Saccular aneurysm induction by elastase digestion of the arterial wall: a new animal model

OBJECTIVE: To develop a rabbit aneurysm model that is more realistic in gross appearance and histological features than previous models and to enable the development of a larger animal model. METHODS: Ten rabbits received porcine pancreatic elastase, five at the right common carotid artery bifurcation and five others at the right superior thyroid artery origin. One control animal received collagenase and another received papaverine, each at the right superior thyroid artery origin. The agents were topically delivered to the arterial adventitia with a microsyringe after surgical exposure of the targeted arteries. The arteries were monitored for aneurysm growth with a video camera for up to 3 hours and were then removed and processed for histology. RESULTS: Saccular aneurysms developed in one of five animals after elastase application at the carotid bifurcation and in all five animals receiving elastase at the superior thyroid artery origin. Among the six aneurysms, recurrent minor hemorrhages occurred in four, thrombosis of the aneurysm sac in three, and rupture causing severe bleeding in one. Histological sections revealed thin-walled aneurysms composed only of collagen fibers and some cellular elements. No saccular dilation resulted from papaverine application. Collagenase application resulted in a hemorrhagic-thrombotic lesion in the arterial wall but no aneurysm formation. CONCLUSION: Arterial saccular aneurysms were induced in rabbits by topical application of elastase with an easy and efficient method. These aneurysms are histologically similar to natural aneurysms, and their arterial nature renders them more authentic than those of surgical models. This aneurysm model may serve as a foundation for further aneurysm research.     

Endovascular repair of peripheral aneurysms, pseudoaneurysms, and arteriovenous fistulas

Endovascular repair of peripheral arterial lesions was performed in 10 patients including two iliac aneurysms, two iliac anastomotic pseudoaneurysms, one subclavian pseudoaneurysm, one axillary anastomotic disruption, two prosthetic pseudoaneurysms, and two posttraumatic arteriovenous (AV) fistulas. The indications for repair were aneurysm size in five cases, massive hematoma in one, threatened prosthetic dialysis graft in two, venous hypertension with non-healing ulcer in one, and arm pain in one. Vascular access was obtained through surgical cutdown in all cases, via the femoral artery in five patients, the proximal brachial artery in three and a prosthetic graft in two. Stented prosthetic grafts were used in five cases (1 polyester and polytetrafluoroethylene 4 [PTFE]), and PTFE-covered stents in five cases. Concomitant procedures were done in four patients including two open repairs of a common femoral artery aneurysm, a transluminal dilatation of a proximal aortic anastomotic stenosis, and an iliac artery transluminal angioplasty. Eight of 10 cases were technically successful. Completion arteriography revealed complete exclusion of all lesions, except for one minimal proximal stented graft leak in a pseudoaneurysm, and an incomplete obliteration of an AV fistula. No complications occurred. Operative time ranged from 45 min to 5 hours. Postoperative hospital stay was 1 day in five patients, 2 days in three patients, and 4 days in two patients. Follow-up contrast CT scan, arteriography, or duplex scanning demonstrated complete exclusion of all lesions except an AV fistula, and decrease in size in three aneurysms. The proximal leak initially present in a stented graft resolved. All grafts and covered stents remained patent at 2-19 months of followup. Endovascular exclusion of peripheral arterial aneurysms, pseudoaneurysms, and AV fistulas can be done with a high degree of technical success, low morbidity, and short hospital stay. Short-term follow up is encouraging, however, long term follow up of these procedures is warranted to assess durability of the repair and absence of complications.     

Arteriography using helicoidal computerized tomography in the study of complex aneurysms of the circle of Willis

INTRODUCTION: Computed tomography angiography (CTA) can add information to digital subtraction angiography (DSA) in selected cases of aneurysms of the circle of Willis. CLINICAL CASES: 1. Patient with progressive visual loss and headache. CT and DSA showed an image of partially thrombosed suprasellar aneurysm. CTA better defined the relationship between the lesion and regional vessels. 2. Woman with subarachnoid hemorrhage (SAH). CTA defined the aneurysmal neck and its relationship to the clinoid process. 3. Man with SAH, CT and DSA showed an arteriovenous malformation and three arterial aneurysms one of which was in a tortuous vessel. CTA confirmed digital angiographic data. CONCLUSION: CTA is a new image technique that can either add or confirm DSA findings in complex aneurysms of the circle of Willis.     

