Coronary artery aneurysm is commonly defined as a localized dilatation exceeding the diameter of adjacent normal coronary segments by 50% . Coronary artery aneurysms may be fusiform, involving the full circumference of the coronary artery, or saccular, involving only a portion of the circumference . Causes of coronary artery aneurysms include atherosclerosis (accounting for 50% of cases), Kawasaki disease, polyarteritis nodosa, infection, trauma, coronary dissection, percutaneous coronary angioplasty, and congenital malformations . The abnormal blood flow within the coronary artery aneurysm may lead to thrombus formation, embolization, rupture, myocardial ischemia or myocardial infarction . Here we present a case of a giant fusiform coronary artery aneurysm who passed away due to coronary rupture after acute myocardial infarction.
Objectives: Cardioembolic etiology is a frequent source of ischemic stroke. Echocardiogram is the mainstay of cardioembolic source detection with regard to plan secondary stroke management, however it remains unclear how often clinically actionable findings are provided hereby. In addition, it is uncertain whether echocardiography should be performed transthoracic or transesophageal (TEE). In a monocenter study, we evaluated the frequency of pathological findings from TEE evaluation in patients with ischemic stroke with suspected cardioembolic and cryptogenic source and determined whether there was an associated adjustment in the prescribed administration of antithrombotic therapy.
Materials and Methods: Over a 21-month period (2012-2013), we enrolled 143 patients in a prospective monocenter study (mean age ± standard deviation, 70 ± 12 years; females, 44.1%) who were admitted to the Department of Neurology at the University of Lübeck due to ischemic stroke and who underwent TEE due to supposed cardiac embolism. We assessed the presence of atrial fibrillation; days from admission to TEE; and TEE findings, including atrial septal aneurysm, thrombogenic aortic arch, valve failure, presence of left atrial thrombus, and patent foramen ovale. Demografic information and medical history were drawn from patient records and the hospital information system.
Results: On average, TEE was performed 4 days after admission to the hospital. Left atrial thrombus was detected in 3 patients (2.1%), patent foramen ovale (PFO) in 27 (18.9%), atrial septum aneurysm in 17 (11.9%), and thrombogenic aortic arch in 29 (20.3%). Findings from TEE were commonly associated with therapeutic adjustment; antiplatelet therapy increased from 30.1% to 80.4%, oral anticoagulation therapy increased from 2.8% to 27.3%.
Conclusion: Findings from TEE for the evaluation of ischemic stroke lead to frequent adjustment of prior antithrombotic therapy, antiplatelet as well as anticoagulation.
Despite the background of advances in cardiac surgery procedures for higher risk population, the postoperative complication has already been a challenge for cardiac surgeon and Heart-Team. Future perspectives to exceed this challenge could be periodically patient’s follow up and advance diagnostic workup. We describe the diagnosis of a large sub mitral left Ventricle Pseudoaneurysm that was identified in a 59-year-old woman 17 years after she underwent aortic and mitral valve replacement for rheumatic valvular disease
The Objective: to improve the treatment results for patients with cerebral arterial saccular aneurysms by optimizing of differentiated approach to the using of endovascular assisting occlusion techniques.
Materials and Methods: The work is based on the comprehensive survey and treatment of 1345 patients with cerebral saccular arterial aneurysms (AA), who were treated at the SO “Scientific-Practical Center of endovascular neuroradiology of NAMS of Ukraine” from 2002 to 2016. 214 cases were selected for further clinical-instrumental dynamic observation in follow-up period. All patients were operated by endovascular approach in “before hemorrhage” period, in acute or “cold” period of the disease on for symptomatic or asymptomatic intracranial saccular AA in both vascular pools with balloon-remodeling or stent-assisting techniques using with the coiling or just detachable coils (DC) using-mono-coils occlusion technique. Depending on the initial endovascular occlusion method, the patients were divided into three groups for observation: I group (mono-coils occlusion)-82 (38.3%) patients, II group (balloon-remodeling technique using)-68 (31.8%) patients, group III (stent-assisting technique occlusion)-64 (29.9%) patients. The life quality and the level of social adaptation were evaluated before hospital discharge and at the follow-up control examinations by Glasgow Outcome Scale (GOS) and by the modified Rankine scale (mRS). AA radicalism occlusion was assessed by Modified Raymond-Roy Scale (MRRS) (Mascitelli JR, et al., 2015). AA occlusion I and II by MRRS was considered as “Effective”.
