showed distinct pulsatile flow velocities (20–80 cm/s) as well as lower flow velocities and a vortex inside the aneurysm. All three dynamic methods (MPI, MRI, and DSA) also showed a clear pulsation pattern as well as delayed contrast agent dynamics within the aneurysm, which is most likely caused by the vortex within the aneurysm. Due to the high temporal resolution of MPI and DSA, it was possible to track the contrast agent bolus through the model and to estimate the average flow velocity (about 60 cm/s), which is in accordance with the 4D pc-fq measurements.

Conclusions

The ionizing radiation free, 4D high resolution MPI method is a very promising tool for imaging and characterization of hemodynamics in human. It carries the possibility of overcoming certain disadvantages of other modalities like considerably lower temporal resolution of dynamic MRI and limited 2D characteristics of DSA. Furthermore, additive manufacturing is the key for translating powerful pre-clinical techniques into the clinic.

Optical Coherence Tomography Angiography of Diabetic Retinopathy in Human Subjects

BACKGROUND AND OBJECTIVE

Optical coherence tomography angiography (OCTA) is a novel, non-invasive OCT technique capable of imaging the retinal vasculature. This study aims to evaluate the retinal microvasculature in diabetic human subjects with OCTA and assess potential clinical applications.

PATIENTS AND METHODS

Cross-sectional study of 33 subjects with diabetic retinopathy. OCTA was performed on 3 mm × 3 mm sections using a swept-source OCTA prototype and a phase- and intensity-based contrasting algorithm. OCT angiograms were studied with corresponding clinical examination and fluorescein angiograms, when available, to assess accuracy and clinical utility.

RESULTS

OCTA was able to demonstrate most clinically relevant vascular changes in subjects with diabetic retinopathy, including microaneurysms, impaired vascular perfusion, some forms of intraretinal fluid, vascular loops, intraretinal microvascular abnormalities, neovascularization, and cotton-wool spots that were largely consistent with fluorescein angiography.

CONCLUSION

OCTA generates high-resolution angiograms that illustrate many of the clinically relevant findings in diabetic retinopathy and offers a novel complement or alternative to fluorescein angiography. Although currently an investigational technique, OCTA in combination with standard OCT imaging is at least as good as fluorescein angiography in the evaluation of the macular complications of diabetic retinopathy.

Lattice Boltzmann Model of 3D Multiphase Flow in Artery Bifurcation Aneurysm Problem

This paper simulates and predicts the laminar flow inside the 3D aneurysm geometry, since the hemodynamic situation in the blood vessels is difficult to determine and visualize using standard imaging techniques, for example, magnetic resonance imaging (MRI). Three different types of Lattice Boltzmann (LB) models are computed, namely, single relaxation time (SRT), multiple relaxation time (MRT), and regularized BGK models. The results obtained using these different versions of the LB-based code will then be validated with ANSYS FLUENT, a commercially available finite volume- (FV-) based CFD solver. The simulated flow profiles that include velocity, pressure, and wall shear stress (WSS) are then compared between the two solvers. The predicted outcomes show that all the LB models are comparable and in good agreement with the FVM solver for complex blood flow simulation. The findings also show minor differences in their WSS profiles. The performance of the parallel implementation for each solver is also included and discussed in this paper. In terms of parallelization, it was shown that LBM-based code performed better in terms of the computation time required.

Left Main Coronary Artery Stenting to Relieve Extrinsic Compression by a Giant Pulmonary Artery Aneurysm in a Patient with Idiopathic Pulmonary Artery Hypertension

Pulmonary artery aneurysm (PAA) is a rare but lethal disease. We present a female patient with idiopathic pulmonary artery hypertension (IPAH)-related PAA, who suffered from unstable angina pectoris. Multi-detector computed tomography and coronary angiogram revealed extrinsic compression of the left main coronary artery (LMCA) caused by a giant PAA with severe ostial stenosis. Intravascular ultrasound showed an oval-shaped ostium of the LMCA, indicating extrinsic compression. After successful LMCA stent implantation, chest pain was greatly relieved. This case illustrates that beyond right ventricle ischaemia and coronary atherosclerotic disease, LMCA compression by PAA should be considered in the differential diagnosis of angina in patients with IPAH related PAA. In addition, intravascular ultrasound can be used to confirm the diagnosis and guide the stent implantation safely.

