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1.  Endovascular Repair of Abdominal Aortic Aneurysm 
The Medical Advisory Secretariat conducted a systematic review of the evidence on the effectiveness and cost-effectiveness of endovascular repair of abdominal aortic aneurysm in comparison to open surgical repair. An abdominal aortic aneurysm [AAA] is the enlargement and weakening of the aorta (major blood artery) that may rupture and result in stroke and death. Endovascular abdominal aortic aneurysm repair [EVAR] is a procedure for repairing abdominal aortic aneurysms from within the blood vessel without open surgery. In this procedure, an aneurysm is excluded from blood circulation by an endograft (a device) delivered to the site of the aneurysm via a catheter inserted into an artery in the groin. The Medical Advisory Secretariat conducted a review of the evidence on the effectiveness and cost-effectiveness of this technology. The review included 44 eligible articles out of 489 citations identified through a systematic literature search. Most of the research evidence is based on non-randomized comparative studies and case series. In the short-term, EVAR appears to be safe and comparable to open surgical repair in terms of survival. It is associated with less severe hemodynamic changes, less blood transfusion and shorter stay in the intensive care and hospital. However, there is concern about a high incidence of endoleak, requiring secondary interventions, and in some cases, conversion to open surgical repair. Current evidence does not support the use of EVAR in all patients. EVAR might benefit individuals who are not fit for surgical repair of abdominal aortic aneurysm and whose risk of rupture of the aneurysm outweighs the risk of death from EVAR. The long-term effectiveness and cost-effectiveness of EVAR cannot be determined at this time. Further evaluation of this technology is required.
The objective of this health technology policy assessment was to determine the effectiveness and cost-effectiveness of endovascular repair of abdominal aortic aneurysms (EVAR) in comparison to open surgical repair (OSR).
Clinical Need
An abdominal aortic aneurysm (AAA) is a localized, abnormal dilatation of the aorta greater than 3 cm or 50% of the aortic diameter at the diaphragm. (1) A true AAA involves all 3 layers of the vessel wall. If left untreated, the continuing extension and thinning of the vessel wall may eventually result in rupture of the AAA. The risk of death from ruptured AAA is 80% to 90%. (61) Heller et al. (44) analyzed information from a national hospital database in the United States. They found no significant change in the incidence rate of elective AAA repair or ruptured AAA presented to the nation’s hospitals. The investigators concluded that technologic and treatment advances over the past 19 years have not affected the outcomes of patients with AAAs, and the ability to identify and to treat patients with AAAs has not improved.
Classification of Abdominal Aortic Aneurysms
At least 90% of the AAAs are affected by atherosclerosis, and most of these aneurysms are below the level of the renal arteries.(1)
An abdominal aortic aneurysm may be symptomatic or asymptomatic. An AAA may be classified according to their sizes:(7)
Small aneurysms: less than 5 cm in diameter.
Medium aneurysms: 5-7cm.
Large aneurysms: more than 7 cm in diameter.
Small aneurysms account for approximately 50% of all clinically recognized aneurysms.(7)
Aortic aneurysms may be classified according to their gross appearance as follows (1):
Fusiform aneurysms affect the entire circumference of a vessel, resulting in a diffusely dilated lesion
Saccular aneurysms involve only a portion of the circumference, resulting in an outpouching (protrusion) in the vessel wall.
Prevalence of Abdominal Aortic Aneurysms
In community surveys, the prevalence of AAA is reported to be between 1% and 5.4%. (61) The prevalence is related to age and vascular risk factors. It is more common in men and in those with a positive family history.
In Canada, Abdominal aortic aneurysms are the 10th leading cause of death in men 65 years of age or older. (60) Naylor (60) reported that the rate of AAA repair in Ontario has increased from 38 per 100,000 population in 1981/1982 to 54 per 100,000 population in 1991/1992. For the period of 1989/90 to 1991/92, the rate of AAA repair in Ontarians age 45 years and over was 53 per 100,000. (60) In the United States, about 200,000 new cases are diagnosed each year, and 50,000 to 60,000 surgical AAA repairs are performed. (2) Ruptured AAAs are responsible for about 15,000 deaths in the United States annually. One in 10 men older than 80 years has some aneurysmal change in his aorta. (2)
Symptoms of Abdominal Aortic Aneurysms
AAAs usually do not produce symptoms. However, as they expand, they may become painful. Compression or erosion of adjacent tissue by aneurysms also may cause symptoms. The formation of mural thrombi, a type of blood clots, within the aneurysm may predispose people to peripheral embolization, where blood vessels become blocked. Occasionally, an aneurysm may leak into the vessel wall and the periadventitial area, causing pain and local tenderness. More often, acute rupture occurs without any prior warning, causing acute pain and hypotension. This complication is always life-threatening and requires an emergency operation.
Diagnosis of Abdominal Aortic Aneurysms
An AAA is usually detected on routine examination as a palpable, pulsatile, and non-tender mass. (1)
Abdominal radiography may show the calcified outline of the aneurysms; however, about 25% of aneurysms are not calcified and cannot be visualized by plain x-ray. (1) An abdominal ultrasound provides more accurate detection, can delineate the traverse and longitudinal dimensions of the aneurysm, and is useful for serial documentation of aneurysm size. Computed tomography and magnetic resonance have also been used for follow-up of aortic aneurysms. These technologies, particularly contrast-enhanced computer tomography, provide higher resolution than ultrasound.
Abdominal aortography remains the gold standard to evaluate patients with aneurysms for surgery. This technique helps document the extent of the aneurysms, especially their upper and lower limits. It also helps show the extent of associated athereosclerotic vascular disease. However, the procedure carries a small risk of complications, such as bleeding, allergic reactions, and atheroembolism. (1)
Prognosis of Abdominal Aortic Aneurysms
The risk of rupture of an untreated AAA is a continuous function of aneurysm size as represented by the maximal diameter of the AAA. The annual rupture rate is near zero for aneurysms less than 4 cm in diameter. The risk is about 1% per year for aneurysms 4 to 4.9 cm, 11% per year for aneurysms 5 to 5.9 cm, and 25% per year or more for aneurysms greater than 6 cm. (7)
The 1-year mortality rate of patients with AAAs who do not undergo surgical treatment is about 25% if the aneurysms are 4 to 6 cm in diameter. This increases to 50% for aneurysms exceeding 6 cm. Other major causes of mortality for people with AAAs include coronary heart disease and stroke.
Treatment of Abdominal Aortic Aneurysms
Treatment of an aneurysm is indicated under any one of the following conditions:
The AAA is greater than 6 cm in diameter.
The patient is symptomatic.
The AAA is rapidly expanding irrespective of the absolute diameter.
Open surgical repair of AAA is still the gold standard. It is a major operation involving the excision of dilated area and placement of a sutured woven graft. The surgery may be performed under emergent situation following the rupture of an AAA, or it may be performed electively.
Elective OSR is generally considered appropriate for healthy patients with aneurysms 5 to 6 cm in diameter. (7) Coronary artery disease is the major underlying illness contributing to morbidity and mortality in OSR. Other medical comorbidities, such as chronic renal failure, chronic lung disease, and liver cirrhosis with portal hypertension, may double or triple the usual risk of OSR.
Serial noninvasive follow-up of small aneurysms (less than 5 cm) is an alternative to immediate surgery.
Endovascular repair of AAA is the third treatment option and is the topic of this review.
PMCID: PMC3387737  PMID: 23074438
2.  Endovascular Repair of Descending Thoracic Aortic Aneurysm 
Executive Summary
To conduct an assessment on endovascular repair of descending thoracic aortic aneurysm (TAA).
Clinical Need
Aneurysm is the most common condition of the thoracic aorta requiring surgery. Aortic aneurysm is defined as a localized dilatation of the aorta. Most aneurysms of the thoracic aorta are asymptomatic and incidentally discovered. However, TAA tends to enlarge progressively and compress surrounding structures causing symptoms such as chest or back pain, dysphagia (difficulty swallowing), dyspnea (shortness of breath), cough, stridor (a harsh, high-pitched breath sound), and hoarseness. Significant aortic regurgitation causes symptoms of congestive heart failure. Embolization of the thrombus to the distal arterial circulation may occur and cause related symptoms. The aneurysm may eventually rupture and create a life-threatening condition.
The overall incidence rate of TAA is about 10 per 100,000 person-years. The descending aorta is involved in about 30% to 40% of these cases.
