A retrospective analysis of 513 patients undergoing pedicle subtraction osteotomy for adult spinal deformity by a single surgical team: are elderly patients at an elevated risk for complications?

OBJECTIVE: This study aimed to assess whether elderly patients (aged ≥ 70 years) face an elevated risk of complications following pedicle subtraction osteotomy (PSO) for adult spinal deformity (ASD) compared with younger patients (< 70 years) and to evaluate if clinical and radiological outcomes differ between these age groups. METHODS: A retrospective analysis of 513 patients undergoing PSO for ASD by a single surgical team between January 2006 and January 2023 was conducted. Patients were categorized by age (≥ 70 years and < 70 years). Data on clinical, demographic, comorbidity, and radiographic details were collected and compared between the groups. For health-related quality of life assessment, the authors recorded the Oswestry Disability Index (ODI), numeric rating scale (NRS), and Scoliosis Research Society-22 revised (SRS-22r) scores preoperatively and at 6 weeks and 1 year postoperatively. Perioperative complications included major (neurological deficit, death, acute myocardial infarction, stroke), minor (ileus, arrhythmia, delirium), and intraoperative (durotomy, vascular injury). RESULTS: Of 513 patients, 412 were included in the study. Clinical outcomes, as measured by NRS, ODI, and SRS-22r scores, were comparable between groups, with both groups showing significant improvements postoperatively. Radiographic outcomes also showed significant and comparable improvements in sagittal balance and spinopelvic harmony in both groups. Deformity corrections were also well maintained at 1 year postoperatively. The elderly group (mean age 75.48 years) had a higher rate of perioperative complications (44.64%) than the younger group (mean age 59.60 years; 30.33%) (p = 0.0030), primarily minor complications such as delirium and arrhythmia (16.07% vs 8.61%, p = 0.0279). There was no significant difference between groups regarding the major complication rate (elderly group: 20.83% vs younger group: 14.34%, p = 0.1087), intraoperative complication rate (2.98% vs 3.69%, p = 0.6949), short-term complication rate (10.12% vs 8.20%, p = 0.5024), mechanical complication rate (30.95% vs 32.79%, p = 0.6949), and reoperation rate due to mechanical complications (38.46% vs 43.75% p = 0.5470). CONCLUSIONS: Elderly patients undergoing PSO for ASD experience a higher rate of minor complications but can achieve clinical and radiological outcomes that are comparable to those of younger patients. The authors found no significant increase in major, intraoperative, short-term, or mechanical complication rates and their subsequent reoperation rates among the elderly. These findings underscore the effectiveness of PSO in improving the quality of life for patients with ASD across age groups, emphasizing the critical role of personalized perioperative management in enhancing outcomes and minimizing risks for all patients.

Effects of pelvic fixation strategies and multi-rod constructs on biomechanics of the proximal junction in long thoracolumbar posterior instrumented fusions: a finite-element analysis.

PURPOSE: To assess the effect of various pelvic fixation techniques and number of rods on biomechanics of the proximal junction of long thoracolumbar posterior instrumented fusions. METHODS: A validated spinopelvic finite-element (FE) model was instrumented with L5-S1 ALIF and one of the following 9 posterior instrumentation configurations: (A) one traditional iliac screw bilaterally ("2 Iliac/2 Rods"); (B) T10 to S1 ("Sacral Only"); (C) unilateral traditional iliac screw ("1 Iliac/2 Rods"); (D) one traditional iliac screw bilaterally with one midline accessory rod ("2 Iliac/3 rods"); (E) S2AI screws connected directly to the midline rods ("2 S2AI/2 Rods"); and two traditional iliac screws bilaterally with two lateral accessory rods connected to the main rods at varying locations (F1: T10-11, F2: T11-12, F3: T12-L1, F4: L1-2) ("4 Iliac/4 Rods"). Range of motions (ROM) at T10-S1 and T9-T10 were recorded and compared between models. The T9-T10 intradiscal pressures and stresses of the T9-10 disc's annulus in addition to the von Mises stresses of the T9 and T10 vertebral bodies were recorded and compared. RESULTS: For T10-S1 ROM, 4 iliac/4 rods had lowest ROM in flexion and extension, while 2 S2AI/2 rods showed lowest ROM in rotation. Constructs with 3 or 4 rods had lower stresses on the primary rods compared to 2-rod constructs. At the proximal adjacent disc (T9-10), 4 iliac/4 rods showed lowest ROM, lowest intradiscal pressures, and lowest annular stress in all directions (most pronounced in flexion-extension). Under flexion and extension, 4 iliac/4 rods also showed the lowest von Mises stresses on the T10 vertebral body but the highest stresses on the T9 vertebral body. CONCLUSIONS: Dual iliac screws with 4 rods across the lumbosacral junction and extending to the thoracolumbar junction demonstrated the lowest T10-S1 ROM, the lowest adjacent segment disc (T9-T10) ROM, intradiscal pressures, and annular stresses, and the lowest UIV stresses, albeit with the highest UIV + 1 stresses. Additional studies are needed to confirm whether these biomechanical findings dictate clinical outcomes and effect rates of proximal junctional kyphosis and failure.