[A Case of Left Vertebral Artery Aneurysm Showing Evoked Potentials on Bilateral Electrode by the Left Vagus Nerve Stimulation to Electromyographic Tracheal Tube]

Previously, we reported a case of brainstem cavernous hemangioma showing false positive responses to electromyographic tracheal tube (EMG tube). We concluded that the cause was spontaneous respiration accompanied by vocal cord movement. We report a case of left vertebral artery aneurysm showing evoked potentials on bilateral electrodes by the left vagus nerve stimulation to EMG tube. An 82-year-old woman underwent clipping of a left unruptured vertebral artery-posterior inferior cerebellar artery aneurysm. General anesthesia was induced with remifentanil, propofol and suxamethonium, and was maintained with oxygen, air, remifentanil and propofol. We monitored somatosensory evoked potentials, motor evoked potentials, and electromyogram of the vocal cord. When the manipulation reached brainstem and the instrument touched the left vagus nerve, evoked potentials appeared on bilateral electrodes. EMG tube is equipped with two electrodes on both sides. We concluded that the left vagus nerve stimulation generated evoked potentials of the left laryngeal muscles, and they were simultaneously detected as potential difference between two electrodes on both sides. EMG tube is used to identify the vagus nerve. However, it is necessary to bear in mind that each vagus nerve stimulation inevitably generates evoked potentials on bilateral electrodes.

[Surgical treatment of distal extracranial internal carotid artery aneurysms associated with pathological artery kinking]

Extracranial internal carotid artery (ICA) aneurysms located at the entrance of the skull are a rare pathology. Surgical treatment is indicated for this pathology because of the risk of arterio-arterial embolism and the development of cerebrovascular disease. The domestic and international literature reports single cases or small group cases of successful surgical treatment of patients with distal internal carotid artery aneurysms associated with pathological kinking of the artery. Open surgery for aneurysms of this localization is complicated because of a high injury risk associated with the approach. Endovascular interventions are not always possible due to the presence of degenerative changes in the vascular wall and pathological artery kinking. We propose a surgical option for creating a high-flow ec-ic bypass between the external carotid artery and the M2 segment of the middle cerebral artery. The article describes the results of successful application of this technique in three patients with distal extracranial internal carotid artery aneurysms associated with pathological kinking of the artery.

Occlusion-free Blood Flow Animation with Wall Thickness Visualization

We present the first visualization tool that combines pathlines from blood flow and wall thickness information. Our method uses illustrative techniques to provide occlusion-free visualization of the flow. We thus offer medical researchers an effective visual analysis tool for aneurysm treatment risk assessment. Such aneurysms bear a high risk of rupture and significant treatment-related risks. Therefore, to get a fully informed decision it is essential to both investigate the vessel morphology and the hemodynamic data. Ongoing research emphasizes the importance of analyzing the wall thickness in risk assessment. Our combination of blood flow visualization and wall thickness representation is a significant improvement for the exploration and analysis of aneurysms. As all presented information is spatially intertwined, occlusion problems occur. We solve these occlusion problems by dynamic cutaway surfaces. We combine this approach with a glyph-based blood flow representation and a visual mapping of wall thickness onto the vessel surface. We developed a GPU-based implementation of our visualizations which facilitates wall thickness analysis through real-time rendering and flexible interactive data exploration mechanisms. We designed our techniques in collaboration with domain experts, and we provide details about the evaluation of the technique and tool.

[Use of an iliac branched endoprostheis in endovascular treatment for an abdominal aortic aneurysm combined with aneurysms of both common iliac arteries]

An abdominal aortic aneurysm appears to be combined with aneurysmatic lesions of the common iliac arteries in 30-40% of cases. Like abdominal aortic aneurysms, aneurysms of the common iliac arteries rarely manifest themselves clinically. The lethality rate in case of rupture is comparable to that for rupture of an abdominal aortic aneurysm. During endoprosthetic repair of abdominal aortic aneurysms combined with aneurysms of the common iliac arteries, in order to prevent endoleaks and to improve the distal zone of fixation of endografts surgeons often resort to embolization of internal iliac arteries, which may lead to ischaemic postoperative complications. One of the methods of preserving pelvic blood flow is the use of an iliac branched endograft. A series of studies evaluating long-term outcomes demonstrated that this method proved to be both safe and effective, and with the suitable anatomy is a method of choice in high surgical risk patients. The present article deals with a clinical case report concerning bilateral endoprosthetic repair of the common iliac arteries, combined with endoprosthetic repair of an abdominal aortic aneurysm, with the description of technical peculiarities of implanting an iliac branched graft.

