Coronary aneurysms represent anomalies identified in 0.15%–4.9% of patients undergoing coronary angiography. At present, there is no uniform definition of this pathology. Aneurysms of the left main coronary artery (LMCA) are extremely uncommon, with an incidence of 0.1%. It has been demonstrated that atherosclerosis is the main cause of these anomalies in adults, and Kawasaki disease in children and adolescents. Other causes include connective tissue disorders, trauma, vasculitis, congenital, mycotic, and idiopathic. These dilated sections of the coronary artery are not benign pathology because they are subject to spasm, thrombosis, and subsequent distal embolism, spontaneous dissection and rupture. Treatment options include anticoagulation, custom-made covered stents, reconstruction, resection, and exclusion with bypass. Our report on an old case illustrates the giant saccular LMCA aneurysm leading to myocardial ischemia due to coronary steal phenomenon.
Coronary aneurysm; Coronary artery disease; Coronary angiography
Mycotic aneurysms are rarely seen in patients who have infective endocarditis, and the management of these patients remains controversial. We present the case of a patient who had infective endocarditis complicated by a mycotic aneurysm of the left middle cerebral artery. There was substantial mitral regurgitation, and Streptococcus viridans was isolated from the blood samples. Dysarthria appeared during the 4th week of the antibiotic therapy, but resolved completely 8 hours after onset. The left middle cerebral artery was embolized with platinum detachable coils. On the 7th day after the radiologic intervention, the native mitral valve was replaced with a 33-mm St. Jude Medical® bileaflet mechanical mitral prosthesis. Most mycotic aneurysms show notable regression of symptoms with effective antibiotic treatment, and a very few may diminish in size. However, it is impossible to predict the response of these aneurysms to therapy. To prevent the perioperative rupture of mycotic aneurysms and intracranial hemorrhage, priority should be given to endovascular interventions to treat cerebrovascular aneurysms in patients such as ours.
Aneurysm, infected; embolization, therapeutic; endocarditis, bacterial; intracranial aneurysm/therapy; mitral valve/surgery
Although internal mammary artery pseudoaneurysms are a rare vascular abnormality, they are sometimes seen after sternotomy, diagnostic and therapeutic vascular access or penetrating chest trauma. To our knowledge, internal mammary artery pseudoaneurysm caused by pulmonary actinomycosis has not been reported previously. We report a case of pseudoaneurysm of the left internal mammary artery caused by pulmonary actinomycosis. A 50-year-old woman initially presented with clinical and radiological features of pneumonia, for which she was treated empirically with antibiotics. Later, she developed haemoptysis along with pain and swelling in the left upper chest wall. Multidetector CT (MDCT) with CT angiography showed a cavitating mass in the left upper lobe of the lung that infiltrated into the chest wall and a pseudoaneurysm of the left internal mammary artery. Imaging suggested that the lung mass resulted from pulmonary actinomycosis, which was confirmed by the histopathology of a fine-needle aspiration specimen.
Pulmonary artery aneurysms (PAAs) are uncommon entities. PAAs are caused mostly by trauma (often iatrogenic), infections and Behcet’s disease (BD). Less common causes are pulmonary hypertension, congenital heart disease and neoplasm. BD is a multisystem disorder presenting with recurrent oral and genital ulcerations, as well as ocular involvement, and PAA is one of its rare complications. A case of huge PAA, in which the usual criteria for the clinical diagnosis of BD were present, is described. Transcatheter embolization resulted in clinical improvement.
Behcet’s disease; Pulmonary artery aneurysms
Aneurysms of the left main coronary artery are rare with an incidence of 0.1% in large angiographic series. The majority are atherosclerotic in origin. Other causes include connective tissue disorders, trauma, vasculitis, congenital, mycotic and idiopathic. The primary complication is myocardial ischemia or infarction, with rupture being rare. Treatment options include anticoagulation, custom made covered stents, reconstruction, resection, and exclusion with bypass.
