Evolution of open aneurysmorrhaphy for management of sac expansion after endovascular repair of abdominal aortic aneurysms.

OBJECTIVE: We evaluated the perioperative and mid-term clinical outcomes of open aneurysmorrhaphy (OA) for the treatment of sac expansion after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms. METHODS: OA involves sac exposure without dissection of the proximal or distal neck, sacotomy and ligation of back-bleeding vessels, preservation of the prior stent graft, and tight closure of the sac around the stent graft. We performed a retrospective review of all patients who had undergone OA for nonruptured sac expansion after standard EVAR at our institution between January 2015 and June 2021. The primary end points were 30-day mortality and aneurysm-related death. The secondary end points were postoperative complications, overall survival, freedom from reintervention, and sac regrowth rate. RESULTS: A total of 28 patients had undergone OA. Their mean age was 76.9 ± 6.7 years. The median sac diameter at OA was 79 mm (interquartile range [IQR], 76-92 mm). The median duration from the index EVAR to OA was 82 months (IQR, 72-104 months). Preoperative computed tomography angiography confirmed a type II endoleak (EL) in 20 patients, 1 of whom had had a coexisting type Ia EL; a type IIIb EL was identified in 1 patient. Concomitant endovascular procedures had been performed in six patients to treat a type I or III EL or reinforce the proximal and distal seals. The OA technique has been modified since 2017, with the addition of more aggressive dissection of the sac and complete removal of the mural thrombus to further decrease the sac diameter. Postoperative complications occurred in two patients and included abdominal lymphorrhea and failed hemostasis of the common femoral artery requiring surgical repair in one patient each. The 30-day mortality was 0%. During the median follow-up of 36 months (IQR, 14-51 months), the overall survival was 92.7% and 86.9% at 12 and 36 months, respectively, without any aneurysm-related death. In the late (2017-2021) treatment group, the median sac diameter immediately after OA was smaller than that in the early (2015-2016) treatment group (early group: median, 50 mm; IQR, 39-57 mm; vs later group: median, 41 mm; IQR, 32-47 mm; P = .083). Furthermore, in the late group, the sac regrowth rate was lower (early group: median, 0.36 mm/mo; IQR, 0.23-0.83 mm/mo; vs late group: median, 0 mm/mo; IQR, 0-0.11 mm/mo; P = .0075) and the freedom from reintervention rate was higher (late group: 94.7% at both 12 and 36 months, respectively; early group: 71.4% and 53.6% at 12 and 36 months, respectively; log-rank P = .070). CONCLUSIONS: Our results have shown that OA for the management of post-EVAR sac expansion is feasible with acceptable mid-term outcomes. Aggressive dissection and tight plication of the sac might be imperative for better mid-term outcomes after OA.

[Sleeve Shaping Technique for Two Cases of Peripheral Artery Aneurysms Involving Important Branches].

Peripheral artery aneurysms,with low incidence and complex anatomic structure,often involve important branches.This paper introduces a new surgical technique-sleeve shaping on the basis of two cases.The basic data,including characteristics,imaging,operation and follow-up data of the cases,were collected.The data were then combined with the previous literature for explaining in detail that this technique can be used as a supplementary method of reconstruction following resection or endovascular repair.

[Reconstructive operations for aneurysmatic transformation of veins in patients on programmed haemodialysis]. / Rekonstruktivnye operatsii pri anevrizmaticheskoi transformatsii ven u patsientov, nakhodiashchikhsia na programmnom gemodialize.

