Abstract:

Introduction: pseudo-aneurysm of subclavian artery is a rare pathology and most often develops due to trauma or iatrogenic causes. Despite the rarity of this pathology, it can be accompanied by the risk of lethal rupture or distal embolism. Article presents a case report of endovascular treatment of post-traumatic pseudo-aneurysm of right subclavian artery with a stent-graft.

Aim: was to demonstrate advantages of endovascular treatment of pseudo-aneurysms, based on case report of patient with post-traumatic pseudo-aneurysm of right subclavian artery.

Material and methods: a case report of a patient with post-traumatic pseudo-aneurysm of right subclavian artery, polytrauma and pulmonary embolism is presented.

Results: successful endovascular treatment of pseudo-aneurysm of right subclavian artery with the implantation of stent-graft was performed. Postoperative period was uneventful, and the patient was discharged with improved health.

Conclusions: endovascular treatment is the preferred method, due to its less invasiveness and lower complication frequency in comparison with open surgery.

Abstract:

In interventional radiology department of clinical hospital № 27 (Moscow) since 2002 till 2009 TIPS was performed in 62 patients for hepatic cirrhosis with portal hypertension. One of the patients underwent orthotopic liver transplantation in Germany.
Material and methods. Mean age in the group was 5f ,6 y. o., 17 women, 45 men. Three types of stents were used: matrix stents, self-expanding and stent-grapfts. Patients were divided in 2 groups. In Group 1 (17 pts) we performed TIPS with stent-grafts (Gore Viatorr TIPS Endoprosthesis); in Group 2 (47 pts) bare metal stents were used (matrix stents Perico, Genesis, JoMed and self-expanding stents Za-stent, Zilver, Wallstent, sinus-SuperFlex Visual-Stent, SMART-control).
Results. During 18 months follow-up there were no thrombosis, significant stenosis in patients of Group 1, and primary patency rate was 100%. In Group 2 primary and secondary patency rates were 69,3% and 85,6% correspondingly. Freedom from recurr­ ent esophageal varices hemorrhage was 82,8% in Group 1 and 69,3% in Group 2, ascitis and hydrothorax regression - 93,9% and 80,0%, absence of hepatic cerebropathy progression - 93,9% and 80,0%, overall survival - 87,8% и 76,0% correspondingly.
Conclusions. Therefore use of stent-graft in TIPS procedure improve patency of intrahepatic shunt (p < 0,01), significantly reduce risk of recurrent variceal hemorrhage (0,1 < p < 0,5), and reduce volume of ascitis (0,1 < p < 0,5). It worth saying that cerebropathy progression was caused by non-compliance to diet, and was corrected with medicamental treatment. In long-term follow-up stent­ graft «Viatorr» deployment improves survival of patients (0,1 < p < 0,5). Introduction of stent-grafts marked a new stage of TIPS pro­ cedure improvement.

Abstract

Background: pancreatic cancer (PC) - oncologic disease with nonsignificant clinics on early stages and tendention of spreadind in population, as a result - late diagnosis and low rate of radical treatment (10-25%). Carried radical treatment, such as pancreaticoduodenectomy (PDE) - has a high risk of postoperative complications (30-70%) due to its difficulty Most often and dangerous complications are: bleeding, anastomotic leakage, postoperative pancreatitis, purulent complications. Bleeding occurs in 5-10% of cases, mortality varries between 30,7% and 58,5% according to moderd literature. "Sentinel bleeding" - term that meand non-fatal bleeding through drainage or gastrointestinal bleeding (GIB) that follows PDE, and is a predictor of further massive fatal bleeding. Material and methods: article presents data of patient (male, 64y) who underwent gastropancreaticoduodenectomy (GPDE) through bilateral hypochondriacal access as treatment of moderate differentiated (MD) ductal adenocarcinoma of pancreatic head. On 21st day after surgery - massive GIB with source of bleeding as pseudoaneurysm of right hepatic artery Taking into consideration "adverse anatomy", impossibility of stent-graft implantation and failure of primary embolization with "front-to-back-door" technique - against the background of reccurent bleeding, patient undewent coiling of pseudoaneurysm and subseqent coil implantation into right hepatic artery anc common hepatic artery Against the background of second reccurency of GIB - patient underwent successful "front-to-back-door" embolization with combinaton of coils and Onyx.