A 66 year-old man was referred for evaluation of a 2 × 2 centimeter saccular aneurysm originating from the distal left main coronary artery. There was associated calcification and mild stenosis of the LM. The workup was prompted by a non-ST elevation myocardial infarction suffered following a laparotomy for a ruptured appendix. The past medical history was pertinent for hypertension, hyperlipidemia, and a left carotid endarterectomy.
Cardiopulmonary bypass with hyperkalemic cardioplegic arrest was utilized. The aneurysm was exposed in the atrioventricular groove. The aneurysm was resected and oversewn. Calcification precluded patch angioplasty. The patient then underwent coronary bypass grafting with the left internal thoracic artery placed to the left anterior descending artery and a reversed greater saphenous vein graft to an obtuse marginal branch of the circumflex artery. The postoperative course was uneventful and discharge to home occurred on the fourth postoperative day. Surgical pathology confirmed an atheromatous coronary artery aneurysm.
Left main coronary artery aneurysms in adult patients are predominantly atherosclerotic in origin. The clinical presentation is that of myocardial ischemia, likely from associated embolism. Rupture is rare. Operative treatment is exclusion and revascularization.
Mycotic aneurysm of the thoracic aorta is a rare and life threatening condition. Two patients are presented (both male, aged 66 and 59 years) in whom coronary artery bypass surgery was complicated by the development of a mycotic aneurysm. Fever preceded the radiological and echocardiographic signs of the aneurysm by at least several months in both cases. Blood cultures were negative for one patient and the source of Corynebacterium sp infection in the other was not determined for several months. Both patients died before surgery could correct the aneurysm.
Keywords: mycotic aneurysm; aorta; revascularisation; surgical complications
Mycotic aneurysms constitute a small proportion of aortic aneurysms. Endovascular repair of mycotic aneurysms has been applied with good short-term and midterm results. However, the uncommon aortoenteric fistula formation remains a potentially fatal complication when repairing such infective aneurysms. We present the case of an 80-year-old woman with thoracic and abdominal aortic mycotic aneurysms, which were successfully treated with endografting. However, the patient presented 3 months later with upper gastrointestinal bleeding secondary to erosion of the thoracic graft into the oesophagus. The patient was treated conservatively due to the high risk of surgical repair. There is currently little exposure to the management of mycotic aortic aneurysms. If suspected, imaging of the entire vasculature will aid initial diagnosis and highlight the extent of the disease process, allowing for efficient management. Aortic endografting for mycotic thoracic aneurysms is a high-risk procedure yet is still an appropriate intervention. Aortoenteric fistulae pose a rare but severe complication of aortic endografting in this setting.
The aim of this study was to investigate the advantages and disadvantages of a two-stage treatment for ruptured cerebral aneurysms; partial embolization in acute stage followed by clipping in chronic stage of subarachnoid hemorrhage.
Between April 1997 and August 1999, twenty ruptured cerebral aneurysms were initially treated endovasculary using Guglielmi detachable coils in our institution. Among them, complete embolization could not be achieved in 6 lesions. For these lesions, subsequent clipping was added. The radiological and operative findings, and outcomes of these cases were retrospectively reviewed.
In 1 case, rerupture occurred during the endovascular procedure. Rerupture was not observed in any cases in the postembolization period. In 2 cases, complications related to the clipping but not the endovascular procedure occurred. These complications included impaired visual acuity for unverified reasons, and memory disturbance due to sacrifice of a perforator arising from the anterior communicating artery. In 3 cases, coil extraction was needed during the clipping, because the loops of the coil extended into the residual neck. Complications related to coil extraction were not observed in these 3 cases.