Endovascular Embolization of a Large High-Flow Splenic Arteriovenous Fistula and Aneurysm Using the Amplatzer Vascular Plug II

We describe the use of an Amplatzer Vascular Plug (AVP) II for embolizing a large high-flow splenic arteriovenous fistula and an aneurysm in a young patient. This patient presented to our center with persistent mild abdominal discomfort, 5 years after open splenectomy. Contrast-enhanced computed tomography angiography showed the presence of a fistula between the splenic arterial and splenic venous remnants and a resultant fusiform aneurysmal dilatation of the residual splenic vein. We decide to embolize the splenic artery with a 12-mm diameter AVP II with an oversizing by 70% of the vessel diameter. Celiac angiography performed 5 min postembolization revealed complete obliteration of the splenic artery and closure of the arteriovenous fistula. The overall procedure time was 40 min, and overall radiation exposure was 32 Gy cm(2) (dose-area product).

Macular Cavernous Hemangioma Associated With Peripheral Vascular Anomalies and Nonperfusion

Retinal cavernous hemangiomas are benign vascular anomalies that are typically unilateral and located outside of the macula. Fluorescein angiography findings include an early slow-filling, non-leaking lesion with late intermixed lobules of hyperfluorescence and hypofluoresence secondary to plasma and erythrocyte sedimentation. We present a novel case of unilateral macular cavernous hemangioma with bilateral peripheral vascular anomalies and nonperfusion. This may represent a phenotypic variation of hemangiomas that, in conjunction with recent histopathologic and genetic findings, may aid in future therapies for a disease that has been traditionally observed due to slow progression.

Management of Giant Splenic Artery Aneurysm: Comprehensive Literature Review

To provide an overview of the medical literature on giant splenic artery aneurysm (SAA).The PubMed, Medline, Google Scholar, and Google databases were searched using keywords to identify articles related to SAA. Keywords used were splenic artery aneurysm, giant splenic artery aneuryms, huge splenic artery aneurysm, splenic artery aneurysm rupture, and visceral artery aneurysm. SAAs with a diameter ≥5 cm are considered as giant and included in this study. The language of the publication was not a limitation criterion, and publications dated before January 15, 2015 were considered.The literature review included 69 papers (62 fulltext, 6 abstract, 1 nonavailable) on giant SAA. A sum of 78 patients (50 males, 28 females) involved in the study with an age range of 27-87 years (mean ± SD: 55.8 ± 14.0 years). Age range for male was 30-87 (mean ± SD: 57.5 ± 12.0 years) and for female was 27-84 (mean ± SD: 52.7 ± 16.6 years). Most frequent predisposing factors were acute or chronic pancreatitis, atherosclerosis, hypertension, and cirrhosis. Aneurysm dimensions were obtained for 77 patients with a range of 50-300 mm (mean ± SD: 97.1 ± 46.0 mm). Aneurysm dimension range for females was 50-210 mm (mean ± SD: 97.5 ± 40.2 mm) and for males was 50-300 mm (mean ± SD: 96.9 ± 48.9 mm). Intraperitoneal/retroperitoneal rupture was present in 15, among which with a lesion dimension range of 50-180 mm (mean ± SD; 100 ± 49.3 mm) which was range of 50-300 mm (mean ± SD: 96.3 ± 45.2 mm) in cases without rupture. Mortality for rupture patients was 33.3%. Other frequent complications were gastrosplenic fistula (n = 3), colosplenic fistula (n = 1), pancreatic fistula (n = 1), splenic arteriovenous fistula (n = 3), and portosplenic fistula (n = 1). Eight of the patients died in early postoperative period while 67 survived. Survival status of the remaining 3 patients is unclear. Range of follow-up period for the surviving patients varies from 3 weeks to 42 months.Either rupture or fistulization into hollow organs risk increase in compliance with aneurysm diameter. Mortality is significantly high in rupture cases. Patients with an evident risk should undergo either surgical or interventional radiological treatment without delay.

