The Dilemma after Sealing an Endovascular Aortic Aneurysm – Three Ways Out

2021 ◽  
Vol 146 (05) ◽  
pp. 498-505
Author(s):  
Eliza Pleban ◽  
Jacek Michalak ◽  
Jaroslaw Iwanowski ◽  
Piotr Szopinski
Keyword(s):  
Intensive Care Unit ◽  
Open Repair ◽  
Perioperative Period ◽  
Aneurysm Rupture ◽  
Iliac Arteries ◽  
Late Failure ◽  
Distal Migration ◽  
Type Ia ◽  
The Mean

Abstract Introduction Endovascular aneurysm sealing (EVAS) was commercially introduced in 2013. The initial results of EVAS were positive, leading to its widespread use. The mid- and long-term reports showed greater than expected rates of migration, which led to a recall of the device. In the present article, we describe our experience in managing type Ia endoleaks and migration occurring with the Nellix system in three different ways: open repair with Nellix explantation, Nellix-in-Nellix application (NINA technique), and the use of the multibranched Colt device originally dedicated to the treatment of thoracoabdominal aneurysms. Materials and Methods From February 2014 to June 2021, we performed 20 procedures for failed EVAS or ChEVAS (migration, type Ia endoleak, secondary aneurysm rupture). All patients treated for EVAS failure were male, aged 65 – 79. Results Seven Nellix explantations were performed. Three patients were admitted to our hospital with ruptured aneurysms that occurred 3 weeks to 4 years (mean 124 weeks) after EVAS, and another four with type Ia endoleak. In all but one case, removal of the Nellix system was easy. In two patients, tube grafts were implanted and in the remaining five cases, bifurcated grafts were implanted. In four patients, graft legs were anastomosed with the internal iliac arteries. One patient with secondary aneurysm rupture died from multiorgan failure on the 4th postoperative day. In two cases, transient renal failure was noticed in the perioperative period. All patients were admitted to the intensive care unit for 1 to 4 days (mean 2 days). The mean hospital stay was 9 days. All patients stayed in follow-up (3 – 56 months), but no other complications occurred. Eight patients were treated with the NINA technique: five for distal migration of the Nellix and three for failed ChEVAS. Four patients had a NINA procedure performed with three chimneys, three with two and one with one chimney. In one case, two iliac limbs were implanted to avoid kinking of the external iliac arteries. The median hospitalization time after the procedure was 9 days (range 3 – 12). Four patients developed transient acute renal insufficiency in the perioperative period. The follow-up ranged between 4 and 72 months. In one patient, deterioration of preexisting chronic renal insufficiency developed 5 months after the procedure, but dialysis was not required. One patient died from exacerbation of heart failure 7 months after the NINA procedure. The Colt device was implanted in five patients for the treatment of distal migration with type Ia endoleaks. None of the patients developed any signs of spinal cord ischemia. All patients were admitted to the intensive care unit for 1 or 2 days. In two cases, transient acute renal failure was noticed in the perioperative period. The mean hospital stay was 9 days. All patients remained in follow-up (6 – 22 months). In one case, the occlusion of the celiac trunk branch was found in contrast computed tomography 1 month after implantation of the Colt device, but without any symptoms. No other complications occurred. Conclusions Normal strategies for the management of complications for late failure of EVAR, including stent-graft extensions, are not suitable after EVAS; therefore, alternatives are necessary. Conversion to open repair carries an extensive burden on the patient, so it is not recommended for patients with high surgical risk. The use of a Nellix-in-Nellix application to treat late failure of EVAS is not within the instructions for use but could be an effective strategy for a type Ia endoleak with or without migration. The use of this technique has been extremely limited since the Nellix system was recalled from the market. The use of the Colt multibranched device may be an alternative option, but due to the small number of patients, this method needs further evaluation.