Acute partial embolization of ruptured aneurysm appears to be effective for the prevention of subsequent rerupture during the subacute period, in which treatment for vasospasm should be performed, and the clipping procedure. However, in the case of relatively large aneurysms, small arteries or other normal structures behind the aneurysm cannot be observed directly during surgery, because of the immovability of the embolized aneurysm. Further; complete clip closure is impossible when loops of coil herniate into the neck. In such situations, coil extraction with or without resection of the aneurysm might be necessary, and care must be taken not to damage parent artery and surrounding vessels.
ruptured cerebral aneurysm, partial embolization, clipping, electrolytically detachable coil
Takayasu aortoarteritis (TA) rarely affects the nervous system, but when it does, it usually manifests as cerebral ischemia or stroke. These strokes have mainly been attributed to stenotic extracranial vessels. Stenoses of intracranial vessels, although rare in TA, can occur due to either embolization into the vessel or because of the vasculitic process itself. Intracranial aneurysms are very rare in patients with TA. Bilateral cavernous internal carotid artery (ICA) aneurysms are rarer. They have been reported following radiation therapy and in association with fibromuscular dysplasia and juvenile Paget disease. Bilateral mycotic intracavernous aneurysms also occur. Bilateral giant cavernous ICA aneurysms with carotid-cavernous fistula (CCF) consequent to rupture into the cavernous sinus in a case of TA are extremely unusual. We report a case that fulfilled both American College of Rheumatology and European League against Rheumatology criteria for TA. The patient had bilateral cavernous sinus giant aneurysms and CCF because the right-sided aneurysm had ruptured and was leaking into the cavernous sinus.
Bilateral giant ICA aneurysms; carotid cavernous fistula; Takayasu arteritis
A true aneurysym is a dilation of arterial lumen as a consequence of congenital or acquired abnormalities leading to a reduction of mechanical resistance of vascular wall, most commonly caused by its defected structure in the form of absence or weakening of the muscular and/or elastic layer. From the pathophysiological point of view, cerebral aneurysms can be classified as ‘saccular’ – most commonly occurring, and ‘other types’, including fusiform/dolichoectatic, dissecting, serpentine, posttraumatic, mycotic and giant aneurysms with or without intra-aneurysmal thrombosis.
We present a rare case of a patient with multiple fusiform dilations of cerebral vessels and giant fusiform aneurysm in supraclinoid segment of the internal carotid artery. The patient presented to hospital because of sudden, severe vertigo with nausea, impaired balance and disturbed vision. Vascular anomalies were detected on CT scanning without contrast. The diagnostic work-up was complemented by CT angiography, MRI and cerebral angiography.
Aneurysm located within the intracranial arteries is one of the most common vascular defects of the brain. The number, size and location of aneurysms are highly variable. Aneurysms can have either supra- or infratentorial location, affecting a single or multiple arteries within one or both brain hemispheres. There is often a correlation between the location of the aneurysm and its etiology, as in case of so-called mirror-image aneurysms. Symmetrically located aneurysms may indicate a defect in vascular structure. Asymmetric location, as in the patient described above, is more likely due to acquired causes, mainly atherosclerosis, but also septic emboli or blood disorders.
fusiform aneurysm; dolichoectasia; cerebral giant aneurysm; angio-CT; angiography; endovascular treatment
Staphylococcus aureus is the major cause of bacteremia, with the potential for some complications, namely mycotic aneurysms, defined as irreversible dilatation of an artery due to destruction of the vessel wall by infection.
The authors present the case of a 52 year-old-Caucasian male, admitted with Staphylococcus aureus bacteremia and mycotic aneurysm of the right superficial femoral artery, associated with advanced atherosclerotic process.
Mycotic aneurysms are rare, and a high index of suspicion is needed, because appropriate treatment will certainly affect the outcome, as they are associated with high morbidity and mortality.