Effect of GF120918, a potent P-glycoprotein inhibitor, on morphine pharmacokinetics and pharmacodynamics in the rat

PURPOSE: Studies have shown that 11% to 18% of patients with an abdominal aortic aneurysm (AAA) have a first-degree relative with an AAA. A familial pattern among patients with peripheral arterial aneurysms and arteriomegaly has not been reported. The objective of this study was to examine familial patterns among patients with peripheral arterial aneurysm and arteriomegaly and compare them with patterns among patients with AAA. METHODS: Pedigrees were constructed for first-degree relatives of patients who received the diagnosis of peripheral arterial aneurysm, arteriomegaly, or AAA from 1988 through 1996. The presence of aneurysms and risk factors was confirmed for patients and relatives by means of telephone interviews and review of hospital and physician records. RESULTS: Seven hundred three first-degree relatives older than 50 years were contacted for 140 probands with peripheral arterial aneurysm, AAA, or arteriomegaly. There were differences in risk factors for hernia and diabetes mellitus among the probands with peripheral arterial aneurysm, AAA, or arteriomegaly but none for relatives. Patients with peripheral arterial aneurysm (n = 40) had a 10% (4/40) familial incidence rate of an aneurysm, patients with AAA (n = 86) had a 22% (19/86) familial incidence rate, and patients with arteriomegaly (n = 14) had a 36% (5/14) familial incidence rate. AAA (24/28, or 86%) was the aneurysm diagnosed most commonly among first-degree relatives. Most aneurysms (85%) occurred among men. CONCLUSION: There appears to be a gradation of familial patterns from peripheral arterial aneurysm to AAA to arteriomegaly among patients with degenerative aneurysmal disease, and there appears to be a predominance among men. Relatives of patients with any of the 3 lesions-peripheral arterial aneurysm, AAA, arteriomegaly--most frequently have AAA. Relatives of patients with AAA, peripheral arterial aneurysm, or arteriomegaly may be screened by means of a physical examination for peripheral aneurysmal disease. Screening by means of ultrasound examination of the aorta should be limited to first-degree relatives of patients with aortic aneurysms or arteriomegaly.     

Rupture during treatment of recently ruptured aneurysms with Guglielmi electrodetachable coils

BACKGROUND AND PURPOSE: We describe four cases of aneurysmal rupture during embolization with Guglielmi electrodetachable coils (GDCs) in an attempt to identify those aneurysms whose rupture during embolization represents a life-threatening risk; our emphasis is on emergency management, in particular, ventriculostomy. METHODS: Medical records were reviewed retrospectively for 91 aneurysms treated with GDCs 0 to 21 days after subarachnoid hemorrhage. Rupture was ascertained by the presence of extravascular effusion of contrast medium. RESULTS: Of the perforated aneurysms, two involved the anterior communicating artery, one the posterior inferior communicating artery, and one the basilar artery. Only two patients, whose aneurysms were located in the posterior fossa, had major complications (arterial hyperpressure, mydriasis, angiographically documented circulatory arrest or slowing). One of these patients died and the other improved after emergency ventriculostomy. CONCLUSION: Aneurysmal perforation during embolization may be accompanied by severe intracranial hypertension, which causes either a decrease or arrest of cerebral perfusion, the duration of which determines clinical outcome. Emergency ventriculostomy (which should be performed in the angiographic suite) is an effective means to reduce intracranial pressure. Recognition of aneurysms associated with a high risk of mortality by rupture in the course of embolization (recently ruptured small aneurysms, posterior fossa aneurysms, associated ventricular dilatation, massive cisternal hemorrhage) and use of proper logistics should ensure the effective management of this devastating complication.     