Aneurysmatic transformation of a fistulous vein is one of the most frequently encountered complications in patients on programmed dialysis. This complication increases the risk of dysfunction of an arteriovenous fistula. However, there are no common approaches to correction of this complication. This study was aimed at assessing the results of aneurysmorrhaphy for treating aneurysms of fistulous veins in patients on programmed dialysis. For this purpose, we carried out a retrospective analysis of the results of operations in a total of 87 patients with aneurysmatic transformation of an arteriovenous fistula. All patients were subjected to aneurysmorrhaphy supplemented, if necessary, by plasty of stenosis with the use of the tissue of the wall of the resected aneurysm. The vein was placed into a new subcutaneous channel (transposition with transection of the vein) or a pocket formed by the separated subcutaneous tissue (transposition without transection). Secondary patency after 1 year amounted to 95.3%, after 2 years to 91.4%, and after 3 years to 87.6%. At 4.8 years, 69% (95% CI 44.9-84.2) of the arteriovenous fistulas proved patent. CONCLUSION: Aneurysmorrhaphy supplemented with correction of concomitant complications of aneurysms of fistulous veins is an effective and safe operation making it possible to maintain the function of an arteriovenous fistula for a long period of time.

Giant abdominal aortic aneurysm of uncommon etiology due to Behçet disease.

Behçet disease is a multisystem disorder presenting with recurrent oral and genital ulcerations as well as with ocular involvement. Vascular involvement can occur in up to 50% of affected patients. Arterial aneurysms are often multiple and are characterized by a saccular configuration with increased risk of unexpected rupture, thrombosis, and aneurysm recurrence. Here we report a case of giant infrarenal abdominal aortic aneurysm in a 34-year-old man with Behçet disease who underwent aneurysmorrhaphy and aortobifemoral bypass.

A single center's experience with total arterial revascularization and spiral aneurysmorrhaphy for ischemic cardiac disease.

The restoration of left ventricular (LV) geometry in combination with coronary artery bypass grafting for the treatment of ischemic cardiac disease remains controversial. We hereby present the experience of our center with total arterial myocardial revascularization (TAMR) and spiral aneurysmorrhaphy for ischemic heart disease. A retrospective analysis of 101 patients with advanced cardiovascular disease who underwent TAMR and spiral aneurysmorrhaphy was performed. Spiral aneurysmorrhaphy is a modification of the linear aneurysmorrhaphy and was applied to patients who had a LV aneurysm with a diameter of less than 5 cm. Peri-operative and in-hospital data were retrieved. The majority of the patients were male (87.13%) with a mean age of 63.1 years. Mean pre-operative ejection fraction (EF) was 35.7% ranging between 20 and 65%. An average of 3.23 grafts was required per patient. Early mortality was 6.93% (one intra-operative and six in-hospital deaths). Addition of concomitant valve surgery was associated with prolonged total operative, cardiopulmonary bypass and cross-clamp time (p < 0.001), increased need for blood (p = 0.012) and plasma (p = 0.038), longer intensive care unit (ICU) stay (p = 0.045) and higher rate of post-operative cerebrovascular accident (p = 0.011). Furthermore, patients with a pre-operative EF between 30 and 50% had a shorter ICU stay (p = 0.045) and LoS (p = 0.029) compared with patients with EF <30%. Early mortality and post-operative complication rates following this combined procedure are in consistency with the relevant available data suggesting its feasibility regardless of the EF or addition of concomitant surgeries. Data from the follow-up of these patients are required to examine the long-term efficacy of this surgical modality.

Internal maxillary artery bypass for the treatment of complex middle cerebral artery aneurysms.

OBJECTIVEThe rapid innovation of the endovascular armamentarium results in a decreased number of indications for a classic surgical approach. However, a middle cerebral artery (MCA) aneurysm remains the best example of one for which results have favored microsurgery over endovascular intervention. In this study, the authors aimed to evaluate the experience and efficacy regarding surgical outcomes after applying internal maxillary artery (IMA) bypass for complex MCA aneurysms (CMCAAs).METHODSAll IMA bypasses performed between January 2010 and July 2018 in a single-center, single-surgeon practice were screened.RESULTSIn total, 12 patients (9 males, 3 females) with CMCAAs managed by high-flow IMA bypass were identified. The mean size of CMCAAs was 23.7 mm (range 10-37 mm), and the patients had a mean age of 31.7 years (range 14-56 years). The aneurysms were proximally occluded in 8 cases, completely trapped in 3 cases, and completely resected in 1 case. The radial artery was used as the graft vessel in all cases. At discharge, the graft patency rate was 83.3% (n = 10), and all aneurysms were completely eliminated (83.3%, n = 10) or greatly diminished (16.7%, n = 2) from the circulation. Postoperative ischemia was detected in 2 patients as a result of graft occlusion, and 1 patient presenting with subarachnoid hemorrhage achieved improved modified Rankin Scale scores compared to the preoperative status but retained some neurological deficits. Therefore, neurological assessment at discharge showed that 9 of the 12 patients experienced unremarkable outcomes. The mean interval time from bypass to angiographic and clinical follow-up was 28.7 months (range 2-74 months) and 53.1 months (range 19-82 months), respectively. Although 2 grafts remained occluded, all aneurysms were isolated from the circulation, and no patient had an unfavorable outcome.CONCLUSIONSThe satisfactory result in the present study demonstrated that IMA bypass is a promising method for the treatment of CMCAAs and should be maintained in the neurosurgical armamentarium. However, cases with intraoperative radical resection or inappropriate bypass recipient selection such as aneurysmal wall should be meticulously chosen with respect to the subtype of MCA aneurysm.

