Successful endovascular exclusion of Mycobacterium bovis mycotic aneurysm following intravesical bacille Calmette-Guerin therapy.

Bacille Calmette-Guerin (BCG) is a live-attenuated strain of Mycobacterium bovis. It is routinely used in the treatment of early-stage transitional cell carcinoma. The development of mycotic aneurysm in the context of prior intra-vesical BCG treatment has not been reported. This case demonstrates a rare but potentially catastrophic vascular complication of BCG. A high index of suspicion is required for any patient presenting with new aneurysmal disease in the context of previous BCG therapy. The value of endovascular surgery as a bridge to definitive surgical repair and diagnostic considerations is discussed.

Supra-aortic vessels aneurysms: diagnosis and prompt intervention.

PURPOSE: Aneurysms involving the supra-aortic vessels are rare but carry serious risk of embolization, thrombosis, and rupture. We describe our experience with the diagnosis, treatment strategies, and outcomes in patients with extended follow-up. METHODS: Data during a 17-year period (January 1990 to December 2007) was analyzed. We assessed age, gender, presenting symptoms, localization, pathologic diagnosis, type of procedures, complications, and survival. RESULTS: A total of 74 patients were treated for supra-aortic aneurysms. Of all aneurysms treated, 63% were degenerative, 24% iatrogenic, 8% traumatic, 3% genetic, and 1% mycotic. The subclavian artery was most commonly affected (50%, 2/3 in the right side), followed by the common carotid (36%), internal carotid (10%), innominate (3%), and vertebral (1%). At the time of diagnosis, 52 patients (70%) were asymptomatic, but of those symptomatic 68% had an embolic event as a presenting symptom. Embolic episodes were more common in patients with smaller aneurysms (P < .006). Open surgery was performed in 77% of all cases, and the use of endovascular techniques became the predominant treatment modality over the last 4 years. Survival at 30 days was 100%. Five- and 10-year survival rates were 87% and 43%, respectively. CONCLUSION: Most cases of supra-aortic aneurysm are asymptomatic and embolization as opposed to rupture represents the greatest risk to the patient. Most cases can be detected prior to symptoms. Endovascular repair is an emerging alternative of treatment and, with the current development of appropriate devices, will likely form the mainstay of therapy in the near future.

Revised duplex criteria and outcomes for renal stents and stent grafts following endovascular repair of juxtarenal and thoracoabdominal aneurysms.

OBJECTIVES: To assess outcomes and develop duplex scan criteria that will reliably determine the luminal status of covered and uncovered renal stents following fenestrated and branched endovascular repair. METHODS: A prospective database of patients treated with fenestrated and branched endografts between 2001 and 2006 was reviewed. All patients with evidence of renal artery pathology including duplex scan assessed peak systolic velocity (PSV) <50 or >200 cm/s, renal aortic ratio (RAR) >3.5, elevation of the serum creatinine >30%, computed tomography (CT) evidence of renal stenosis underwent further analyses including medical chart review, and a review of CT and duplex scan imaging data. Correlations of ultrasound scan, CT, angiographic, and clinical outcomes were conducted and receiver operator curve (ROC) analysis was performed. Freedom from stenosis or occlusion was determined by Kaplan-Meier analysis with differences assessed by log rank tests. RESULTS: A total of 518 renal arteries were treated with uncovered or covered renal stents (287 patients). Mean follow-up was 25 months. The estimated freedom from stenosis at 12, 24, and 36 months were 95% (95% confidence interval [CI] 93-98), 92% (89-96), and 89% (85-93) for uncovered stents, and 98% (96-100), 97% (95-100), and 95% (91-100) for covered stents (log rank P = .04). Secondary interventions were performed in 20% of the patients who developed stenoses. Only one of the detected stenoses that was not treated with a secondary intervention progressed to occlusion. Duplex scan criteria derived from ROC analysis correlating with curved planar reconstruction (CPR) from axial imaging data calculated a 60-99% in-stent stenosis to be associated with a PSV >280 cm/s or RAR >4.5. Occlusions were best identified by a mid renal artery PSV <57 cm/s in conjunction with an RAR <1.2. CONCLUSION: Revised ultrasound scan criteria have been developed to improve the sensitivity and specificity of non-invasive interrogation of renal stents following endovascular aneurysm repair (EVAR). Covered renal stents are associated with a lower incidence of in-stent stenosis and are thus recommended over uncovered stents for use in fenestrated or branched endografts.