Results: 9 criteria of cerebral saccular AA complexity inherent in endovascular surgery have been developed based on the technical and surgical features of endovascular methods of the cerebral AA occlusion and X-ray-anatomical characteristics of aneurysms, which complicated the “effective” reconstructive occlusion of AA cavity.
The evaluation of the AA complexity criteria prognostic significance to achieve the “effective” primary occlusion, shown different results in different groups: high prognostic significance of 4 criteria was shown in group I, of 2 criteria - in group III, and no any criteria significance in group II.
There was no statistically significant difference between groups in the primary AA occlusion efficacy and initial good results by GOS and mRS.
It was proved that endovascular occlusion of complex cerebral AA with the assisting methods using has high efficiency in all periods of the disease, unlike the method of mono-coils occlusion, which is most effective in acute and “cold” periods.
There was no statistically significant difference between the number of intraoperative, postoperative and non-surgical complications (p>0.05).
It was found that all methods of complex AA endovascular occlusion can effectively prevent the disease recurrence despite the differences between them in the stability of the AA cavity occlusion.
Conclusions: Consideration of developed AA complexity criteria during endovascular surgery planning allows to choose the most optimal and safe individual method of primary or phased AA occlusion and helps to reduce the frequency of AA recanalization in follow-up period. The choice of the complex AA occlusion method doesn’t effect on result of primary treatment, the number of intraoperative complications and the quality of primary occlusion. However, an analysis of the long-term treatment results indicates that the assisting techniques have proven advantages according to the occlusion stability.
Background: Haemodialysis is the commonest method of Renal Replacement Therapy in Nigeria. Despite an advancement in the technicality and better understanding of haemodialysis, a number of complications are known to be associated with this procedure..
Objective: We aimed to highlight our experiences and share some of the uncommon complications encountered during haemodialysis and present the outcome of our patients.
Subjects and methods: A retrospective review of 101 patients during the last two years was done. Data extracted include: sociodemographic characteristic, aetiology of kidney disease, type of vascular access, intradialytic complication and outcome of treatment.
Results: The total number of dialysis session during the period was 823. Males constituted a higher proportion (64.4%) and were found to be older than female patients 49.8 vs 42.8 years (P=0.001).
Majority (89.1%) had chronic kidney disease while chronic glomerulonephritis was the main cause of CKD as seen in about 45% of the patient.
Due to the cost implication, only 2(1.98%) were able to undergo 3 sessions of dialysis per week for up to 1 month.
Vascular access was femoral (66.3%), internal jugular vein (25.7%), while only 2% used Artero-venous-fistula and one patient had femoral vessel pseudoaneurysm from frequent cannulation.
The commonest complication was hypotension which was present in 15.8%. Twenty-eight deaths were recorded, 44(43%) were either lost to follow up or absconded while 5% were transplanted at a referral centre.
Conclusion: Challenges of renal replacement therapy is overwhelming in our country due to poor human and financial resources. Early diagnosis and adequate government support are advocated.
Introduction: Peripherally inserted central venous catheters (PICCs) have been increasingly used as an alternative to conventional central venous catheters for long-term administration of chemotherapy, antibiotics, parenteral nutrition, and hydration in patients with difficult venous access. Traumatic complications to arteries and nerves adjacent to veins selected for PICC placement have been rarely described.
Case presentation: We report the case of a PICC placement in the brachial vein of the right upper limb of a 78-year-old woman that resulted in brachial artery pseudoaneurysm and median nerve lesion.