Renal Stent Crushed During Open Aneurysmorrhaphy for Endoleak After Fenestrated EVAR.

PURPOSE: To report a complication of renal stent crushing during open aneurysmorrhaphy performed 10 years after fenestrated endovascular aneurysm repair (FEVAR). CASE REPORT: A 67-year-old male patient underwent elective FEVAR of a juxtarenal aortic aneurysm. Uncovered balloon-expandable stents were placed through the fenestrations for the superior mesenteric and right renal arteries; the left renal artery received a Jostent covered balloon-expandable stent. The uncovered right renal stent was noted to be crushed on the first imaging after FEVAR, but was left untreated; the right kidney was thereafter significantly smaller than the left. Over several years, the aneurysm expanded, and type II endoleak involving the lumbar arteries was embolized with coils 7 years after FEVAR. Despite this, the aneurysm continued to enlarge and reached a diameter of 12.8 cm. Open aneurysmorrhaphy and selective ligation of lumbar arteries was performed 10 years after FEVAR. The first surveillance imaging after aneurysmorrhaphy demonstrated a new finding of a crushed left renal stent, which was presumed to be related to surgical instrumentation. The stent was successfully redilated percutaneously, and renal function remained stable. Computed tomography demonstrated a normal appearance of the left renal covered stent after re-expansion. Doppler ultrasound after 7.5 months showed normal renal perfusion. CONCLUSION: Balloon-expandable visceral artery stents are susceptible to crush injury during aortic surgery. Consideration should be given to early imaging after such surgery in FEVAR patients.

Reinforced aneurysmorrhaphy for true aneurysmal haemodialysis vascular access.

OBJECTIVE: In 2008, a new technique of reinforced aneurysmorrhaphy with a polyester mesh tube for salvaging true aneurysmal arteriovenous (AV) haemodialysis access was described by us. In this study, the long-term patency and complication rates associated with this procedure were analysed, and the effect of reinforced aneurysmorrhaphy on high-flow vascular access was assessed. METHODS: This was a retrospective non-randomised study with prospectively collected data performed at a single centre. Patients with true aneurysmal haemodialysis AV access who underwent aneurysmorrhaphy with external mesh prosthesis between March 2007 and October 2012 were included. Clinical assessment and duplex ultrasound were performed preoperatively, 1, 3, and 12 months postoperatively, and annually thereafter. RESULTS: Data from 62 patients (median age 60 years, range 28-81 years; 63% men) were analysed. The commonest indication was high-flow vascular access associated with the risk of high output cardiac failure (24 patients, 39%). The mean follow-up time was 14.66 ± 12.80 months. Primary patency rates at 6 and 12 months were 86% and 79% respectively. Assisted primary patency rates at 6 and 12 months were 89% and 80% respectively. In 23 patients (96%) operated on for high-flow vascular access, decreased vascular access flow was observed after the procedure. The average flow reduction after aneurysmorrhaphy was 2,197 mL/minute. Postoperative bleeding and infection necessitating surgical revision occurred in three (4.8%) and three (4.8%) patients respectively. CONCLUSIONS: Reinforced aneurysmorrhaphy with an external mesh prosthesis is an effective method for treating true aneurysmal haemodialysis AV access, with excellent long-term patency and minimal complications due to infection.