Modeling of valve-in-valve transcatheter aortic valve implantation after aortic root replacement using a 3-dimensional artificial intelligence algorithm.

OBJECTIVE: Aortic root replacement requires construction of a composite valve-graft and reimplantation of coronary arteries. This study assessed the feasibility of valve-in-valve transcatheter aortic valve implantation after aortic root replacement. METHODS: A retrospective review was conducted on 74 consecutive patients who received a composite valve-graft at a single institution from 2019 to 2021. Forty patients had bioprosthetic valves with adequate postoperative gated computed tomographic angiography scans. Computational simulations of balloon and self-expanding transcatheter valve deployments were performed. The modeled coronary distances were compared with traditional, manually measured valve-to-coronary distances. RESULTS: There was a statistically significant difference in the modeled versus manual measurements of valve to coronary distances for all patients regardless of valve type or coronary artery analyzed (P < .05). Most patients are low risk for coronary obstruction per 3-dimensional modeling, including those with a valve-to-coronary distance <4 mm. Only 1 patient (2.5%) was at risk for coronary obstruction for the left coronary artery using a balloon valve. No other valve combination was considered high risk of coronary obstruction. Five patients (12.5%) were at risk for possible valve stent deformation at the outflow, due to angulation at the graft anastomosis. CONCLUSIONS: Following aortic root replacement, all patients were candidates for valve-in-valve procedure using 1 or both types of transcatheter heart valves. Self-expanding valves may be at higher risk for stent frame deformation at graft anastomotic lines and balloon-expandable valves may be at higher risk of coronary obstruction.

Self-administered gerocognitive examination (SAGE) aids early detection of cognitive impairment at primary care provider visits.

Introduction: Current estimates indicate that up to 50-75% of dementia cases are undiagnosed at an early stage when treatments are most effective. Conducting robust accurate cognitive assessments can be time-consuming for providers and difficult to incorporate into a time-limited Primary Care Provider (PCP) visit. We wanted to compare PCP visits with and without using the self-administered SAGE to determine differences in identification rates of new cognitive disorders. Methods: Three hundred patients aged 65-89 without diagnosed cognitive disorders completing a non-acute office visit were enrolled (ClinicalTrials.gov identifier: NCT04063371). Two PCP offices conducted routine visits for 100 consecutive eligible patients each. One office used the SAGE in an additional 100 subjects and asked available informants about cognitive changes over the previous year. Chart reviews were conducted 60 days later. One-way analysis of variance and Fisher exact tests were used to compare the groups and outcomes. Results: When SAGE was utilized, the PCP documented the detection of new cognitive conditions/concerns six times (9% versus 1.5%) as often (p = 0.003). The detection rate was nearly 4-fold for those with cognitively impaired SAGE scores (p = 0.034). Patients having impaired SAGE score and informant concerns were 15-fold as likely to have new cognitive conditions/concerns documented (p = 0.0007). Among providers using SAGE, 86% would recommend SAGE to colleagues. Discussion: SAGE was easily incorporated into PCP visits and significantly increased identification of new cognitive conditions/concerns leading to new diagnoses, treatment, or management changes. The detection rate increased 15-fold for those with impaired SAGE scores combined with informant reports.

Completely Minimally Invasive Implant Removal and Transforaminal Lumbar Interbody Fusion for Adjacent Segment Disease: Case Series and Operative Video.