Experience with computed tomographic angiography for the detection of intracranial aneurysms in the setting of acute subarachnoid hemorrhage

OBJECTIVE: To objectively compare computed tomographic angiography (CTA) with selective digital subtraction angiography (DSA) in the detection and anatomic definition of intracranial aneurysms, particularly in the setting of acute subarachnoid hemorrhage (SAH). METHODS: In a blinded prospective study, 40 patients with known or suspected intracranial saccular aneurysms underwent both CTA and DSA, including 32 consecutive patients with SAH in whom CTA was performed after CT images were obtained diagnostic for SAH. The CT angiograms were interpreted for presence, location, and size of the aneurysms, and anatomic features, such as the number of aneurysms lobes, aneurysm neck size (< or = 4 mm), and the number of adjacent arterial branches were suggested. The images obtained with CTA were then compared with the images obtained with DSA, with the later images serving as controls. RESULTS: DSA revealed 43 aneurysms in 30 patients and ruled out intracranial aneurysms in the remaining 10 patients. For aneurysm presence alone, the sensitivity and specificity for CTA was 86 and 90%, respectively. For the presence of an aneurysms, six CT angiogram showed false negative results and one CT angiogram showed a false positive result. False negative results were usually caused by technical problems with the image, tiny aneurysm domes (< 3 mm), and unusual aneurysm locations (i.e., intracavernous carotid or posterior inferior cerebellar artery aneurysms). The results obtained with CTA were, compared with the results obtained with DSA, more than 95% accurate in determining dome and neck size of aneurysm, aneurysm lobularity, and the presence and number of adjacent arterial branches. In addition, CTA provided a three-dimensional representation of the aneurysmal lesion, which was considered useful for surgical planning. CONCLUSION: CTA is useful for rapid and relatively noninvasive detection of aneurysms in common locations, and the anatomic information provided in images showing positive results is at least equivalent to that provided by DSA. In cases of SAH in which the nonaugmented CT and CTA results indicate a clear source of bleeding and provide adequate anatomic detail, we think it is possible to forego DSA before urgent early aneurysm surgery. In all other cases, DSA is indicated.     

Multiple aneurysms of the visceral arteries with migrating vascular bruit on postural change: a case report

Multiple aneurysms of the gastroepiploic artery and the ileocecal branch of the superior mesenteric artery were found in a 68-year-old male patient by angiography. The patient presented with one-hour postprandial epigastric pain of 10 years duration. Abdominal bruit was auscultated at the two different sites, one of which shifted downwards upon upright position. From the freely movable nature of the great omentum, this bruit, migrating upon postural change, was most likely from the gastroepiploic artery aneurysms. The aneurysms were excised and the abdominal bruit disappeared. The etiology of the aneurysms was suggested to be arterial fibrodysplasia histologically. From this experience, it was stressed that postural change should be added to a routine physical examination to rule out an aneurysm from the freely movable great omentum.     

Retinal arteriovenous shunt at the arteriovenous crossing

OBJECTIVE: The purpose of the study was to demonstrate that the arteriovenous shunt at the arteriovenous crossing could occur in major retinal vascular diseases other than Takayasu disease. DESIGN: Clinical review of consecutive case series. PARTICIPANTS: The authors studied 1885 eyes with retinal vascular diseases such as diabetic retinopathy, branch retinal vein occlusion, central retinal vein occlusion, central retinal artery occlusion, Leber's miliary aneurysms, Eales disease, Beh?et disease, and systemic lupus erythematosus retinopathy. INTERVENTION: Fluorescein fundus angiography using a wide-field fundus camera (60 degrees) was performed. MAIN OUTCOME MEASURES: Dye transit from artery to vein through sequential angiography. RESULTS: The arteriovenous shunt at the arteriovenous crossing was found in 8 eyes with proliferative diabetic retinopathy, 27 eyes with branch retinal vein occlusion in the chronic stage, 2 eyes with central retinal vein occlusion, 2 eyes with central retinal artery occlusion, and 2 eyes with miliary aneurysms. The arteriovenous shunt was formed by a direct inflow from artery to vein, showing vasodilation and hyperpermeability, followed by obliteration peripheral to the shunts. The pattern of initial inflow was classified into axial flow and laminar flow, and the inflow became wider and more rapid in the advanced stage. CONCLUSIONS: These findings indicate that the arteriovenous shunt at the arteriovenous crossing is not a unique phenomenon in Takayasu disease but rather is a basic pattern of retinal vascular reaction pathologic states.     