Mycotic celiac artery aneurysm following infective endocarditis is extremely rare and, to our knowledge, only four cases have been reported in the literature to date. We describe the case of a 60 year-old man who developed a mycotic aneurysm of the celiac artery, which was detected by computed tomography (CT) following an episode of infective endocarditis. He successfully underwent endovascular isolation and packing of the aneurysm using N-butyl cyanoacrylate (NBCA) with embolization coils.
mycotic celiac artery aneurysm; embolization; n-butyl cyanoacrylate
During an histological study of pulmonary thromboembolism, arterial wall splits, many associated with saccular microaneurysms, were observed in association with emboli or their fibrous residue. Other aneurysmal lesions, non-inflammatory focal medial necrosis, and medial scars were also seen in a few cases. The nature of the arterial rents indicates that they arose by mechanical splitting after acute stretching of the artery at the time of embolic impaction. Saccular aneurysms then developed in some. Impaction could also have caused the foci of medial necrosis while the medial scars could represent healed former necrosis of rupture. Though the observed incidence of lesions was relatively low, this seems to be due to their small sizes and the sampling inherent in conventional histological analysis. It is concluded that arterial splits are probably a common effect of pulmonary embolism and often give rise to small aneurysms.
Cerebral mycotic aneurysms are rare sequelae of systemic infections that can cause profound morbidity and mortality with rupture. Direct bacterial extension and vessel integrity compromise from septic emboli have been implicated as mechanisms for formation of these lesions. We report the 5-day development of a ruptured mycotic aneurysm arising from a septic embolism that caused a focal M1 pseudoocclusion.
A 14-year-old girl developed acute left-sided hemiparesis while hospitalized for subacute bacterial endocarditis that was found after she presented with a 2-week history of fever, myalgia, shortness of breath, and lethargy. Mitral valve vegetations were confirmed in the setting of hemophilus bacteremia. Brain magnetic resonance (MR) imaging and angiography confirmed middle cerebral artery infarct with focal pseudoocclusion of the distal M1 segment. Given that further middle cerebral artery territory was at risk, a trial of heparin was attempted for revascularization but required discontinuation owing to hemorrhagic conversion. Decline of the patient's mental status necessitated craniectomy for decompression. Postoperatively, her mental status improved with residual left hemiparesis. On the third postoperative day (5 days after MR angiography), the patient's neurologic condition acutely declined, with development of right-sided mydriasis. Computed tomography (CT) angiography revealed a ruptured 19 × 16 mm pseudoaneurysm arising from the M1 site of the previous occlusion. Emergent coiling of aneurysm and parent vessel followed by hematoma evacuation ensued. At discharge, the patient had residual left hemiparesis but intact speech and cognition.
Focal occlusions due to septic emboli should be considered high-risk for mycotic aneurysm formation, prompting aggressive monitoring with neuroimaging and treatment when indicated.
Cerebral aneurysm; infective endocarditis; mycotic aneurysm; septic emboli
Cases of true mycotic popliteal artery aneurysm are rare. Presentation is variable but invasive and non-invasive investigations collectively facilitate diagnosis and guide operative procedures. Definitive treatment generally utilizes surgical intervention with excision and reconstruction using autologous vein graft. Prolonged targeted antibiotic therapy is an important adjuvant.
We describe the clinical presentation, radiological investigations and strategies on the management of a 47-year-old Caucasian Irish man who presented with a mycotic aneurysm of the popliteal artery due to thromboembolisation from Streptococus pneumoniae endocarditis.
Cases of true mycotic popliteal artery aneurysms are rare. To the best of our knowledge this is the first documented case of a popliteal artery mycotic aneurysm developing secondary to Streptococus pneumoniae highlighting the changing profile of causative microorganisms.
Eight months after successful repair of a ruptured infrarenal aneurysm, a 50-year-old hypertensive male patient was found to have a 2nd aneurysm restricted to the juxtarenal segment of the aorta, and not in continuity with the infrarenal lesion. While there have been reports both of true aneurysms arising independently in the abdominal (infrarenal) and thoracic (suprarenal) aortic segments, and of false aneurysms arising secondary to abdominal aortic repair (at the suture line or as dilatations of residual aneurysmal tissue), we believe our case unusual in that the new aneurysm was a discrete and “true” thoracoabdominal dilatation arising just above the renal arteries and terminating just below the superior mesenteric artery. This strictly juxtarenal dilatation conforms better to a descriptive pattern for atherosclerotic occlusive disease than it does to the standard scheme for classifying thoracoabdominal aortic aneurysms. (Texas Heart Institute Journal 1989;16:113-6)
Aorta, abdominal; aorta, thoracic; aortic aneurysm; aortic rupture/aorta, abdominal; arteriosclerosis; nomenclature, diagnostic
A persistent sciatic artery (PSA) is a rare vascular anomaly with an estimated incidence of 0.02–0.04% and with a high rate of complications such as aneurysm formation, thromboembolism, and ischemia, that may lead to amputation.