BACKGROUND AND OBJECTIVES: Adjacent segment disease is a relatively common late complication after lumbar fusion. If symptomatic, certain patients require fusion of the degenerated adjacent segment. Currently, there are no posterior completely minimally invasive techniques described for fusion of the adjacent segment above or below a previous fusion. We describe here a novel minimally invasive technique for both implant removal (MIS-IR) and adjacent level transforaminal lumbar interbody fusion (MIS-TLIF) for lumbar stenosis. METHODS: Demographic, surgical, and radiographic outcome data were collected for patients with lumbar stenosis and previous lumbar fusion, who were treated with MIS-IR and MIS-TLIF through the same incision. Radiographic outcomes were assessed postoperatively and complications were assessed at the primary end point of 3 months. RESULTS: A total of 14 patients (7 female and 7 male), with average age 64.6 years (SD 13.4), were included in this case series. Nine patients had single-level MIS-IR with single-level MIS-TLIF. Three patients had 2-level MIS-IR with single-level MIS-TLIF. Two patients had single-level MIS-IR with 2-level MIS-TLIF. Only 1 patient had a postoperative complication-hematoma requiring same-day evacuation. There were no other complications at the primary end point and no fusion failure at the hardware removal levels to date (average follow-up, 11 months). Average increases in posterior disk height and foraminal height after MIS-TLIF were 4.44, and 2.18 mm, respectively. CONCLUSION: Minimally invasive spinal IR can be successfully completed along with adjacent level TLIF through the same incisions, via an all-posterior approach.

Timelines for Return to Different Sports Types After Eight Cervical Spine Fractures in Recreational and Elite Athletes: A Survey of the Association for Collaborative Spine Research.

STUDY DESIGN: Prospective cross-sectional survey. OBJECTIVE: To identify timelines for when athletes may be considered safe to return to varying athletic activities after sustaining cervical spine fractures. BACKGROUND: While acute management and detection of cervical spine fractures have been areas of comprehensive investigation, insight into timelines for when athletes may return to different athletic activities after sustaining such fractures is limited. METHODS: A web-based survey was administered to members of the Association for Collaborative Spine Research that consisted of surgeon demographic information and questions asking when athletes (recreational vs elite) with one of 8 cervical fractures would be allowed to return to play noncontact, contact, and collision sports treated nonoperatively or operatively. The third part queried whether the decision to return to sports was influenced by the type of fixation or the presence of radiculopathy. RESULTS: Thirty-three responses were included for analysis. For all 8 cervical spine fractures treated nonoperatively and operatively, significantly longer times to return to sports for athletes playing contact or collision sports compared with recreational and elite athletes playing noncontact sports, respectively (P< 0.05), were felt to be more appropriate. Comparing collision sports with contact sports for recreational and elite athletes, similar times for return to sports for nearly all fractures treated nonoperatively or operatively were noted. In the setting of associated radiculopathy, the most common responses for safe return to play were "when only motor deficits resolve completely" and "when both motor and sensory deficits resolve completely." CONCLUSIONS: In this survey of spine surgeons from the Association for Collaborative Spine Research, reasonable timeframes for return to play for athletes with 8 different cervical spine fractures treated nonoperatively or operatively varied based on fracture subtype and level of sporting physicality.

Coronal Alignment in Adult Spine Surgery.

Coronal realignment is an important goal in adult spine surgery that has been overshadowed by emphasis on the sagittal plane. As coronal malalignment drives considerable functional disability, a fundamental understanding of its clinical and radiographic evaluation and surgical techniques to prevent its development is of utmost importance. In this study, we review etiologies of coronal malalignment and their radiographic and clinical assessments, risk factors for and functional implications of postoperative coronal malalignment, and surgical strategies to optimize appropriate coronal realignment in adult spine surgery.

Anterior lumbar interbody fusion versus transforaminal lumbar interbody fusion for correction of lumbosacral fractional curves in adult (thoraco)lumbar scoliosis: A systematic review.