Midterm Follow-up of Fenestrated and Scalloped Physician-Modified Endovascular Grafts for Zone 2 TEVAR

2019 ◽  
Vol 27 (3) ◽  
pp. 377-384 ◽  
Author(s):  
Lucien Chassin-Trubert ◽  
Marcello Mandelli ◽  
Baris Ata Ozdemir ◽  
Pierre Alric ◽  
Thomas Gandet ◽  
...  
Keyword(s):  
Spinal Cord Ischemia ◽  
Intramural Hematoma ◽  
Perioperative Period ◽  
Aneurysm Rupture ◽  
Traumatic Rupture ◽  
Stent Fracture ◽  
Endovascular Grafts ◽  
Number Of Patients ◽  
Type Ia

Purpose: To investigate the midterm outcomes of scalloped or fenestrated physician-modified endovascular grafts (PMEGs) for zone 2 thoracic endovascular aortic repairs (TEVAR). Materials and Methods: Between November 2013 and May 2019, 54 consecutive patients (mean age 63 years; 41 men) were treated with thoracic PMEGs modified with 7 scallops or 47 fenestrations for the left subclavian artery (LSA). Indications for aortic repair were acute complicated type B aortic dissection (17, 31%), degenerative aneurysm (13, 24%), acute traumatic rupture of the aortic isthmus (9, 16%), post chronic dissection aneurysmal evolution (8, 15%), penetrating aortic ulcer (3, 6%), intramural hematoma (2, 4%), and floating thrombus (2, 4%). Results: Technical success was 94%; 3 (6%) LSAs were unintentionally covered. An intraoperative type Ia endoleak was treated during the index procedure. One (2%) patient suffered spinal cord ischemia, with irreversible bilateral paraplegia. Three (6%) patients experience postoperative minor strokes with full neurological recovery. Four (7%) patients died in the perioperative period; 2 (2%) were due to aneurysm rupture. Mean follow-up was 26±16 months; 15 (28%) patients had at least 3 years of follow-up. Two (4%) type II endoleaks were identified and successfully treated (4% reintervention rate); no other endoleaks were identified. All the LSAs remained clinically and radiologically patent. There were no conversions to open repair, ruptures, retrograde dissection, stent fracture, migrations, or other aortic complications. Conclusion: Scalloped or single-fenestrated PMEGs for the LSA appear to be durable and safe in the midterm. Combined with low periprocedural morbidity and mortality, these results suggest that this approach can be considered as an off-label alternative to extend proximal seal to zone 2 for TEVAR. Further studies with a larger number of patients and long-term outcomes are needed to fully validate this approach.

Factors associated with early and late failure after goniotomy for primary pediatric glaucoma

2018 ◽  
Vol 30 (1) ◽  
pp. 162-167 ◽  
Author(s):  
Dina H Hassanein ◽  
Ahmed Awadein ◽  
Hala Elhilali
Keyword(s):  
Risk Factors ◽  
Intraocular Pressure ◽  
First Year ◽  
Failure Rates ◽  
Factors Associated ◽  
Pediatric Glaucoma ◽  
Late Failure ◽  
Before And After ◽  
The Mean

Purpose: To analyze the risk factors associated with early and late failure after goniotomy for primary pediatric glaucoma. Methods: A retrospective study was done on infants who underwent goniotomy as the initial surgical procedure for primary pediatric glaucoma, and had a follow-up period ⩾48 months after surgery. Early and late failures were defined as intraocular pressure ⩾18 mmHg or signs of glaucoma progression before and after the end of first year, respectively. Results: A total of 81 eyes of 47 children were included. The mean age at the time of surgery was 6.1 ± 6.7 months, 34 children (72.3%) were bilateral. The mean follow-up was 5.9 ± 2.8 years. Of the included eyes, 41 eyes (50.6%) showed success, 25 eyes (30.9%) showed an early failure, and 15 eyes (18.5%) showed a late failure. The mean survival time was 43 months. However, only surgery before the end of the first month and positive consanguinity of the parents (P < 0.01 for both) were independent risk factors for early and late failure of goniotomy for primary pediatric glaucoma. Patients with late failure showed a statistically significant lower preoperative intraocular pressure (P = 0.02). A larger preoperative corneal diameter and a male gender were associated with higher but statistically insignificant failure rates. There were no differences in the early or late failure rates between unilateral and bilateral cases. Conclusion: A positive consanguinity of the parents and surgery before the end of the first month are the major predictors of failure of goniotomy.