Vascular "remodeling"

Vascular remodeling means a specific organization of the vascular wall around a diminished lumen as to the before existing conditions, with consequent vascular geometry modification. This organization comes from the response of all vascular components (endothelium, muscular cells, connective component, etc.) to physical and chemical stimuli. Particular behaviour of the vascular wall has lately been pointed out, both in long known pathologies (arteriosclerosis, arterial hypertension, diabetes mellitus, arteriosclerotic aneurysms) and in situations involving both physiopathology (ischaemia-reperfusion, angiogenesis) as therapy (angioplasty).     

Multiple nonanastomotic aneurysms in an external velour ringed Dacron femoropopliteal vascular prosthesis

Nonanastomotic aneurysms of arterial prosthetic grafts are an infrequent but well-documented complication of arterial bypass surgery. Several cases of nonanastomotic aneurysm formation of the external velour-type Dacron graft have been reported. We present a case of an external velour ringed Dacron (Sauvage EXS) femoropopliteal bypass graft with multiple nonanastomotic aneurysms. An extensive review of the English literature shows this to be the first reported case of multiple aneurysms occurring in this type of prosthesis.     

Partial thrombosis of canine carotid bifurcation aneurysms with cellulose acetate polymer

OBJECTIVE: To investigate the usefulness of a cellulose acetate polymer (CAP) solution for partial thrombosis of aneurysms. METHODS: We created 14 canine cervical carotid bifurcation aneurysms, 11 of which were subsequently thrombosed partially with CAP solution. We then conducted angiographic and histological investigations. RESULTS: Nine aneurysms were thrombosed 50 to 70% by volume, although a significant crescent crevice between the aneurysmal sac and the CAP mass was left in four of the aneurysms. In the remaining two aneurysms in which a crescent crevice had been seen in the initial stage of CAP injection, 80% and more than 95% thrombosis were needed to occlude the crevice, respectively. Follow-up angiograms of the seven aneurysms with no crescent crevice revealed no shifts of position of the CAP mass toward the bottom of the aneurysm sac, but slight ballooning of the remnants was observed in two of them. The angiograms of the other four aneurysms with significant crescent crevices demonstrated rupture with a massive hematoma in one and shifts of the CAP mass with marked enlargement of remnants in three. Histologically, the seven aneurysms with no enlarged remnants had newly developed membranes consisting of endothelium, infiltrated spindle-shaped cells, collagen, and elastic fibers. In contrast, in the three markedly enlarged aneurysms, there were only recent clots between the CAP mass and the aneurysm lumen and no development of endothelium. CONCLUSION: Partial thrombosis with CAP solution is useful to keep aneurysms in a stable configuration, unless a crescent crevice has been left.     

Aortoiliac surgery in chronic hemodialysed patients

Thirty eight patients on chronic hemodialysis were operated on for treatment of complicated aortoiliac atherosclerosis: 31 had aneurysms and 7 had stenotic or obstructive lesions. The 35 male and three female patients ranged in age from 39 to 78 years (mean: 55.3). The duration of hemodialysis treatment before the operation ranged from one month to 22 years but 80% of the patients were operated on during the first five years following the beginning of maintenance hemodialysis. The surgical repairs consisted of long aorta to femoral artery prosthesis in obstructive lesions and of short prostheses in cases of aneurysms so as not to make more difficult subsequent renal transplantation. All patients were operated on from 6 to 18 hours after a dialysis. Hemodialysis was resumed on the day of surgery in few patients or later according to the level of kalemia. Postoperative mortality rate was 10.5% and morbidity 13.5%. Only seven patients underwent secondary renal transplantation. The long-term survival rate was 43% at five years and 11% at ten years. Late deaths were due to coronary artery disease or to worsening of arterial lesions in the lower limbs.     

