Rare and potentially lethal case of a round lesion in the lung.

A pulmonary venous aneurysm (PVA) is extremely rare. A PVA can be either congenital or acquired. Possible symptoms include thoracic pain, dyspnoea, haemoptysis and palpitations but can also occur asymptomatically. Treatment can be conservative or surgical depending on growth and risk of rupture or development of mitral insufficiency, symptoms and thrombus formation. Only a few cases have been described in the literature. A recent case study and a literature review are described below.

A Unique Case Of A Giant Popliteal Artery Aneurysm Presenting As Popliteal Mass.

INTRODUCTION: Popliteal artery aneurysms (PAA) can be very challenging, especially in cases of very large PAAs, with a minimal number of case reports published in the literature. METHODS: This is a case report of a 68-year-old male patient with hypertension, hyperlipidemia, diabetes, and schizophrenia who was found to have a giant (10x8x6cm) partially thrombosed PAA, treated with interposition polytetrafluoroethylene (PTFE) graft via a posterior approach. RESULTS: Under general anesthesia, the patient was placed in a prone position, and an extended lazy "S" incision was made on the popliteal fossa. After obtaining proximal and distal exposure, the aneurysm sac was skeletonized, preserving the popliteal vein and the tibial nerve. After proximal and distal control was obtained, the patient was systemically heparinized, and the aneurysm sac was opened. Some genicular branches were ligated inside the aneurysm, and part of the aneurysm sac was excised. A 7 mm PTFE graft was used for reconstruction in an end-to-end fashion. Suction drains were placed in the popliteal space, and the fascia and skin were approximated. The patient was discharged home on the 2nd postoperative day on aspirin and statin with ultrasound surveillance. The patient has remained asymptomatic during follow-up with a patent graft. CONCLUSIONS: Open surgical repair constitutes the gold standard of care for huge PAAs to prevent distal thromboembolic events and mass pressure effects from the aneurysm. Documentation of additional experience with open repair of huge PAAs would be beneficial and could help clinical decision-making.

Current Approaches for Mesenteric Ischemia and Visceral Aneurysms.

This article provides an overview of acute mesenteric ischemia, chronic mesenteric ischemia, and visceral aneurysms, with a focus on treatment. Acute mesenteric ischemia can be a challenging diagnosis. Early recognition and adequate revascularization are key to patient outcomes. Chronic mesenteric ischemia is a more insidious process, typically caused by atherosclerosis. Various options for revascularization exist, which must be tailored to each patient. Visceral aneurysms are rare and the natural history is not well defined. However, given the risk of rupture and high mortality, treatment may be complex.

An Epithelioid Hemangioma Camouflaged As Radial Aneurysm.

Epithelioid hemangioma (EH) is an uncommon benign vascular lesion usually present as subcutaneous nodules in the head and neck area. Sometimes, these lesions can occur in the peripheral arteries, and when they do, they can be mistaken for aneurysmal dilatations of that respective vessel. We report a case of a 43-year-old male who underwent surgical recession of a radial aneurysm, which after anatomopathological examination, revealed an EH.

Association Between the Degree of Severity of Pulmonary Hypertension With the Presence of Pulmonary Artery Aneurysm: A Brief Updated Review for Clinicians.

Pulmonary hypertension (PH) is defined as an increase in mean pulmonary arterial pressure (mPAP) ≥20 mm Hg at rest as assessed by right cardiac catheterization. It has a median survival nowadays of 6 years, compared to 2.8 years in the 1980s. A pulmonary artery aneurysm (PAA) is the focal dilation of a blood vessel involving all 3 layers of the vessel wall; they have a diameter greater than 4 cm measured in the trunk of the pulmonary artery. PAAs can be classified into proximal (or central) and peripheral. The clinical manifestations of PAA are primarily nonspecific, and most patients remain undiagnosed, even those with large PAA, due to its silent course; however, clinical manifestations occur unless when there are complications such as bronchial or tracheal compression (leading to cough and dyspnea), dissection, or rupture (leading to hemoptysis). PAH is observed in 66% of patients with PAA. PA dissections are usually associated with PAH; 80% of dissections occur in the main pulmonary trunk. Although there is no clear guideline for the best treatment of PAA, surgery is indicated in patients with a pulmonary trunk aneurysm >5.5 cm. It has been observed that patients in the PAH group associated with congenital heart disease tend to develop PAA more commonly. Those with PAH associated with connective tissue disease have a smaller diameter of PA dilation. This report presents a comprehensive review of PAA, discussing critical aspects of the clinical and imaging diagnosis, hemodynamics, and treatment. A comprehensive updated literature review is included; we believe this article will interest cardiopulmonologists.

