Reconstructive treatment of symptomatic vertebral artery dissecting aneurysms with Willis covered stent: Initial experience

Background:Symptomatic vertebral artery dissecting aneurysm(VADA)is a challenging disease with controversy on treatment strategy due to anatomic configuration and their nature.Moreover,the outcomes of reconstructive treatment have not been well established.Objective:To evaluate the safety and efficacy of reconstructive endovascular treatment(EVT)for symptomatic VADAs with Willis covered stent.Methods:We evaluated retrospectively 13 patients with symptomatic VADAs who treated with Willis covered stent,compared with stent-assisted coiling(SAC)on the characteristics,posttreatment course,angiographic and clinical follow-up outcomes at an average of 14.4 months(range,3-48 months).Results:A total of 33 patients with symptomatic VADAs were reviewed,23 of these patients with ruptured VADAs.The technical successful rate is 100%respectively in Willis covered stent(Group A)and SAC(Group B,n=20).The initial complete occlusion rate was significant higher in group A(100%)than group B(30%)(p<0.01).Major procedure-related complications were not significant different in the two groups.Serial follow-up angiograms revealed 5 recurrent VADAs in group B and no recurrence in group A(p>0.05).No obvious in-stent stenosis and no re-hemorrhage and delayed ischemic symptoms during the follow-up period.The final angiograms of all survived patients demonstrated the complete occlusion rate was higher in group A(100%)than group B(80%),but no significant statistical difference(p>0.05).Clinical outcomes were favorable in 31(93.9%),severe disability occurred in one in group B,and only one death in group A.The final clinical outcomes were also not significant difference in the two groups(p>0.05).Conclusions:Our initial result demonstrated reconstructive EVT with Willis covered stent provides a viable approach for selected symptomatic VADAs involving the intracranial and extracranial segments,which is similar to favorable results with SAC.However,an expanded clinical experiences and larger cohort studies are needed.

The interactions between bloodstream and vascular structure on aortic dissecting aneurysmal model: A numerical study

Stent-graft implantation is an important means of clinical treatment for aortic dissecting aneurysm （ADA）. However, researches on fluid dynamics effects of stent were rare. Computer simulation was used to investigate the interactions between bloodstream and vascular structure in a stented ADA, which endures the periodic pulse velocity and pressure. We obtained and analyzed the flow velocity distribution, the wall displacement and wall stress in the ADA. By comparing the different results between a non-stented and a stented ADA, we found that the insertion of a vascular graft can make the location of maximum stress and displacement move from the aneurysm lumen wall to the artery wall, accompanied with a greatly decrease in value. These results imply that the placement of a stent-graft of any kind to oc-clude ADA will result in a decreased chance of rupture.

Treatment of pediatric intracranial dissecting aneurysm with clipping and angioplasty,and next-generation sequencing analysis:A case report and literature review

BACKGROUND Large intracranial dissecting aneurysm(IDA)in the anterior cerebral circulation is rare in children.There has been no consensus on the diagnosis and treatment for IDA in children.CASE SUMMARY We report a 3-year-old boy with a large ruptured IDA in the right middle cerebral artery(16 mm×14 mm).The IDA was successfully managed with clipping and angioplasty.Next-generation sequencing of the blood sample followed by bioinformatics analysis suggested that the rs78977446 variant of the ADAMTS13 gene is a risk for pediatric IDA.Three years after surgery,the boy was developmentally normal.CONCLUSION Clipping and angioplasty are effective treatments for ruptured IDA in the anterior cerebral circulation.ADAMTS13 rs78977446 is a risk factor for pediatric IDA.