We present a case of a female patient with complete symptomatic ambilateral PSA and with unilateral aneurysm. The aneurysm was excised and the PTFE graft was interposed at the aneurismal sac (femoro-popliteal bypass could not be performed because of the high degree hypoplasia of the superficial femoral artery). The graft endured continuous compression and stretching during regular daily life of the patient. At check-up 18 years after the operation, the Doppler ultrasound showed a patent graft and no new aneurismal dilatation of the sciatic artery.
To our knowledge the follow-up of the presented case is the longest reported so far in the literature. The uneventful course of the patient confirms that classical aneurysmectomy still constitutes one of the treatment options of PSA aneurysm.
persistent sciatic artery; PSA aneurysm; vascular anomaly
Pulmonary artery aneurysm is an uncommon disorder with severe complications. The diagnosis is often difficult, since the clinical manifestations are non-specific and the treatment is controversial, as the natural history of the disease is not completely understood.
We describe the cases of two patients with pulmonary artery aneurysms. The first patient was a 68-year-old Caucasian man with an idiopathic low-pressure pulmonary artery aneurysm together with a pulmonary embolism. The patient preferred a conservative approach and was stable at the 10-month follow-up visit after being placed on anti-coagulant treatment. The second patient was a 66-year-old Caucasian woman with a low-pressure pulmonary artery aneurysm also presented together with a pulmonary embolism. The aneurysm was secondary to pulmonary valve stenosis. She received anti-coagulants and, after stabilization, underwent percutaneous balloon valvuloplasty.
Pulmonary embolism may be the initial presentation of a low-pressure pulmonary artery aneurysm. No underlying cause for pulmonary embolism was found in either of our patients, suggesting a causal association with low-pressure pulmonary artery aneurysm.
Aortic arch aneurysm is a rare condition but carries a high risk of rupture. We report one case of aortic arch aneurysm combined with aortic arch coarctation and left internal carotid artery aneurysm, which is extremely rare. Left internal carotid artery aneurysm resection and revascularization, carotid and carotid graft bypass combined with endovascular stent graft and embolization with coils were successfully performed. There were no any complaints and complications at 8 months follow-up. The follow-up CTA demonstrated thrombus formation in the aneurysm lumen, no endoleak and the aortic arch and bypass graft were all patent. We feel that hybrid procedure may be a valuable therapeutic alternative when treating this type of lesion. However, long-term clinical efficacy and safety have yet to be confirmed.
Aneurysm; Aortic arch; Stent graft; Hybrid procedure
Aortic pathology progression and/or procedure related complications following endovascular repair should always be considered mostly in older patients. We herein describe a hybrid procedure for treatment of rapidly expanding thoracoabdominal aneurysm following endovascular treatment of a descending thoracic aortic aneurysm in an older patient.
A 82-year-old man at 18 months after endovascular surgery for a contained rupture of descending thoracic aortic aneurysm revealed a type IV thoracoabdominal aneurysm with significant increase of the aortic diameters at superior mesenteric and renal artery levels. A hybrid approach consisting of preventive visceral vessel revascularization and endovascular repair of entire abdominal aorta was performed. Under general anaesthesia and by xyphopubic laparotomy, the infrarenal aneurysmatic aorta and common iliac arteries were replaced by a bifurcated woven prosthetic graf. From each of the prosthetic branches two reverse 14x7 mm bifurcated PTFE prosthetic grafts were anastomized to both renal arteries and to the celiac axis and superior mesenteric artery, respectively. Vessel ischemia was restricted to the time required for anastomosis. Three 10 cm Gore endovascular stent-grafts for a total length of 15 cm, were used. The overlapping of the stent-grafts was carried out from the bottom upwards, starting from the aorto-iliac prosthetic body up to the healthy segment of thoracic aorta, 40 mm from the previous stent-grafts.