Background: Anterior lumbar interbody fusion (ALIF) or transforaminal lumbar interbody fusion (TLIF) may be used to correct the lumbosacral fractional curve (LsFC) in de novo adult (thoraco) lumbar scoliosis. Yet, the relative benefits of ALIF and TLIF for LsFC correction remain largely undetermined. Purpose: To compare the currently available data comparing radiographic correction of the LsFC provided by ALIF and TLIF of LsFC in adult (thoraco)lumbar scoliosis. Methods: A systematic review was performed on original articles discussing fractional curve correction of lumbosacral spinal deformity (using search criteria: "lumbar" and "fractional curve"). Articles which discussed TLIF or ALIF for LsFC correction were presented and radiographic results for TLIF and ALIF were compared. Results: Thirty-one articles were returned in the original search criteria, with 7 articles included in the systematic review criteria. All 7 articles presented radiographic results using TLIF for LsFC correction. Three of these articles also discussed results for patients whose LsFC were treated with ALIFs; 2 articles directly compared TLIF and ALIF for LsFC correction. Level III and level IV evidence indicated ALIF as advantageous for reducing the coronal Cobb angle of the LsFC. There were mixed results on relative efficacy of ALIF and TLIF in the LsFC for restoration of adequate global coronal alignment. Conclusions: Limited level III and IV evidence suggests ALIF as advantageous for reducing the coronal Cobb angle of the LsFC in de novo adult (thoraco) lumbar scoliosis. Relative efficacy of ALIF and TLIF in the LsFC for restoration of global coronal alignment may be dictated by several factors, including directionality and magnitude of preoperative coronal deformity. Given the limited and low-quality evidence, additional research is warranted to determine the ideal interbody support strategies to address the LsFC in adult (thoraco) lumbar scoliosis.

An Integrated 3-Dimentional Navigation System Increases the Accuracy, Efficiency, and Safety of Percutaneous Thoracolumbar Pedicle Screw Placement in Minimally Invasive Approaches: A Randomized Cadaveric Study.

STUDY DESIGN: Cadaveric study. OBJECTIVES: The purpose of this study was to compare a novel, integrated 3D navigational system (NAV) and conventional fluoroscopy in the accuracy, efficiency, and radiation exposure of thoracolumbar percutaneous pedicle screw (PPS) placement. METHODS: Twelve skeletally mature cadaveric specimens were obtained for twelve individual surgeons. Each participant placed bilateral PS at 11 segments, from T8 to S1. Prior to insertion, surgeons were randomized to the sequence of techniques and the side (left or right). Following placement, a CT scan of the spine was obtained for each cadaver, and an independent reviewer assessed the accuracy of screw placement using the Gertzbein grading system. Outcome metrics of interest included a comparison of breach incidence/severity, screw placement time, total procedure time, and radiation exposure between the techniques. Bivariate statistics were employed to compare outcomes at each level. RESULTS: A total of 262 screws (131 using each technique) were placed. The incidence of cortical breaches was significantly lower with NAV compared to FG (9% vs 18%; P = .048). Of breaches with NAV, 25% were graded as moderate or severe compared to 39% in the FG subgroup (P = .034). Median time for screw placement was significantly lower with NAV (2.7 vs 4.1 min/screw; P = .012), exclusive of registration time. Cumulative radiation exposure to the surgeon was significantly lower for NAV-guided placement (9.4 vs 134 µGy, P = .02). CONCLUSIONS: The use of NAV significantly decreased the incidence of cortical breaches, the severity of screw breeches, screw placement time, and radiation exposure to the surgeon when compared to traditional FG.

Bilateral dual iliac screw pelvic fixation for adult spinal deformity: a case report of a superior gluteal artery pseudoaneurysm secondary to aberrant iliac screw trajectory.

PURPOSE: To present a case of a pseudoaneurysm of a branch of the left superior gluteal artery (SGA) secondary to lateral wall perforation from an iliac screw and its subsequent evaluation and management. METHODS: Case report. RESULTS: A 67-year-old female with a history of degenerative flatback and scoliosis and pathological fractures of T12 and L1 secondary to osteodisciitis underwent a single0stage L5-S1 ALIF and T9-pelvis posterior instrumented fusion with bilateral dual iliac screw fixation, revision T11-S1 decompression, and T12 and L1 irrigation and debridement and partial corpectomies. During the operation, non-pulsatile bleeding was encountered after creating an initial trajectory for the more proximal of the two left iliac screws. While the initial post-operative course was benign, the patient was readmitted for hypotension and anemia. Computed tomography of the abdomen/pelvis demonstrated a pseudoaneurysm (2.3 cm × 2.1 cm × 2.3 cm) of a branch of the left SGA. Diagnostic angiogram confirmed a pseudoaneurysm off of one of the branches of the left SGA. Endovascular embolization using multiple coils resulted in a complete cessation of blood flow in the pseudoaneurysm. At 2 years follow-up, no symptoms suggestive of recurrence of the pseudoaneurysm were reported. CONCLUSIONS: A pseudoaneurysm of a branch of the left superior gluteal artery as a result of lateral wall perforation from an aberrantly placed iliac screw during an adult spinal deformity operation involving dual screw pelvic fixation is reported. Prompt recognition, multidisciplinary collaboration, and appropriate intervention were key in achieving a successful outcome and preventing further morbidity.