Simultaneous endovascular repair of an iatrogenic carotid-jugular fistula and a large iliocaval fistula presenting with multiorgan failure: a case report.

INTRODUCTION: Iliocaval fistulas can complicate an iliac artery aneurysm. The clinical presentation is classically a triad of hypotension, a pulsatile mass and heart failure. In this instance, following presentation with multiorgan failure, management included the immediate use of an endovascular stent graft on discovery of the fistula. CASE PRESENTATION: A 62-year-old Caucasian man presented to our tertiary hospital for management of iatrogenic trauma due to the insertion of a central venous line into his right common carotid artery, causing transient ischemic attack. Our patient presented to a peripheral hospital with fever, nausea, vomiting, acute renal failure, acute hepatic dysfunction and congestive heart failure. A provisional diagnosis of sepsis of unknown origin was made. There was a 6.5 cm×6.5 cm right iliac artery aneurysm present on a non-contrast computed tomography scan. An unexpected intra-operative diagnosis of an iliocaval fistula was made following the successful angiographic removal of the central line to his right common carotid artery. Closure of the iliocaval fistula and repair of the iliac aneurysm using a three-piece endovascular aortic stent graft was then undertaken as part of the same procedure. This was an unexpected presentation of an iliocaval fistula. CONCLUSION: Our case demonstrates that endovascular repair of a large iliac artery aneurysm associated with a caval fistula is safe and effective and can be performed at the time of the diagnostic angiography. The presentation of an iliocaval fistula in this case was unusual which made the diagnosis difficult and unexpected at the time of surgery. The benefit of immediate repair, despite hemodynamic instability during anesthesia, is clear. Our patient had two coronary angiograms through his right femoral artery decades ago. Unusual iatrogenic causes of iliocaval fistulas secondary to previous coronary angiograms with wire and/or catheter manipulation should be considered in patients such as ours.

Endoleaks following endovascular repair of thoracic aortic aneurysm: etiology and outcomes.

PURPOSE: To evaluate the incidence and natural history of endoleaks following thoracic endovascular aortic repair (TEVAR) of thoracic aortic aneurysm (TAA). METHODS: A retrospective review was conducted on 200 TAA patients (122 men; mean age 69+/-12 years) who underwent elective TEVAR in the descending thoracic aorta between January 2001 and December 2006. The mean aneurysm diameter was 66 mm (range 50-124), and most (75%) of the aneurysms were atherosclerotic in origin. Medical records and multidetector computed tomography studies were evaluated on a 3-dimensional workstation to categorize endoleak, establish morphological characteristics, and assess outcomes. The outcomes following any secondary interventions were noted in the context of endoleak etiology and the magnitude of the intervention. RESULTS: Over a mean follow-up of 30 months (range 12-73), 39 (19.5%) patients developed an endoleak (33 primary and 8 secondary); 3 people had 2 distinct types of endoleaks. Endoleaks were associated with the presence of a carotid-subclavian bypass (p = 0.0001) and lengthy aortic coverage by the stent-graft (p = 0.005). The proportion of the 170 patients with a Zenith stent-graft who had an endoleak (17%, n = 39) was significantly lower (p<0.01) than the proportion of endoleaks (34%, n = 10) in the 30 patients with Gore or Talent devices. Secondary interventions for endoleak were performed in 79% of type I, 24% of type II, and 57% of type III endoleaks. CONCLUSION: In this study, 1 in 5 TAA patients with TEVAR had endoleak. Most type I and III endoleaks required secondary intervention, while conservative treatment was most frequent for type II. Characterization of endoleak type was not always precise, and routine surveillance of all patients with endoleak is recommended.