Endovascular treatment of intracranial dissecting aneurysm

Objective To analyze the clinical features of intracranial dissecting aneurysm and summarize the experience of its endovascular embolization. Methods 16 cases of intracranial dissecting aneurysm were treated by endovascular embolization. Among these 16 patients,3 patients were treated with single stent or double

Treatment of extracranial internal carotid artery dissecting aneurysm with SUPERA stent implantation:Two case reports

BACKGROUND There is no standard endovascular treatment for extracranial internal carotid artery dissecting aneurysms.In the past,stent-graft isolation and stent-assisted coil embolization were commonly used for wide-necked and fusiform aneurysms.Here,we present two cases of extracranial internal carotid artery dissecting aneurysms treated successfully using the SUPERA stent.CASE SUMMARY Case 1 was a 57-year-old male patient with sudden right limb weakness and vague speech and diagnosed with cerebral infarction in February 2019.Cervical computed tomographic angiography(CTA)revealed left internal carotid artery dissection with stenosis.CTA at 2 mo showed an eccentric wide-necked dissecting aneurysm(5 mm×5 mm×12 mm,10-mm neck)that was enlarged at 4 mo(7 mm×6 mm×12 mm,11-mm neck).The patient underwent SUPERA stent implantation.His condition was stable in July 2020.Case 2 was a 57-year-old man who suddenly felt dizzy and developed unsteady walking in November 2019.Cervical CTA suggested right internal carotid artery dissecting aneurysm(11 mm×9 mm×31 mm)complicated with severe lumen stenosis(95%).The patient underwent SUPERA stent implantation.The patient had no residual symptoms and was stable in December 2020.CONCLUSION SUPERA stent implantation might achieve good results in treating wide-necked or long fusiform internal carotid artery dissecting aneurysms.

Unruptured Right Sinus of Valsalva Aneurysm Dissecting into Interventricular Septum Causing Complete Heart Block: Can Early Surgical Correction Revert Rhythm Disturbances?

A sinus of Valsalva aneurysm (SOVA) is abnormal dilatation of the either aortic sinuses, area of the aortic root between the aortic valve annulus and the sinotubular junction. Their clinical presentation may range from being asymptomatic as an incidental finding on cardiac imaging to symptomatic presentations related to the compression of adjoining structures or intracardiac shunting caused by rupture of the SOVA mostly into the right side of the heart. The compression leads to findings of tricuspid valve regurgitation, right ventricular outflow tract (RVOT) obstruction and rarely complete heart block (CHB). Dissection or erosion into interventricular septum is one of the rarest complications of SOVA. The symptomatic presentation is almost always a surgical emergency. Here we present a case report of a patient with unruptured sinus of valsalva originating from right sinus dissecting into interventricular septum causing complete heart bock. In this case after surgical correction the complete heart block reverted to sinus rhythm.

Innovation in pathogenesis and management of aortic aneurysm

Aortic aneurysm(AA)refers to the persistent dilatation of the aorta,exceeding three centimeters.Investigating the pathophysiology of this condition is important for its prevention and management,given its responsibility for more than 25000 deaths in the United States.AAs are classified based on their location or morphology.various pathophysiologic pathways including inflammation,the immune system and atherosclerosis have been implicated in its development.Inflammatory markers such as transforming growth factorβ,interleukin-1β,tumor necrosis factor-α,matrix metalloproteinase-2 and many more may contribute to this phenomenon.Several genetic disorders such as Marfan syndrome,Ehler-Danlos syndrome and Loeys-Dietz syndrome have also been associated with this disease.Recent years has seen the investigation of novel management of AA,exploring the implication of different immune suppressors,the role of radiation in shrinkage and prevention,as well as minimally invasive and newly hypothesized surgical methods.In this narrative review,we aim to present the new contributing factors involved in pathophysiology of AA.We also highlighted the novel management methods that have demonstrated promising benefits in clinical outcomes of the AA.