Cutaneous fistula after open repair of a popliteal artery aneurysm: case report and review of the literature.

BACKGROUND: For many years, the reference treatment for popliteal artery aneurysms (PA) consists of surgical exclusion by proximal and distal ligation, combined with popliteopopliteal, femoropopliteal or femorotibial bypass. These aneurysms excluded, but left in situ, generally decrease in size by thrombosis. However, this is not always the case. We report on a patient with bilateral PAs. The right aneurysm was completely resected, with a normal follow-up. The left one was excluded by ligation and bypass, without resection, but continued to be perfused, and fistulised to the skin. The aneurysm continued to grow due to retrograde collateral circulation through the knee's articular arteries, corresponding to a "type 2 endoleak." We therefore performed resection of the aneurysm and its fistulous path. The evolution was favourable and the patient has a satisfactory arterial condition since then. This extremely rare case prompted us to review PAs' treatment options and explore the arterial aneurysms' fistulising potential. METHODS: A review of the literature was performed on the aneurysmal fistulas' clinical manifestation, their pathophysiology, and the PAs' surgical and endovascular treatment. RESULTS: Various studies demonstrated a superiority of resection treatments, with better results and fewer reinterventions than exclusion treatments alone. CONCLUSIONS: In view of this case, and as demonstrated by a literature search, we consider the surgical resection of PAs to be the optimal method for their management, rather than the surgical or endovascular exclusion treatment alone.

Combined endovascular and surgical treatment of a giant celiac artery aneurysm with consequent gastric outlet obstruction: a case report and literature review.

BACKGROUND: Visceral artery aneurysms (VAA) are rare with an incidence of up to 0.2% and mortality of up to 40%. Aneurysms larger than 5 cm are referred to as giant visceral artery aneurysms (GVAA). We present a case of a celiac artery aneurysm of 14 cm which required endovascular and surgical management. A review of the literature with focus on treatment is also provided. CASE PRESENTATION: In this case report, a 76-year-old male presented with postprandial nausea and vomitus. An ultrasound and computed tomography scan showed an aneurysm of the celiac artery of approximately 14 cm. Initial treatment was conducted with coiling. Despite this treatment, patient presented again with the same complaints, most likely due to gastric outlet syndrome caused by the aneurysm sac. Partial open removal of the aneurysm sac was performed with release of the duodenum. Due to recurring dysphagia and postprandial nausea, a gastroenterostomy was created, which was later supplemented with a Roux-en-Y anastomosis due to gastroparesis. Patient recovered uneventful after the Roux-en-Y and was discharged from the hospital. CONCLUSION: Giant visceral artery aneurysms sometimes need multimodal treatment. We showed that an endovascular first approach of a giant visceral artery aneurysm is not only technically feasible, but it also facilitates subsequent open surgery due to limiting blood loss and reducing the need for extensive mobilisation of the viscera to gain arterial control.

IRVAN syndrome: A retrospective review of 9 cases from Tunisia.

PURPOSE: To describe clinical features, relevant imaging findings, disease course, and response to treatment in 9 patients (18 eyes) with idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN) syndrome. METHODS: Retrospective review of the charts of nine patients (18 eyes) diagnosed with IRVAN syndrome at Fattouma Bourguiba University Hospital, Monastir, Tunisia, from January 1, 2011 to January 1, 2022. RESULTS: Nine patients were included with bilateral involvement in all cases. Mean initial best-corrected visual acuity (VA) was 20/32 (range, 20/1600-20/20). Clinical findings at presentation included vitreous cells (10 eyes, 55.6%), peripapillary exudates (12 eyes, 66.7%), partial or complete macular star (11 eyes, 61.1%), and vascular sheathing (11 eyes, 61.1%). Fluorescein angiography showed arteriolar aneurysms (18 eyes, 100%), areas of peripheral capillary non-perfusion (16 eyes, 88.9%), and retinal neovascularization (6 eyes, 33.3%). Optical coherence tomography showed macular edema in 5 eyes (27.8%). Optical coherence tomography angiography of the optic disc demonstrated papillary aneurysms in 4 eyes of 2 patients. Indocyanine green angiography showed retinal arteriolar aneurysmal dilatations in 4 eyes of 2 patients. Ten eyes (55.6%) had stage 2 disease, 6 eyes (33.3%) had stage 3, and 2 eyes (11.1%) had stage 1. Treatment modalities included peripheral photocoagulation (16 eyes, 88.9%), intravitreal bevacizumab (4 eyes, 22.2%), and intravitreal triamcinolone acetonide (1 eye, 5.6%). Mean final best-corrected VA was 20/32 (range, 20/600-20/20). Ocular complications included vitreous hemorrhage in 3 eyes (16.7%), branch retinal artery occlusion in 2 eyes (11.1%) and submacular fibrosis in 3 eyes (16.7%). CONCLUSION: IRVAN syndrome should be highly suspected in patients with peripapillary exudates associated with vascular sheathing and vitreous cells. Multimodal imaging confirms the diagnosis by showing retinal macroaneurysms. Early treatment of macular edema and/or peripheral retinal non-perfusion is mandatory to improve prognosis.

