Brief review: Pulmonary artery aneurysms and pseudoaneurysms.

The purpose of this review article is to provide a brief overview of pulmonary artery aneurysms and pseudoaneurysms, to discuss the classifications of these conditions, review the role of imaging and discuss management in affected patients.

True aneurysm in autologous hemodialysis fistulae: definitions, classification and indications for treatment.

INTRODUCTION: Definition, etiology, classification and indication for treatment of the arteriovenous access (AVA) aneurysm are poorly described in medical literature. The objectives of the paper are to complete this information gap according to the extensive review of the literature. METHODS: A literature search was performed of the articles published between April 1, 1967, and March 1, 2014. The databases searched included Medline and the Cochrane Database of Systematic Reviews. The eligibility criteria in this review studies the need to assess the association of aneurysms and pseudoaneurysms with autologous AVA. Aneurysms and pseudoaneurysms involving prosthetic AVA were not included in this literature review. From a total of 327 papers, 54 non-English papers, 40 case reports and 167 papers which did not meet the eligibility criteria were removed. The remaining 66 papers were reviewed. RESULTS: Based on the literature the indication for the treatment of an AVA aneurysm is its clinical presentation related to the patient's discomfort, bleeding prevention and inadequate access flow. A new classification system of AVA aneurysm, which divides it into the four types, was also suggested. CONCLUSIONS: AVA aneurysm is characterized by an enlargement of all three vessel layers with a diameter of more than 18 mm and can be presented in four types according to the presence of stenosis and/or thrombosis. The management of an AVA aneurysm depends on several factors including skin condition, clinical symptoms, ease of cannulation and access flow. The diameter of the AVA aneurysm as a solo parameter is not an indication for the treatment.

Carotid and vertebral injury study (CAVIS) technique for characterization of blunt traumatic aneurysms with reliability assessment.

Traumatic aneurysms occur in up to 20% of blunt traumatic extracranial carotid artery injuries. Currently there is no standardized method for characterization of traumatic aneurysms. For the carotid and vertebral injury study (CAVIS), a prospective study of traumatic cerebrovascular injury, we established a method for aneurysm characterization and tested its reliability. Saccular aneurysm size was defined as the greatest linear distance between the expected location of the normal artery wall and the outer edge of the aneurysm lumen ("depth"). Fusiform aneurysm size was defined as the "depth" and longitudinal distance ("length") paralleling the normal artery. The size of the aneurysm relative to the normal artery was also assessed. Reliability measurements were made using four raters who independently reviewed 15 computed tomographic angiograms (CTAs) and 13 digital subtraction angiograms (DSAs) demonstrating a traumatic aneurysm of the internal carotid artery. Raters categorized the aneurysms as either "saccular" or "fusiform" and made measurements. Five scans of each imaging modality were repeated to evaluate intra-rater reliability. Fleiss's free-marginal multi-rater kappa (κ), Cohen's kappa (κ), and interclass correlation coefficient (ICC) determined inter- and intra-rater reliability. Inter-rater agreement as to the aneurysm "shape" was almost perfect for CTA (κ = 0.82) and DSA (κ = 0.897). Agreements on aneurysm "depth," "length," "aneurysm plus parent artery," and "parent artery" for CTA and DSA were excellent (ICC > 0.75). Intra-rater agreement as to aneurysm "shape" was substantial to almost perfect (κ > 0.60). The CAVIS method of traumatic aneurysm characterization has remarkable inter- and intra-rater reliability and will facilitate further studies of the natural history and management of extracranial cerebrovascular traumatic aneurysms.

Solución del caso 3. Seudoaneurisma femoral micótico de origen espontáneo / Case 3. Spontaneous mycotic femoral pseudoaneurysm

No disponible

Peripancreatic pseudoaneurysms: a management-based classification system.

BACKGROUND: Peripancreatic pseudoaneurysms can arise in a number of different clinical settings but are associated mostly with pancreatitis and pancreatobiliary surgery. The aim of this study is to review the current literature and to propose a management classification system based on the pathophysiological processes and the exact anatomical site of peripancreatic pseudoaneurysms. METHODS: A systematic review of the literature from 1995 to 2012 was performed. Articles on studies describing peripancreatic pseudoaneurysms in the setting of pancreatitis or major hepatic or pancreatic surgery with more than ten patients were included. Seventeen eligible studies were identified and reviewed. RESULTS: The demographic characteristics of the patients in all studies were similar with a predominance of males and a mean age of 55 years. The overall mortality rate varied greatly among the studies, ranging from 0 to 60%. Embolisation was the first line of management in the majority of the studies, with surgery reserved for failed embolisation or for haemodynamically unstable cases. Embolisation of the hepatic artery or its branches was associated with high rates of morbidity (56%) and hepatic failure (19%). More recent studies show that stents are used increasingly for vessels that cannot be embolised safely. Late bleeding, a major cause of mortality and morbidity, is generally underreported. The proposed classification system is based on three factors: (1) the type of artery from which the pseudoaneurysm arises, (2) whether communication with the gastrointestinal tract is present, and (3) whether there is high concentration of pancreatic juice at the bleeding site. CONCLUSION: The management of peripancreatic pseudoaneurysms usually comprises a combination of interventional radiology and surgery and this may be assisted by a logical classification system.

Multiple overlapping stents as monotherapy in the treatment of 'blister' pseudoaneurysms arising from the supraclinoid internal carotid artery: a single institution series and review of the literature.