The prognosis of large untreated TAAs is poor, with a 3-year survival rate as low as 25%. Intervention is strongly recommended for any symptomatic TAA or any TAA that exceeds twice the diameter of a normal aorta or is 6 cm or larger. Open surgical treatment of TAA involves left thoracotomy and aortic graft replacement. Surgical treatment has been found to improve survival when compared with medical therapy. However, despite dramatic advances in surgical techniques for performing such complex operations, operative mortality from centres of excellence are between 8% and 20% for elective cases, and up to 50% in patients requiring emergency operations. In addition, survivors of open surgical repair of TAAs may suffer from severe complications. Postoperative or postprocedural complications of descending TAA repair include paraplegia, myocardial infarction, stroke, respiratory failure, renal failure, and intestinal ischemia.
The Technology
Endovascular aortic aneurysm repair (EVAR) using a stent graft, a procedure called endovascular stent-graft (ESG) placement, is a new alternative to the traditional surgical approach. It is less invasive, and initial results from several studies suggest that it may reduce mortality and morbidity associated with the repair of descending TAAs.
The goal in endovascular repair is to exclude the aneurysm from the systemic circulation and prevent it from rupturing, which is life-threatening. The endovascular placement of a stent graft eliminates the systemic pressure acting on the weakened wall of the aneurysm that may lead to the rupture. However, ESG placement has some specific complications, including endovascular leak (endoleak), graft migration, stent fracture, and mechanical damage to the access artery and aortic wall.
The Talent stent graft (manufactured by Medtronic Inc., Minneapolis, MN) is licensed in Canada for the treatment of patients with TAA (Class 4; licence 36552). The design of this device has evolved since its clinical introduction. The current version has a more flexible delivery catheter than did the original system. The prosthesis is composed of nitinol stents between thin layers of polyester graft material. Each stent is secured with oversewn sutures to prevent migration.
Review Strategy
To compare the effectiveness and cost-effectiveness of ESG placement in the treatment of TAAs with a conventional surgical approach
To summarize the safety profile and effectiveness of ESG placement in the treatment of descending TAAs
Measures of Effectiveness
Primary Outcome
Mortality rates (30-day and longer term)
Secondary Outcomes
Technical success rate of introducing a stent graft and exclusion of the aneurysm sac from systemic circulation
Rate of reintervention (through surgical or endovascular approach)
Measures of Safety
Complications were categorized into 2 classes:
Those specific to the ESG procedure, including rates of aneurysm rupture, endoleak, graft migration, stent fracture, and kinking; and
Those due to the intervention, either surgical or endovascular. These include paraplegia, stroke, cardiovascular events, respiratory failure, real insufficiency, and intestinal ischemia.
Inclusion Criteria
Studies comparing the clinical outcomes of ESG treatment with surgical approaches
Studies reporting on the safety and effectiveness of the ESG procedure for the treatment of descending TAAs
Exclusion Criteria
Studies investigating the clinical effectiveness of ESG placement for other conditions such as aortic dissection, aortic ulcer, and traumatic injuries of the thoracic aorta
Studies investigating the aneurysms of the ascending and the arch of the aorta
Studies using custom-made grafts
Literature Search
The Medical Advisory Secretariat searched The International Network of Agencies for Health Technology Assessment and the Cochrane Database of Systematic Reviews for health technology assessments. It also searched MEDLINE, EMBASE, Medline In-Process & Other Non-Indexed Citations, and Cochrane CENTRAL from January 1, 2000 to July 11, 2005 for studies on ESG procedures. The search was limited to English-language articles and human studies.
One health technology assessment from the United Kingdom was identified. This systematic review included all pathologies of the thoracic aorta; therefore, it did not match the inclusion criteria. The search yielded 435 citations; of these, 9 studies met inclusion criteria.
Summary of Findings
The results of a comparative study found that in-hospital mortality was not significantly different between ESG placement and surgery patients (2 [4.8%] for ESG vs. 6 [11.3%] for surgery).
Pooled data from case series with a mean follow-up ranging from 12 to 38 months showed a 30-day mortality and late mortality rate of 3.9% and 5.5%, respectively. These rates are lower than are those reported in the literature for surgical repair of TAA.
Case series showed that the most common cause of early death in patients undergoing endovascular repair is aortic rupture, and the most common causes of late death are cardiac events and aortoesophageal or aortobronchial fistula.
Technical Success Rate
Technical success rates reported by case series are 55% to 100% (100% and 94.4% in 2 studies with all elective cases, 89% in a study with 5% emergent cases, and 55% in a study with 42% emergent cases).
Surgical Reintervention
In the comparative study, 3 (7.1%) patients in the ESG group and 14 (26.5%) patients in the surgery group required surgical reintervention. In the ESG group, the reasons for surgical intervention were postoperative bleeding at the access site, paraplegia, and type 1 endoleak. In the surgical group, the reasons for surgery were duodenal perforation, persistent thoracic duct leakage, false aneurysm, and 11 cases of postoperative bleeding.
Pooled data from case series show that 9 (2.6%) patients required surgical intervention. The reasons for surgical intervention were endoleak (3 cases), aneurysm enlargement and suspected infection (1 case), aortic dissection (1 case), pseudoaneurysm of common femoral artery (1 case), evacuation of hematoma (1 case), graft migration (1 case), and injury to the access site (1 case).
Endovascular Revision
In the comparative study, 3 (7.1%) patients required endovascular revision due to persistent endoleak.
Pooled data from case series show that 19 (5.3%) patients required endovascular revision due to persistent endoleak.
Graft Migration
Two case series reported graft migration. In one study, 3 proximal and 4 component migrations were noted at 2-year follow-up (total of 5%). Another study reported 1 (3.7%) case of graft migration. Overall, the incidence of graft migration was 2.6%.
Aortic Rupture
In the comparative study, aortic rupture due to bare stent occurred in 1 case (2%). The pooled incidence of aortic rupture or dissection reported by case series was 1.4%.
Postprocedural Complications
In the comparative study, there were no statistically significant differences between the ESG and surgery groups in postprocedural complications, except for pneumonia. The rate of pneumonia was 9% for those who received an ESG and 28% for those who had surgery (P = .02). There were no cases of paraplegia in either group. The rate of other complications for ESG and surgery including stroke, cardiac, respiratory, and intestinal ischemia were all 5.1% for ESG placement and 10% for surgery. The rate for mild renal failure was 16% in the ESG group and 30% in the surgery group. The rate for severe renal failure was 11% for ESG placement and 10% for surgery.
Pooled data from case series show the following postprocedural complication rates in the ESG placement group: paraplegia (2.2%), stroke (3.9%), cardiac (2.9%), respiratory (8.7%), renal failure (2.8%), and intestinal ischemia (1%).
Time-Related Outcomes
The results of the comparative study show statistically significant differences between the ESG and surgery group for mean operative time (ESG, 2.7 hours; surgery, 5 hours), mean duration of intensive care unit stay (ESG, 11 days; surgery, 14 days), and mean length of hospital stay (ESG, 10 days; surgery, 30 days).
The mean duration of intensive care unit stay and hospital stay derived from case series is 1.6 and 7.8 days, respectively.
Ontario-Based Economic Analysis
In Ontario, the annual treatment figures for fiscal year 2004 include 17 cases of descending TAA repair procedures (source: Provincial Health Planning Database). Fourteen of these have been identified as “not ruptured” with a mean hospital length of stay of 9.23 days, and 3 cases have been identified as “ruptured,” with a mean hospital length of stay of 28 days. However, because one Canadian Classification of Health Interventions code was used for both procedures, it is not possible to determine how many were repaired with an EVAR procedure or with an open surgical procedure.
Hospitalization Costs
The current fiscal year forecast of in-hospital direct treatment costs for all in-province procedures of repair of descending TAAs is about $560,000 (Cdn). The forecast in-hospital total cost per year for in-province procedures is about $720,000 (Cdn). These costs include the device cost when the procedure is EVAR (source: Ontario Case Costing Initiative).
Professional (Ontario Health Insurance Plan) Costs
Professional costs per treated patient were calculated and include 2 preoperative thoracic surgery or EVAR consultations.
The professional costs of an EVAR include the fees paid to the surgeons, anesthetist, and surgical assistant (source: fee service codes). The procedure was calculated to take about 150 minutes.
The professional costs of an open surgical repair include the fees of the surgeon, anesthetist, and surgical assistant. Open surgical repair was estimated to take about 300 minutes.