Results: technique of «front-to-back-door» embolization led to stable hemostasis and patient's discharge in satisfactory condition without recurrence of bleeding.

Conclusions: surgical hospital, carrying on resections of pancreas as a routine, should have a CathLab unit, equipped with wide specter of angiografic instruments and 24/7 surgical team with experience of hemostatic interventions. Bleeding after PDE should be considered as «sentinel bleeding». In case of side-injury of large vessels - stent-graft implantation is preferable, if it is impossible - "front-to-back-door" embolization should be used. 

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33.    Iatrogenic and non-iatrogenic trauma. Casebased discussion. Marie Cerna. Cirse 2015.

Abstract:

Open surgery is a basis of treatment of major vascular injuries, although some of injuries can be treated by means of endovascular surgery

Aim: was to investigate the possibility of endovascular treatment of full transection of major arteries. Material and methods: а retrospective analysis of patients histories of 52 patients with limbs' vascular injuries was performed. Opinions of physicians of different surgical specialties about practicability of endovascular technologies use in trauma surgery were investigated. Using a created stand-desk, consisted with container filled with gelatin mass, simulating a hematoma in a zone of vascular rupture, plunged into gelatin ends of silicone tubes 6 mm in internal diameter, and a web-camera fixed above the stand, comparative analysis of efficacy of 6 different methods of vessel recanalization was done.

Results: еndovascular methods of treatment can be performed in 42,3% of patients with major arterial injuries. Of those, 13,5% of patients may need to undergo recanalization of full vascular transection followed by stent-graft implantation. Our study demonstrated the possibility of through-and-through recanalization of the full major vascular transection, and most effective methods of recanalization - methods with use of a special endovascular loop, a retrieval device, and a standard folded guidewire. Preliminary balloon inflation inside a proximal part of the artery should be considered in case of unstable hemodynamics of a patient.

The questionnaire showed that integration of endovascular surgical methods is perspective for the future of trauma surgery; however, there are some retaining obstacles such as organizational and fiscal issues. It is likely that training of general surgeons in basic endovascular skills is practical. 

References

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Abstract:

Company Endogene Pty. Ltd. designd an endoluminal stapler. The purpose of the study was to report the use of device in a living canine model and appraise the technology in a living canine model, and to assess reliability of the delivery system and deployment process, security of the rings discharge and fixation, as well as maintenance of the vessel patency and abcence of thrombotic complications.

Reference:

1.     Slonim S.M., Nyman U., Semba C.P., Miller D.C., Mitchell R.S., Dake M.D. Aortic dissection: percutaneous management of ischemic complications with endovascular stents and balloon fenestration. J. Vasc. Surg. 1996; 23:241-253.

2.     Leurs L.J., Buth J., Laheij R.J.F. Long-term results  of endovascular  abdominal  aortic aneurysm treatment with the first generation of commercially available stent grafts. Arch. Surg. 2007; 142: 33-41.

3.     Brewster D.C.,Jones J.E., Chung T.K., Lamuraglia G.M., Kwolek C.J., Watkins M.T., Hodgman T.M., Cambria R.P. Long-term outcomes after endovascular abdominal aortic aneurysm repair. Ann. Surg. 2006; 244 (3): 426-438

Abstract:

Traumatic lesions of peripheral arteries which lead to pseudoaneurysm formation is the rare pathology Originally surgical treatment was the main method of pseudoaneurysms' treatment. However, now endovascular procedures are preferable as a method such patients' treatment. The case of successful endovascular treatment of posttraumatic pseudoaneurysm of subclavian artery with stent-graft implantation is shown This clinical case report demonstrates main advantages of endovascular method of such location pseudoaneurysms treatment.

Abstract:

Purpose. Evaluation of twelve-year results of abdominal aortic aneurysm treatment by Ella stent-grafts with regard to safety and effectiveness in relation to morphology of the aneurysm.