Discussion: The pseudoaneurysm was successfully repaired with thrombin injection, but neurological deficits to the hand resulting from nerve injury persisted even four months after the procedure.
Symptomatic vasospasm represents an uncommon complication of perimesencephalic nonaneurysmal subarachnoid hemorrhage (SAH) which is a benign form of SAH without any recognizable source of bleeding accounting for about 15% of non-traumatic SAH [1,2].
Objective: To report our experience of direct carotid puncture and its use in the management of a large and rapidly expanding cavernous aneurysm.
Methods: A patient with a cavernous aneurysm that measured 25mm in maximum diameter underwent treatment with flow diversion. The initial treatment strategy was parent vessel occlusion however she failed the balloon occlusion test at 3 minutes. Due to extremely tortuous vessels stable access via a common femoral artery approach was impossible to achieve. We present our strategy, the post-operative management and long term results.
Results: Using a direct carotid puncture three telescoped Pipeline embolisation devices were successfully deployed across the neck of the cavernous aneurysm without complication. The puncture site formed a stable platelet plug after direct compression with an ultrasound probe for 90 minutes with no post-operative complications either intracranially or at the neck puncture site. At 2 year follow-up the aneurysm is completely excluded from the circulation.
Conclusion: Direct carotid puncture can be used as access for intracranial interventional procedures even if patients are on dual anti-platelet medication.
Hypogastric artery aneurysms are an uncommon entity. When the diameter achieves > 30-35 mm, they should be treated. Endovascular repair may be considered as first line therapy. One therapeutic option for internal iliac artery aneurysm exclusion is its embolization with or without covering the ostium with a covered stent. They may be some complications when it is not, as a distal coil migration that may produce ischemic symptoms.
We are presenting a 73-years-old male admitted to hospital with an acute right lower limb ischemia caused by a coil migration. He recently underwent a right hypogastric artery aneurysm endovascular treatment by coil embolization without covering the hypogastric ostium with a covered stent. The patient underwent an emergency surgery to remove the coil by a transfemoral surgical approach with posterior thrombectomy of the secondary thrombus. Actually, he remains asymptomatic and with right posterior tibial pulse.
Covered stent placement at the common iliac artery and external iliac artery could be the best option to avoid the risk of aneurysm rupture caused by endotension and the risk of distal coil migration.
Background: Popliteal artery aneurysms (PAAs) are rare, but the diagnosis should not be missed because of the limb and life threatening complications. The purpose of this study was to reach a consensus about the management of PAA based on our own experience and the available literature.
Materials and Methods: This is a retrospective analysis of all patients who underwent an open surgical PAA repair at our institution from January 2015 to December 2016. Demographic data, risk factors, clinical presentation, aneurysm characteristics, type of repair and results were reviewed. Results include patency and major complications.
Results: Seven patients underwent an open surgical PAA repair (six men). Median age was 72 years. A posterior approach (PA) was chosen four times and a medial approach (MA) was chosen three times. We performed six resections with interposition of a graft and only one ligation with a bypass. Five patients recovered well, did not develop any complication and did not need a second intervention to guarantee patency. These patients underwent a resection of the aneurysm and interposition of a graft (four via a PA and one via a MA). One patient treated by resection and interposition of a Dacron graft via a MA underwent an above-the-knee amputation at postoperative day 14. This patient had a preoperatively dysfunctional leg since several months with no patent outflow vessels. Our patient treated by ligation and bypass via a MA, developed an acute ischemia four months postoperatively because of an extreme flexion of the knee during several hours while watching TV. After unsuccessful trombolysis, he underwent a femorotibial bypass and a partial forefoot amputation. No long-term results are yet available.