BACKGROUND: The 'blister-type' aneurysm is one of the most devastating cerebrovascular lesions. Flow diversion with stent reconstruction is an emerging treatment and has shown promising initial results. OBJECTIVE: To evaluate the experience of one institution using stent reconstruction for pseudoaneurysms of the supraclinoid internal carotid artery and to compare with a review of the literature. METHODS: A retrospective review from one institution identified eight patients with 'blister' aneurysms over a 47-month period. The Raymond scale was used to classify the aneurysms. Clinical data were obtained using the modified Rankin Scale (mRS) and the National Institute of Health Stroke Scale. A literature review was performed and compared with our results. Clinical and angiographic data were obtained. RESULTS: After treatment, two aneurysms were Raymond class 1 (25%) and six were class 3 (75%). Of the class 3 aneurysms, two required retreatment, three (50%) progressed to complete occlusion and three (50%) had persistent aneurysm filling. Clinical data revealed two patients with mRS score of 0 (25%), five with mRS score of 1 (62.5%) and one with mRS score of 2 (12.5%). From the literature review, residual filling was evident in nine patients (64.3%) and complete occlusion in four (28.6%). On follow-up angiography, nine (64.3%) were occluded, two (14.3%) had residual neck filling and one (7.1%) had persistent aneurysm filling. Thirteen patients (92.9%) had an mRS score of 2 or better. Combining the available experience, patients demonstrated either improvement (n=9, 41%) or stability (n=11, 50%). Only two (9%) had progression requiring retreatment. CONCLUSIONS: Endovascular stent remodeling of 'blister-type' aneurysms is a safe and effective strategy.

A new classification scheme for treating blunt aortic injury.

BACKGROUND: There are numerous questions about the treatment of blunt aortic injury (BAI), including the management of small intimal tears, what injury characteristics are predictive of death from rupture, and which patients actually need intervention. We used our experience in treating BAI during the past decade to create a classification scheme based on radiographic and clinical data and to provide clear treatment guidelines. METHODS: The records of patients admitted with BAI from 1999 to 2008 were retrospectively reviewed. Patients with a radiographically or operatively confirmed diagnosis (echocardiogram, computed tomography, or angiography) of BAI were included. We created a classification system based on the presence or absence of an aortic external contour abnormality, defined as an alteration in the symmetric, round shape of the aorta: (1) intimal tear (IT)-absence of aortic external contour abnormality and intimal defect and/or thrombus of <10 mm in length or width; (2) large intimal flap (LIF)-absence of aortic external contour abnormality and intimal defect and/or thrombus of ≥10 mm in length or width; (3) pseudoaneurysm-presence of aortic external contour abnormality and contained rupture; (4) rupture-presence of aortic external contour abnormality and free contrast extravasation or hemothorax at thoracotomy. RESULTS: We identified 140 patients with BAI. Most injuries were pseudoaneurysm (71%) at the isthmus (70%), 16.4% had an IT, 5.7% had a LIF, and 6.4% had a rupture. Survival rates by classification were IT, 87%; LIF, 100%; pseudoaneurysm, 76%; and rupture, 11% (one patient). Of the ITs, LIFs, and pseudoaneurysms treated nonoperatively, none worsened, and 65% completely healed. No patient with an IT or LIF died. Most patients with ruptures lost vital signs before presentation or in the emergency department and did not survive. Hypotension before or at hospital presentation and size of the periaortic hematoma at the level of the aortic arch predicted likelihood of death from BAI. CONCLUSIONS: As a result of this new classification scheme, no patient without an external aortic contour abnormality died of their BAI. ITs can be managed nonoperatively. BAI patients with rupture will die, and resources could be prioritized elsewhere. Those with LIFs do well, and currently, most at our institution are treated with a stent graft. If a pseudoaneurysm is going to rupture, it does so early. Hematoma at the arch on computed tomography scan and hypotension before or at arrival help to predict which pseudoaneurysms need urgent repair.

Classification of blunt aortic injuries a new systematic overview of aortic trauma.

Blunt (non-penetrating) aortic injuries, in which the arterial wall is damaged in the direction from the intima towards the adventitia, are most commonly the result of a traffic accident. The various forms of blunt aortic injuries, from limited laceration of the intima to complete transection of the aorta, depend on the morphological structure of the arterial wall and the strength of forces causing the trauma. An overview of the literature and medical documentation reveals that different terms, including tear, laceration, disruption, transection, rupture and pseudoaneurysm, are used to describe certain forms of traumatic aortic injuries, which can lead to misinterpretation of findings or diagnoses. We therefore, propose a classification that would enable uniform systematic screening of all forms of blunt aortic injuries. In a retrospective examination of autopsy reports from 1999 to 2006, all those who had died in traffic accidents and who had blunt aortic injuries were selected from the archive at the Institute of Forensic Medicine of the Medical Faculty of the University of Ljubljana, Slovenia. Blunt aortic injuries (ruptures) were classified into three basic types and corresponding subtypes: type I (intramural), type II (transmural) and type III (multiple) aortic ruptures. The study included 230 deceased persons with 355 aortic ruptures. According to our classification, type I ruptures were observed in 25 (11%), type II ruptures in 131 (57%) and type III ruptures in 74 (32%) cases. The new classification we propose allows simple and systematic screening of all types of blunt aortic injuries. It prevents misinterpretation of various types of aortic injury in medical practice.

Traumatic aortic transection with intraluminal aortic fat: transesophageal echocardiographic characteristics and implications.

Aortic transection can be a catastrophic complication of blunt chest trauma. Transesophageal echocardiography is a useful tool for assessing aortic pathology. Presented is a case of traumatic aortic transection in which periaortic fat was found within the aortic lumen. Transesophageal echocardiographic characteristics are reviewed and clinical implications discussed.