Methods. From a group of 297 patients with abdominal aortic aneurysm, for whom elective endovascular treatment was considered, 204 of them (68,68%) were found to be suitable for this type of therapy. The bifurcated type of stent-graft was implanted in 176 patients, uniiliacal type in 23 patients and only 5 patients were found to be suitable for tubular type of stent-graft. Additional necessary procedures (internal iliac artery occlusion or contra lateral common iliac artery occlusion in a group of patients with uniiliacal type of stent-graft) were performed surgically during the stent-graft implantation.

Results. Primary technical success was achieved in 193 of the 204 patients (94,6%). Primary endoleak was recorded in 11 patients (primary endoleak type I in 7 patients, type I b in 3 patients and type III a in one patient). Assisted technical success after reintervention or spontaneous seal was 99,02%.

Surgical conversion was indicated in 2 patients (0,98%). Perioperative mortality rate was 3,43%. In 20 patients (9,80%) secondary endoleak type II and in 4 patients (1,96%) secondary endoleak type III was found at control CT and in three patients partial thrombosis of the stent-graft was found. There was one aneurysm rupture during follow-up.

Conclusion. Treatment of abdominal aortic aneurysm with Ella stent-graft system is effective and safe. Bifurcated stent-graft is the most frequently used type. Uniiliacal type of stent-graft is used by us only in cases of complicated morphology. 

References

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8.        Hausegger K.A., Mendel H., Tiessenhausen K., Kaucky M., Aman W., Tauss J., Koch G. Endoluminal treatment of infrarenal aortic aneurysms: Clinical experience with the Talent stentgraft system. J. Vasc. Interv. Radiol. 1999; 10: 267–274.

9.        Kato N., Dake M.D., Semba C.P., Razavi M.K., Kee S.T., Slonim S.M., Samuels S.L.W., Terasaki K.K., Zarins C.K., Mitchell R.S., Miller D.C. Treatment of aortoiliacal aneurysms with use of single-piece tapered stent-grafts. J. Vasc. Interv. Radiol. 1998; 9: 41–49.

10.      Tutein Nolthenius R.P., van Herwaarden J.A., van den Berg J.C., van Marrewijk C., Teijink J.A., Moll F.L. Three year single centre experience with the AneuRx aortic stent-graft. Eur. J. Vasc. Endovasc. Surg. 2001; 22: 257–264.

11.      Hill B.B., Wolf Y.G., Lee W.A., Arko F.

Abstract:

Aim: was to assess the efficacy of surgical treatment of post-traumatic arteriovenous fistula with use of stent-grafts.

Materials and methods: stent-grafts were successfully used in treatment of 4 patients with post-traumatic arteriovenous fistula (AVF). In 2 cases AVF were located in iliac vessels, in 1 case in shin and in 1 case - thigh. In 3 cases, appearance of AVF was a result of gunshot wound, in 1 case - stab wound

Results: technical success was achieved in all cases. In 1 case after endovascular elimination of AVF on the level of iliac vessels, retroperitoneal hematoma with infection was revealed, that leaded to open surgical operation.

Conclusion: the use of stent-grafts in surgical correction of vessel injury can decrease operational trauma, and can achieve better clinical results and good long-term prognosis.  

References

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5.    Zotov S.P., Shherbakov A.V., Kugeev A.F., Zajcev S.S., Shakirov R.G., Semashko T.V., Zhabreev A.V., Panov I.O. Klinicheskie osobennosti posttravmaticheskih arterio- venoznyh svishhej [Clinical features of post-traumatic arteriovenous fistula]. Angiologija i sosudistaja hirurgija. 2011; 17(2):133-137 [In Russ].

6.    Li F., Song X., Liu C., Liu B., Zheng Y Endovascular stent-graft treatment for a traumatic vertebrovertebral arteriovenous fistula with pseudoaneurysm. Ann. Vasc. Surg. 2014; 2:489.

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8.    Park H.K., Choe W.J., Koh YC., Park S.W. Endovascular management of great vessel injury following lumbar microdiscectomy. Korean J. Spine. 2013; 4:264-267.

