Coil embolization of an acutely expanding spontaneous splenic artery dissection.

Symptomatic dilation of a spontaneous splenic artery dissection is a very rare and potentially catastrophic nonatherosclerotic vascular disease. Splenic artery rupture has not been reported after acute diffuse dilation, but it has been reported with celiac artery dissections. We believe treatment is mandatory if pain persists despite blood pressure control. The presentation and endovascular treatment of a spontaneous celiac trunk dissection with continued expansion of the splenic artery branch are discussed.

Acute expansion of a hospital-acquired methicillin-resistant Staphylococcus aureus-infected abdominal aortic aneurysm.

Infected aortic aneurysms (IAAs) are rare but can have devastating outcomes, particularly if diagnosis and treatment are delayed. The incidence of IAA is between 0.65% and 2% of all aortic aneurysms. The disease has a poor prognosis because these aneurysms have an increased tendency to grow rapidly and to rupture, and patients often have severe comorbidities and coexisting sepsis. Typical microorganisms associated with IAA are Salmonella, Streptococci, and Staphylococcus aureus. Methicillin-resistant Staphylococcus aureus (MRSA) continues to emerge as a cause of serious infections, but its association with IAA is extremely rare. We present a rare case of infected abdominal aortic aneurysm caused by hospital-acquired (HA) MRSA. This case adds another presentation to the clinical spectrum of HA MRSA infections, and it highlights the problems encountered in the choice of the therapy of serious HA or health care-acquired infections in an era of increasing MRSA infections. We will discuss the clinical spectrum of HA MRSA infections as well as the problems encountered in the management of IAA, and will review the relevant literature.

Single-incision external iliac artery endarterectomy and patch angioplasty.

An isolated external iliac artery chronic total occlusion is currently treated either with subintimal percutaneous transluminal angioplasty and stent or with a bypass. This article describes a new application of an old technique, endarterectomy and patch angioplasty, performed on the external iliac artery through a single flank incision. This novel approach can provide lasting patency with a low risk of complications. We present four cases and a review of the literature on the other available treatment options. This minimally invasive technique may provide a viable alternative that can be used alone or in combination with other open or endovascular techniques and can be applied in cases of groin sepsis.

Intimal sarcoma of the superficial femoral artery with osteosarcomatous differentiation.

Sarcomas of the large vessels usually present centrally in the aorta, pulmonary artery, and inferior vena cava. Peripheral arterial sarcomas are exceptionally rare. They have been reported in the iliac and common or profunda femoral arteries, and are frequently undifferentiated. In this study, we describe a differentiated intimal sarcoma of the superficial femoral artery with abundant osteosarcoma within the specimen. Before knowing the diagnosis, treatment was for a presumed pseudoaneurysm using excision and bypass. Postoperatively, the patient received palliative radiation therapy. The tumor's location and histopathology are unique. A differentiated intimal sarcoma has never been reported in the superficial femoral artery, and it represents the second peripheral arterial intimal sarcoma reported with osteosarcomatous differentiation.

Bilateral asymptomatic extracranial carotid artery aneurysms.

Aneurysms of the extracranial carotid arteries are rare and account for 0.4-1% of all arterial aneurysms and about 4% of all peripheral arterial aneurysms. Causes include atherosclerosis, fibromuscular dysplasia, trauma (penetrating and blunt cervical trauma and hyperextension of the neck), iatrogenic lesions, infection, congenital defects, and irradiation arteritis. Atherosclerosis is responsible for 46-70% of all carotid artery aneurysms. The most frequent site of carotid artery aneurysms is the common carotid artery, particularly at its bifurcation and proximal internal carotid artery (ICA). The middle and distal portions of the ICA are the next most common sites. Aneurysms at the point of bifurcation are usually fusiform, whereas those located in the middle and distal portions of the ICA are usually saccular. This uncommon but interesting vascular disorder usually presents as a parapharyngeal pulsatile mass. It can be partially or completely thrombosed and thereby cause embolization or compression of neurovascular structures, with ruptures and ischemic events as other complications. Surgical treatment of extracranial carotid aneurysms is required in most cases, to avert disastrous consequences. Conservative management of extracranial ICA aneurysms has resulted in a mortality rate of nearly 71%. Nonoperative treatment is generally indicated in young patients who have nonpenetrating traumatic and spontaneously dissecting aneurysms. However, when anticoagulation therapy fails or when persistent neurologic symptoms or progressive expansion of the aneurysm occurs, surgical repair is indicated.