Successful prosthetic fitting of a 73-year-old hip disarticulation amputee patient with cardiopulmonary disease

A 68-year-old female and a 47-year-old male patients underwent clipping surgery for giant basilar arterial and thrombotic internal carotid arterial aneurysms respectively with closed-chest extracorporeal circulation (femoro-femoral bypass). Profound hypothermia and continuous infusion of thiamylal were used to prevent brain damage. Blood outflow via the femoral vein was sufficient to induce profound hypothermia down to 20 degrees C. Hemodynamics were controllable without catecholamines during closed-chest extracorporeal circulation. Preoperative symptoms significantly improved and no neurological complication was observed in either case postoperatively. Right femoral phlebothrombosis was, however, observed in one case. In conclusion, profound hypothermia with closed-chest extracorporeal circulation is a safe technique to reduce the complications induced by open-chest technique, but special attention should be given to postoperative phlebothrombosis.     

Alpha-1-antitrypsin phenotypes among patients with intracranial aneurysms

A deficiency of alpha 1-antitrypsin has been implicated in the development of arterial aneurysms, including intracranial aneurysms. The authors determined the prevalence of alpha 1-antitrypsin deficiency of different phenotypes in 100 consecutive patients with intracranial aneurysms and compared the distribution of alpha 1-antitrypsin phenotypes to that in the general population (904 people). The study population consisted of 44 men and 56 women with a mean age of 52 years (range 15-81 years). The heterozygous alpha 1-antitrypsin deficiency states (PiMS and PiMZ) were more common in patients (16%) than in the general population (7%), providing an odds ratio of 2.56 (95% confidence interval (CI) 1.32-4.75; p = 0.005). In addition, one patient (1%) was homozygous for the deficient allele (PiZZ) compared to an expected number of 0.015, providing an odds ratio of 67.0 (95% CI 2.0-363.3; p = 0.015). These findings lead the authors to suggest that the heterozygous and homozygous alpha 1-antitrypsin deficiency states are genetic risk factors for the development of intracranial aneurysms.     

Non-aortic extracranial arterial aneurysm

Aortic and intracranial arterial aneurysms constitute frequent clinical entities for which sophisticated vascular surgical and interventional radiological therapeutic procedures have been established. To a much lesser extent arterial aneurysms can also occur at any other vascular site due to a large number of possible reasons. In this article we conducted a Medline search of the world literature for reports on these rare vascular disorders and summarize the most important clinical aspects on this subject. Altogether 5535 cases of non-aortic extracranial aneurysms are reviewed.     

Bilateral aneurysms of the popliteal artery

INTRODUCTION: Popliteal artery aneurysms are the most common of peripheral arterial aneurysms. Popliteal aneurysms are bilateral in 42% of patients. Atherosclerosis and bacterial invasion of the arterial wall are the predominant etiologic factors of popliteal artery aneurysms. CLINICAL CASE: A male of 67 years old was referred to our institution for bilateral claudication and 150 m. free interval. The angiogram showed a partial occluded aneurysm of the right popliteal artery and a complete thrombosis of the left popliteal artery aneurysms. The left aneurysm was resected and a femoral popliteal by-pass was performed, using the inverted saphenous vein graft, associated with left lumbar sympathectomy. Six months later the contralateral aneurysm was excised and a Dacron femoro-popliteal by-pass graft was performed. Two years later Arteriographic and Doppler examination showed patent by-pass bilaterally. CONCLUSION: Popliteal artery aneurysms can be a threaten for the lower limbs, because of thromboembolic phenomena and occasional rupture. Surgery is the best treatment before the appearance of an acute complication and a by-pass with an autogenous vein graft or a Dacron graft are the most common surgical procedures performed. Thrombolytic therapy offers good results where an acute complication appears.     

A combined microsurgical skull-base and endovascular approach to giant and large paraclinoid aneurysms