9.    Sin'kov M.A., Murashkovskij A.L., Pogorelov E.A., Golovin A.A., Kalichenko N.A., Haes B.L., Kokov A.N., Heraskov V.Ju., Evtushenko S.A., Popov V.A., Barbarash L.S. Sluchaj uspeshnogo jendovaskuljarnogo zakrytija jatrogennogo arterio-venoznogo soust'ja podvzdoshnoj arterii i veny, projavljajushhegosja venoznym trombojembolicheskim sindromom i pravozheludochkovoj nedostatochnost'ju [Successful endovascular occlusion of iatrogenic arteriovenous fistula of the iliac artery and vein with thromboembolic syndrome and right ventricular insufficiency]. Diagnosticheskaja i intervencionnaja radiologija. 2014; 8(2):98-102 [In Russ].

Abstract:

46-year old man with obstructive jaundice has a complication of hemobilia after performed earlier percutaneous transhepatic biliary drainage (PTBD). Angiography failed to localize the bleeding site, that is why selective therapeutic embolization was not done. We performed implantation of Gore stent-graft into biliary ducts, and hemobilia stopped immediately.

Abstract:

Aneurism of the splenic artery is a rare, but potentially life-threatening condition. In the majority of patients with an aneurism of unpaired visceral arteries the endovascular procedure is a treatment of choice. Of them stent graft implantation is considered as the most promising method. However, until recent only balloon-dilated stent grafts were used. Due to a rigid delivering system this type of grafts cannot be implanted in distal branches of visceral arteries, that is significant limitation of this technique. Technological advances and developing of low-profile soft self-expanding grafts allow overcoming this limitation. New type of grafts opens the possibility to exclude aneurisms even in conditions of marked vessel tortuosity and complex vascular anatomy

Conclusion: stent-graft implantation is an effective and safe method of treatment of splenic artery false aneurisms. This method allows to reliably exclude an aneurism from the circulation and is not associated with increased risk of thrombotic complications. Modern low-profile soft self-expanding grafts open new possibility in treatment of visceral arteries aneurisms even in conditions of marked vessel tortuosity and complex vascular anatomy.

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Abstract:

Intraoperative vascular injury is infrequent complication (0.02-0.06%) during surgical operations on lumbar discs. We report a case of a 44-year-old man with oedema and varicose veins of the right lower limb. Despite an 4-year history of oedema and varicose veins, he appeared to be asymptomatic and could recollect no traumatic injury or surgery that might have caused it. Near the vertebral column, we found a small scar, the result of spinal disk surgery six years before. CT scan showed pseudoaneurysm of the right iliac artery with a 54 mm diameter. Thereafter, we located the suspected arteriovenous fistula by selective angiography of the aorta and its branches: a communication of the right iliac artery with the right iliac vein had resulted in a large shunt. This lesion was repaired by transluminal placement of stent-grafts Aorfix (Lombard Medical, UK). We had to use three stent-grafts due to the large difference in diameter between the common and external right iliac arteries. Hemodynamic improvement was immediate, and the postoperative course was uneventful. At the present time, almost six months postoperatively, the patient is asymptomatic. Sealing of pseudoaneurysm and arteriovenous fistula as a complication of lumbar-disc surgery with a stent graft is simple and is suggested as an excellent alternative to open surgery for iatrogenic vessel injuries. 

References

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Abstract:

Successful endovascular occlusion of iatrogenic arteriovenous fistula of the iliac artery and vein with tromboembolic syndrome and right ventricular insufficiency, occurred after surgical intervention on spine (mircodiscectomy of L4-L5, decompression of L5 radix). Disease spreaded under clinic of tromboembolic syndrome with formation of arteriovenous fistula and manifested like thromboembolic syndrome with right ventricular insufficiency.

References

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Abstract:

Case report of successful endovascular treatment of pseudoaneurysm of common hepatic artery (patient underwent laparoscopic gastrectomy, cholecystectomy with lymph node dissection in treatment of gastric adenocarcinoma) is presented.