Comparison of costs of staged versus simultaneous lower extremity arterial hybrid procedures.

BACKGROUND: Hybrid procedures combine endovascular and open surgical techniques. We examined utilization rates and ways of performing them more efficiently. METHODS: Hybrids were selected using codes for femoral endarterectomy, infrainguinal, or aorto-iliac-femoral bypass and angioplasty from Nationwide Inpatient Sample (NIS) data, then categorized as staged, or performed on the same day. Outcomes included utilization rates, total hospital charges, and length of stay (LOS). Confounders of charges and LOS were identified and excluded from final comparisons. RESULTS: Utilization increased 7% from 2000 to 2004. Univariate associations linked staging to variables included in linear regressions for hospital charges and LOS. Excluding identified confounders from the final subgroup analysis still showed large differences in charges (same-day = $34,206, staged = $60,087) and LOS (same-day = 3 days, staged = 7 days). CONCLUSIONS: Utilization of hybrids is increasing. Performing hybrids on the same day, if possible, greatly reduces hospital charges and LOS, emphasizing preadmission planning and simultaneous coordination of both portions.

Fate of excluded popliteal artery aneurysms.

OBJECTIVE: Popliteal artery aneurysms (PAA) are frequently treated with ligation and exclusion bypass grafting. It is assumed that these aneurysms will shrink and remain asymptomatic. This may not always be true. We sought to elucidate the fate of excluded PAA over time. METHODS: Data for all PAAs treated with ligation and exclusion bypass grafting between 1986 and 1999 were retrospectively reviewed. Computed tomography (CT) scans and duplex ultrasound scans provided aneurysm patency data and maximal transverse diameter measurements of the popliteal artery during late postoperative follow-up. This information was compared with that from similar preoperative studies. RESULTS: Forty-one patients (39 men, 2 women) underwent 57 ligation and exclusion bypass grafting procedures. Both preoperative and late postoperative (mean, 4.0 years; range, 0.43-13.5 years) CT scans or duplex ultrasound scans were available for review of 25 PAAs in 18 patients (ages 42-80 years; mean, 63 years). Preoperative PAA size ranged from 14 to 45 mm (mean, 28.7 mm). In late follow-up, 12 (48%) PAA had decreased in size (mean, 7.3 mm), 5 (20%) remained unchanged, and 8 (32%) increased in mean transverse diameter (mean, 5.9 mm). One large aneurysm increased by 50%. Contrast material enhancement was identified in the excluded sac in 11 aneurysms. CONCLUSIONS: PAA treated with ligation and exclusion bypass grafting often expand and can become symptomatic. This may be analogous to type II endoleak or endotension noted after aortic endovascular repair. We recommend PAA excision or endoaneurysmorrhaphy when feasible.

Caudal migration of endoprostheses after treatment of abdominal aortic aneurysms.

BACKGROUND: The purpose of this study is to assess the migration of endoprostheses 2 years after endovascular abdominal aortic aneurysm repair. METHODS: Ten patients underwent placement of bifurcated endoprostheses for infrarenal aneurysm and had 2-year CT follow-up. Standardized contrast-enhanced CT with 1.5- or 2-mm overlapping slice thickness was used. Four independent observers measured the distance from the lowest renal artery to the craniad end of the graft. RESULTS: As a whole, the endoprostheses migrated an average of 2.7 +/- 2.6 mm caudad at 24 months compared with baseline (P < 0.001). Four patients (40%) experienced > or =3-mm migration of the endoprostheses. On review of the 6- and 12-month follow-up CT scans, movement occurred at both the first- and the second-year intervals. CONCLUSIONS: Endovascular stent-grafts frequently migrate away from the renal arteries. This may be due to natural elongation of the native infrarenal aortic segment, but could also result from inadequate attachment of the proximal stent-graft. Although there have been no adverse clinical events in this group, continued close follow-up is mandatory following endovascular aneurysm repair.