Services provided by professionals in intensive care units were also taken into consideration, as were the costs of 2 postoperative consultations that the patients receive on average once they are discharged from the hospital. Therefore, total Ontario Health Insurance Plan costs per treated patient treated with EVAR are on average $2,956 (ruptured or not ruptured), as opposed to $5,824 for open surgical repair and $6,157 for open surgical repair when the aneurysm is ruptured.
Endovascular stent graft placement is a less invasive procedure for repair of TAA than is open surgical repair.
There is no high-quality evidence with long-term follow-up data to support the use of EVAR as the first choice of treatment for patients with TAA that are suitable candidates for surgical intervention.
However, short- and medium-term outcomes of ESG placement reported by several studies are satisfactory and comparable to surgical intervention; therefore, for patients at high risk of surgery, it is a practical option to consider. Short- and medium-term results show that the benefit of ESG placement over the surgical approach is a lower 30-day mortality and paraplegia rate; and shorter operative time, ICU stay, and hospital stay.
PMCID: PMC3382300  PMID: 23074469
3.  Juxtarenal Aortic Pseudoaneurysm – Right Renal Vein Fistula with Circumaortic Renal Collar-Delayed Manifestation of a Gunshot Injury – an Uncommon Entity Diagnosed with CT Angiography 
Polish Journal of Radiology  2016;81:114-119.
Delayed presentation of post-traumatic aortic pseudoaneurysm and its fistulous communication with the right renal vein is a very rare entity. Most of the cases described in literature are due to abdominal aortic aneurysm (AAA) rupture into the left renal vein. To the best of our knowledge, communication with the right renal vein has not been described in published literature. Our patient also had a circumaortic renal collar, which is a rare renal vein anomaly. Aortic pseudoaneurysm, its fistulous communication with the right renal vein and circumaortic renal collar in a single patient is of extremely rare occurrence.
Case Report
A 29-year-old male presented to the cardiology department with complaints of breathlessness, abdominal pain and hematuria for the last 6 months. On clinical examination there was evidence of audible bruit over the abdomen. He had a past history of a gunshot injury around two years back. CT angiography revealed a large partially calcified pseudoaneurysm arising from the right lateral wall of the abdominal aorta with the neck of the pseudoaneurysm at juxtarenal location with a fistula between the anterior wall of the pseudoaneurysm and the posterior wall of the right renal vein. There was an associated incidental finding of circumaortic left renal vein with gross aneurysmal dilatation of both pre- and retro-aortic part of the renal vein.
Delayed presentation of aortic pseudoaneurysm with its fistulous communication with the right renal vein is a rare entity. CT angiography is a non-invasive modality for diagnosis of the exact site of communication, length of aneurysm, proximal and distal extent of the affected segment and its relationship with surrounding structures.
PMCID: PMC4801142  PMID: 27057262
Aneurysm, False; Aorta; Arteriovenous Fistula; Renal Veins
4.  Secondary aortoduodenal fistula following endovascular repair of inflammatory abdominal aortic aneurysm due to Streptococcus anginosus infection: A case report and literature review☆ 
Aortoenteric fistula is a rare but very serious complication of both surgical and endovascular abdominal aortic reconstruction. Since the advent of endovascular abdominal aortic aneurysm repair (EVAR), 20 cases of aortoduodenal fistula associated with aortic stent grafts have been reported.1 However, only a handful has been reported following inflammatory abdominal aortic aneurysm repair. It most commonly presents with bleeding, usually from the upper gastro-intestinal tract. With recent advances in the screening, diagnosis and management of abdominal aortic aneurysms either surgically or through an endovascular approach, the diagnosis of an aortoduodenal fistula in patients with gastro-intestinal bleeding must be suspected and excluded.
We describe a case of secondary aortoduodenal fistula that occurred two and a half years following endovascular stent graft repair of an inflammatory abdominal aortic aneurysm. We also outline the emergency correction plan and the attempts at repair.
This case defies the general concept that patients with inflammatory abdominal aortic aneurysms are relatively immune to rupture. Although the presence of a peri-aneurysm thick inflammatory membrane decreases the possibility of rupture, these patients are more susceptible to other related complications such as aorto-enteric and aorto-caval fistulas.2 This case also demonstrates the peculiar presence of Streptococcus anginosus as the pathological organism leading to graft infection and subsequent fistula, as opposed to enterococci which are often found in endograft infection.
Aorto-enteric fistulas are associated with a grave prognosis. Early diagnosis is crucial and extra vigilance should be taken in cases of inflammatory AAA.
PMCID: PMC4189064  PMID: 25201477
5.  Aorta–Left Renal Vein Fistula in a Woman 
Spontaneous rupture of an abdominal aortic aneurysm into a retroaortic left renal vein is an uncommon occurrence. A 55-year-old woman presented with shortness of breath, vomiting, and diffuse abdominal pain that had radiated to her back and legs for the preceding 10 days. A pulsatile abdominal mass, hematuria, renal insufficiency, and heart failure were present at the initial evaluation. Computed tomography showed an infrarenal abdominal aortic aneurysm that communicated with a retroaortic left renal vein. After urgent surgical repair, cardiac and renal function were dramatically improved. To the best of our knowledge, this is the 1st reported case of a woman with such a fistula. We review treatments reported in the literature.
PMCID: PMC548250  PMID: 15745300
Aortic aneurysm, abdominal/complications; arteriovenous fistula/diagnosis/etiology/surgery; renal veins/abnormalities; rupture, spontaneous; tomography, X-ray computed
6.  Aorto-Left Renal Vein Fistula Caused by a Ruptured Abdominal Aortic Aneurysm 
Annals of Vascular Diseases  2013;6(4):738-740.
Retroaortic left renal vein is a malformation in which the left renal vein courses dorsal to the abdominal aorta. In patients with abdominal aortic aneurysm, an aorto-left renal vein fistula can form if the left renal vein is sandwiched between the aneurysm wall and lumbar vertebrae. The patient was an 84-year-old man with lower back pain. We performed a contrast-enhanced computed tomography (CT), although renal dysfunction was noted. The CT showed a ruptured juxta-renal abdominal aortic with aorto-left renal vein fistula. This clinical condition can cause severe renal dysfunction, in spite of which an enhanced contrasted CT scan would be extremely informative preoperatively.
PMCID: PMC3866365  PMID: 24386025
aorto-left renal vein fistula; abdominal aneurysm; retroaortic left renal vein
7.  Successful surgical repair of an ilio-iliac arteriovenous fistula associated with a ruptured common iliac artery aneurysm 
•We report the successful surgical treatment of an ilio-iliac arteriovenous fistula.•Although rare, this disease can be life-threatening.•Use of multiple imaging modalities facilitates correct preoperative diagnosis.•Balloon occlusion technique is used to minimize blood loss during open repair.•There was no sign of high-output heart failure because of venous flow failure.
We describe the case of an 86-year-old man with an ilio-iliac arteriovenous fistula (AVF) resulting from a ruptured aneurysm. This condition rarely occurs, has a high mortality rate, and was successfully treated via surgery.
Presentation of case
The patient presented with a temporary loss of consciousness and left leg edema. A pulsatile abdominal mass with vascular murmur and thrill was detected. Enhanced computed tomography showed abdominal aortic and iliac aneurysms with left common iliac vein occlusion, and the left external iliac vein was easily seen through the AVF. We directly sutured the AVF and performed aneurysmectomy and prosthetic graft replacement. During surgery, placement of occlusive balloon catheters through the AVF minimized intraoperative bleeding. The patient recovered uneventfully, and swelling of the left leg was immediately reduced after surgery.
Although rare, AVFs can be life-threatening, and urgent treatment and intensive care are occasionally needed. Surgical management of AVF requires a definitive preoperative diagnosis and control of venous bleeding during surgery. Fulfilling these major requirements can potentially reduce morbidity and mortality in patients with AVFs. Interestingly, there was no sign of high-output heart failure throughout the treatment course due to compression of the aneurysm and consequent blood flow failure to the left iliac vein.
Using the balloon occlusion technique, we were able to minimize blood loss during open repair. Use of multiple imaging modalities facilitates correct preoperative diagnosis and consequently improves surgical outcome.