Materials and methods: patient E., 61 year. In anamnesis: ulcer disease for the period of 8 years. In 2013, gastric adenocarcinoma T4N0M0 had been revealed and in January 2014 patient underwent laparoscopic gastrectomy, cholecystectomy with lymph node dissection D2. Postoperative period was complicated by thrombosis of left branch of portal vein, external biliary fistula, left subdiaphragmatic abscess with further drainage. During CT-angiography - adenoma of left adrenal gland and aneurysm of proper hepatic artery were revealed. Selective angiography revealed aneurysm of common hepatic artery in middle third, sized 10x20 mm. Patient underwent double-staged treatment. Primary patient underwent embolization of aneurysm with Azur-18 coils, but aneurysm cavity had incomplete thrombosis. As a second stage patient underwent stent-graft implantation in hepatic artery.

Results: stent implantation was uncomplicated, aneurysm was excluded from blood flow. Patient was discharged in good condition, without any additional operation. Control angiography was performed in 3 months and thrombosis of stent with collateral blood flow were revealed. 

References

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2.     Hossain A., Reis E.D., Dave S.P, Kerstein M.D., Hollier L.H. Visceral artery aneurysms: experience in a tertiary-care center. Am. Surg. 2001 May;67(5):432-7.

3.     Kasirajan K., Greenberg R.K., Clair D., Ouriel K. Endovascular management of visceral artery aneurysm. J. Endovasc. Ther. 2001 Apr; 8(2):150-5.

4.     Gabelmann A., Gorich J., Merkle E.M. Endovascular treatment of pseudoaneurysm of the common hepatic artery with intra-aneurysmal glue (N-butyl 2-cyanoacrylate) embolization. Cardiovasc. Intervent. Radiol. 2007 Sep-Oct; 30(5):999-1002.

5.     Grego F.G., Lepidi S., Ragazzi R., Iurilli V., Stramanа R., Deriu G.P Visceral artery aneurysms: a single center experience. Cardiovasc. Surg. 2003 Feb;11(1):19-25.

6.     Garg A., Banait S., Babhad S., Kanchankar N.. Nimade P, Panchal C. Endovascular treatment of visceral artery aneurysms. J. Endovasc. Ther. 2002 Feb;9(1): 38-47.

7.     Sakai H., Urasawa K., Oyama N., Oabatake A., Successful covering of a hepatic artery aneurysm with a coronary stent graft. Cardiovasc. Intervent. Radiol. 2004 May- Jun;27(3):274-7.

8.     Jenssen G.L., Wirsching J., Pedersen G., Amundsen S.R., Aune S., Dregelid E., Jonung T., Daryapeyma A., Lax- dal E. Treatment of a hepatic artery aneurysm by endovascular stent-grafting. Cardiovasc. Intervent. Radiol. 2007 May-Jun;30(3):523-5.

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10.   Jecko V., Benali L., Vignes J.F., Vignes J.R. Hepatic artery aneurysm rupture after lumbar stenosis surgery. Medico-legal thinking. France Neurochirurgie. 2014 Feb- Apr;60(1-2):38-41.

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12.   Asai K., Watanabe M., Kusachi S., Matsukiyo H., Saito T., Kodama H., Enomoto T., Nakamura Y, Okamoto Y, Saida Y, lijima R., Nagao J. Successful treatment of a common hepatic artery pseudoaneurysm using a coronary covered stent following pancreatoduodenectomy: report of a case. Surg. Today. 2014 Jan; 44(1):160-5.

13.   Lu PH., Zhang X.C., Wang L.F., Chen Z.L., Shi H.B. Stent graft in the treatment of pseudoaneurysms of the hepatic arteries. ^ina Vasc. Endovascular Surg. 2013 Oct; 47(7):551-4.

14.   Suvorova U.V., Tarazov P.G., Polikarpov A.A., Balahin P.V., Polehin A.S. Stentirovanie obschey pechenochnoy i verhney bryzheechnoy arterii dlia ostanovki massivnogo arterialnogo krovotechenia [Stenting of common hepatic artery and superior mesenteric artery for stopping of massive arterial bleeding.] Mezhdunarodniy zhurnal interventsionnoy kardioangiologii. 2013; 35: 73 [In Russ].