Conclusions: In our opinion, open surgical repair of PAAs by resection of the aneurysm and interposition of a venous graft has the best results. Depending on the relation to the knee joint and thus the accessibility of the aneurysm, a posterior approach is preferred. We are not convinced of endovascular techniques in the treatment of popliteal artery aneurysms
Ruptured abdominal aortic aneurysm (rAAA) carries high morbidity and mortality. Advances in endovascular techniques in the last two decades allow for minimally invasive approach for repair of these aneurysms. A succinct but comprehensive pre-operative is essential for delivery of a safe anesthetic for the patient with rAAA. Placement of proximal occlusion balloon in the descending aorta using the rapid control technique can be life-saving. Endovascular aortic repair (EVAR) can be performed under monitored anesthesia care using local anesthetic and IV sedation, and with fewer invasive lines. However, rapid conversion to general endotracheal anesthesia should be expected. Anesthesiologists should be familiar with the hemodynamic management of rAAA and be ready to provide resuscitation to correct for anemia, coagulopathy, and acidemia. In addition, the anesthesiologist should be aware of the common complications related to EVAR, including abdominal compartment syndrome, distal ischemia, and local vessel injury.
Dissecting aortic aneurysm with ST segment elevation, and pulmonary embolism with ST segment elevation are two of a number of clinical entities which can simulate ST segment elevation myocardial infarction.
Objective: The purpose of this review is to analyse clinical features in anecdotal reports of 138 dissecting aortic aneurysm patients with STEMI-like presentation, and 102 pulmonary embolism patients with STEMI-like presentation in order to generate insights which might help to optimise triage of patients with STEMI-like clinical presentation.
Methods: Reports were culled from a literature search covering the period January 2000 to March 2020 using Googlescholar, Pubmed, EMBASE and MEDLINE. Reports were included only if there was a specification of the location of ST segment elevation and an account of the clinical signs and symptoms. Search terms were “ST segment elevation”,”aortic dissection”, “pulmonary embolism”, “myocardial infarction”, and “paradoxical embolism”. Fisher’s exact test was utilised for two-sided comparison of proportions. Proportion was calculated for each group as the number of patients with that parameter relative to the total number of patients assessed for that parameter.
Findings: There were 138 patients with aortic dissection, 91 of whom were either fast-tracked to coronary angiography (81 patients) or fast-tracked to thrombolytic treatment (10 patients). There were 47 patients managed with neither of those strategies. There were 102 patients with pulmonary embolism, 71 of whom were fast tracked to coronary angiography, and 31 who did not receive that evaluation. Compared with their dissecting aortic aneurysm counterparts, those dissecting aortic aneurysm patients initially managed by percutaneous coronary intervention or by thrombolysis were significantly (p = 0.0003) more likely to have presented with chest pain, and significantly (p = 0.018) less likely to have presented with breathlessness. The preferential fast-tracking to coronary angiography prevailed in spite of comparable prevalence of back pain in fast tracked and in non-fast tracked subjects. Use of transthoracic echocardiography was also comparable in the two subgroups of dissecting aortic aneurysm patients. Pulmonary embolism patients fast tracked to percutaneous coronary intervention were significantly (p = 0.0008) more likely to have presented with chest pain than their pulmonary embolism counterparts who were not fast-tracked. The prevalence of paradoxical embolism was also significantly (p = 0.0016) higher in fast-tracked patients than in counterparts not fast-tracked. Cardiac arrest was significantly (p = 0.0177) less prevalent in fast-tracked pulmonary embolism patients than in pulmonary embolism patients who were not fast-tracked. Preferential fast-tracking to coronary angiography prevailed in spite of the fact that prevalence of documented deep vein thrombosis was comparable in fast-tracked subjects and in subjects not fast-tracked. The prevalence of use of transthoracic echocardiography was also similar in fast-tracked pulmonary embolism patients vs counterparts not fast tracked. Overall, however, transthoracic echocardiography had been utilised significantly (p = 0.007) less frequently in dissecting aneurysm patients than in pulmonary embolism patients.