scholarly journals An Ex-Press implant versus trabeculectomy in a fibrotic bleb with late failure after previous trabeculectomy

2021 ◽  
Vol 14 (3) ◽  
pp. 383-387
Author(s):  
Faried Wagdy ◽  
◽  
Hisham Elsorogy ◽  
Ahmed Alnagdy ◽  
Dina Abd Elfattah ◽  
...  
Keyword(s):  
Postoperative Complications ◽  
Open Angle Glaucoma ◽  
Implant Surgery ◽  
Late Failure ◽  
Group I ◽  
The Mean ◽  
The Difference ◽  
One Year ◽  
Age Range

AIM: To compare the outcome of an Ex-Press implant and subscleral trabeculectomy (SST) in the management of glaucoma after previous trabeculectomy on a fibrotic bleb. METHODS: This randomized prospective study included 28 eyes from 28 patients (age range: 42-55y) with primary open angle glaucoma (POAG) presented with elevated intraocular pressure (IOP) with fibrotic bleb despite previous SST for more than 4mo. The eyes enrolled in the study were divided into two groups: group I (subjected to Ex-Press implant surgery) and group II [subjected to SST with mitomycin C (MMC)]. The follow-up continued one year after surgery to evaluate IOP, visual acuity (VA), visual field (VF), and postoperative complications. RESULTS: A significant decrease in IOP was found in both groups with a higher reduction in Ex-Press implant surgery with the mean IOP of 14.50 mm Hg (P=0.001), while the SST group recorded the mean IOP of 16.50 mm Hg (P=0.001) after one year. However, the difference between the two groups in terms of the decrease in IOP was insignificant. Fewer postoperative complications were recorded in the Ex-Press implant surgery and more cases requiring further anti-glaucomatous medications were seen in the SST group. Both groups showed stability in terms of VA and VF. CONCLUSION: Ex-Press implant surgery and SST with MMC are two surgical alternatives for controlling IOP in late failure that occurs more than 4mo after previous SST with a fibrotic bleb. However, Ex-Press shunt is a safer surgery with fewer complications.

scholarly journals Combined endoscopic and mini-open repair of chronic complete proximal hamstring tendon avulsion: a novel approach and short-term outcomes

2021 ◽  
Author(s):  
Shai Factor ◽  
Amal Khoury ◽  
Ran Atzmon ◽  
Matias Vidra ◽  
Eyal Amar ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Open Repair ◽  
Hamstring Tendon ◽  
Activity Level ◽  
Short Term ◽  
The Mean ◽  
Proximal Hamstring ◽  
Tendon Avulsion ◽  
Mini Open

  To evaluate the outcome of a novel, combined endoscopic and mini-open repair (CEMR) of a chronic complete retracted proximal hamstring tendon avulsion (PHA). A retrospective case series of a single-surgeon database for all patients, with a minimum of 1-year follow-up, who underwent CEMR between July 2015 and September 2019 was performed. Patients were evaluated for their functional outcome using the Perth Hamstring Assessment Tool (PHAT). At the latest follow-up, patients were evaluated for their muscle strength, subjective satisfaction and post-operative complications. Twelve patients who underwent endoscopic surgery for chronic PHA were identified, of which seven patients underwent CEMR. After exclusion of one patient from the study due to an open claim for health insurance, six patients (five males) with a mean age of 48 years (range 20–61 years) were evaluated. The mean time from injury to surgery was 12 months (range 2–43 months). At a mean follow-up of 28 months (range 12–55 months), the average PHAT score was 73 (range 70–80). The mean subjective activity level percentage improved from 34 (range 20–50) pre-surgery to 81 (range 75–90) post-surgery. The mean strength of the quadriceps, hamstring at 30°, and hamstring at 90° of the operated leg compared to the uninjured leg did not differ significantly. One patient underwent adhesiolysis 1 year after the index procedure for treatment of subcutaneous adhesions. CEMR is a viable and safe option for the treatment of chronic complete proximal hamstring tears, with good to excellent short-term functional outcome. Level of evidence: IV.