[When the tissue tolerance fiber tears]

We report a 65 year old patient who presented with both an aneurysm of the axillary artery and, some years later, with an acute aortic dissection type Stanford A. After surgical intervention of the dissection in the further workup, no specific etiology could be found. The most likely reason for the two aneurysms was the inadequately treated hypertension. Therefore, follow-up strategies aim to treat the risk factors which are known to promote aneurysm growth.

Dolichoectasia and the risk of stroke and vascular disease: a critical appraisal

Dolichoectasia (DE) in cerebral arteries is a poorly understood arteriopathy that has been associated with increased risk of vascular morbidity and mortality. Dolichoectasia tends to affects older individuals with vascular risk factors, but it can also be secondary to specific conditions related with extracellular matrix health. The range of methods used to study DE and the biases inherent to hospital-based samples weaken the generalizability of DE study results to the general population. Within the context of these limitations, there is growing evidence that DE is a serious condition that can increase the risk of vascular death. Recurrent strokes and compressive symptoms are among the major causes of morbidity, but cardiac ischemic disease and aortic aneurysms are not uncommon in populations with DE. The devastating outcomes of patients with DE are a call to action aimed at improving the quality of research on the topic and discovering therapies that can palliate the burden of DE in the population.

Portal vein aneurysm associated with Budd-Chiari syndrome treated with transjugular intrahepatic portosystemic shunt: A case report

A 65-year-old woman with Budd-Chiari syndrome (BCS) presented with right upper quadrant pain. A computed tomography (CT) scan showed a saccular aneurysm located at the extrahepatic portal vein main branch measuring 3.2 cm in height and 2.5 cm × 2.4 cm in diameter. The aneurysm was thought to be associated with BCS as there was no preceding history of trauma and it had not been present on Doppler ultrasound examination performed 3 years previously. Because of increasing pain and concern for complications due to aneurysm size, the decision was made to relieve the hepatic venous outflow obstruction. Transjugular intrahepatic portosystemic shunt (TIPS) was created without complications. She had complete resolution of her abdominal pain within 2 d and remained asymptomatic after 1 year of follow-up. CT scans obtained after TIPS showed that the aneurysm had decreased in size to 2.4 cm in height and 2.0 cm × 1.9 cm in diameter at 3 mo, and had further decreased to 1.9 cm in height and 1.6 cm × 1.5 cm in diameter at 1 year.

[Surgical treatment of an aneurysm of the upper mesenteric artery]

Presented herein is a clinical case report concerning successful surgical treatment of an aneurysm of the upper superior mesenteric artery. Diagnosis included contrast-enhanced multispiral computed tomography. Thought the middle laparotomy we exposed an aneurysm of the superior mesenteric artery measuring 3 mm in diameter. A peculiarity of the aneurysm was that it was tightly adhered to the body of the pancreas and had a "neck" with pronounced signs of infiltration, with the latter extending to the right lateral and upper wall of the aneurysm. The aneurysm was resected along its "neck" which made it possible to suture the defect without residual stenosis and with no use of a synthetic patch. The woman was discharged on day 8 postoperatively in a satisfactory condition. Based on the morphological examination of the micropreparation the following diagnosis was made: fibromuscular dysplasia, aneurysm of the superior mesenteric artery.

Comparative efficacy of pure yellow (577-nm) and 810-nm subthreshold micropulse laser photocoagulation combined with yellow (561-577-nm) direct photocoagulation for diabetic macular edema

PURPOSE

To compare the efficacy of 577- and 810-nm subthreshold micropulse laser photocoagulation (SMLP) combined with direct photocoagulation to microaneurysms in diabetic macular edema (DME).

METHODS

A prospective nonrandomized interventional case series. Forty-nine consecutive patients (53 eyes) with DME were recruited. In 20/24 (83.3%) eyes, 810-nm SMLP (810-nm MP) to achieve a confluent grid pattern was followed by direct photocoagulation to microaneurysms via a continuous 561-nm wavelength laser. In 21/29 (72.5%) eyes, 577-nm SMLP (577-nm MP) was combined with direct photocoagulation to microaneurysms via the same instrument. Best-corrected visual acuity (BCVA) and central macular thickness (CMT) were examined 1, 2, 3, 6 and 12 months after treatment.