PMCID: PMC4529642  PMID: 26117446
AVF, arteriovenous fistula; CIAA, common iliac artery aneurysm; AAA, abdominal aortic aneurysm; CT, computed tomography; CIA, common iliac artery; CIV, common iliac vein; Ilio-iliac arteriovenous fistula; Iliac artery aneurysm; Surgical repair; Iliac vein occlusion
8.  Aortocaval Fistula: A Rare Cause of Venous Hypertension and Acute Renal Failure 
Case Reports in Surgery  2012;2012:487079.
Spontaneous rupture of abdominal aortic aneurysm into the inferior vena cava is rare and is associated with high mortality and morbidity. The clinical presentation can be variable and thus the diagnosis can be difficult. It can present with symptoms and signs of an abdominal emergency, venous hypertension, or systemic hypoperfusion. The traditional method of repair has been open surgery which is associated with high rate of complications. We report a case of aortocaval fistula (ACF) presenting with acute renal failure and heart failure, which was treated successfully with a novel, endovascular approach.
PMCID: PMC3546445  PMID: 23346449
9.  Dural arteriovenous fistula discovered in patient presenting with recent head trauma 
Male, 32
Final Diagnosis: Dural arterio-venous fistula
Symptoms: Eye redness • post-trauma headache • tinnitus
Medication: —
Clinical Procedure: Fistula embolization
Specialty: Neurology
Mistake in diagnosis
A dural arteriovenous fistula (DAVF), is an abnormal direct connection (fistula) between a meningeal artery and a meningeal vein or dural venous sinus. The pathogenesis of DAVF still remains unclear. Sinus thrombosis, head trauma, chronic central nervous system, hypercoagulable state, surgery, and hormonal influence are the pre-disposing factors that initiate this disease. The symptoms experienced by the patient will depend on the location of the fistula.
Case Report:
Thirty-two year old Hispanic male who presented one day after a rear ended motor vehicle collision (MVC) with a severe throbbing headache in the left parietal region, left eye redness but no retro-orbital pain and tinnitus in the left ear. He was initially misdiagnosed to have a carotid-cavernous fistula but upon cerebral angiogram was actually diagnosed with a dural arterio-venous fistula in the posterior fossa venous system followed by successful embolization of the fistula.
A cerebral angiography is the gold standard for detection and characterization of a DAVF and will distinguish it from a CCF. Endovascular surgery involves a catheter-based technique for embolization of the lumen of arteries feeding the DAVF, or directly into the vein draining the DAVF. It is very important to recognize the typical findings of patients presenting with a DAVF then quickly proceeding with a cerebral angiogram to determine the exact location of the fistula and the appropriate treatment plan. By diagnosing and treating a DAVF as early as possible, the associated fatal complications can be averted.
PMCID: PMC3816749  PMID: 24194975
dural arteriovenous fistula; cerebral angiography; endovascular embolization; trauma
10.  A false aneurysm with an aorto-superior vena cava fistula after replacement of the ascending aorta: report of a case 
Surgery Today  2013;44(12):2385-2387.
A 58-year-old female presenting with congestive heart failure due to a fistula between an aortic false aneurysm and the superior vena cava (SVC) is described. She had a history of Takayasu’s arteritis (TA) and she had undergone aortic valve and ascending aorta replacement and coronary artery bypass grafting 6 years before. The false aneurysm had occurred 1 year after the surgery, and she had been conservatively managed. The operation revealed that the cause of the false aneurysm was the detachment of the two proximal saphenous vein anastomoses to the ascending aortic graft. After the surgery, the patient made an uneventful recovery. A false aneurysm of the ascending aorta is one of the most serious complications after replacement of the ascending aorta for patients with TA (Miyata et al. in J Vasc Surg 27:438–445, 1998). We herein present the exceptional case of a fistula between an aortic false aneurysm and the SVC that occurred after ascending aorta graft replacement.
PMCID: PMC4231212  PMID: 24197671
Aortic operation; CHD; Valve; CABG; Venous grafts
11.  Endovascular GDC Treatment of an Idiopathic Carotid-Cavernous Fistula Caused by Aneurysmal Rupture of the Intra-Cavernous Carotid Artery 
Interventional Neuroradiology  2006;12(Suppl 1):174-177.
Aneurysmal rupture of the intra-cavernous carotid artery may cause idiopathic carotid-cavernous fistula (CCF), and the treatment choice for occluding shunting fistula in this type of CCF is an endovascular approach using detachable balloons. However, little has been reported on treating such lesions with the intra-aneurysmal embolization using Guglielmi detachable coils (GDCs). To our knowledge, ours is the first reported case of successful treatment by selective intra-fistula and intra-aneurysmal embolization with GDCs. A 74-year-old woman exhibited proptosis and chemosis of her left eye over a period of one month. Symptoms of double vision in conversion and pulsatile murmur in her left eye were also noted. Angiography revealed an intra-cavernous aneurysm of the left internal carotid artery (ICA) with a shunting fistula, which drained into the dilated cavernous sinus, superior orbital vein (SOV), superior petrosal sinus, inferior petrosal sinus, and pterygoid plexus. We thought the fistula would occlude by intra-aneurysmal embolization, but we had no confidence of tight packing of the aneurysm since the aneurismal neck was relatively wide. So, we embolized the venous side of the shunting fistula and then the dome of the aneurysm with GDCs. Immediately after the operation, her symptoms and signs were ameliorated, and complete occlusion of the CCF was observed on long-term follow-up. We suggest selective intrafistula and intra-aneurysmal embolization with GDCs as an alternative method of treatment of idiopathic CCF originating from aneurysmal rupture of the intra-cavernous carotid artery.
PMCID: PMC3387948  PMID: 20569626
idiopathic CCF; aneurysm; GDC
12.  Simultaneous endovascular repair of an iatrogenic carotid-jugular fistula and a large iliocaval fistula presenting with multiorgan failure: a case report 
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.
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.
PMCID: PMC3277481  PMID: 22273992
13.  Life-threating upper gastrointestinal bleeding due to a primary aorto-jejunal fistula 
•Primary aorto-enteric fistula is an uncommon life-threating condition.•Primary aorto-enteric fistula is usually caused by an untreated abdominal aortic aneurysm.•The treatment of choice for aorto-enteric fistula is emergent surgery.•High clinical suspicion is essential to make a correct diagnosis of aorto-enteric fistula.
Primary aorto-enteric fistula (AEF) is an uncommon life-threating condition. Only 4% of them involve the jejunum or ileum and its mortality ranges from 33 to 85%.
Presentation of case
A 54-year-old female was admitted to the Emergency Department with syncope and hematemesis. The esophagogastroduodenoscopy found a pulsatile vessel in the second portion of the duodenum. A computed tomography scan showed an AEF with an infrarenal aortic aneurysm and iliac artery thrombosis. During surgery, an infrarenal aortic aneurysm complicated with an aorto-jejunal fistula was found. An axilo-bifemoral bypass, open repair of the aneurysm and segmental small bowel resection with primary suture of the jejunal defect were performed.
Depending on previous aortic grafting, AEF can be classified as primary or secondary. Primary AEF is usually caused by an untreated abdominal aortic aneurysm, commonly presenting an infectious etiology. The main clinical sign is a “herald” hemorrhage. The EGD is considered as the first step in diagnosing AEF. The treatment of choice for AEF is emergent surgery. Use of broad-spectrum antibiotics is mandatory in the postoperative period to avoid fistula recurrence.
AEF is a rare entity with a high mortality. High clinical suspicion is essential to make a correct diagnosis, which is crucial for the prognosis of these patients, such is the case of our patient. If hemodynamic stability is achieved, it allows to employ surgical strategies in which extra-abdominal bypass is performed before fistula is treated.
PMCID: PMC4353932  PMID: 25616071
AEF, aorto-enteric fistula; EGD, esophagogastroduodenoscopy; CT, computed tomography; PTFE, polytetrafluoroethylene; Aorto-enteric fistula; Upper gastrointestinal bleeding; Abdominal aneurysm; Esophagogastroduodenoscopy; Surgery
14.  Cardiovascular magnetic resonance and computed tomography in the evaluation of aneurysmal coronary-cameral fistula 
Coronary artery fistulas represent abnormal communications between a coronary artery and a major vessel like venae cavae, pulmonary arteries or veins, the coronary sinus, or a cardiac chamber. The latter is called coronary cameral fistula is a rare condition and is most of the times congenital but can be also post traumatic or post surgical, especially after cardiovascular interventional procedures. Most patients are asymptomatic and coronary-cameral fistulae are discovered incidentally during angiographic evaluation for coronary vascular disorders, while other patients have a clinical presentation ranging from angina pectoris to heart failure. In this article, we report a rare case of an aneurysmal right coronary cameral fistula draining into the left ventricle. Echocardiography usually represents the first diagnostic imaging approach, but often due to a poor acoustic window may not show the entire course of the fistula which is crucial for the final diagnosis. ECG-gated cardiovascular CT may play an important role in the evaluation of the origin, course, termination and morphology of the fistula, its relation to the adjacent anatomical structures as well as the morphology and contractility of the heart. Cardiac MRI instead plays an additional crucial role regarding not only the above mentioned factors but also in estimating the blood flow within the fistula, providing more detailed information about the cardiac function but also about myocardial wall viability.
PMCID: PMC4638407  PMID: 26629294
Coronary artery fistula; Coronary-cameral fistula; cardiovascular CT; image reformats; cardiovascular MR; late gadolinium enhancement
15.  A rare case of aortic sinuses of valsalva fistula to multiple cardiac chambers secondary to periannular aortic abscess formation from underlying Brucella endocarditis 
The concomitant presence of abnormal connection from three aortic valsalva sinuses to cardiac chambers is a rare complication of native aortic Brucella endocarditis. This case report presents a 37-year-old Iranian female patient who had native aortic valve Brucella endocarditis complicated by periannular abscess formation and subsequent perforation to multi-cardiac chambers associated with congestive heart failure and left bundle branch block. Multiple aorto-cavitary fistulas to right atrium, main pulmonary artery, and formation of a pocket over left atrial roof were detected by transthoracic echocardiogram (TTE). She had received a full course of antibiotics therapy in a local hospital and was referred to our center for further surgery. TTE not only detected multiple aorto-cavitary fistulas but also revealed large vegetation in aortic and mitral valve leaflets and also small vegetation in the entrance of fistula to right atrium. However, the tricuspid valve was not involved in infective endocarditis. She underwent open cardiac surgery with double valve replacement with biologic valves and reconstruction of left sinus of valsalva fistula to supra left atrial pocket by pericardial patch repair. The two other fistulas to main pulmonary artery and right atrium were closed via related chambers. The post-operative course was complicated by renal failure and prolonged dependency to ventilator that was managed accordingly with peritoneal dialysis and tracheostomy. The patient was discharged on the 25th day after admission in relatively good condition. The TTE follow-up one year after discharge revealed mild paravalvular leakage in aortic valve position, but the function of mitral valve was normal and no residual fistulas were detected.
PMCID: PMC4644062  PMID: 26605134
fistula; Brucella; endocarditis; heart surgery
16.  Coil Embolization for Intracranial Aneurysms 
Executive Summary
To determine the effectiveness and cost-effectiveness of coil embolization compared with surgical clipping to treat intracranial aneurysms.
The Technology
Endovascular coil embolization is a percutaneous approach to treat an intracranial aneurysm from within the blood vessel without the need of a craniotomy. In this procedure, a microcatheter is inserted into the femoral artery near the groin and navigated to the site of the aneurysm. Small helical platinum coils are deployed through the microcatheter to fill the aneurysm, and prevent it from further expansion and rupture. Health Canada has approved numerous types of coils and coil delivery systems to treat intracranial aneurysms. The most favoured are controlled detachable coils. Coil embolization may be used with other adjunct endovascular devices such as stents and balloons.
Intracranial Aneurysms
Intracranial aneurysms are the dilation or ballooning of part of a blood vessel in the brain. Intracranial aneurysms range in size from small (<12 mm in diameter) to large (12–25 mm), and to giant (>25 mm). There are 3 main types of aneurysms. Fusiform aneurysms involve the entire circumference of the artery; saccular aneurysms have outpouchings; and dissecting aneurysms have tears in the arterial wall. Berry aneurysms are saccular aneurysms with well-defined necks.
Intracranial aneurysms may occur in any blood vessel of the brain; however, they are most commonly found at the branch points of large arteries that form the circle of Willis at the base of the brain. In 85% to 95% of patients, they are found in the anterior circulation. Aneurysms in the posterior circulation are less frequent, and are more difficult to treat surgically due to inaccessibility.
Most intracranial aneurysms are small and asymptomatic. Large aneurysms may have a mass effect, causing compression on the brain and cranial nerves and neurological deficits. When an intracranial aneurysm ruptures and bleeds, resulting in a subarachnoid hemorrhage (SAH), the mortality rate can be 40% to 50%, with severe morbidity of 10% to 20%. The reported overall risk of rupture is 1.9% per year and is higher for women, cigarette smokers, and cocaine users, and in aneurysms that are symptomatic, greater than 10 mm in diameter, or located in the posterior circulation. If left untreated, there is a considerable risk of repeat hemorrhage in a ruptured aneurysm that results in increased mortality.
In Ontario, intracranial aneurysms occur in about 1% to 4% of the population, and the annual incidence of SAH is about 10 cases per 100,000 people. In 2004-2005, about 660 intracranial aneurysm repairs were performed in Ontario.
Treatment of Intracranial Aneurysms
Treatment of an unruptured aneurysm attempts to prevent the aneurysm from rupturing. The treatment of a ruptured intracranial aneurysm aims to prevent further hemorrhage. There are 3 approaches to treating an intracranial aneurysm.
Small, asymptomatic aneurysms less than 10 mm in diameter may be monitored without any intervention other than treatment for underlying risk factors such as hypertension.
Open surgical clipping, involves craniotomy, brain retraction, and placement of a silver clip across the neck of the aneurysm while a patient is under general anesthesia. This procedure is associated with surgical risks and neurological deficits.
Endovascular coil embolization, introduced in the 1990s, is the health technology under review.
Literature Review
The Medical Advisory Secretariat searched the International Health Technology Assessment (INAHTA) Database and the Cochrane Database of Systematic Reviews to identify relevant systematic reviews. OVID Medline, Medline In-Process and Other Non-Indexed Citations, and Embase were searched for English-language journal articles that reported primary data on the effectiveness or cost-effectiveness of treatments for intracranial aneurysms, obtained in a clinical setting or analyses of primary data maintained in registers or institutional databases. Internet searches of Medscape and manufacturers’ databases were conducted to identify product information and recent reports on trials that were unpublished but that were presented at international conferences. Four systematic reviews, 3 reports on 2 randomized controlled trials comparing coil embolization with surgical clipping of ruptured aneurysms, 30 observational studies, and 3 economic analysis reports were included in this review.
Safety and Effectiveness
Coil embolization appears to be a safe procedure. Complications associated with coil embolization ranged from 8.6% to 18.6% with a median of about 10.6%. Observational studies showed that coil embolization is associated with lower complication rates than surgical clipping (permanent complication 3-7% versus 10.9%; overall 23% versus 46% respectively, p=0.009). Common complications of coil embolization are thrombo-embolic events (2.5%–14.5%), perforation of aneurysm (2.3%–4.7%), parent artery obstruction (2%–3%), collapsed coils (8%), coil malposition (14.6%), and coil migration (0.5%–3%).
Randomized controlled trials showed that for ruptured intracranial aneurysms with SAH, suitable for both coil embolization and surgical clipping (mostly saccular aneurysms <10 mm in diameter located in the anterior circulation) in people with good clinical condition:Coil embolization resulted in a statistically significant 23.9% relative risk reduction and 7% absolute risk reduction in the composite rate of death and dependency compared to surgical clipping (modified Rankin score 3–6) at 1-year.
The advantage of coil embolization over surgical clipping varies widely with aneurysm location, but endovascular treatment seems beneficial for all sites.
There were less deaths in the first 7 years following coil embolization compared to surgical clipping (10.8% vs 13.7%). This survival benefit seemed to be consistent over time, and was statistically significant (log-rank p= 0.03).
Coil embolization is associated with less frequent MRI-detected superficial brain deficits and ischemic lesions at 1-year.
The 1- year rebleeding rate was 2.4% after coil embolization and 1% for surgical clipping. Confirmed rebleeding from the repaired aneurysm after the first year and up to year eight was low and not significantly different between coil embolization and surgical clipping (7 patients for coil embolization vs 2 patients for surgical clipping, log-rank p=0.22).
Observational studies showed that patients with SAH and good clinical grade had better 6-month outcomes and lower risk of symptomatic cerebral vasospasm after coil embolization compared to surgical clipping.
For unruptured intracranial aneurysms, there were no randomized controlled trials that compared coil embolization to surgical clipping. Large observational studies showed that:
The risk of rupture in unruptured aneurysms less than 10 mm in diameter is about 0.05% per year for patients with no pervious history of SAH from another aneurysm. The risk of rupture increases with history of SAH and as the diameter of the aneurysm reaches 10 mm or more.
Coil embolization reduced the composite rate of in hospital deaths and discharge to long-term or short-term care facilities compared to surgical clipping (Odds Ratio 2.2, 95% CI 1.6–3.1, p<0.001). The improvement in discharge disposition was highest in people older than 65 years.
In-hospital mortality rate following treatment of intracranial aneurysm ranged from 0.5% to 1.7% for coil embolization and from 2.1% to 3.5% for surgical clipping. The overall 1-year mortality rate was 3.1% for coil embolization and 2.3% for surgical clipping. One-year morbidity rate was 6.4% for coil embolization and 9.8% for surgical clipping. It is not clear whether these differences were statistically significant.
Coil embolization is associated with shorter hospital stay compared to surgical clipping.
For both ruptured and unruptured aneurysms, the outcome of coil embolization does not appear to be dependent on age, whereas surgical clipping has been shown to yield worse outcome for patients older than 64 years.
Angiographic Efficiency and Recurrences
The main drawback of coil embolization is its low angiographic efficiency. The percentage of complete aneurysm occlusion after coil embolization (27%–79%, median 55%) remains lower than that achieved with surgical clipping (82%–100%). However, about 90% of coiled aneurysms achieve near total occlusion or better. Incompletely coiled aneurysms have been shown to have higher aneurysm recurrence rates ranging from 7% to 39% for coil embolization compared to 2.9% for surgical clipping. Recurrence is defined as refilling of the neck, sac, or dome of a successfully treated aneurysm as shown on an angiogram. The long-term clinical significance of incomplete occlusion following coil embolization is unknown, but in one case series, 20% of patients had major recurrences, and 50% of these required further treatment.
Long-Term Outcomes
A large international randomized trial reported that the survival benefit from coil embolization was sustained for at least 7 years. The rebleeding rate between year 2 and year 8 following coil embolization was low and not significantly different from that of surgical clipping. However, high quality long-term angiographic evidence is lacking. Accordingly, there is uncertainty about long-term occlusion status, coil durability, and recurrence rates. While surgical clipping is associated with higher immediate procedural risks, its long-term effectiveness has been established.
Indications and Contraindications
Coil embolization offers treatment for people at increased risk for craniotomy, such as those over 65 years of age, with poor clinical status, or with comorbid conditions. The technology also makes it possible to treat surgical high-risk aneurysms.
Not all aneurysms are suitable for coil embolization. Suitability depends on the size, anatomy, and location of the aneurysm. Aneurysms more than 10 mm in diameter or with an aneurysm neck greater than or equal to 4 mm are less likely to achieve total occlusion. They are also more prone to aneurysm recurrences and to complications such as coil compaction or parent vessel occlusion. Aneurysms with a dome to neck ratio of less than 1 have been shown to have lower obliteration rates and poorer outcome following coil embolization. Furthermore, aneurysms in the middle cerebral artery bifurcation are less suitable for coil embolization. For some aneurysms, treatment may require the use of both coil embolization and surgical clipping or adjunctive technologies, such as stents and balloons, to obtain optimal results.
Information from 3 countries indicates that coil embolization is a rapidly diffusing technology. For example, it accounted for about 40% of aneurysm treatments in the United Kingdom.
In Ontario, coil embolization is an insured health service, with the same fee code and fee schedule as open surgical repair requiring craniotomy. Other costs associated with coil embolization are covered under hospitals’ global budgets. Utilization data showed that in 2004-2005, coil embolization accounted for about 38% (251 cases) of all intracranial aneurysm repairs in the province. With the 2005 publication of the positive long-term survival data from the International Subarachnoid Aneursym Trial, the pressure for diffusion will likely increase.
Economic Analysis
Recent economic studies show that treatment of unruptured intracranial aneurysms smaller than 10 mm in diameter in people with no previous history of SAH, either by coil embolization or surgical clipping, would not be effective or cost-effective. However, in patients with aneurysms that are greater than or equal to 10 mm or symptomatic, or in patients with a history of SAH, treatment appears to be cost-effective.
In Ontario, the average device cost of coil embolization per case was estimated to be about $7,500 higher than surgical clipping. Assuming that the total number of intracranial aneurysm repairs in Ontario increases to 750 in the fiscal year of 2007, and assuming that up to 60% (450 cases) of these will be repaired by coil embolization, the difference in device costs for the 450 cases (including a 15% recurrence rate) would be approximately $3.8 million. This figure does not include capital costs (e.g. $3 million for an angiosuite), additional human resources required, or costs of follow-up. The increase in expenditures associated with coil embolization may be offset partially, by shorter operating room times and hospitalization stays for endovascular repair of unruptured aneurysms; however, the impact of these cost savings is probably not likely to be greater than 25% of the total outlay since the majority of cases involve ruptured aneurysms. Furthermore, the recent growth in aneurysm repair has predominantly been in the area of coil embolization presumably for patients for whom surgical clipping would not be advised; therefore, no offset of surgical clipping costs could be applied in such cases. For ruptured aneurysms, downstream cost savings from endovascular repair are likely to be minimal even though the savings for individual cases may be substantial due to lower perioperative complications for endovascular aneurysm repair.
The two Guidance documents issued by the National Institute of Clinical Excellence (UK) in 2005 support the use of coil embolization for both unruptured and ruptured (SAH) intracranial aneurysms, provided that procedures are in place for informed consent, audit, and clinical governance, and that the procedure is performed in specialist units with expertise in the endovascular treatment of intracranial aneurysms.
For people in good clinical condition following subarachnoid hemorrhage from an acute ruptured intracranial aneurysm suitable for either surgical clipping or endovascular repair, coil embolization results in improved independent survival in the first year and improved survival for up to seven years compared to surgical clipping. The rebleeding rate is low and not significantly different between the two procedures after the first year. However, there is uncertainty regarding the long-term occlusion status, durability of the stent graft, and long-term complications.
For people with unruptured aneurysms, level 4 evidence suggests that coil embolization may be associated with comparable or less mortality and morbidity, shorter hospital stay, and less need for discharge to short-term rehabilitation facilities. The greatest benefit was observed in people over 65 years of age. In these patients, the decision regarding treatment needs to be based on the assessment of the risk of rupture against the risk of the procedure, as well as the morphology of the aneurysm.
In people who require treatment for intracranial aneurysm, but for whom surgical clipping is too risky or not feasible, coil embolization provides survival benefits over surgical clipping, even though the outcomes may not be as favourable as in people in good clinical condition and with small aneurysms. The procedure may be considered under the following circumstances provided that the aneurysm is suitable for coil embolization:
Patients in poor/unstable clinical or neurological state
Patients at high risk for surgical repair (e.g. people>age 65 or with comorbidity), or
Aneurysm(s) with poor accessibility or visibility for surgical treatment due to their location (e.g. ophthalmic or basilar tip aneurysms)
Compared to small aneurysms with a narrow neck in the anterior circulation, large aneurysms (> 10 mm in diameter), aneurysms with a wide neck (>4mm in diameter), and aneurysms in the posterior circulation have lower occlusion rates and higher rate of hemorrhage when treated with coil embolization.
The extent of aneurysm obliteration after coil embolization remains lower than that achieved with surgical clipping. Aneurysm recurrences after successful coiling may require repeat treatment with endovascular or surgical procedures. Experts caution that long-term angiographic outcomes of coil embolization are unknown at this time. Informed consent for and long-term follow-up after coil embolization are recommended.
The decision to treat an intracranial aneurysm with surgical clipping or coil embolization needs to be made jointly by the neurosurgeon and neuro-intervention specialist, based on the clinical status of the patient, the size and morphology of the aneurysm, and the preference of the patient.
The performance of endovascular coil embolization should take place in centres with expertise in both neurosurgery and endovascular neuro-interventions, with adequate treatment volumes to maintain good outcomes. Distribution of the technology should also take into account that patients with SAH should be treated as soon as possible with minimal disruption.
PMCID: PMC3379525  PMID: 23074479
17.  Primary aorto-enteric fistula – a unique complication of poorly differentiated large B-cell lymphoma 
Patient: Male, 76
Final Diagnosis: Aorto-enteric fistula
Symptoms: Abdominal pain • bloody vomiting • shock
Medication: —
Clinical Procedure: CT abdomen with contrast
Specialty: Gastroenterology • vascular surgery
Rare disease
Primary Aorto-Enteric Fistula (PAEF) is a unique and rare life threatening communication between the Aorta and Gastrointestinal Tract with an unusually high mortality rate and delayed diagnosis. Aortic abdominal aneurysms are implicated in a vast majority of cases while cancer as an etiology of PAEF is extremely rare.
Case Report:
We present the first case report of a PAEF secondary to Large B-Cell Lymphoma, followed by a review of literature in regards to malignant aorto-enteric fistulae.
We conclude that physicians should maintain a high index of suspicion for PAEF in any patient with unexplained anemia and history of aortic abdominal aneurysm complicated by cancer.
PMCID: PMC3700467  PMID: 23826466
gastrointestinal hemmorage; aortoenteric fistula; lymphoma
18.  Extra-hepatic portal vein aneurysm: A case report, overview of the literature and suggested management algorithm 
Portal venous aneurysms are a rare finding. The reported incidence is on the rise with increasing use of modern imaging techniques in clinical practice. However, there is still much to be elicited regarding their aetiology, natural history, and management.
An 80-year-old woman presented with abdominal pain and nausea. Investigations showed a hypoechoic area in the region of the head of pancreas on ultrasound, which was found to be a portal venous aneurysm on CT. In view of her multiple comorbidities, a conservative approach was taken.
Portal venous aneurysms represent approximately 3% of all venous aneurysms with a reported prevalence of 0.43%. They may be congenital, due to failure of complete regression of the right vitelline vein, or acquired secondary to portal hypertension. The primary presentation of portal vein aneurysm is abdominal pain, followed by incidental detection on imaging, with a minority of patients presenting with gastrointestinal bleeding. Complications of PVA include thrombosis, biliary tract obstruction, inferior vena cava obstruction, and duodenal compression. On the whole PVAs are stable and have a low risk of complications with 88% of patients showing no progression of aneurysm size or complications on subsequent follow up scans.
We recommend that portal venous aneurysms be assessed using colour Doppler ultrasonography in the first instance with CT scans reserved for indeterminate cases or symptomatic patients. Due to the slow progression of such aneurysms, surgery is recommended only for symptomatic patients or those with complications secondary to portal venous aneurysms.
PMCID: PMC3437391  PMID: 22922358
PVA, portal vein aneurysm; PV, portal vein; SV, splenic vein; SMV, superior mesenteric vein; Portal vein aneurysm; Venous aneurysm; Splenic vein aneurysm; Superior mesenteric vein aneurysm
19.  Iliofemoral-popliteal deep vein thrombosis at 35th week of pregnancy: treated with cesarean section and vena cava blockage plus thrombectomy 
Pregnancy, due to its adaptive physiological changes, is a risk factor for deep vein thrombosis. Incidence of thromboembolic complications during pregnancy ranges from 0.76 to 1.72 per 1000 births. We present in this case report a pregnant woman with iliofemoral-popliteal deep vein thrombosis diagnosed at the 35th week of her pregnancy, who was treated with vena cava blockage and thrombectomy followed by cesarean section. Unfortunately, a rethrombosis developed in the patient after three days. We determined that the a-v fistula was blocked and not working. We found additionally that the deep vein thrombosis was closing the iliac vein completely on the left side and the blockage descending down through the inferior vena cava inlet with MRI. The patient underwent insertion of a retrievable vena cava filter, two stent implantation to the venous narrowings and surgical iliofemoral venous thrombectomy with concomitant re-creation of a temporary femoral arterio-venous fistula. Anticoagulation therapy with enoxaparine was started after the operation. The patient was discharged with warfarin under control of the INR value, and also with additional compression therapy (compression stockings) from the clinic. Without jeopardizing the mother and the baby, planning a combined surgical procedure, with a multidisciplinary approach is the best way to eliminate the risks of serious complications such as pulmonary embolism and mortality.
PMCID: PMC3939137  PMID: 24592024
Deep vein thrombosis; pregnancy; complications; thrombectomy; inferior vena cava
20.  Relationship between encephalopathy and portal vein-vena cava shunt: Value of computed tomography during arterial portography 
AIM: To assess the value of computed tomography during arterial portography (CTAP) in portal vein-vena cava shunt, and analysis of the episode risk in encephalopathy.
METHODS: Twenty-nine patients with portal-systemic encephalopathy due to portal hypertension were classified by West Haven method into grade I (29 cases), grade II (16 cases), grade III (10 cases), grade IV ( 4 cases). All the patients were scanned by spiral-CT. Plane scans, artery phase and portal vein phase enhancement scans were performed, and the source images were thinly reconstructed to 1.25 mm. We reconstructed the celiac trunk, portal vein, inferior vena cava and their branches and subjected them to three-dimensional vessel analysis by volume rendering (VR) technique and multiplanar volume reconstruction (MPVR) technique. The blood vessel reconstruction technique was used to evaluate the scope and extent of portal vein-vena cava shunt, portal vein emboli and the fistula of hepatic artery-portal vein. The relationship between the episode risk of portal-systemic encephalopathy and the scope and extent of portal vein-vena cava shunt, portal vein emboli and fistula of hepatic artery-portal vein was studied.
RESULTS: The three-dimensional vessel reconstruction technique of spiral-CT could display celiac trunk, portal vein, inferior vena cava and their branches at any planes and angles and the scope and extent of portal vein-vena cava shunt, portal vein emboli and the fistula of hepatic artery-portal vein. In twenty-nine patients with portal-systemic encephalopathy, grade I accounted for 89.7% esophageal varices, 86.2% paragastric varices; grade II accounted for 68.75% cirsomphalos, 56.25% paraesophageal varices, 62.5% retroperitoneal varices and 81.25% dilated azygos vein; grade III accounted for 80% cirsomphalos, 60% paraesophageal varices, 70% retroperitoneal varices, 90% dilated azygos vein, and part of the patients in grades II and III had portal vein emboli and fistula of hepatic artery-portal vein; grade IV accounted for 75% dilated left renal vein, 50% paragallbladder varices, all the patients had fistula of hepatic artery-portal vein.
CONCLUSION: The three-dimensional vessel reconstruction technique of spiral-CT can clearly display celiac trunk, portal vein, inferior vena cava and their branches at any planes and angles and the scope and extent of portal vein-vena cava shunt. The technique is valuable for evaluating the episode risk in portal-systemic encephalopathy.
PMCID: PMC4572235  PMID: 15222041
21.  Aortocaval fistulas and the use of transvenous balloon tamponade. 
Six cases of acute aortocaval fistula are reported, which illustrate the difficulties of diagnosis and management in a rare life-threatening condition. Five cases arose from spontaneous rupture of aortic aneurysms and one from trauma. In four cases the diagnosis was made before surgery. Useful diagnostic features included inappropriate jugular venous distension in five patients, lower abdominal and trunk cyanosis in three patients and a palpable thrill in three patients. Preoperative diagnosis permitted attempts to control venous haemorrhage in three cases, one by balloons through the aortic sac and two by transvenous positioning of balloon catheters in the vena cava before aortic opening. The use of transvenous balloon catheters was found to be helpful in reducing haemorrhage. Four patients left hospital alive. Preoperative recognition of the signs of an acute aortocaval rupture and preliminary balloon tamponade appear to be valuable in the management of acute aortocaval fistulas.
PMCID: PMC2499192  PMID: 2221772
22.  Surgical correction of ruptured aneurysms of the sinus of Valsalva using on-pump beating-heart technique 
Rupture of aneurysms of the sinus of Valsalva results in abrupt onset of congestive heart failure. On-pump beating-heart surgery may reduce cardiac impairment by maintaining coronary blood flow and avoiding cardioplegia. Herein, we report the operative correction of thirty-one patients of ruptured aneurysms of the sinus of Valsalva, using the on-pump beating-heart technique.
Thirty-one patients with ruptured aneurysms of the sinus of Valsalva underwent operative corrections using the on-pump beating-heart technique. In patients with fistula diameter less than 1 cm and no aortic regurgitation, the aorta was unclamped throughout cardiopulmonary bypass(CPB) while receiving antegrade heart perfusion. In remainder of patients, retrograde perfusion was used.
After intracardiac manipulation was complete and the nasopharyngeal temperature was raised to 36-37°C, the patients were smoothly weaned off CPB. There were no early or late postoperative deaths. All patients were in New York Heart Association functional class I at follow-up (range, 0.5-1 year). Mild-to-moderate aortic valve regurgitation was observed in one patient. No recurrence of the left-to-right shunt from ruptured aneurysms of the sinus of Valsalva was observed.
Beating heart on pump allows adequate examination of the aortic lesion under near-physiologic conditions, allows decrease in ischemia-reperfusion injury and potentially decreases the risk of serious or fatal rhythm disturbances. On-pump beating-heart technique for repair of ruptured aneurysm of sinus of Valsalva is feasible and promising. Antegrade heart perfusion is suitable for patients with a fistula diameter <1 cm and no aortic regurgitation, and retrograde perfusion is suitable for the others.
PMCID: PMC2877041  PMID: 20470371
23.  Current characteristics of congenital coronary artery fistulas in adults: A decade of global experience 
World Journal of Cardiology  2011;3(8):267-277.
AIM: To describe the characteristics of coronary artery fistulas (CAFs) in adults, including donor vessels and whether termination was cameral or vascular.
METHODS: A PubMed search was performed for articles between 2000 and 2010 to describe the current characteristics of congenital CAFs in adults. A group of 304 adults was collected. Clinical data, presentations, diagnostic modalities, angiographic fistula findings and treatment strategies were gathered and analyzed. With regard to CAF origin, the subjects were tabulated into unilateral, bilateral or multilateral fistulas and compared. The group was stratified into two major subsets according to the mode of termination; coronary-cameral fistulas (CCFs) and coronary-vascular fistulas (CVFs). A comparison was made between the two subsets. Fistula-related major complications [aneurysm formation, infective endocarditis (IE), myocardial infarction (MI), rupture, pericardial effusion (PE) and tamponade] were described. Coronary artery-ventricular multiple micro-fistulas and acquired CAFs were excluded as well as anomalous origin of the coronary arteries from the pulmonary artery (PA).
RESULTS: A total of 304 adult subjects (47% male) with congenital CAFs were included. The mean age was 51.4 years (range, 18-86 years), with 20% older than 65 years of age. Dyspnea (31%), chest pain (23%) and angina pectoris (21%) were the prevalent clinical presentations. Continuous cardiac murmur was heard in 82% of the subjects. Of the applied diagnostic modalities, chest X-ray showed an abnormal shadow in 4% of the subjects. The cornerstone in establishing the diagnosis was echocardiography (68%), and conventional contrast coronary angiography (97%). However, multi-slice detector computed tomography was performed in 16%. The unilateral fistula originated from the left in 69% and from the right coronary artery in 31% of the subjects. Most patients (80%) had unilateral fistulas, 18% presented with bilateral fistulas and 2% with multilateral fistulas. Termination into the PA was reported in unilateral (44%), bilateral (73%) and multilateral (75%) fistulas. Fistulas with multiple origins (bilateral and multilateral) terminated more frequently into the PA (29%) than into other sites (10.6%) (P = 0.000). Aneurysmal formation was found in 14% of all subjects. Spontaneous rupture, PE and tamponade were reported in 2% of all subjects. In CCFs, the mean age was 46.2 years whereas in CVFs mean age was 55.6 years (P = 0.003). IE (4%) was exclusively associated with CCFs, while MI (2%) was only found in subjects with CVFs. Surgical ligation was frequently chosen for unilateral (57%), bilateral (51%) and multilateral fistulas (66%), but percutaneous therapeutic embolization (PTE) was increasingly reported (23%, 17% and 17%, respectively).
CONCLUSION: Congenital CAFs are currently detected in elderly patients. Bilateral fistulas are more frequently reported and PTE is more frequently applied as a therapeutic strategy in adults.
PMCID: PMC3163242  PMID: 21876777
Coronary artery fistulas; Congenital heart defect; Coronary angiography; Multi-detector computed tomography angiography
24.  Surgical Repair of Abdominal Aortic and Renal Artery Aneurysms in Takayasu's Arteritis 
Takayasu's arteritis is a large vessel vasculitis that can be a challenging diagnosis to make and has a varied clinical presentation. Management largely depends on affected vessel disease severity and individual patient considerations. The diagnosis must be considered in a young patient with large vessel aneurysms. We present a case of a 30 year-old woman of Pacific Islander descent who presented to the Tripler Army medical Center Vascular Surgery Department in Honolulu, Hawai‘i seeking repair of her abdominal aortic and renal artery aneurysms prior to conception.
A 30 year-old Pacific Islander woman with a history of a saccular abdominal aortic aneurysm and renal artery aneurysms presented to our clinic seeking vascular surgery consultation prior to a planned pregnancy. She had a renal artery stent placed at an outside institution for hypertension. She met the diagnosis of Takayasu's arteritis by Sharma's criteria. Physical exam was significant for a palpable, pulsatile, abdominal mass and CT angiography revealed a saccular irregular-appearing infra-renal abdominal aortic aneurysm, extending to the aortic bifurcation, with a maximum diameter of 3.3 cm. A right renal artery aneurysm was also identified proximally, contiguous with the aorta, with a maximal transverse diameter of 1.7 cm. The patient underwent a supraceliac bypass to the right renal artery with a 7mm Dacron graft, as well as excision of the right renal artery aneurysm. The abdominal aortic aneurysm was replaced using a Hemashield Dacron bifurcated 14mm x 7mm bypass graft. Intraoperative measurements of the renal artery aneurysm were 1.5 x 1.5 cm and the saccular appearing distal abdominal aortic aneurysm measured 3.6 x 3.3cm. The patient was discharged from the hospital 7 days post-operatively. At 1-year follow up, CT scan of the abdominal aorta revealed the repair was without any evidence of aneurysm formation, anastomotic pseudoaneurysm formation, or areas of stenosis. She has remained normotensive with a normal serum creatinine 18 months after her repair. She has since delivered her second child.
It is rare for Takayasu's arteritis to present with aneurysmal disease. It is much more common to present with stenosis or occlusion. It has yet to be proven that Takayasu's truly has a higher incidence in those of Asian descent. Takayasu's can be a difficult diagnosis to make but can be aided with the use of Sharma's criteria. Our particular patient posed unique considerations on the effects of the physiology of pregnancy on her aneurysms and repair.
Managing the active phases of disease is imperative, and though medical management is first line, surgical intervention may be necessary. Surgical intervention should be performed in a quiescent period of disease if possible given that biological inflammation at the time of intervention increases the complication rate. Repair of aneurysmal disease in a young female should also be considered prior to pregnancy.
PMCID: PMC4733819  PMID: 26870600
Arterial Aneurysms; Pregnancy; Abdominal Aortic Aneurysm; Renal Artery Aneurysm
25.  Rat Model of Parkes Weber Syndrome 
PLoS ONE  2015;10(7):e0133752.
The Parkes Weber syndrome is a congenital vascular malformation, characterized by varicose veins, arterio-venous fistulas and overgrown limbs. No broadly accepted animal model of Parkes Weber syndrome has been described. We created side-to-side arterio-venous fistula between common femoral vessels with proximal non-absorbable ligature on common femoral vein limiting the enlargement of the vein diameter in Wistar rats. Contralateral limb was sham operated. Invasive blood pressure measurements in both iliac and inferior cava veins were performed in rats 30 days after fistula creation. Tight circumference and femoral bone length were measured. Histopathology and morphology of soleus muscle, extensor digitorum longus muscle, and the common femoral vessel were analyzed. 30 days following arterio-venous fistula creation, a statistically significant elevation of blood pressure in common iliac vein and limb overgrowth was observed. Limb enlargement was caused by muscle overgrowth, varicose veins formation and bone elongation. Arterio-venous fistula with proximal outflow limitation led to significant increase of femoral vein circumference and venous wall thickness. Our study indicates that the described rat model mimics major clinical features characteristic for the human Parkes Weber syndrome: presence of arterio-venous fistula, venous hypertension and dilatation, varicose veins formation, and the limb hypertrophy. We reveal that limb overgrowth is caused by bone elongation, muscle hypertrophy, and venous dilatation. The newly established model will permit detailed studies on the mechanisms underlying the disease and on the efficacy of novel therapeutic strategies for the Parkes Weber syndrome treatment.
PMCID: PMC4517880  PMID: 26217941

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