Massive inferior wall aneurysm presenting with ventricular tachycardia and refractory cardiomyopathy requiring multiple interventions:A case report

BACKGROUND Inferior wall left ventricular aneurysms are rare,they develop after transmural myocardial infarction(MI)and may be associated with poorer prognosis.We present a unique case of a large aneurysm of the inferior wall complicated by ventricular tachycardia(VT)and requiring surgical resection and mitral valve replacement.CASE SUMMARY A 59-year-old male was admitted for VT one month after he had a delayed presentation for an inferior ST-segment elevation MI and was discovered to have a large true inferior wall aneurysm on echocardiography and confirmed on coronary computed tomography(CT)angiography.Due to the sustained VT,concern for aneurysm expansion,and persistent heart failure symptoms,the patient was referred for surgical resection of the aneurysm with patch repair,mitral valve replacement,and automated implantable cardioverter defibrillator insertion with significant improvement in functional and clinical status.CONCLUSION Inferior wall aneurysms are rare and require close monitoring to identify electrical or contractile sequelae.Coronary CT angiography can outline anatomic details and guide surgical intervention to ameliorate life-threatening complications and improve performance status.

Giant cavernous aneurysms occluded by aneurysmal thrombosis,calcification,parent artery occlusion:A case report and review of literature

BACKGROUND Patients with giant intracranial aneurysms(GIAs)are at a high risk of rupture,morbidity,and mortality even after surgical or endovascular treatment.We described a case of a spontaneously occluded GIA secondary to gradual growth of the GIA,continuously progressed aneurysmal thrombosis,complete aneurysmal calcification and complete occlusion of the parent artery-the right internal carotid artery(RICA).CASE SUMMARY A 72-year-old female patient complained of sudden pain in her right eye upon admission to our hospital.She had been diagnosed with a GIA[30 mm(axial)×38 mm(coronal)×28 mm(sagittal)]containing an aneurysmal thrombus located in the cavernous sinus segment of RICA diagnosed by magnetic resonance imaging(MRI),enhanced MRI,and magnetic resonance angiography more than 14 years ago.Later,with slow growth of the cavernous carotid GIA,aneurysmal thrombosis progressed continuously,spontaneous occlusion of the RICA,complete aneurysmal calcification,and occlusion of the GIA occurred gradually.She had no history of subarachnoid hemorrhage but missed the chance for endovascular therapy at an early stage.As a result,she was left with severe permanent sequelae from the injuries to the right cranial nerves Ⅱ,Ⅲ,Ⅳ,V1/V2,and Ⅴ.CONCLUSION The risk of rupture of the cavernous carotid GIAs was relatively low and possibly further be reduced by the stasis flow and spontaneous occlusion of the parent artery internal carotid artery(ICA)induced by the mass effect of the cavernous carotid GIAs and the extremely rare aneurysmal calcification.However,nowadays,it is advisable to recommend early endovascular treatment for the cavernous carotid GIAs to prevent injuries to the surrounding intracranial nerves and occlusion of the ICA,mainly caused by the mass effect of the cavernous carotid GIAs.

Central nervous injury risk factors after endovascular repair of a thoracic aortic aneurysm with type B aortic dissection

Aortic dissection is the deadliest disease of the cardiovascular system.Type B aortic dissection accounts for 30%-60%of aortic dissections and is mainly treated by endovascular repair of thoracic endovascular aneurysm repair(TEVAR).However,patients are prone to various complications after surgery,with central nervous system injury being the most common,which seriously affects their prognosis and increases the risk of disability and death.Therefore,exploring the risk factors of central nervous system injury after TEVAR can provide a basis for its prevention and control.AIM To investigate the risk factors for central nervous system injury after the repair of a thoracic endovascular aneurysm with type B aortic dissection.METHODS We enrolled 306 patients with type B aortic dissection who underwent TEVAR at our hospital between December 2019 and October 2022.The patients were categorized into injury(n=159)and non-injury(n=147)groups based on central nervous system injury following surgery.The risk factors for central nervous system injury after TEVAR for type B aortic dissection were screened by comparing the two groups.Multivariate logistic regression analysis was performed.RESULTS The Association between age,history of hypertension,blood pH value,surgery,mechanical ventilation,intensive care unit stay,postoperative recovery times on the first day after surgery,and arterial partial pressure of oxygen on the first day after surgery differed substantially(P<0.05).Multivariate logistic regression analysis indicated that age,surgery time,history of hypertension,duration of mechanical ventilation,and intensive care unit stay were independent risk factors for central nervous system injury after TEVAR of type B aortic dissection(P<0.05).CONCLUSION For high-risk patients with central nervous system injury after TEVAR of type B aortic dissection,early intervention measures should be implemented to lower the risk of neurological discomfort following surgery in high-risk patients with central nervous system injury after TEVAR for type B aortic dissection.