Conclusion: Given the high prevalence of STEMI-like presentation in aortic dissection there is a need for greater use of point-of-care transthoracic echocardiography to mitigate risk of inappropriate percutaneous coronary intervention(which might delay implementation of aortic repair surgery) and inappropriate thrombolysis(which might precipitate hemorrhagic cardiac tamponade) (75) during triage of patients presenting with ST segment elevation simulating ST segment elevation myocardial infarction (STEMI). Furthermore, during triage of patients with STEMI-like clinical presentation, the combined use of point-of -care echocardiography and evaluation for deep vein thrombosis will facilitate the differentiation between acute myocardial infarction, STEMI-like aortic dissection, and STEMI-like pulmonary embolism. Among STEMI-like patients in whom DAA has been ruled out by point of care TTE, fast tracking to PCI might generate an opportunity to identify and treat paradoxical coronary artery embolism by thrombectomy. Thereby mitigating the mortality risk associated with coronary occlusion. Concurrent awareness of PE as the underlying cause of paradoxical embolism also generates an opportunity to relieve the clot burden in the pulmonary circulation, either by pulmonary embolectomy or by thrombolysis. Above all, frontline clinicians should have a greater awareness of the syndrome of STEMI-like presentation of aortic dissection and STEMI-like pulmonary embolism so as to mitigate the risk of inappropriate thrombolysis and inappropriate percutaneous coronary angiography which seems to prevail even in the presence of red flags such as back pain (for aortic dissection) and deep vein thrombosis(for pulmonary embolism).
Delayed cerebral ischemia (DCI) is one of the main complications of spontaneous subarachnoid haemorrhage and one of its causes is the cortical spreading depolarizations (CSDs). Cortical spreading depolarizations are waves of neuronal and glial depolarizations in which there is loss of neuronal ionic homeostasis with potassium efflux and sodium and calcium influx. In damaged brain areas and brain areas at risk, such as those adjacent to subarachnoid haemorrhage (SAH), CSDs induce microvascular vasoconstriction and, therefore, hypoperfusion and spread of ischemia. Several studies have been devoted to minimize secondary injuries that occur hours to days after an acute insult. Ketamine, a drug until recently contraindicated in the neurosurgical population for potentially causing intracranial hypertension, has re-emerged as a potential neuroprotective agent due to its pharmacodynamic effects at the cellular level. These effects include anti-inflammatory mechanisms, and those of microthrombosis and cell apoptosis controls, and of modulation of brain excitotoxicity and CSDs. A literature review was performed at PubMed covering the period from 2002 to 2019. Retrospective studies confirmed the effects of ketamine on the control of CSDs and, consequently, of DCI in patients with SAH, but did not show improvement in clinical outcome. The influence of ketamine on the occurrence/development of DCI needs to be further confirmed in prospective randomized studies
Background/Aim: Aortic aneurysm is the bulging of a weakened portion of the aorta. The aorta is the major blood vessel that feeds blood (carrying oxygen, nutrients and water) to the tissues of the body. When a portion of the wall of the aorta becomes weak, blood pushing against the vessel wall can cause it to bulge like a balloon (aneurysm) leading to aortic dissection (a tear in the wall of the aorta that can cause life-threatening bleeding or sudden death). Blood pressure is the force arterial blood exerts on the wall of the artery. When this pressure is consistently high above 140/100 mmHg it is referred to as hypertension. As an individual gets older over time, physiological functions of the body depreciate leading to some abnormalities. Smoking is the consumption of tobacco mostly by inhalation of the smoke that is produced from burning the tobacco. This review article examines the close interactions between age, smoking, hypertension and aortic aneurysm, with a view to understanding mechanisms by which these factors predispose a patient to an aortic aneurism. It is also to observe if these factors interfere with treatment and recovery from aneurysms. Conclusion: After careful review, it is observed that age and smoking are risk factors for hypertension, and together with hypertension, the three factors predispose an individual to high risk for aortic aneurysm.
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Department of Agricultural Economics, Agribusiness and Extension, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana