[TREATMENT DILEMMAS IN BEHÇET'S SYNDROME].

Behçet's disease is an inflammatory systemic disorder, characterized by a relapsing and remitting course, it manifests with oral and genital ulcerations, skin lesions, uveitis, vasculitis, central nervous system and gastrointestinal involvement. The main histopathological finding is widespread vasculitis of the arteries and veins. Therapy is variable and depends largely on the severity of the disease and organ involvement. There is common practice to treat with anticoagulation in patients suffering from vessel thrombosis, but there are no control trials to support this tendency. Anticoagulation treatment can cause major bleeding events in patients suffering from aneurysms. In this case report we describe a treatment dilemma in a patient suffering from deep vein thrombosis and pulmonary aneurysms.

Staple aneurysmorrhaphy to salvage autogenous arteriovenous fistulas with aneurysm-related complications.

OBJECTIVE: Aneurysm-related complications could lead to loss of a functioning arteriovenous fistula (AVF). We report our midterm and long-term results with the staple aneurysmorrhaphy technique to repair and preserve aneurysmal AVFs. METHODS: We retrospectively reviewed our surgical treatment of patients with aneurysmal autogenous AVF complicated by skin erosion, bleeding, infection, pain, and difficulty with needle access from 2007 through 2014. We identified 52 patients, 40 (77%) of whom underwent repair with the staple aneurysmorrhaphy technique. The operation involved mobilizing the entire aneurysmal segments. A TA (Covidien, Norwalk, Conn) or Endo GIA (Covidien, Mansfield, Mass) stapler was used to resect the redundant aneurysm wall to create a 6- to 8-mm-diameter conduit. A subcutaneous skin flap was created after excising compromised skin. The remodeled vein was repositioned underneath the subcutaneous flap, with the staple line rotated laterally to avoid needle puncture. RESULTS: We attempted staple aneurysmorrhaphy in 40 patients with complicated AVF aneurysms, of which 38 repairs (95%) were successful. Median patient age was 66 years (range, 29-88 years). Median AVF age was 63 months (range, 12-136 months). Median follow-up was 20 months (range, 5-81 months). At 1 year, primary patency was 67%, assisted primary patency was 88%, and secondary patency was 91%. At 2 years, primary patency was 59%, assisted primary patency was 84%, and secondary patency was 91%. At 3 years, primary patency was 46%, assisted primary patency was 69%, and secondary patency was 85%. Surgery was performed under local-regional anesthesia in 28 patients (70%) and under general anesthesia in the remaining 12 (30%). Proximal venous outflow stenoses were detected in 19 of 40 AVFs (48%) preoperatively and in 11 of 38 AVFs (29%) postoperatively. Aneurysm recurrence occurred in two repaired AVFs. CONCLUSIONS: Our experience with staple aneurysmorrhaphy shows that it is an effective, safe, and durable procedure to preserve a functioning autogenous AVF with complicated aneurysmal degeneration. Key principles are to reduce the vein to normal adjacent diameter and to provide healthy skin coverage. The remodeled AVF has a low aneurysm recurrence rate and maintains the beneficial properties of superior patency and low infection. It is important to aggressively monitor for and treat proximal outflow venous stenoses to prevent aneurysm recurrence. The surgery can be done safely under local anesthesia in selected patients.

Endovascular therapy of bronchial artery aneurysm: five cases with six aneurysms.

The objective of this study was to investigate the effect of transcatheter arterial embolization (TAE) with N-butyl-2-cyanoacrylate (NBCA)-Lipiodol mixture in patients with bronchial artery aneurysm (BAA). From January 2005 to January 2010, five patients presenting hemoptysis with six BAAs were treated with NBCA-Lipiodol mixture, including intra-aneurysm embolization (IAE) in one patient. Adjuvant embolization with spherical polyvinyl alcohol (PVA) embolic microparticles or NBCA was first performed to embolize the distal engorged bronchiectatic arteries. Bronchial arterial angiography showed six BAAs (four in the right lobe and two in the left lobe) and some engorged, tortuous bronchial arteries. TAE through microcatheter was successful in all cases. Postembolization angiogram demonstrated the NBCA cast and total occlusion of BAAs and bronchiectatic engorged vessels. After these procedures, hemoptysis completely disappeared in all patients. Follow-up computed tomography (CT) scan was performed at an average of 3 months (range 2 to 6), which showed no enhancement of BAAs and accumulation of NBCA. TAE is a minimally invasive, effective, and reliable approach for treatment for patients with BAA. NBCA-Lipiodol mixture provides a good choice for treatment of BAA, especially when catheterization of the efferent branches is impossible.

Microsurgical complications in the upper extremity.