A rare combination of post-ductal coarctation of the aorta and adjunct tortuous aneurysm: a neonate with Posterior fossa anomalies, Haemangiomas of the head and neck, Arterial, Cardiovascular, and Eye anomalies and ventral developmental defect syndrome.

A 4-day-old girl with Posterior fossa anomalies, Haemangiomas of the head and neck, Arterial, Cardiovascular, and Eye anomalies and ventral developmental defect syndrome comprising a facial haemangioma, aortic coarctation at the aortic arch, torturous aortic aneurysm distal to coarctation, and ductus arteriosus originating proximal to the coarctation is presented. The aortic arch was successfully reconstructed without cardiopulmonary bypass, and she is currently doing well after 4 years and 8 months.

Pulmonary Artery Aneurysm Diagnosed by Dynamic Digital Chest Radiography.

Pulmonary artery aneurysms (PAAs) are rare but clinically important because their rupture can cause sudden death. This report describes a case of an asymptomatic patient with an unruptured PAA that was successfully diagnosed by dynamic digital chest radiography (DDCR) and was treated surgically. DDCR is an advanced, temporally resolved radiographic technique that offers high-quality fluoroscopy-like images at a low radiation dose. Although noncontrast chest computed tomography revealed only a nonspecific nodule, DDCR delineated this lesion as a pulsatile nodule synchronized with cardiac pulsations, thereby establishing the diagnosis of PAA. This diagnosis was confirmed by computed tomographic pulmonary angiography and surgery.

Natural history, growth rates, and treatment of popliteal artery aneurysms.

BACKGROUND: The natural history of a cohort of patients monitored for popliteal artery aneurysms (PAAs) has not been well described. A prevailing uncertainty exists regarding the optimal surveillance strategies and timing of treatment. The primary aim of the present study was to describe the care trajectory of all patients with PAAs identified at two tertiary vascular centers, both in surveillance and eventually treated. The secondary aim was to define the PAA growth rates. METHODS: A retrospective, multicenter cohort study was performed of all patients with PAAs at two vascular centers in two countries (Sweden, 2009-2016; New Zealand, 2009-2017). Data were collected from electronic medical records regarding the comorbidities, treatment, and outcomes and analyzed on a patient- and extremity-specific level. Treatment was indicated at the occurrence of emergent symptoms or considered at a PAA threshold of >2 cm. The PAAs were divided into small (≤15 mm) and large (>15 mm) aneurysms. The mean surveillance follow-up was 5.1 years. RESULTS: Most of the 241 identified patients (397 limbs) with a diagnosis of PAAs had bilateral aneurysms (n = 156). Most patients were treated within the study period (163 of 241; 68%), and one half of the diagnosed extremities with PAA had been treated (54%; 215 of 397). Among those who had undergone elective repair, treatment had usually occurred within 1 year after the diagnosis (66%; 105 of 158). More small PAAs were detected in the group that had required emergent repair compared with elective repair (6 of 57 [11%] vs 12 of 158 [8%]; P < .001). No differences were found in the mean diameters between the elective and emergent groups (30.1 mm vs 32.2 mm; P = .39). Growth was recorded in 110 PAAs and on multivariate analysis was associated with a larger index diameter (odds ratio, 1.138; 95% confidence interval, 1.040-1.246; P = .005) and a concurrent abdominal aortic aneurysm (odds ratio, 2.553; 95% confidence interval, 1.018-6.402; P = .046). CONCLUSIONS: The present cohort of patients represented a true contemporary clinical setting of monitored PAAs and showed that most of these patients will require elective repair, usually within 1 year. The risk of emergent repair is not negligible for patients with smaller diameter PAAs. However, the optimal selection strategy for preventive early repair is still unknown. Future morphologic studies are needed to support the development of individualized surveillance protocols.