Thoracoscopic resection of giant left atrial appendage aneurysm: A case report

Left atrial appendage aneurysm(LAAA)was first reported in the 1960s.1 LAAA is a rare condition,with just over 100 congenital or acquired cases reported to date.2 LAAA is frequently diagnosed incidentally during echocardiography or computed tomography(CT)scans.Most patients with LAAA are asymptomatic,while a few exhibit nonspecific symptoms,such as dyspnea,palpitation,and chest tightness.Patients with LAAA frequently present with atrial arrhythmias and systemic thromboembolism,such as stroke or multiorgan infarctions,due to the formation of a left atrial appendage thrombus.3 The lesion may be cured using aneurysm resection.Considering it as the potential cause of atrial arrhythmias and thromboembolism,the lesion must be identified on time and cured using a suitable treatment approach.

Differences and Correlations of Morphological and Hemodynamic Parameters between Anterior Circulation Bifurcation and Side-wall Aneurysms

Objective:The objective of this research was to explore the difference and correlation of the morphological and hemodynamic features between sidewall and bifurcation aneurysms in anterior circulation arteries,utilizing computational fluid dynamics as a tool for analysis.Methods:In line with the designated inclusion criteria,this study covered 160 aneurysms identified in 131 patients who received treatment at Union Hospital of Tongji Medical College,Huazhong University of Science and Technology,China,from January 2021 to September 2022.Utilizing follow-up digital subtraction angiography(DSA)data,these cases were classified into two distinct groups:the sidewall aneurysm group and the bifurcation aneurysm group.Morphological and hemodynamic parameters in the immediate preoperative period were meticulously calculated and examined in both groups using a three-dimensional DSA reconstruction model.Results:No significant differences were found in the morphological or hemodynamic parameters of bifurcation aneurysms at varied locations within the anterior circulation.However,pronounced differences were identified between sidewall and bifurcation aneurysms in terms of morphological parameters such as the diameter of the parent vessel(Dvessel),inflow angle(θF),and size ratio(SR),as well as the hemodynamic parameter of inflow concentration index(ICI)(P<0.001).Notably,only the SR exhibited a significant correlation with multiple hemodynamic parameters(P<0.001),while the ICI was closely related to several morphological parameters(R>0.5,P<0.001).Conclusions:The significant differences in certain morphological and hemodynamic parameters between sidewall and bifurcation aneurysms emphasize the importance to contemplate variances in threshold values for these parameters when evaluating the risk of rupture in anterior circulation aneurysms.Whether it is a bifurcation or sidewall aneurysm,these disparities should be considered.The morphological parameter SR has the potential to be a valuable clinical tool for promptly distinguishing the distinct rupture risks associated with sidewall and bifurcation aneurysms.

Knowledge domain and emerging trends in the rupture risk of intracranial aneurysms research from 2004 to 2023

BACKGROUND Intracranial aneurysms(IAs)pose significant health risks,attributable to their potential for sudden rupture,which can result in severe outcomes such as stroke and death.Despite extensive research,the variability of aneurysm behavior,with some remaining stable for years while others rupture unexpectedly,remains poorly understood.AIM To employ bibliometric analysis to map the research landscape concerning risk factors associated with IAs rupture.METHODS A systematic literature review of publications from 2004 to 2023 was conducted,analyzing 3804 documents from the Web of Science Core Collection database,with a focus on full-text articles and reviews in English.The analysis encompassed citation and co-citation networks,keyword bursts,and temporal trends to delineate the evolution of research themes and collaboration patterns.Advanced software tools,CiteSpace and VOSviewer,were utilized for comprehensive data visualization and trend analysis.RESULTS Analysis uncovered a total of 3804 publications on IA rupture risk factors between 2006 and 2023.Research interest surged after 2013,peaking in 2023.The United States led with 28.97%of publications,garnering 37706 citations.Notable United States-China collaborations were observed.Capital Medical University produced 184 publications,while Utrecht University boasted a citation average of 69.62 per publication.“World Neurosurgery”published the most papers,contrasting with“Stroke”,the most cited journal.The PHASES score from“Lancet Neurology”emerged as a vital rupture risk prediction tool.Early research favored endovascular therapy,transitioning to magnetic resonance imaging and flow diverters.CONCLUSION This study assesses global IA research trends and highlights crucial gaps,guiding future investigations to improve preventive and therapeutic approaches.