Although many advances have been made in microsurgery, it is not without complications. As microsurgeons continue to make advances in technology, technique, and applications that expand the utility of this field to more and more patients, they must be prepared to deal with the complications related to donor and recipient sites and the medical comorbidity that accompanies these large endeavors in the pre-, post-, and intraoperative periods.

Long-term follow-up of hypothenar hammer syndrome: a series of 47 patients.

Hypothenar hammer syndrome (HHS) is an uncommon form of secondary Raynaud phenomenon, occurring mainly in subjects who use the hypothenar part of the hand as a hammer; the hook of the hamate strikes the superficial palmar branch of the ulnar artery in the Guyon space, leading to occlusion and/or aneurysm of the ulnar artery. In patients with HHS, such injuries of the palmar ulnar artery may lead to severe vascular insufficiency in the hand with occlusion of digital artery. To date, only a few series have analyzed the long-term outcome of patients with HHS. This prompted us to conduct the current retrospective study to 1) evaluate the prevalence of HHS in patients with Raynaud phenomenon and 2) assess the short-term and long-term outcome in patients with HHS. From 1990 to 2006, 4148 consecutive patients were referred to the Department of Internal Medicine at the University of Rouen medical center for evaluation of Raynaud phenomenon using nailfold capillaroscopy. HHS was diagnosed in 47 of these 4148 patients (1.13% of cases).Forty-three patients (91.5%) had occupational exposure to repetitive palmar trauma. The more common occupations were factory worker (21.3%), mason (12.8%), carpenter (10.6%), and metal worker (10.6%); the mean duration of occupational exposure to repetitive palmar trauma at HHS diagnosis was 21 years. One patient (2.1%) had recreational exposure (aikido training) to repetitive trauma of the palmar ulnar artery, and 3 other patients (6.4%) developed HHS related to a single direct injury to the hypothenar area. Clinical manifestations were more often unilateral (87.2%) involving the dominant hand (93%). HHS complications included digital ischemic symptoms (ischemia: n = 21, necrosis: n = 20) and irritation of the sensory branch of the ulnar nerve (n = 11). In HHS patients, angiography demonstrated occlusion of the ulnar artery in the area of the Guyon space (59.6%), aneurysm of the ulnar artery in the area of the Guyon space (40.4%), and embolic multiple occlusions of the digital arteries (57.4%). All patients were advised to change their occupational exposure. They were given vasodilators, including calcium channel blocker (n = 37) and buflomedil (n = 12); 36 patients (76.6%) also received oral platelet aggregation inhibitors. Twenty-one patients with digital ischemia/necrosis were further given hemodilution therapy to reduce the hematocrit level to 35%. In 3 patients with HHS-related digital necrosis who exhibited partial improvement with vasodilators, prostacyclin analog therapy (a 5-day regimen of intravenous prostacyclin analog) was instituted, resulting in complete healing of digital ulcer in these 3 patients. Other conservative treatment options included controlling risk factors (smoking cessation, low-lipid diet, therapy for arterial hypertension) and careful local wound care of fingers in the 20 patients with digital necrosis. Only 2 patients, exhibiting digital necrosis and multiple digital artery occlusions, with nonthrombotic ulnar artery aneurysm underwent reconstructive surgery, that is, resection of the aneurysm with end-to-end anastomosis of the ulnar artery. The median length of follow-up in patients with HHS was 15.9 months. Thirteen patients (27.7%) exhibited clinical recurrences of HHS; the median time of HHS recurrence onset was 11 months. Outcome of HHS relapse was favorable with conservative measures in all cases. Awareness of HHS is required to increase suspicion of the disorder so that further exposure to risk factors like repetitive hypothenar trauma can be avoided for these patients; this is of great importance for their overall prognosis. We found favorable outcomes in most patients after conservative measures were initiated; therefore we suggest that surgery may be undertaken in the subgroup of patients who exhibit partial improvement while receiving conservative therapy. Finally, because we observed recurrence of HHS in 27.7% of patients, we note that HHS patients require close follow-up, including both regular and systematic physical vascular examination.

Endovascular treatment of visceral aneurysms associated with pancreatitis and a suggested classification with therapeutic implications.

PURPOSE: To describe a 10-year experience of endovascular and percutaneous treatment of aneurysms and pseudoaneurysms complicating pancreatitis, and to analyze this experience and propose a classification based on computed tomography (CT) and angiographic findings that has therapeutic implications. This may reduce the rate of recurrent bleeding after surgery or endovascular treatment. MATERIALS AND METHODS: Twenty-three patients with aneurysms or pseudoaneurysms associated with acute pancreatitis were treated by endovascular or percutaneous methods. All underwent CT and angiography. The early development of a simple classification based on the CT and angiographic findings was used to guide treatment decisions. In accordance with this classification, 19 patients were treated by primary coil embolization and four were treated by primary percutaneous thrombin injection. RESULTS: Among the 19 patients treated by primary coil embolization, there were two early recurrences of the pseudoaneurysm. All four patients treated by percutaneous thrombin injection exhibited late recurrences and were successfully treated by percutaneous thrombin injections. Twenty-one patients (91.3%) were alive at 6 months. CONCLUSIONS: Endovascular and percutaneous treatment of aneurysms and pseudoaneurysms complicating pancreatitis is safe and effective and is associated with good outcomes, but careful follow-up is necessary. The decision of which treatment option is most appropriate can be made in accordance with a classification based on CT and angiographic appearance.

Transfusion-free complex cardiac surgery with cardiopulmonary bypass in a 3.55-kg Jehovah's Witness neonate.

Complex cardiac surgery using cardiopulmonary bypass normally requires the transfusion of autologous blood components, particularly in neonates. This is predominately caused by the relatively high priming volume of the circuit with subsequent extreme hemodilution and the often extended and complex perfusions leading to progressive consumption of platelets and coagulation factors. We report on a strategy to minimize the cardiopulmonary bypass circuit and adjust the perfusion technique that resulted in transfusion-free correction of tetralogy of Fallot with an absent pulmonary valve and an aneurysm of the left pulmonary artery in a 3.55 kg Jehovah's Witness neonate boy.

[Experiences with the endovascular embolization therapy of aneurysms of the splanchnic arteries--a report on 13 cases]. / Erfahrungen mit der endovaskulären Embolisationstherapie von Aneurysmata der Splanchnikusarterien--Bericht über 13 Fälle.

PURPOSE: The authors report on their experience in endovascular embolization therapy in 13 cases with splanchnic artery aneurysms or pseudoaneurysms. PATIENTS AND METHODS: Three patients suffered from true aneurysms, ten patients presented pseudoaneurysms of different origin. Eight patients were transferred to our department for life-threatening intestinal bleeding. Five patients showed transpapillary bleeding, four of whom presented with haemobilia and one patient had intermittent bleeding into the pancreatic duct due to a true aneurysm of the splenic artery. Embolization was performed using a coaxial microcatheter coil delivery system. In 4 patients the aneurysm-bearing vessel was temporarily blocked during the intervention. RESULTS: In 11 patients definite occlusion of the aneurysm was obtained without surgical intervention. In one patient, suffering from a splenic aneurysm, we observed a partial inadvertent embolisation of the spleen which did not require further treatment. In one case, rupture of an hepatic aneurysm during embolization occurred. One patient with pseudoaneurysm due to displacement of a port catheter showed severe rebleeding one day after embolisation. CONCLUSION: Transcatheter embolization is an effective method for treatment of aneurysms of the splanchnic arteries. To avoid life-threatening bleeding due to rupture of the aneurysm, the feeding vessel should be temporarily blocked during embolization therapy.

Multiple intrahepatic aneurysms following transcatheter arterial embolization. Work in progress.

PURPOSE: To discuss the mechanism of multiple intrahepatic aneurysm formation after transcatheter arterial embolization (TAE) performed in five patients with hepatocellular carcinoma. MATERIALS AND METHODS: TAE was performed with gelatin sponge particles and iodized oil as embolic materials. Mitomycin C was also used in four cases. RESULTS: Three to 14 aneurysms 1-6 mm in diameter were found in third-to sixth-order branches of the hepatic arteries at repeat angiography performed 25-45 days after TAE. Follow-up angiograms in three cases revealed that most aneurysms were no longer apparent except in one patient in whom two aneurysms remained and were larger than before. In none of the five cases were any signs of aneurysm rupture noted. CONCLUSION: Radiologists should be aware of this complication of TAE. It is speculated that the main cause of aneurysm formation in these patients was the embolic agents used.

Enhancement of CO2 laser microvascular anastomoses by fibrin glue.

Laser-assisted microvascular anastomoses (LAMA) are characterized by low early bursting strength and high aneurysm rates. The effects of fibrin glue on bursting strength (BS), patency, and aneurysm rate of LAMAs were compared to standard suture and laser anastomosis. Rat femoral arteries (0.9-1.1 mm) were anastomosed end-to-end by three methods: (1) conventionally with 8 to 10 interrupted 10-O nylon sutures; (2) 3 stay sutures and CO2 laser (spot size, 0.275 mm; pulse, 0.2 sec, 80 mW); and (3) cryoprecipitated fibrinogen, 35 mg/cc, crystallized thrombin, CaCl, 20 mg/cc, aprotinin (2000 kIU/cc) applied to weld site in conjunction with laser weld as in (2) above. Patency, aneurysms, and histology were evaluated at 3 weeks, and BS (mm Hg) was measured in six additional vessels at 1 and 24 hr. There was no statistically significant difference in patency rates. Both the suture and fibrin glue groups had significantly higher 1 and 24 hr bursting strengths (P less than 0.05) and significantly lower aneurysm rates (P less than 0.001) than standard laser. There was no significant difference in bursting strength between suture and fibrin glue groups. Histology in the fibrin glue group showed medial damage similar to the LAMA and calcification of aneurysmal vessels. Fibrin glue enhancement of LAMAs produces equal patency, higher early bursting strength, and fewer aneurysms at 3 weeks compared to conventional laser.

Lumbar artery aneurysm with acute aortic occlusion resulting from chiropractic manipulation: a case report.

A 44-year-old man with an acute aortic occlusion after chiropractic manipulation was found to have a lumbar artery aneurysm. This article presents a previously undescribed entity, a lumbar artery aneurysm, which manifested as a unique cause of distal aortic occlusion in a patient with chronic back pain.

[A case of moyamoya disease associated with a peripheral artery aneurysm of the thalamus].

The authors report a case of moyamoya disease associated with a peripheral artery aneurysm in the thalamus of a 54-year-old woman. Plain CT scans revealed the right thalamic hemorrhage with ventricular penetration. Cerebral angiography demonstrated the characteristic appearance of moyamoya disease with a peripheral artery aneurysm in the territory of the right medial posterior choroidal artery. This aneurysm ruptured three times during 8 days since onset and the thalamic hemorrhage became larger on each occasion. Although the clinical symptoms and signs and plain CT scans disclosed thalamic hemorrhage, it was difficult to explain the cause of the hemorrhage. The authors emphasize that cerebral angiography and enhanced CT scans are quite necessary to clarify the genesis of cerebrovascular disease.

Trends in access surgery for hemodialysis.

Vascular access for chronic hemodialysis is for both doctors and nurses on one side and patients on the other a permanent, challenging problem. In respect to patency and complication rate, the direct AV fistula represents the most satisfactory solution and therefore should be achieved whenever feasible. In addition to the classic Brescia-Cimino and the brachiocephalic fistula, the most distal location in the snuff-box on one end and a transposed basilic vein at the upper arm on the other offer most satisfactory angioaccess alternatives that must be used stepwise from the periphery to more proximal sites. Graft fistulas should clearly be reserved for the patient for whom all autologous possibilities (with the exclusion of the autologous saphenous vein graft) have been used. Only ePTFE grafts have a patency rate comparable with direct autologous fistulas at a much higher cost.

Popliteal artery aneurysms. Past and present.

Popliteal artery aneurysms have had an important historic role in the development of modern vascular surgery. Early methods of surgical therapy for these aneurysms are detailed in this report for a persepctive. Clinical aspects of surgical diagnosis and treatment of 35 popliteal artery aneurysms in 26 patients are also reviewed. Such aneurysms often present with varied symptoms and should be considered a treacherous disease entity since limb loss occurs in a considerable number of patients. Coexisting disease frequently complicates both the intraoperative and postoperative course of these patients. In this series of popliteal aneurysms, excision and venous autograft interposition offered the most successful operative therapy.

Retinal microangiopathy in systemic lupus erythematosus.

We performed complete ocular examination, including fluorescein angiography of the fundus, in 50 ambulatory patients with moderately active or inactive systemic lupus erythematosus; none had ocular symptoms. One patient had drusen and two patients had increased intraocular pressures with disk cupping attributable to orally administered corticosteroids. No patient had detectable abnormalities by ophthalmoscopic examination. Despite this apparently normal condition, fluorescein angiography revealed single or multiple microaneurysms in nine patients (13 eyes) and retinal capillary dilatations with leakage of fluorescein in six patients (six eyes). Both abnormalities occurred in two patients. These capillary changes in moderately ill patients with lupus erythematosus are probably the residue of previous acute vasculitis, perhaps due to immune-complex deposition.

Partial cardio-pulmonary bypass in peripheral vascular surgery: case reports.

Two cases of aneurysmatic vascular lesions (a large cranio-encephalic angiodysplasia with arterio-venous communications and a post-traumatic aneurysm of the vertebral artery) are reported; both were of a very difficult surgical approach and were successfully treated with the use of extra-corporeal circulation. The partial cardiopulmonary bypass, with femoro-femoral cannulation, allowed complete recovery of the lost blood, controlled hypotension, and a certain degree of hypothermia. These factors were decisive for the good outcome of the operations.