Clinical variations and therapeutic challenges in the management of symptomatic retinal artery macroaneurysm: a tertiary center experience.

PURPOSE: To find out clinical characteristics, therapeutic options, and visual outcome in symptomatic retinal artery macroaneurysm (RAMA) patients. METHOD: Newly diagnosed cases of symptomatic RAMA from January 2015 to December 2019 were included. Fifteen eyes of 15 patients with mean age 62.46 years ± 14.89 (SD) fulfilled the inclusion criteria. RESULT: Hypertension was present in 66.6% of the patients, and the commonest site was superotemporal (12 eyes, 80%). The most commonly employed treatment was Nd: Yag laser hyaloidotomy in 4 eyes (26.6%). Other treatments were intravitreal bevacizumab in 3 eyes (20%), focal laser with intravitreal bevacizumab in 3 eyes (20%), PPV with focal laser (13.3%) in 2, focal laser only in one (6.6%), PPV with focal and intravitreal bevacizumab in one (6.6%). The mean best-corrected visual acuity (BCVA) at baseline was 1.35 ± 0.84 LogMAR, which improved to 0.39 ± 0.53 LogMAR at the last follow-up. Presenting VA 0.77 (±0.40) improved to 0.20 (±0.17) p value (0.180) in intravitreal bevacizumab only group, 1.29 (±0.35) to 0.75 (±0.15) p value 0.66 in Nd: Yag laser group, 2.67 (±0.58) to 0.46 (±0.28) p value 0.019 in PPV group and did not improve in combined anti-VEGF and focal laser group due to dense hard exudates at the fovea in one and persistent cystoid macular edema in another case. CONCLUSION: With regard to its presentation, which can vary tremendously, there are no approved guidelines for its treatment. The present study reinforces the need for a treatment guideline development. Customization of treatment should be considered depending on the clinical presentation of each case.

Retinal arterial macroaneurysm in leukemia.

INTRODUCTION: Retinal arterial macroaneurysm (RAM) is an acquired vascular dilatation usually seen at the site of arterial bifurcation or arterial-vein crossing. It's often seen in the first three branches of the central retinal artery. CASE DESCRIPTION: A 15-year-old male patient was admitted to the outpatient clinic with complaints of weakness, headache, and bruising on the body for a few weeks. During the physical examination, a hepatomegaly and a common patchy ecchymosis in the body were detected at the abdominal examination. Hemoglobin was 6.6 g/dl, white blood cells were 40,000/mm3, platelet was 24,000/mm3 at the whole blood count done. The 70% blast was detected in peripheral spread. Bone marrow aspiration evaluation was consistent with pre-B cell acute lymphoblastic leukemia. There was two macroaneurysms in the inferior arcuate of the left eye. The patient was examined on a weekly basis. During control examinations, retinal macroaneurysms in left eye and the hemorrhages significantly regressed. CONCLUSION AND IMPORTANCE: The fact that RAM is not often seen in the pediatric age group, indicates the importance of this phenomenon. It should be remembered that a complete ophthalmic examination should be performed on leukemia patients.

Successful Endovascular and Endoscopic Treatment of a Symptomatic Celiac Artery Aneurysm for Obstructive Jaundice: A Clinical Case Report.