BACKGROUND: The treatment of giant and large paraclinoid aneurysms remains challenging. To improve exposure, facilitate the dissection of aneurysms, assure vascular control, reduce brain retraction and temporary occlusion time, enable simultaneous treatment of associated lesions, and achieve more successful treatment of "difficult" (atherosclerotic and calcified) aneurysms, we combined the skull-base approach with endovascular balloon occlusion of the internal carotid artery (ICA) and suction decompression of the aneurysm. METHODS: Sixteen female patients were treated, eight with giant aneurysms and eight with large aneurysms. Eight aneurysms occurred on the right side and eight on the left. Eight patients had an additional aneurysm; five were clipped during the same procedure. Three patients had infundibular arterial dilation. One patient had an associated hemangioma of the ipsilateral cavernous sinus. The cranio-orbital-zygomatic approach was used for all patients. The anterior clinoid was drilled, and the optic nerve was decompressed, dissected, and mobilized. Transfemoral temporary balloon occlusion of the ICA in the neck was followed by placement of a temporary clip proximal to the posterior communicating artery. Suction decompression was then applied. All aneurysms were then successfully clipped, except one that had a calcified neck and wall that could not be collapsed. Intraoperative angiography performed in 13 of 15 patients with clipped aneurysms confirmed obliteration of the aneurysm and patency of the blood vessels. RESULTS: Postoperative results were good in 14 patients. One patient had right-sided hemiplegia and expressive aphasia, which improved after rehabilitation. One patient with an additional basilar tip aneurysm clipped simultaneously died on the fifth postoperative day because of intraventricular hemorrhage. The origin of bleeding could not be determined on autopsy. Surgical difficulties and morbidity stemmed mainly from a severely calcified or atherosclerotic aneurysmal neck. CONCLUSION: The combination of skull-base approaches and endovascular balloon occlusion coupled with suction decompression is a successful option for the treatment of these challenging aneurysms.     

Retinal hypoxia in long-term diabetic cats

PURPOSE: To determine whether the retina is hypoxic in early stages of diabetic retinopathy in cats and to correlate intraretinal PO2 with fluorescein angiographic and histologic alterations. METHODS: Intraretinal PO2 was measured with microelectrodes in three cats with long-standing diabetes (>6 years) that had been followed with fluorescein angiographs every 6 months. Average PO2 in the inner vascularized half of the retina was compared with similar measurements in 21 control animals. Photoreceptor oxygen consumption was also compared. The retinal vascular endothelium of the diabetic animals was stained for ADPase activity in flatmounts, and transverse sections were used to visualize microscopic alterations in vascular structure. RESULTS: PO2 in the inner half of the retina was abnormally low in the diabetic cats, 7.7+/-5.2 mm Hg (35 penetrations in 3 cats) versus 16.4+/-9.3 mm Hg in normal cats (85 penetrations in 21 cats) (P < 0.001). Oxygenation was almost normal in some regions of the diabetic retinas, but little evidence of oxygen supply from the retinal circulation was observed in other regions. Inner retinal hypoxia was present in areas with no detectable capillary dropout in fluorescein angiograms or flatmounts. The worst changes histologically were microaneurysms, leukocyte and platelet plugging of aneurysms and venules, and degenerating endothelial cells in capillary walls. These histologic abnormalities were confined to small regions, some of which could be positively correlated with markedly abnormal PO2 profiles. Photoreceptor oxygen utilization was not affected in two diabetic cats, but was below normal in one animal in which choroidal PO2 was low. CONCLUSIONS: This is the first direct demonstration of retinal hypoxia in early diabetic retinopathy, before capillary dropout was evident clinically. Hypoxia was correlated with endothelial cell death, leukocyte plugging of vessels, and microaneurysms.     

Preliminary clinical outcome and imaging criterion for endovascular prosthesis development in high-risk patients who have aortoiliac and traumatic arterial lesions