Salvage Aneurysmorrhaphy as an Adaptable and Still Pertinent Technique in the Management of Challenging True Aneurysms of Arteriovenous Fistulas: A Case Series of Different Variations, With Illustrative Surgical Pictures.

Introduction: Aneurysmorrhaphy, described as reduction aneurysmoplasty, partial aneurysmectomy, or vessel wall recalibration, can be considered a suitable surgical plan for true aneurysms of arteriovenous fistulas (AVFs), allowing for a dynamic approach to reconstruction of aneurysmal AVFs of different severities, ensuring salvage of the native access. Report: Six challenging cases of AVF aneurysms are presented, some with extremely dilated and tortuous megafistulas, for which three surgical technique variations were performed. The patients had a mean age of 59.2 years, 50% were female, with brachiocephalic (n = 5, 83.3%) or brachiobasilic (n = 1, 16.7%) AVFs. The fistulas were created an average of 4.67 years previously, and the aneurysms had an average maximum diameter of 37.5 mm (range 25-60 mm). Surgical indications were rupture risk, thrombosis, or outflow stenosis compromising haemodialysis, infections, and concerns for quality of life (affected by post-puncture bleedings, disfiguring aesthetics, pain, and discomfort). The surgical techniques were simple aneurysmorrhaphy (n = 3, 50%), aneurysmorrhaphy with partial excision of aneurysmal segment with end to end anastomosis of venous ends (n = 2, 33.3%), and aneurysmorrhaphy with establishment of new venous outflow (n = 1, 16.7%). All AVFs were patent post-operatively and at follow up (mean 5.6 months, median one month). Haemodialysis was resumed through the AVFs at a mean of 2.17 weeks post-operatively, with placement of an alternative route for haemodialysis in the meantime. No patients experienced post-operative complications. Discussion: Experience with the more challenging cases shows that aneurysmorrhaphy can still be considered an acceptable, flexible, and pertinent method for salvage of megafistulas, giving the surgeon the much needed versatility to adapt to anatomical and pathological variations, with high patency rates and minimal complications, especially when other treatment options are not possible in complicated cases. AVF salvage through aneurysmorrhaphy allows for a dynamic approach to the reconstruction of severely tortuous, dilated veins, ensuring patency of the native AVF.

Giant Coeliac Artery Aneurysm Treated with a Hybrid Approach: A Case Report.

Introduction: Coeliac artery aneurysms are rare and have a high mortality rate when ruptured. Although they are often asymptomatic, treatment is recommended for patients with true coeliac aneurysms >2.5 cm, noted enlargement, or associated symptoms. Less invasive endovascular treatment is predominantly performed for coeliac artery aneurysms, while open surgery is preferred for patients with compression symptoms. Here, a case of symptomatic giant coeliac artery aneurysm that was successfully treated with hybrid surgery is reported. Report: A 73 year old man was referred with continuous epigastric discomfort and loss of appetite for two weeks. Abdominal ultrasound and computed tomography revealed a 12 cm aneurysm of the coeliac artery. The splenic and common hepatic arteries were severely distorted and compressed by the aneurysm, making their origins unclear. Considering the risk of rupture, semi-urgent surgery was performed with interruption of the inflow and outflow arteries using open and endovascular techniques together with aneurysmorrhaphy. Vascular reconstruction was omitted because abundant collateral flow to the liver and spleen was confirmed on angiography. Discussion: With the hybrid approach, aneurysmorrhaphy was performed safely with minimal incision and dissection. Short term outcomes were satisfactory, with complete resolution of compression symptoms and remarkable sac shrinkage at 12 months. Owing to the possibility of the pancreaticoduodenal arcade developing as a collateral pathway, periodic surveillance for de novo aneurysms is warranted.

Salvage of a megafistula causing high-output cardiac failure in a young adult with aneurysmorrhaphy and banding.

We present the case of a 21-year-old male with significant lengthening and aneurysmal degeneration of his brachiocephalic arteriovenous fistula resulting in a megafistula and high-output cardiac failure. A computed tomography angiogram showed narrowing at the cephalic arch. Further evaluation during the operation revealed kinking and elongation of the fistula in addition to compression of the cephalic arch in the deltopectoral groove leading to outflow obstruction. The aneurysmal fistula was treated successfully with aneurysmorrhaphy of the remaining conduit and banding of the inflow. This case demonstrates a unique etiology of venous outflow obstruction for a fistula and describes the surgical approach to its treatment in a young patient suffering from cardiac failure.

Open aneurysmorrhaphy for repair of a massive iliac vein aneurysm and review of the recent literature.

An iliac vein aneurysm is a rare vascular anomaly, scarcely reported in the vascular literature. We present the case of a 72-year-old man with a history of a remote heart transplant complicated by severe tricuspid regurgitation and traumatic abdominal injury, who was incidentally found to have a 10-cm right common iliac vein aneurysm. Because of the size and risk of rupture, we elected to treat him with surgical iliac vein aneurysmorrhaphy. His iliac venous diameter and flow continued to be stable at subsequent follow-up.

External iliac vein aneurysm treated via balloon-assisted aneurysmorrhaphy with a contemporary review of the literature.

Isolated external iliac vein aneurysm is exceedingly rare, not well-described in the literature, and presents several potential surgical approaches. Herein, we describe the case of a 72-year-old woman who presented with incidentally found 4.3 cm × 3.4 cm × 5.6 cm right external iliac vein aneurysm after undergoing magnetic resonance imaging for orthopedic work-up. She was treated via parallel supra- and infra-inguinal incisions and novel combination of primary aneurysmorrhaphy with intraluminal balloon mandrel-assisted closure. The patient was discharged on postoperative day two, and 6-month follow-up ultrasound showed a normal caliber vessel with normal compressibility, suggesting this technique is safe and effective for appropriately selected patients.

Pulmonary embolism secondary to popliteal vein aneurysm: case report and literature review.

Aim: Aneurysms are rarely detected in the popliteal vein as only a few cases have been reported in the literature so far. However, such aneurysms can be fatal due to thromboembolic complications or rupture. Case presentation: A 47-year-old male who had multiple bilateral pulmonary embolisms secondary to saccular right popliteal vein aneurysm discovered by lower limb duplex ultrasound and successfully treated with tangential aneurysmectomy with venorrhaphy. Conclusion: Popliteal vein aneurysm should be ruled out as a cause of pulmonary embolism, and medical treatment should be started rapidly, but surgical management remains the gold standard.

Surgical management of venous aneurysms.

BACKGROUND: Venous aneurysms (VA) are often underestimated as a dangerous vascular condition that can lead to fatal complications. We have adopted a more aggressive surgical approach to treatment of venous aneurysms that seems to be safe and effective, and report herein the results of this approach. METHODS: A retrospective analysis of patients presented with VA between January 2013, and January 2018. RESULTS: We identified 13 VA in 13 patients. The mean patient age was 21.6 years (range, 7-42 years). Six patients were male (46.2%) and seven were female (53.8%). All patients presented with swellings in different areas, mostly in the neck (nine patients [69.2%]). Two patients had a short saphenous vein aneurysm complicated with paresthesia (15.3%). All patients underwent surgical correction. Tangential excision was done for noncomplicated saccular aneurysms (six patients [46.2%]), whereas ligation and excision were done for fusiform aneurysms (five patients) and two saccular aneurysms presenting with thrombosis (53.8%). No signification complications were noted. CONCLUSIONS: Surgical treatment of venous aneurysms is safe and may help to avoid possible pulmonary embolism.

Surgical intervention for upper extremity nerve compression related to arteriovenous hemodialysis accesses.