The patient was discharged on the 9th postoperative day.
This technique offers the advantage of a less invasive treatment, reducing the risk of paraplegia, visceral ischaemia and pulmonary complications, mostly in older patients.
A 46-year-old man was admitted for surgery on a ruptured mycotic abdominal aortic aneurysm. Emergency repair was performed, during which certain anomalies were noted. First, the bifurcation of the aorta was posterior to the left common iliac vein. Second there were no internal iliac arteries. Also, there were prominent lumbar arteries compensating for the absent internal iliac arteries bilaterally. This, we consider, is the first reported case of congenitally absent bilateral internal iliac arteries.
Bilateral congenital absence of internal iliac arteries
We report two cases of superior gluteal artery aneurysms successfully treated with coil embolization and review treatment options for these lesions. Our experience in the treatment of three total aneurysms, two likely post-traumatic in etiology and one mycotic, suggests that endovascular therapy is an effective alternative to open surgery when treating superior gluteal artery aneurysms.
Gluteal aneurysm; coil embolization; endovascular
Endovascular repair of aortic aneurysms (EVAR) is obtained through the positioning of an aortic stent-graft, which excludes the aneurysmatic dilation. Type I endoleak is the most common complication, and it is caused by an incompetent proximal or distal attachment site, causing the separation between the stent-graft and the native arterial wall, and in turn creating direct communication between the aneurysm sac and the systemic arterial circulation. Endoleak occurrence is associated with high intrasac pressures, and requires a quick repair to prevent abdominal aortic aneurysm rupture.
We report the first case of a 80-year-old man undergoing percutaneous closure of a peri-graft endoleak (type I) by transcatheter embolization through radial arterial access.
The transradial approach has been shown to be a safe and effective alternative to the traditional transfemoral approach. A decrease in vascular complications and improved patient comfort are the primary benefits of this technique in patients with previous EVAR.
The coexistent biliary atresia with aneurysmal dilatation of hepatic artery is a rare association. To know these anomalies will avoid many per operative complications. It is also important to mention that these children require liver transplantation in the long run then these vascular anomalies become more relevant.
PRESENTATION OF CASE
A four month old male child presented with features of biliary atresia. On exploration a cystic expansile mass was detected beneath thread like common bile duct. Subsequent aspiration and studies proved it to be aneurysmal dilatation of hepatic artery.
With biliary atresia many vascular and cardiac malformations have been described but aneurysmal dilatation of hepatic artery is a rare association. These anomalies may have impact on aetiopathogenesis of biliary atresia and also future liver transplantation.
Awareness of rare association of hepatic artery aneurysm with biliary atresia will help in understanding aetiopathogenesis of biliary atresia and planning liver transplantation in such cases.
Biliary atresia; Choledochal cyst; Aneurysmal dilatation of hepatic artery
A 65-year-old woman, recently diagnosed with diabetes, presented with fever and a warm,
pulsatile, tender mass over the medial aspect of her left thigh. She gave a history of
diarrhea two weeks earlier. All lower limb pulses were present. CRP was 18.3 mg/l with
evidence of neutrophil leukocytosis.
Contrast angiography demonstrated a saccular aneurysm in her left superficial femoral
artery (SFA). The aneurysm and surrounding infected, necrotic muscle was excised, and the
limb was re-vascularized in-situ. Cultures from the aneurysmal wall grew both coliform
bacilli and staphylococcus aureus. A mycotic aneurysm of the SFA, following a previous
gastroenteritis, harbouring both staphylococcal and coliforms, makes this case unique.
mycotic; aneurysm; rare