Abstract WMP30: Risk Analysis Of Growth And Rupture In Unruptured Intreacranial Aneurysms : Single Institutional Cohort Study

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Yuichi Murayama ◽  
Toshihiro Ishibashi ◽  
Hiroyuki Takao ◽  
Ichiro Yuki ◽  
Hideki Arakawa ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Three Dimensional ◽  
Aneurysm Rupture ◽  
Posterior Circulation ◽  
Single Center ◽  
Risk Of Rupture ◽  
Aneurysm Growth ◽  
The Mean ◽  
Small Aneurysms

Introduction: Risk of growth and rupture in unruptured intracranial saccular aneurysm (UIA) are still unclear. Hypothesis: Gowth and risk of UIA may be correlated and they were evaluated our single center large cohort. Methods: Between January 2003 and March 2011, a total of 2122 patients with 2756 UIA were referred to our institution. 1403 patients with 2037 UIAs were assigned for conservative management. The mean follow up duration was 6201 aneurysm-years. Bi-annual three-dimensional computed tomography angiography (3D CTA) was performed and aneurysm growth was evaluated using 3D workstation. The aneurysm growth was defined as size increase more than 1mm. Results: During observation, 14.6% aneurysms increased their size. Female and male growth rate were 16% and 11% respectively. 130 patients stopped observation and therapeutic intervention was performed due to increase their size or anxiety. During observation 50 UIAs ruptured resulting in a 0.8% rupture rate per year. Aneurysm growth, IC-pcom aneurysms, posterior circulation, female, and SAH associated multiple aneurysms were risk factor for aneurysm rupture. Growing aneurysm was 10 times higher relative risk of rupture compare to stable aneurysm. No aneurysm demonstrated reduction of their size after rupture. Conclusions: Risk of Aneurysm growth and rupture may be correlated. Risk of rupture of UIAs was similar that was reported before but even small aneurysms can be rupture during observation. Growing UIAs should be considered to treat as soon as possible even in small size.

scholarly journals Early outcomes of patients transferred with ruptured suprarenal aneurysm or dissection

2018 ◽  
Vol 100 (4) ◽  
pp. 316-321 ◽  
Author(s):  
N Rudarakanchana ◽  
M Hamady ◽  
S Harris ◽  
E Afify ◽  
RGJ Gibbs ◽  
...  
Keyword(s):  
Mortality Rates ◽  
Local Hospital ◽  
Tertiary Centre ◽  
Number Of Patients ◽  
Type Ia ◽  
Hybrid Repair ◽  
Specialist Centre ◽  
The Mean ◽  
One Year

Objective Despite centralisation of the provision of vascular care, not all areas in England and Wales are able to offer emergency treatment for patients with acute conditions affecting the aorta proximal to the renal arteries. While cardiothoracic centres have made network arrangements to coordinate care for the repair of type A dissections, a similar plan for vascular care is lacking. This study investigates early outcomes in patients with ruptured suprarenal aortic aneurysm or dissection (rSRAD) transferred to a specialist centre. Methods Retrospective observational study over a five-year period (2009–2014) assessing outcomes of patients with ruptured sRAD diagnosed at their local hospital and then transferred to a tertiary centre capable of offering such treatment. Results Fifty-two patients (median age 73 years, 32 male) with rSRAD were transferred and a further four died during transit. The mean distance of patient transfer was 35 miles (range 4–211 miles). One patient did not undergo intervention due to frailty and two died before reaching the operating theatre. A total of 23 patients underwent endovascular repair, 9 hybrid repair and 17 open surgery. Median follow-up was 12 months (range 1–43 months). Complications included paraplegia (n = 3), stroke (n = 2), type IA endoleak (n = 4); 30-day and in-hospital mortality were 16% and 27%. For patients discharged alive from hospital, one-year survival was 67%. Conclusions Although the number of patients with rSRAD is low and those who are transferred alive are a self-selecting group, this study suggests that transfer of such patients to a specialist vascular centre is associated with acceptable mortality rates following emergency complex aortic repair.

scholarly journals Techniques and long-term outcomes of cotton-clipping and cotton-augmentation strategies for management of cerebral aneurysms