RESULTS

The mean power required for SMLP was lower in the 577-nm than in the 810-nm MP group (204.1 vs. 954.1 mW) (p < 0.0001). Significant reductions in CMT persisted from 3 to 12 months after treatment in all patients (p < 0.01). There were no significant intergroup differences in CMT until 12 months. In both groups, mean BCVA remained stable until 12 months after treatment. Additional treatment for persistent macular edema was performed within 12 months in 4/24 eyes (16.7%) in the 810-nm MP group and 1/29 eyes (3.4%) in the 577-nm MP group.

CONCLUSION

Either 577-nm MP or 810-nm MP combined with direct photocoagulation for microaneurysm closure reduced DME, maintained visual acuity and reduced the additional treatment rate within 12 months. The 577-nm MP apparatus required less energy for SMLP than the 810-nm MP instrument and was suitable for direct photocoagulation of microaneurysms.

Splenic artery aneurysm presenting with abdominal discomfort and weight loss

Splenic artery aneurysm (SAA) is uncommon, but it is the most frequent visceral artery aneurysm. It is more common in women, especially during pregnancy. SAA is usually asymptomatic, but abdominal pain and rupture may develop. At present, computerized tomography (CT) angiogram is the best diagnostic test but not the only. Surgical or endovascular treatment may be considered both in symptomatic or asymptomatic aneurysms greater then 2 cm in diameter. We present the case of an elderly woman with an SAA and review the literature.

Surgical treatment of giant aneurysm of hepatic artery: report of three cases

BACKGROUND/AIMS

To explore the surgical way of treating giant hepatic artery aneurysm(HAA).

METHODOLOGY

Three hepatic artery aneurysm patients who were performed aneurysm resection without revascularization of the hepatic artery were reviewed. After surgery, the values of liver function and enhanced CT scan of the patients were followed.

RESULTS

All the three patients were recovered well postoperatively and only several values of biochemistry marks of liver function as ALT, AST, TBIL and DB in one case with liver cirrhosis were elevated and decreased to normal ranges in a few days postoperatively. The values of biochemistry marks of liver function in other two cases were within normal limits. The enhanced CT scan also showed arteries in the liver after hepatic artery aneurysm resection.

CONCLUSIONS

Giant HAA may be safely removed without revascularization of the hepatic artery.

CT angiography to evaluate hemodynamic changes in popliteal artery aneurysms during flexion and extension of the knee joint

AIM

The aim of this study was to find out which characteristics of an asymptomatic popliteal artery aneurysm (PAA) will increase the risk for acute thrombosis.

METHODS

This was a single-center prospective study of consecutive patients with asymptomatic PAAs presenting from January 2010 to April 2012. Computed tomography angiography was used to perform measurements of the PAA during 0º extension and 90º flexion of the knee. After semi-automated segmentation of the popliteal artery (PA) lumen, a center lumen line (CLL) was automatically constructed.

RESULTS

The study included 16 asymptomatic PAAs. Median lumen area of the PA was directly proximal and distal of the PAA 57 mm2 (IQR, 44-87 mm2) and 46 mm2 (IQR, 32-66 mm2) in extension vs. 51 mm2 (IQR, 38-73 mm2) and 38 mm2 (IQR, 30-62 mm2) during 90º flexion, respectively (P=0.007) and (P=0.03). The median of the greatest decrease in lumen area after flexion and extension of the knee was 36 mm (IQR, 28-48 mm) in PAAs≥30 mm compared with 11 mm (IQR, 4-18 mm) in PAAs<30 mm (P<0.05). The proximal angulation was a median 48° in extension (IQR, 27-61º) and 75° during flexion (IQR, 46-99º; P=0.02). Distal angulation was a median of 31° (IQR, 21-42º) after extension vs. 62° (IQR, 33-81º) during flexion (P=0.03).

CONCLUSION

Knee bending in patients with PAAs will lead to a reduction in the lumen area of the PAA and a change in the degree of angulation of the PAA. A significant decrease in lumen area was seen in PAAs≥30 mm compared with PAAs<30 mm after flexion of the knee.