A novel hybrid approach to the treatment of common iliac aneurysms: antegrade endovascular hypogastric stent grafting and femorofemoral bypass grafting.

A progressively enlarging left common iliac artery aneurysm developed in a 72-year-old man 7 years after open abdominal aortic aneurysm repair with a bifurcated Dacron graft. Because both the right hypogastric and inferior mesenteric arteries had been ligated at the initial operation, preservation of left hypogastric flow was critical to avoid pelvic or intestinal ischemia. He was a poor open surgical candidate owing to obesity, a hostile abdomen, and multiple medical comorbidities. Therefore, a novel hybrid approach was used consisting of left transbrachial selective left hypogastric artery catheterization, followed by deployment of two, overlapping, antegrade, covered stent grafts extending from the proximal left graft limb into the left hypogastric artery. A right-to-left femorofemoral crossover bypass was added to perfuse the left lower extremity and was performed in end-to-end fashion to the left common femoral artery to exclude and prevent retrograde flow into the iliac aneurysm. Also presented are potential procedural pitfalls and a detailed review of open, endovascular and hybrid options to preserve hypogastric flow when treating iliac aneurysms in complex, high-risk patients.

Long-term experience of girdling the ascending aorta with Dacron mesh as definitive treatment for aneurysmal dilation.

BACKGROUND: The management of the mildly to moderately dilated ascending aorta (3.5 to 4.9 cm) in cardiac surgery remains controversial. Therapeutic options have included radical aortic resection with synthetic graft substitution, external aortic reinforcement or wrap, with or without partial aortic wall excision, and a watch-and-wait approach. We reviewed our institutional experience with Dacron (DuPont, Wilmington, DE) mesh wrap support of dilated ascending aortas. METHODS: During the last 20 years, 102 patients with aneurysmal dilatation of the ascending aorta underwent wrapping of the ascending aorta with a fine Dacron mesh from the ventricular-aortic junction to the origin of the innominate artery. For the last 10 years, the wrap was anchored to the aortic annulus with pledgeted sutures. Aortic diameters up to 6 cm, without focal areas of thinning, were wrapped. Aortic diameters exceeding 6 cm, or with focal thinning, underwent tailored aortic wall resection and wrapping. Primary end points of the study included mortality, aortic diameter growth, dissection or rupture, or both. RESULTS: The mean age of the group was 54.7 +/- 19 years (range, 12 to 90 years). A single patient underwent aortic wrapping without cardiopulmonary bypass. Sixty-six patients (65%) required additional aortic valve surgery. Five patients (5%) had reinforcement of dilated sinuses with glutaraldehyde-treated pericardial patches combined with wrapping. Twenty-seven patients (26%) had combined coronary and valve surgery, and 2 patients had coronary revascularization alone. There was neither early nor hospital mortality. Among the 81 patients (79%) we were able to contact, 7 (7%) late deaths had occurred at 0.5, 1, 3, and 9 years after operation that were unrelated to aortic pathology. Various levels of follow-up were obtained in the 88 patients (86.2%). In 78 patients, echocardiograms, computed tomography angiograms, or magnetic resonance angiograms were obtained. In 2 of these patients, aneurysmal dilatation of the sinuses developed below the wrap and reoperation was required. No patient in whom the mesh wrap was anchored to the aortic annulus required reoperation. All 81 patients that were contacted by us and monitored by referring physicians were asymptomatic and free of problems related to the aorta. The mean (+/- SD) preoperative diameter of the ascending aorta was 49.2 +/- 7.8 mm (range, 35 to 87 mm), the postwrap intraoperative diameter was 32.9 +/- 3.4 mm (range, 20 to 40 mm), and the follow-up postoperative aortic diameter was 35.6 +/- 12.7 mm (range, 27 to 52 mm). The mean average change in the aortic diameter during the follow-up period was 2.6 +/- 14.8 mm (range, -7 to 22 mm), a mean of 8%. The mean follow-up period was 5.7 years (median, 4.77 years; range, 9 days to 21 years). There were no infections or other early complications related to the wrap. CONCLUSIONS: Dacron mesh support of the moderately dilated aneurysmal ascending aorta, alone or in conjunction with coronary revascularization, aortic root surgery, or valvular operations, or both, is safe and durable. Dacron mesh is transparent and stretchable, permitting tight girdling of the aorta. These properties prevent hematoma formation, facilitate proximal vein graft anastomoses, and provide visualization and access to aortic suture lines. Finally, this technique retards further aortic dilation, altering the natural history of aortic aneurysms.

Aesthetic skin branding: a novel form of body art with adverse clinical sequela.

Branding is a form of body art wherein third-degree burns are inflicted on the skin to produce permanent scars. This method of scarification is a common practice among many indigenous cultures and has become exceedingly common in western societies. As with other forms of body art, branding is not a manifestation of a psychiatric disorder but, rather, a method of self-expression. The process can be performed through the use of electrocautery, laser, chemicals, freezing, and hot metal. Complications arising from the procedure include acute infection, transmission of blood-borne pathogens, allergic reactions, and sequelae arising from third-degree burns. In addition, skin branding has been shown to be associated with substance abuse and high-risk behaviors among adolescents. The purpose of this article is to present the following case report and review to familiarize clinicians with this dangerous method of body art.

Is eclampsia preventable? A case control review of consecutive cases from an urban underserved region.

OBJECTIVES: The purpose of this study was to determine whether eclampsia is potentially preventable. METHODS: This was a retrospective case control study comparing 25 cases of eclampsia, 33 cases of preeclampsia and 50 pregnant controls. Eclampsia cases were classified as follows: group A was potentially preventable by patient education if there were preeclamptic symptoms before presenting to the hospital; group B was potentially preventable by health care provider if patient presented to health care with evidence of preeclampsia and was not appropriately treated; group C was not preventable if eclampsia developed without symptoms or preeclampsia. Statistical analysis was done as applicable. RESULTS: The mean gestational age at seizure was 34 weeks; 50% of seizures occurred outside a hospital and 44% had multiple seizures. Twenty were antepartum, three intrapartum, and two postpartum. Fourteen (56%) cases were classified as group A, 4 (16%) as group B and 7 (28%) as group C. Compared to controls, African-Americans, nulliparity, premature delivery, and increased neonatal morbidity were significantly associated with eclampsia. Compared with preeclamptics, eclamptic subjects had more symptomatology and more adverse maternal complications. CONCLUSIONS: In this underserved population, a significant percentage of eclampsia cases are potentially preventable by patient education or health care response. In a smaller percentage, eclampsia may develop without any symptomatology or preeclampsia.