2016 ◽  
Vol 125 (3) ◽  
pp. 720-729 ◽  
Author(s):  
Sam Safavi-Abbasi ◽  
Felix Moron ◽  
Hai Sun ◽  
Mark E. Oppenlander ◽  
M. Yashar S. Kalani ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Recurrence Rate ◽  
Aneurysm Rupture ◽  
Unruptured Aneurysms ◽  
Aneurysm Neck ◽  
Augmentation Strategies ◽  
Augmentation Techniques ◽  
The Mean ◽  
Clipping Technique

OBJECTIVE To address the challenges of microsurgically treating broad-based, frail, and otherwise complex aneurysms that are not amenable to direct clipping, alternative techniques have been developed. One such technique is to use cotton to augment clipping (“cotton-clipping” technique), which is also used to manage intraoperative aneurysm neck rupture, and another is to reinforce unclippable segments or remnants of aneurysm necks with cotton (“cotton-augmentation” technique). This study reviews the natural history of patients with aneurysms treated with cotton-clipping and cotton-augmentation techniques. METHODS The authors queried a database consisting of all patients with aneurysms treated at Barrow Neurological Institute in Phoenix, Arizona, between January 1, 2004, and December 31, 2014, to identify cases in which cotton-clipping or cotton-augmentation strategies had been used. Management was categorized as the cotton-clipping technique if cotton was used within the blades of the aneurysm clip and as the cotton-clipping technique if cotton was used to reinforce aneurysms or portions of the aneurysm that were unclippable due to the presence of perforators, atherosclerosis, or residual aneurysms. Data were reviewed to assess patient outcomes and annual rates of aneurysm recurrence or hemorrhage after the initial procedures were performed. RESULTS The authors identified 60 aneurysms treated with these techniques in 57 patients (18 patients with ruptured aneurysms and 39 patients with unruptured aneurysms) whose mean age was 53.1 years (median 55 years; range 24–72 years). Twenty-three aneurysms (11 cases of subarachnoid hemorrhage) were treated using cotton-clipping and 37 with cotton-augmentation techniques (7 cases of subarachnoid hemorrhage). In total, 18 patients presented with subarachnoid hemorrhage. The mean Glasgow Outcome Scale (GOS) score at the time of discharge was 4.4. At a mean follow-up of 60.9 ± 35.6 months (median 70 months; range 10–126 months), the mean GOS score at last follow-up was 4.8. The total number of patient follow-up years was 289.4. During the follow-up period, none of the cotton-clipped aneurysms increased in size, changed in configuration, or rebled. None of the patients experienced early rebleeding. The annual hemorrhage rate for aneurysms treated with cotton-augmentation was 0.52% and the recurrence rate was 1.03% per year. For all patients in the study, the overall risk of hemorrhage was 0.35% per year and the annual recurrence rate was 0.69%. CONCLUSIONS Cotton-clipping is an effective and durable treatment strategy for intraoperative aneurysm rupture and for management of broad-based aneurysms. Cotton-augmentation can be safely used to manage unclippable or partially clipped intracranial aneurysms and affords protection from early aneurysm re-rupture and a relatively low rate of late rehemorrhage.

The significance of unruptured intracranial saccular aneurysms

1987 ◽  
Vol 66 (1) ◽  
pp. 23-29 ◽  
Author(s):  
David O. Wiebers ◽  
Jack P. Whisnant ◽  
Thoralf M. Sundt ◽  
W. Michael O'Fallon
Keyword(s):  
Aneurysm Rupture ◽  
Content Type ◽  
Unruptured Aneurysms ◽  
Short Period ◽  
Long Term Follow Up ◽  
The Mean ◽  
Low Probability ◽  
Saccular Aneurysms

✓ The authors report the results of a long-term follow-up study of 130 patients with 161 unruptured intracranial saccular aneurysms. Their findings suggest that unruptured saccular aneurysms less than 10 mm in diameter have a very low probability of subsequent rupture; The mean diameter of the aneurysms that subsequently ruptured was 21.3 mm, compared with a diameter of 7.5 mm for aneurysms defined after rupture at the same institution. Part of the explanation for this discrepancy may be that the size of the filling compartment of the aneurysm decreases after rupture. There is also evidence from the present study that intracranial saccular aneurysms develop with increasing age of the patient and stabilize over a relatively short period, if they do not initially rupture, and that the likelihood of subsequent rupture decreases considerably if the initial stabilized size is less than 10 mm in diameter. Consequently, the critical size for aneurysm rupture is likely to be smaller if rupture occurs at the time of or soon after aneurysm formation. There seems to be a substantial difference in potential for growth and rupture between previously ruptured and unruptured aneurysms.