Abdominal lymphocele following multi-level anterior lumbar interbody fusion (ALIF) managed with a laparoscopic peritoneal window: case report and review of the literature.

PURPOSE: Lymphocele formation following anterior lumbar interbody fusion (ALIF) is not common, but it can pose diagnostic and treatment challenges. The purpose of this case is to report for the first time the treatment of a postoperative lymphocele following a multi-level ALIF using a peritoneal window made through a minimally invasive laparoscopic approach. METHODS: Case report. RESULTS: A 74-year-old male with a history of prostatectomy and pelvic radiation underwent a staged L3-S1 ALIF (left paramedian approach) and T10-pelvis posterior instrumented with L1-5 decompression/posterior column osteotomies for degenerative scoliosis and neurogenic claudication. Three weeks after surgery, swelling of the left abdomen and entire left leg was reported. Computed tomography of the abdomen/pelvis demonstrated a large (19.2 × 12.0 × 15.4 cm) retroperitoneal fluid collection with compression of the left ureter and left common iliac vein. Fluid analysis (80% lymphocytes) was consistent with a lymphocele. Percutaneous drainage for 4 days was ineffective at clearing the lymphocele. For more definitive management, the patient underwent an uncomplicated laparoscopic creation of a peritoneal window to allow passive drainage of lymphatic fluid into the abdomen. Three years after surgery, he had no back or leg pain, had achieved spinal union, and had no abdominal swelling or left leg swelling. Advanced imaging also confirmed resolution of the lymphocele. CONCLUSIONS: In this case report, creation of a peritoneal window minimally invasively via a laparoscope allowing passive drainage of lymphatic fluid into the abdomen was safe and effective for management of an abdominal lymphocele following a multi-level ALIF.

Odontoid fractures above C2 to pelvis posterior instrumented fusions: a single center's 11-year experience.

PURPOSE: To define the prevalence, characteristics, and treatment approach for proximal junction failure secondary to odontoid fractures in patients with prior C2-pelvis posterior instrumented fusions (PSF). METHODS: A single institution's database was queried for multi-level fusions (6+ levels), including a cervical component. Posterior instrumentation from C2-pelvis and minimum 6-month follow-up was inclusion criteria. Patients who sustained dens fractures were identified; each fracture was subdivided based on Anderson & D'Alonzo and Grauer's classifications. Comparisons between the groups were performed using Chi-square and T tests. RESULTS: 80 patients (71.3% female; average age 68.1 ± 8.1 years; 45.0% osteoporosis) were included. Average follow-up was 59.8 ± 42.7 months. Six patients (7.5%) suffered an odontoid fracture post-operatively. Cause of fracture in all patients was a mechanical fall. Average time to fracture was 23 ± 23.1 months. Average follow-up after initiation of fracture management was 5.84 ± 4 years (minimum 1 year). Three patients sustained type IIA fractures one of which had a concomitant unilateral C2 pars fracture. Three patients sustained comminuted type III fractures with concomitant unilateral C2 pars fractures. Initial treatment included operative care in 2 patients, and an attempt at non-operative care in 4. Non-operative care failed in 75% of patients who ultimately required revision with proximal extension. All patients with a concomitant pars fracture had failure of non-operative care. Patients with an intact pars were more stable, but 50% required revision for pain. CONCLUSIONS: In this 11-year experience at a single institution, the prevalence of odontoid fractures above a C2-pelvis PSF was 7.5%. Fracture morphology varied, but 50% were complex, comminuted C2 body fractures with concomitant pars fractures. While nonoperative management may be suitable for type II fractures with simple patterns, more complex and unstable fractures likely benefit from upfront surgical intervention to prevent fracture displacement and neural compression. As all fractures occurred secondary to a mechanical fall, inpatient and community measures aimed to minimize risk and prevent mechanical falls would be beneficial in this high-risk group.