The incidence rate and histological characteristics of intimal hyperplasia in elastase-induced experimental abdominal aortic aneurysms in mice

Intimal hyperplasia(IH)is a negative vascular remodeling after arterial injury.IH occasionally occurs in elastase-induced abdominal aortic aneurysm(AAA)mouse models.This study aims to clarify the incidence and histological characteristics of IH in aneurysmal mice.A retrospective study was conducted by including 42 male elastaseinduced mouse AAA models.The IH incidence,aortic diameters with or without IH,and hyperplasia lesional features of mice were analyzed.Among 42 elastase-induced AAA mouse models,10 mice developed mild IH(24%)and severe IH was found in only 2 mice(5%).The outer diameters of the AAA segments in mice with and without IH did not show significant difference.Both mild and severe IH lesions show strong smooth muscle cell positive staining,but endothelial cells were occasionally observed in severe IH lesions.There was obvious macrophage infiltration in the IH lesions of the AAA mouse models,especially in mice with severe IH.However,only a lower numbers of T cells and B cells were found in the IH lesion.Local cell-secreted matrix metalloproteinases(MMP)2 was highly expressed in all IH lesions,but MMP9 was only overexpressed in severe lesions.In conclusion,this study is the first to demonstrate the occurrence of aneurysmal IH and its histological characteristics in an elastaseinduced mouse AAA model.This will help researchers better understand this model,and optimize it for use in AAA-related research.

Mimicking aneurysm in a patient with chronic occlusion of the left middle cerebral artery:A case report

BACKGROUND With the popularization of various cerebrovascular imaging methods and increased attention to the field,more cerebrovascular diseases are being detected in asymptomatic patients.Different cerebrovascular diseases are typically isolated but occasionally occur simultaneously,causing difficulties in diagnosis and treatment.Morphological changes in the collateral circulation of blood vessels in chronic cerebral artery occlusion patients are slow and dynamic,intercepting morphological development at a specific moment.Excessive reliance on single imaging tests such as digital subtraction cerebral angiography(DSA)can lead to misdiagnosis.CASE SUMMARY We report a 52-year-old male who was admitted to our department for treatment of an unruptured aneurysm during a follow-up examination for brain trauma after 1 mo.Computed tomography(CT)scan was negative,but CT angiography(CTA)revealed a sac-like bulge at the bifurcation of the left middle cerebral artery.DSA revealed an unruptured aneurysm with unique scapular morphology.The stump of a middle cerebral artery occlusion was observed during exposure during aneurysm clipping surgery,and the diagnosis of chronic cerebral artery occlusion was confirmed intraoperatively.This case was confusing because of the peculiar morphology of the arterial stump and compensatory angiogenesis due to multiple cerebral artery stenoses observed on preoperative CTA and DSA.The surgery did not cause secondary damage to the patient,and medical treatment for risk factors was continued postoperatively.CONCLUSION Multiple cerebral arterial stenoses can occur in conjunction with aneurysms or arteriovenous malformations,and their unique morphology can lead to misdiagnosis.