scholarly journals Admission patterns in a psychiatric intensive care unit in Ireland: a longitudinal follow-up

2021 ◽  
pp. 1-8
Author(s):  
S. Raaj ◽  
S. Navanathan ◽  
B. Matti ◽  
A. Bhagawan ◽  
P. Twomey ◽  
...  
Keyword(s):  
Mental Health ◽  
Intensive Care Unit ◽  
Intensive Care ◽  
Clinical Characteristics ◽  
Treatment Model ◽  
Care Centre ◽  
Primary Indication ◽  
The Mean ◽  
The Phoenix

Objective: This study aims to describe the course of admission and clinical characteristics of admissions to a psychiatric intensive care unit (PICU) in the Phoenix Care Centre (PCC), Dublin, Ireland. Methods: This retrospective chart study was conducted at the PCC, Dublin, Ireland. The cohort included all admission episodes (n = 91 complete data) over a three-year study period between January 2014 and January 2017. Results: The mean age of admitted cases was 37.1 (s.d. = 11.3; range 18–63). The mean length of stay (LOS) was 59.3 days (s.d. = 61.0; median 39.5 days). All patients were admitted under Mental Health Act legislation. Antipsychotic polypharmacy was used in 61% (n = 55) of the admissions. A diagnosis of acute psychotic disorder (B = −1.027, p = 0.003, 95% CI: −1.691, −0.363) was associated with reduced LOS in PICU. Conclusion: Our study describes the cohort of patients admitted as being predominantly male, younger-aged, single, having a diagnosis of schizophrenia and being legally detained. The primary indication for referral is risk of assault, which highlights the need for the intensive and secure treatment model that a PICU can provide.

scholarly journals Effect of Surgical Resection on Jugular Foramen Tumors: A Retrospective Study

2021 ◽  
Author(s):  
Su Weijie ◽  
Li Xixi ◽  
Wu Honglin ◽  
Tang Hongxing ◽  
Deng Zhong ◽  
...  
Keyword(s):  
Surgical Resection ◽  
Tumor Recurrence ◽  
Skull Base Surgery ◽  
Good Control ◽  
Perioperative Period ◽  
Jugular Foramen ◽  
Anatomical Structure ◽  
Total Resection ◽  
The Mean

Abstract The complex anatomical structure of jugular foramen (JF) makes a challenge for the diagnose and treatment of this region’s tumors. The purpose of the study was to investigate the effect of surgical resection in patients with JF tumors. A total of 77 patients with JF tumors treated with surgical resection between 2012 and 2021 were retrospectively reviewed. General characteristics, tumor classification, surgical approach and outcomes were retrospectively analyzed. The mean follow-up period was 4.5 years (ranging 0.5-8.5 years). Of the enrolled patients, 63 patients (81.82%) were diagnosed with JF schwannomas. 67 cases (87.01%) of the total patients received gross-total resection. Preoperatively, hoarseness and/or dysarthria served as the most complained symptoms (n=41, 53.25%), followed by swallowing disturbance (n = 37, 48.05%), hearing disturbance and/or tinnitus (n = 32, 41.56%). Postoperatively, a total of 52 patients (67.53%) were without significant symptoms. Worsened hoarseness and/or dysarthria symptoms were found in 14 patients (18.18%). Besides, 6 cases (7.79%) of the enrolled patients showed worsened swallowing disturbance. 8 patients (10.39%) presented with facial palsy after operation and 3 of them got improvement during the follow-up. Nine patients (12.68%) had tumor recurrence and there was one death (1.3%) associated with surgery during the perioperative period in the cohort. Therefore, surgical resection was an effective treatment of JF tumors with improvements of symptoms and good control of tumor. However, operation on this region was at the risks of worsening cranial nerve deficits and death, which needed advance in skull base surgery and rich experience.

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