PURPOSE: This report reviews our preliminary experience of prospective treatment of arterial lesions with endoluminal grafts in a Food and Drug Administration (FDA)-approved, investigator-sponsored Investigation Device Exemptions study. The utility and accuracy of various imaging methods, including angiography, cinefluoroscopy, computed tomography (CT), intravascular ultrasonography (IVUS), and duplex scanning, in performing the procedures was also assessed. METHODS: Thirty-one patients were evaluated; 17 patients were treated, including 11 with abdominal aortic aneurysms, one with an aortic occlusive lesion, two with iliac artery aneurysms, and three with traumatic arteriovenous fistulas. Twelve of the 14 patients who had aorta and iliac artery lesions were high-risk. The mean follow-up of patients treated was 9 months (range, 6 to 15 months). RESULTS: Aortoaortic endoluminal interposition procedures were not successful for treating abdominal aortic aneurysms early in the study (n = 3). Aortoiliac endoluminal bypass, contralateral iliac artery occlusion, and femorofemoral bypass procedures were successful in seven of eight subsequent cases (88%), with no incidence of endoleaks at either the proximal or distal fixation sites using the deployment methods described in this report. The 30-day operative mortality rate on follow-up evaluations for patients who underwent aortoiliac procedures was 14% (two of 14). Other major complications included transient renal failure in three patients that required short-term (two to eight times) dialysis, one arterial perforation and one dissection, and one prolonged intubation. No myocardial infarctions or strokes occurred. After major complications or identification of limitations in the study, the protocol was modified with the approval of the FDA to help avoid the recurrence of the same problems. There were no deaths or complications in the trauma cases. CONCLUSIONS: Contrast-enhanced CT (axial images and spiral reconstructions) was the most accurate method to determine candidacy for aortoiliac procedures and to choose the site for deployment of the devices. Angiographic scans were misleading in several patients regarding the critical determinants of patient candidacy and device deployment, particularly regarding the presence of a distal aortic neck. Cinefluoroscopy was used in all patient and was particularly useful for determining the continuity of vascular structures and the anatomy of branch arteries and for enabling precise positioning of stent devices. Determination of fixation sites and assessing dimensional information by cinefluoroscopy and angiography were limited by inaccuracies produced by image magnification, parallax, and uniplanar views. IVUS was used to determine the morphologic features of vascular structures (i.e., calcium, thrombus), to perform real-time observation of the expansion of devices, and to assure firm fixation of balloon-expanded stents before the procedures were completed. Duplex scanning was very helpful in assessing and identifying precisely the location of arteriovenous fistulas before intervention and provided assessment at follow-up intervals. Three-dimensional reconstruction imaging technologies such as spiral CT were particularly helpful for assessing the morphologic features of vascular anatomy before the intervention and at follow-up intervals, whereas 3-D IVUS provided a similar real-time perspective during the procedure.     

Contemporary management of isolated iliac aneurysms

OBJECTIVE: Because isolated common iliac artery aneurysms are infrequent, are difficult to detect and treat, and have traditionally been associated with high operative mortality rates in reported series, we analyzed the outcomes of operative repair of 31 isolated common iliac artery aneurysms in 21 patients to ascertain morbidity and mortality rates with contemporary techniques of repair. METHODS: A retrospective review study was conducted in a university teaching hospital and a Department of Veterans Affairs Medical Center. Perioperative mortality and operative morbidity rates were examined in 17 men and four women with isolated common iliac artery aneurysms between 1984 and 1997. Ages ranged from 38 to 87 years (mean 69 +/- 8 years). Slightly more than half of the cases were symptomatic, with abdominal pain, neurologic, claudicative, genitourinary, or hemodynamic symptoms. One aneurysm had ruptured and one was infected. There was one iliac artery-iliac vein fistula. All aneurysms involved the common iliac artery. Coexistent unilateral or bilateral external iliac aneurysms were present in four patients; there were three accompanying internal iliac aneurysms. Overall, 52% of patients had unilateral aneurysms and 48% had bilateral aneurysms. Aneurysms ranged in maximal diameter from 2.5 to 12 cm (mean 5.6 +/- 2 cm). No patients were unavailable for follow-up, which averaged 5.5 years. RESULTS: Nineteen patients underwent direct operative repair of isolated iliac aneurysms. One patient had placement of an endoluminal covered stent graft; another patient at high risk had percutaneous placement of coils within the aneurysm to occlude it in conjunction with a femorofemoral bypass graft. Patients with bilateral aneurysms underwent aortoiliac or aortofemoral interposition grafts, whereas unilateral aneurysms were managed with local interposition grafts. There were no deaths in the perioperative period. Only one elective operation (5%) resulted in a significant complication, compartment syndrome requiring fasciotomy. The patient treated with the covered stent required femorofemoral bypass when the stent occluded 1 week after the operation. The patient treated with coil occlusion of a large common iliac aneurysm died 2 years later when the aneurysm ruptured. CONCLUSIONS: Isolated iliac artery aneurysms can be managed with much lower mortality and morbidity rates than aneurysm previously been reported by using a systematic operative approach. Percutaneous techniques may be less durable and effective than direct surgical repair.