Proximal Junctional Kyphosis and Failure: Strategies for Prevention.

Proximal junctional kyphosis (PJK) and proximal junctional failure/fractures (PJF) are common complications following long-segment posterior instrumented fusions for adult spinal deformity. As progression to PJF involves clinical consequences for patients and requires costly revisions that may undermine the utility of surgery and are ultimately unsustainable for health care systems, preventative strategies to minimize the occurrence of PJF are of tremendous importance. In this article, the authors present a detailed outline of PJK and PJF with a focus on surgical strategies aimed at preventing their occurrence..

Navigated Hybrid Open/Muscle-sparing Approach to 2-level Cement Augmentation of the UIV and UIV+1 for Prevention of Proximal Junctional Failure: Supplemental Manuscript to Operative Video.

STUDY DESIGN: Operative video and supplemental manuscript. OBJECTIVE: To present a cement augmentation technique of the upper instrumented vertebra (UIV) and UIV+1 for prevention of proximal junctional fractures (PJFs) in multi-level thoracolumbar posterior instrumented fusions. SUMMARY OF BACKGROUND DATA: PJFs are unfortunately a common occurrence after multi-level thoracolumbar instrumented fusions to the pelvis for adult spinal deformity that can result in significant functional disability and often require costly revision operations. As such, their prevention is key. METHODS: A surgical video illustrates the nuances of a 2-level cement augmentation technique, consisting of an open vertebroplasty of the UIV through fenestrated screws and a muscle-sparing kyphoplasty of the UIV+1. RESULTS: Utility of performing an open vertebroplasty of the UIV through fenestrated screws and muscle-sparing kyphoplasty of the UIV+1 lies in its ability to minimize soft-tissue disruption at the adjacent segment while providing additional structural support to the anterior column at this high-risk zone. CONCLUSIONS: Cement augmentation of the UIV and UIV+1 consisting of a hybrid open vertebroplasty and muscle-sparing kyphoplasty can be an effective strategy to decrease the incidence of PJF after multi-level posterior thoracolumbar instrumented fusions to the pelvis for adult spinal deformity.

Lumbar Pedicle Subtraction Osteotomy (PSO): A Novel Surgical Technique for Correction of Sagittal and Coronal Imbalance Using Laterally Based Satellite Rods.

STUDY DESIGN: Operative video and supplemental manuscript. OBJECTIVE: To present a novel step-by-step approach to performing a lumbar pedicle subtraction osteotomy (PSO) using laterally based satellite rods. SUMMARY OF BACKGROUND DATA: Multi-rod constructs have demonstrated paramount for decreasing rates of pseudarthrosis after PSOs. Multi-rods constructs can be achieved using either "satellite" rods (rods not connected to the primary rods) and/or "accessory rods" (rods connected to the primary rods). METHODS: A step-by-step approach to performing a lumbar PSO using a laterally based satellite rod configuration is provided through a case example and surgical technique video. RESULTS: Lateral satellite rods can be particularly useful from a surgical perspective, as they provide temporary stabilization while the PSO is being performed, facilitate closure of the osteotomy site (symmetric and/or asymmetric), and serve as the final fixation rods across the PSO without needing to be exchanged. CONCLUSIONS: Use of laterally based satellite rods is a useful technique for lumbar PSOs, as they provide temporary stabilization while the PSO is being performed, facilitate closure of the osteotomy site, and serve as the final fixation rods across the PSO without needing to be exchanged.

Aortic arch and frozen elephant trunk repair of a right-sided aortic arch with pseudoaneurysm rupture.

A 53-year-old man with a history of vascular ring repair secondary to a right-sided aortic arch with a retroesophageal subclavian artery and ligamentum arteriosum to the descending thoracic aorta presented to our institution with a large aortic pseudoaneurysm of the distal aortic arch. Computed tomography demonstrated a right-sided aortic arch with a 5.8-cm pseudoaneurysm arising from the distal arch with concern for rupture. The patient underwent successful two-stage repair, including a left carotid artery to subclavian artery bypass, followed by total arch replacement with the frozen elephant trunk technique. He recovered well postoperatively, and computed tomography showed complete, successful repair of the pseudoaneurysm.