OBJECTIVE: Chronic renal failure patients with arteriovenous hemodialysis access may exhibit pain and neurological complaints due to local nerve compression by the access conduit vessels of autogenous arteriovenous fistulas or the prosthesis of arteriovenous grafts. In this study, we have examined the results of surgical intervention for vascular access-related nerve compression in the upper extremity. METHODS: A single center retrospective study was performed of all patients referred for persistent pain and neurological complaints after vascular access surgery for hemodialysis. There were four brachial-cephalic, three brachial-basilic upper arm arteriovenous fistulas, and three prosthetic arteriovenous grafts. All patients had pain and sensory deficits in a distinct nerve territory (median nerve: 6; median + ulnar nerve: 1; medial cutaneous nerve: 1), and two patients had additional motor deficits (median nerve). RESULTS: A total of 10 patients (mean age: 59 years; range: 25-73 years; 2 men; 4 diabetics) were treated by surgical nerve release alone (2 patients) or in combination with access revision (8 patients). Mean follow-up was 23 months (range: 8-46 months). Direct complete relief of symptoms was achieved in six patients. Three patients had minor complaints, and one patient had a reoperation with good success. CONCLUSION: Vascular access-related nerve compression is an uncommon cause for pain, sensory and motor deficits after vascular access surgery. Surgical nerve release and access revision have good clinical outcome with relief of symptoms and maintenance of the access site in the majority of patients.

Successful Aneurysmorrhaphy for a Giant Idiopathic Pulmonary Artery Aneurysm.

Idiopathic aneurysm of pulmonary artery is a rare disorder with unclear pathology and mechanism. The indications for its surgical treatment are not clear, especially in cases with normal pulmonary pressure. We report the case of a 64-year-old man with a giant idiopathic aneurysm of the pulmonary artery (max diameter 97.3 mm). The patient successfully underwent surgical treatment with the aneurysmorrhaphy in our Department of Cardiovascular and Thoracic Surgery. The patient was extubated successfully within 6 hours of the operation and discharged hospital after 10 days. In cases with giant aneurysm of the pulmonary artery, the aneurysmorrhaphy may be considered as a safe and feasible choice.

Open bilateral common femoral and popliteal vein aneurysm repair.

Although venous aneurysms are rare, typically asymptomatic, and most commonly found incidentally on imaging studies, patients with this pathology can develop pulmonary emboli owing to these aneurysms acting as a nidus for thrombus formation. There is no clear consensus regarding conservative management with anticoagulation vs operative intervention as the best treatment of deep venous aneurysms. We report the clinical course and surgical treatment of a patient presenting with both bilateral common femoral vein and bilateral popliteal venous aneurysms who had a known history of prior symptomatic pulmonary emboli.

Bipolar Coagulation Aneurysm Dome Remodeling (Aneurysmorrhaphy) for Middle Cerebral Artery Aneurysms.

Adequate visualization of the proximal and distal vessels and clip reconstruction of the bifurcation with complete aneurysm neck exclusion are often difficult in the setting of bulbous small- and moderate-sized middle cerebral artery (MCA) aneurysms. We describe our experience with bipolar aneurysm dome remodeling in the setting of bulbous MCA aneurysms. The charts of the senior author's (Aaron Cohen-Gadol) patients who underwent clip ligation of their MCA aneurysm (220 patients), and more specifically those whose aneurysm clipping was facilitated through bipolar coagulation remodeling (8 patients), were reviewed. Patient demographics, aneurysm characteristics, and postoperative angiographic results were analyzed. Eight patients with eight MCA aneurysms were treated through this technique over a six-year period. Their mean age was 53 years, and six of the eight patients were women. Two involved the anterior temporal artery, and the rest were at the M1 bifurcation or trifurcation. Three of the eight were ruptured; the mean aneurysm maximum diameter was 7 mm. Postoperative angiography demonstrated complete aneurysm obliteration in seven of eight patients; one patient had an asymptomatic mild stenosis of her anterior temporal artery's origin, and another had a small neck remnant in the setting of a highly atherosclerotic neck. On the basis of this experience, dome coagulation remodeling of small- and moderate-sized bulbous aneurysms in the setting of poor proximal and distal vessel visualization was found to be safe for facilitating aneurysm clipping and offers more desirable clip deployment.