Unusual Presentation of Heart Failure Secondary to Ruptured Aneurysmal Sinus of Valsalva: A Case Report

Sinus of Valsalva Aneurysm (SOVA) arises from an abnormal dilation of the aortic root, leading to enlargement between the aortic annulus and the sinotubular junction. Although often presenting without symptoms, these aneurysms bear the potential for life-threatening complications, primarily from the looming risk of rupture. We present the case of a 42-year-old Malay gentleman with a history of bilateral pedal edema and dyspnea on exertion who was diagnosed with a ruptured sinus of Valsalva aneurysm. The patient underwent successful surgical repair of the aneurysm, leading to symptomatic improvement and favorable outcomes. This case highlights the importance of early diagnosis and prompt surgical intervention in managing this uncommon condition.

Hematochezia due to rectal invasion by an internal iliac artery aneurysm: A case report

BACKGROUND This case report presents the rare occurrence of hematochezia due to an internal iliac artery aneurysm leading to an arterioenteric fistula,expanding the differential diagnosis for gastrointestinal bleeding.It emphasizes the importance of considering vascular origins in cases of atypical hematochezia,particularly in the absence of common gastrointestinal causes,and highlights the role of imaging and multidisciplinary management in diagnosing and treating such unusual presentations.CASE SUMMARY A 75-year-old man with a history of hypertension presented with 12 d of hematochezia,experiencing bloody stools 7-8 times per day.Initial computed tomography(CT)scans revealed an aneurysmal rupture near the right internal iliac artery with suspected hematoma development.Hemoglobin levels progressively decreased to 7 g/dL.Emergency arterial angiography and iliac arterycovered stent placement were performed,followed by balloon angioplasty.Despite initial stabilization,minor rectal bleeding and abdominal pain persisted,leading to further diagnostic colonoscopy.This identified a neoplasm and potential perforation at the proximal rectum.An exploratory laparotomy confirmed the presence of a hematoma and an aneurysm invading the rectal wall,necessitating partial rectal resection,intestinal anastomosis,and ileostomy.Postoperative recovery was successful,with no further bleeding incidents and normal follow-up CT and colonoscopy results after six months.CONCLUSION In cases of unusual gastrointestinal bleeding,it is necessary to consider vascular causes for effective diagnosis and intervention.

Isolated Third Nerve Cranial Palsy: Complication of Brain Aneurysm

This case report highlights a critical and emergent condition, isolated third nerve cranial palsy due to a brain aneurysm. It emphasizes the importance of differential diagnosis and attentiveness to the physical exam in an emergency setting. The detailed progression from initial symptoms and misinterpretation to final diagnosis offers valuable insight into the dangers of overlooking critical diagnoses. A bilobed intracranial aneurysm arising from the internal carotid artery (ICA) caused symptoms in this patient that could have been attributed to a less malignant etiology, such as a complex migraine. Overlooking the urgency of the situation and missing the diagnosis could have had a grave and irreversible outcome.

An unusual etiology of subarachnoid hemorrhage,basilar artery perforator aneurysms,in Macao:Three case reports and review of literature

BACKGROUND Subarachnoid hemorrhage is a severe neurological condition that requires prompt and appropriate treatment to prevent complications.Aneurysms are the most common cause of spontaneous subarachnoid hemorrhage.Conversely,basilar artery perforator aneurysms(BAPAs)are a rare etiology.There is no consensus on the optimal management of ruptured BAPAs in the acute setting.CASE SUMMARY We present a case series of 3 patients with ruptured BAPAs who were treated at our institution.Two patients had a modified Fisher grade of I,and one had a grade of IV on initial presentation.The aneurysms were detected by computed tomography angiography in two cases and conventional angiography in one case.The 3 patients underwent endovascular treatment with Guglielmi detachable coils.Post-treatment,the patients had good clinical outcomes,and follow-up brain computed tomography scans showed reduced subarachnoid hemorrhage without any new hemorrhage.However,one patient experienced a cerebral infarction 2 months later and eventually succumbed to the condition.The other 2 patients showed progressive recovery,and no aneurysm recurrence was observed at the 2-year follow-up.CONCLUSION Endovascular treatment may be a preferable approach for managing ruptured BAPAs compared with surgical intervention or conservative management.Early detection and prompt treatment is important to achieve favorable patient outcomes.