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1.  Aortoesophageal fistula as a complication of thoracic aorta aneurism stent grafting – a case report and literature review 
Polish Journal of Radiology  2012;77(4):77-80.
Summary
Background:
Endovascular stent grafting is performed in patients with aneurysms of aorta or other major vessels. The procedure is considered to be generally safe, with a low risk of complications, the most common of which include endoleaks, stenosis or thrombosis at the stagraft and itsmigration.
Very rare complications include aortoesophageal and aortobronchial fistulas (0.5–1.7% cases).
Case Report:
A 64-year-old patient was admitted to our hospital with suspected aortoesophageal fistula. Two years prior, the patient had undergone a stent graft repair of the thoracic aorta at the local vascular surgery clinic. Both laboratory results and CT angiography revealed aortoesophageal fistula, which was also detected in endoscopic examination.
Despite intensive treatment and preparation for surgery, the patient died 6 days after admission.
Conclusions:
Aortoesophageal and aortobronchial fistulas are among the most dangerous and difficult-to-treat complications in the treatment of thoracic aortic aneurysms by endovascular stent-grafting. This clearly indicates that preventive care and regular medical examinations are important to prevent their occurrence.
PMCID: PMC3529719  PMID: 23269943
aortoesophageal fistula; thoracic aortic aneurysm; stent graft
2.  Transcatheter Embolization for Giant Splenic Artery Aneurisms: Still an Open Question 
Case Reports in Radiology  2012;2012:652469.
Transcatheter embolization is the mainstay of the therapy of splenic artery aneurysms (SAAs) in patients with portal hypertension. It is indicated when the SAA diameter reaches 20 mm. Although endovascular techniques are effective and safe for the treatment of medium-sized SAAs, little is known about their applicability to large-sized SAAs. Herein, we report a case of giant SAA, which was treated with transcatheter coil embolization. The case was not considered suitable for surgery because of the presence of severe portal hypertension. The procedure was complicated by bacterial infection of the coils within the aneurismatic sac, leading to the development of hepatic failure. A liver transplant was then successfully performed despite the presence of a nonresponsive infection.
doi:10.1155/2012/652469
PMCID: PMC3414005  PMID: 22900219
15.  Quantitative analysis of vascular signs on early postmortem multi-detector computed tomography 
SpringerPlus  2014;3:169.
Purpose
To clarify the postmortem multi-detector computed tomography (MDCT) vascular signs that occur shortly after death.
Materials and methods
The vascular signs in MDCT images were evaluated quantitatively in 96 early postmortem cardiac arrest patients, 47 cardiac arrest patients who survived due to resuscitation and 47 control patients without cardiac arrest.
Results
Elliptical (40 cases) or collapsed deformity (2 cases, in only the abdominal aorta) and high-attenuated sedimentation (19 cases in the aorta and 10 cases in superior or inferior vena cava) were limited to the postmortem patients. The incidence of elliptical deformity was higher for the abdominal aorta, descending thoracic aorta and ascending thoracic aorta in rank. The sedimentation was observed in the ascending thoracic aorta with a higher frequency than in the descending thoracic and abdominal aorta. A high-attenuating wall in any portion of the aorta was observed in 34 of the postmortem patients, 11 of the surviving patients and 10 of the control group, with a predominance of the ascending thoracic aorta.
Conclusion
Elliptical deformity in the abdominal and descending thoracic aorta and high-attenuated sedimentation in the ascending thoracic aorta were shown to be signs of postmortem MDCT shortly after death.
doi:10.1186/2193-1801-3-169
PMCID: PMC4000595  PMID: 24790818
MDCT; Postmortem imaging; Aorta; Cardiac arrest; Blood vessels
16.  Renal artery stenosis and abdominal aorta aneurysm in patients with pseudoexfoliation syndrome 
Eye  2013;27(6):735-741.
Purpose
To evaluate the renal arteries and abdominal aorta in patients with pseudoexfoliation syndrome (PEX).
Design
Prospective, case–control study.
Methods
The study involved 49 patients with PEX and 42 control subjects. Abdominal aorta and renal arteries were examined by Doppler ultrasonography. In both renal arteries (proximal and distal portions) and abdominal aorta, the peak systolic velocity (PSV) was measured. Renal artery stenosis (RAS) was defined as the renal artery PSV >150 cm/s or renal-to-aortic ratio (RAR) >3.0. Patients who had an abdominal aortic diameter >3 cm were recorded. Computed tomographic angiography was performed to confirm these findings in patients with RAS and/or abdominal aorta aneurysm.
Results
The mean PSV in the proximal renal artery was 88.3 cm/s in PEX group and 79.5 cm/s in control group (P=0.314); in distal renal artery was 91.7 cm/s in PEX group and 93.0 cm/s in control group (P=0.794); in abdominal aorta was 76.0 cm/s in PEX group and 65.2 cm/s in control group (P=0.046). RAS was observed in nine patients with PEX and in only one patient without PEX (P=0.017). Seven out of 10 patients with RAS (six patients in PEX group; one patient in control group) had hypertension. Abdominal aorta aneurysm was observed in four patients in PEX group but not in control group (P=0.061).
Conclusions
Our study has demonstrated that there is a significant association between PEX and RAS. The abdominal aorta aneurysm may be seen in patients with PEX.
doi:10.1038/eye.2013.56
PMCID: PMC3682361  PMID: 23579404
pseudoexfoliation syndrome; renal artery stenosis; abdominal aorta aneurysm; Doppler ultrasonography; computed tomographic angiography
17.  Endovascular Repair of Abdominal Aortic Aneurysm 
EXECUTIVE SUMMARY
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.
OBJECTIVE
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).
BACKGROUND
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
18.  Abdominal Aortic Disease Caused by Penetrating Atherosclerotic Ulcers 
Annals of Vascular Diseases  2012;5(1):8-14.
Objective: Penetrating atherosclerotic ulcer (PAU) of the aorta is defined as an atherosclerotic lesion with ulceration of the aortic intima and media and rupture of the internal elastic lamina. PAU induced aortic dissection, aortic rupture, and secular aortic aneurysm and typically occurs in elderly hypertensive patients with severe atherosclerosis. Although it has been reported that atherosclerosis similarly occurs in the abdominal aorta, its natural history and treatment are still unclear. This study investigated the clinical features, natural history, and treatment of PAU of the abdominal aorta.
Method:Between April 2006 and March 2009, 4 diagnoses of PAU in the abdominal aorta were made by computed tomography (CT) and magnetic resonance imaging (MRI). These 4 cases were analyzed along with 61 previously reported cases from the literature with diagnoses of PAU in the abdominal aorta, aortic rupture, and isolated abdominal aortic dissection over the past 15 years, giving a total of 65 cases.
Results:The patients were men with an average age of 63.5 years. All 4 had hypertension, and 2 had concomitant coronary artery disease. Two patients were asymptomatic, and the other 2 were symptomatic and transmural rupture had occurred. All diagnoses were made by CT and MRI. All 4 patients underwent open surgery with a knitted Dacron graft, with no postoperative deaths. In the literature, 53% of cases were symptomatic, including pain (40%, n = 26), shock (4.6%, n = 3), and lower limb embolism (9.2%, n = 6). The remaining 40% of cases were asymptomatic (n = 26). Six patients were treated medically, while 58 patients underwent surgery, with 2 postoperative deaths.
Conclusion:We suggest that surgical treatment (open surgery or endovascular stent grafting) should be performed to prevent an aortic catastrophe such as intramural hematoma, dissection, or rupture. (English translation of Jpn J Vasc Surg 2010; 19: 723-730.)
doi:10.3400/avd.oa.11.00916
PMCID: PMC3595917  PMID: 23555480
penetrating atherosclerotic ulcer; saccular aortic aneurysm; isolated aortic dissection; aortic rupture
19.  Analysis of anatomical variations of the main arteries branching from the abdominal aorta, with 64-detector computed tomography 
Polish Journal of Radiology  2010;75(2):38-45.
Summary
Background:
Great variability in the vasculature of the abdominal organs makes the pre-operative evaluation of arterial anatomical conditions extremely important and helpful. The aim of our study was to establish the prevalence of anatomical variations of the arteries branching from the abdominal aorta and to compare the results with the ones presented in the literature.
Material/Methods:
The material included computed tomography angiographies (CTA) of 201 patients (91 women and 110 men) performed between September 2007 and December 2008. The CTA examinations were conducted with a 64-detector CT scanner at the Department of Radiology of University Hospital in Wrocław. Images were obtained during the arterial phase and were analyzed for the presence of potential anomalies of the branches of the abdominal aorta.
Results:
In 88 patients (43.8%), there were anatomical variations of the arteries branching from the abdominal aorta. Variations of the renal arteries were observed in 83 (41.3%) patients, anomalies of the celiac trunk in 9 patients (4.5%), including variations of the superior mesenteric artery in 4 (2%) patients. No anatomical anomalies of the inferior mesenteric artery were shown in this study.
The most frequent anomaly of the renal vasculature was the presence of at least one additional renal artery, observed in 65 (32.3%) patients. This concerned the inferior renal polar artery mainly – in 30 (14.9%) patients. Presence of bilateral additional renal arteries was visualized in 10% (20/201) of the cases. The most frequent anomalies of the celiac trunk were the celiacmesenteric trunk (in 3 patients – 1.5%) and the hepatosplenic trunk (in 3 patients – 1.5%). The celiac-mesenteric trunk was also the most frequent variation of the superior mesenteric artery in our material.
Conclusions:
A large part of population – 43.8% of our patients – demonstrated variations of arteries branching from the abdominal aorta. The anomalies were significantly more often found within the renal arteries than within the celiac trunk or the superior mesenteric artery. Sixty-four detector CTA reveals a high sensitivity in the detection of anomalies of the arteries branching from the abdominal aorta.
PMCID: PMC3389861  PMID: 22802775
computed tomography angiography; abdominal aorta; anatomic variations

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