BACKGROUND: Celiac artery aneurysm (CAA) is an infrequent aneurysm of the celiac visceral branch and is potentially life-threatening, mainly due to the risk of rupture. CAA is often diagnosed following rupture and rarely diagnosed secondary to a primary manifestation; obstructive jaundice is extremely rare and poorly described. This clinical case report reports a combined endovascular and endoscopic noninvasive treatment. METHODS: A 51-year old male was admitted to the emergency department at the Arcispedale Santa Maria Nuova in Reggio Emilia following several days of jaundice. The patient did not have any history of abdominal trauma, chronic pancreatitis, bile duct calculus or alcohol abuse. Cholestatic impairment was demonstrated by blood analyses and abdominal ultrasound revealed a large cephalo-pancreatic mass. Contrast-enhanced computed tomography (CT) showed a 40 mm CAA, causing a common bile duct (CBD) compression and dilatation of the hepatic bile ducts. After a multidisciplinary team consultation, a noninvasive, combined endovascular and endoscopic approach was programmed in a hybrid room. RESULTS: Immediate results confirmed successful exclusion of the CAA, stent graft patency and the absence of endoleak with correct positioning of a plastic stent in the CBD. At 1 month, an abdominal CT-angiography (CTA) evidenced a type II endoleak, successfully treated with an endovascular secondary procedure and an asymptomatic, partial downward dislodgement of the plastic stent in the CBD was correct with the positioning of 2 plastic stents. At 3-months cholangiography showed no dilation of intraepatic biliary ducts. CONCLUSIONS: Symptomatic CAA with common bile duct compression could be amenable to a combined endovascular and endoscopic noninvasive treatment.

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.

Selective Photocoagulation of Capillary Macroaneurysms by Navigated Focal Laser.

BACKGROUND AND OBJECTIVE: To evaluate the anatomical and functional outcome of selective photocoagulation of capillary macroaneurysms (CMAs) by navigated focal laser. PATIENTS AND METHODS: Consecutive patients with solitary or secondary CMAs greater than 150 mm in diameter were included in this analysis. All patients were treated with navigated focal laser and received multimodal imaging. RESULTS: Seventeen eyes of 17 patients were retrospectively analyzed. Navigated laser photocoagulation of the CMAs successfully occluded 100% of the CMAs, inducing significative improvement in best-corrected visual acuity at 3 (P = .002) and 6 months (P = .001) and a decrease in central macular thickness (CMT) at 3 (P = .0004) and 6 months (P = .0004). CONCLUSIONS: Solitary or secondary CMAs arising from retinal capillaries are candidates for navigated laser treatment. Navigated focal treatment was able to close all CMAs in this series with an improvement in vision and CMT. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:366-373.].

[Surgical treatment of true aneurysms of permanent vascular access]. / Khirurgicheskoe lechenie istinnykh anevrizm postoiannogo sosudistogo dostupa.

Analyzed herein are the results of surgical treatment of true diffuse aneurysms of the permanent vascular access in 44 patients. Of these, there were 29 men and 15 women, mean age 48.1±2.3 years (19-78 years). The average time having elapsed since the formation of the native access was 109.4±9.5 months (12-276, median - 108 months). The indications for surgical treatment were as follows: haemorrhage including recurrent bleedings (3), thrombosis of the permanent vascular access (26), its dysfunction (5), high flow syndrome (3), large-size aneurysm with disordered function of the limb, pain syndrome or a pronounced cosmetic defect (7). In 14 cases, reconstruction was not performed. We carried out ligating operations, in some instances with partial removal of the aneurysm and establishing a new vascular access. 3 patients underwent resection of the aneurysm with replacement by a graft. In the remote period 1 patient at 46 months developed infection of the prosthesis, resulting in loss of the access. Follow up of the remaining 2 patients demonstrated satisfactory function of the vascular access at 6 and 60 months. 16 patients were subjected to total plasty of the aneurysm using autotissues. On a cylindrical template measuring 6 mm in diameter after dissection of excessive tissues along the posterior wall of the vein, an uninterrupted suture was formed followed by placing the formed transplant into a new bed. 11 patients underwent the operation according to the analogous technique, but the formed autotransplant was reinforced with a thin-wall exoprosthesis made of polytetrafluoroethylene up to 0.2-mm thick and 10 mm in diameter ('Ecoflon'). Two (12.5%) of 16 patients subjected to reconstruction of the aneurysm without reinforcement developed haemorrhage in the early postoperative period, and one developed thrombosis thus resulting in loss of the access. In-hospital patency amounted to 81.3%. In plasty with reinforcement, there were no complications in the early postoperative period. Long-term primary patency after total plasty without reinforcement at 1, 3, and 5 years amounted to 68.2±11.8%, 56.8±14.3%, and 22.7±13.7%, respectively, with secondary patency of 68.2±11.8% at the above-mentioned terms. In the majority of patients aneurysmatic transformation of the transplant occurred again in the remote period. Primary patency at 1, 3 and 4 years after plasty with reinforcement amounted to 80.8±12.2%, 80.8±12-2% and 60.6±19.8%, respectively, with the secondary patency rates of 90.9±8.7% at the above mentioned terms.