15.   Kokov L.S., Cygankov V.N., Shutihina I.V., Zjatenkov A.V. Implantacija samoraskryvajushhihsja stentov-graftov v lechenii lozhnyh anevrizm selezenochnoj arterii [Implantation of self-expanding stent-graft in treatment of pseudoaneurysm of splenic artery]. Diagnosticheskaja i intervencionnaja radiohgija. 2013; 7(1): 75-82 [ In Russ].

16.  Sundeep Punamia, Singapore Transhepatic arterial cannulation and embolisation of hepatic artery pseudoaneurism. poster report frome CIRSE 2014, Glasgow, UK.

Abstract:

Aim: was to evaluate efficiency of stents-grafts in treatment of cerebral aneurysms.

Materials and methods: for the period of 2001-2012 implantation of stent-grafts was performedm 10 patients with cerebral aneurysms. Indications for implantation: huge or giant aneurysms; wide«neck» of aneurysm; difficult localization for neurosurgical techniques; absence of significant tortuosity of artery that could interfere successful stent delivery All patients underwent examination:

MSCT-angiography, MRI, cerebral angiography To predict possible stent thrombosis we performed angiographic tests with pinching of pathological artery and contrasting of opposite artery Then we assessed blood-flow of anterior and posterior communicating arteries and also changes in neurological status. Unsatisfactory condition of collateral blood-flow - was not a contraindication for stenting. In 8 patient, aneurysms were localized in internal carotid artery, and in 2 patients in the vertebrobasilar artery In 3 cases implantation of stent-graft was proceeded in acute period of hemorrhage; that caused late disaggregant therapy (immediately after implantation, drugs were injected through nasogastric tube instead of 4-5 days of preoperative treatment).

Results: exclusion of the aneurysm from the blood-flow was reached 100% of cases. In one case, implantation of micro-coils was necessary due to inability to cover the whole neck of the aneurysm because of tortuosity of artery In 1 case we had thrombosis of stent in vertebral artery with spreading of thrombosis on basilar artery with development of ischemic stroke and further death.

Conclusion: use of stent-grafts for exclusion of huge and giant aneurysms from cerebral blood- flow is a highly effective method.

References

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5.    Tissen T.P., Jakovlev S.B. Bocharov A.V. Buharin E.Ju. Ispol'zovanie stent-grafta v jendovaskuljarnoj nejrohirurgii. Voprosy nejrohirurgii im. N.N. Burdenko [The use of stent-graft in endovascular neurosurgery]. 2006; 2: 53-56. [In Russ].

6.     Vulev I., Klepanec A., Bazik R. et al. Endovascular treatment of internal carotid and vertebral artery aneurysms using a novel pericardium covered stent. Interv. Neuroradiol. 2012; 18 (2): 164-171.

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8.     Li M.H., Li YD., Tan H.Q. et al. Treatment of distal internal carotid artery aneurysm with the willis covered stent: a prospective pilot study. Radiology. 2009; 253 (2): 470-477.

9.     Chalouhi N., Tjoumakaris S., Gonzalez L.F. et al. Coiling of large and giant aneurysms: complications and long-term results of 334 cases. AJNR Am. J. Neuroradiol. 2014; 35 (3): 546-452.

Abstract:

Endovascular treatment of thoracic aortic dissection type B is the method of choice in complicated cases. These interventions are obviously less traumatic, accompanied by less blood loss, shorten the length of stay in the intensive care unit, and there is a smaller number of complications. Successful treatment requires careful planning and determination of the existence of conditions for the implantation of endovascular prostheses. It is important to analyze the question of vascular approach, the availability of landing zone, the feasibility of switching aorta branches before implantation etc. However, you can have experience of not predicted of intraoperative complications. 

Article presents two clinical cases of implantation of stent-grafts in patients with challenging anatomy of the defeat of the thoracic aorta. In both cases, we used hybrid approach. In each case we used carotid-subclavian shunting before implantation of the stent-graft and in one case we usee «chimney» technique. Thoracic Endovascular Aortic Repair in these patients was accompanied by certain difficulties. Anatomical difficulties were overcome by using of not standart technique during operation.

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