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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3710_Библиотеки_им_академика_М_И_Перельмана.pdf
Endovascular Repair ofSplenic
Artery Aneurysm
Physical Examination
A 72-year-old male underwent CT urogram for
left renal artery calculus at the recommendation
of an urologist. An incidental nding of 3.1cm
saccular splenic artery aneurysm arising from the
ventral branch of the splenic artery was visualized, and the aneurysm was near the splenic
hilum (Fig.80.1). Patient had no symptoms pertaining to the aneurysm.
80
Procedure
Patient underwent celiac arteriogram after right
femoral artery access was obtained using micropuncture technique and a 5F sheath was inserted.
Omniush catheter (AngioDynamics, Latham,
NY) was advanced into the splenic artery over
the glidewire, and contrast was injected. The saccular splenic artery aneurysm appeared to be
arising from the ventral segmental branch of the
main splenic artery (Fig.80.2). Contrast injection
showed single outow vessel. A curved lantern
microcatheter was advanced into the aneurysm
sac, and outow vessel was engaged with the
help of 0.018 wire. Repeat arteriogram conrmed
the appropriate position of the outow vessel.
Coil embolization of outow vessel was performed followed by packing of the aneurysm sac
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_80
Fig. 80.1 CT urogram showing splenic artery aneurysm
by a number of coils. Microcatheter was then
advanced into the distal feeding branch of the
main splenic artery (Fig.80.3). Successful embolization of the ventral segmental feeding branch
was performed. The microcatheter was removed,
and repeat arteriogram with a catheter in the main
trunk of the splenic artery showed absent lling
of the aneurysm sac (Fig.80.4).
Patient underwent a follow-up CT scan of the
abdomen on November 21, 2019, later showed
successful embolization of splenic artery aneurysm with preservation of the arterial supply to
the spleen (Fig.80.5).
361
362
Fig. 80.2 Catheter in splenic artery showing large
splenic artery aneurysm
80 Endovascular Repair ofSplenic Artery Aneurysm
Fig. 80.3 Coil embolization of the outow vessel and the
aneurysm sac
Fig. 80.4 Complete thrombosis of aneurysm sac with preserved ow to the spleen
Fig. 80.5 Follow-up CTA abdomen shows complete exclusion of the splenic artery aneurysm
References
363
Discussion
Overall, 87% of patients with splenic artery
aneurysms are women, the majority being multiparous. The mortality from rupture is 10–25%
in nonpregnant women and maybe as high as
70% during pregnancy with fetal mortality close
to 90% [1]. Repair of splenic artery aneurysm is
indicated once the aneurysm is greater than
2–2.5 cm [1]. Hogedoorn from a meta-analysis
with true splenic artery aneurysm in 47 articles
consisting of 1321 patients. They concluded that
endovascular repair has better short-term results.
Endovascular repair has also lower mortality as
compared to the open repair [2]. Open repair is
associated with fewer late complications and
fewer re-interventions [2, 3]. Endovascular repair
is most cost-effective, and elderly patients should
be considered. Elderly patients with splenic
artery aneurysm 2–2.5 cm should be observed
with yearly CT scans of the abdomen. Reed etal.
attempted stent graft repair of splenic artery
aneurysm in ten patients. They observed that selfexpandable stent grafts offer another option
besides coil embolization to treat selected
patients with splenic artery aneurysm [4]. Distal
splenic artery aneurysm with the excessive tortuosity of splenic artery often results in technical
failure for stent graft deployment.
Invited Commentary fromTimur
P.Sarac, MD
Splenic artery aneurysms are the most common
visceral artery aneurysm, accounting for approximately 60% of all non-aortic aneurysms in the
abdomen. Their incidence is reported to be 0.8%
[5]. This case report and summary highlight the
advancements in treating splenic artery aneurysms and increased diagnoses due to frequent
use of CT scans. The rst endovascular treatment
of splenic artery aneurysm was reported in 1990
by Reidy [6]. Since that time, endovascular therapy has evolved at rst-line therapy [1, 7].
Options for treatment include coil emboliza-
tion, glue embolization, and stent grafts. Coil
embolization is the most common and timehonored useful endovascular therapy. Stent grafts
have distinct advantages in that it allows for preserving splenic artery ow. However, the size and
tortuosity of the splenic artery frequently preclude this option. Finally, glue embolization is
also possible, but there are potential problems
with distal embolization and end-organ
perfusion.
References
1. Sarac TP, Gates L. Endovascular management of
splenic artery aneurysms. In: Hans SS, Shephard
AD, Weaver MR, Bove PG, Long GW, editors.
Endovascular and open vascular reconstruction: a
practical approach. Boca Raton: CRC Press; 2018.
p.99–104.
2. Hogendoorn WH, Lavida A, Hunink MGH, Moll
FL. Open repair, endovascular repair, and conservative management of true splenic artery aneurysms. J
Vasc Surg. 2014;60:1667–76.
3. Hogendoorn WH, Lavida A, Hunink MGH, Moll
FL.Cost-effectiveness of endovascular repair and conservative management of splenic artery aneurysms. J
Vasc Surg. 2015;61:1432–40.
4. Reed NR, Oderich GS, Manunga J, Duncan
A. Feasibility of endovascular repair of splenic
artery aneurysm using stent graft. J Vasc Surg.
2011;62:1504–10.
5. Berceli SA. Hepatic and splenic artery aneurysms.
Semin Vasc Surg. 2005;18:196–201.
6. Reidy JF, Rowe PH, Ellis FG.Splenic artery aneurysm
embolization-the preferred technique to surgery. Clin
Radiol. 1990;41:281–2.
7. Larkin RO, Bena JF, Sarac TP, Shah S, Krajewski LP,
Srivastava SD, Clair DG, Kashyap VS.The contemporary management of splenic artery aneurysms. J Vasc
Surg. 2011;53(4):958–64.
Part XXIII
Carotid Stenting
Carotid Stenting forSymptomatic
Carotid Restenosis Secondary
toMyointimal Hyperplasia
History andPhysical Examination
A 69-year-old female underwent right carotid
endarterectomy with bovine pericardial patch for
asymptomatic high-grade right internal carotid
artery stenosis (>80%) on December 1, 2016. She
had an uneventful postoperative course, and in
January 2017, she underwent carotid duplex study
which showed normal peak systolic velocity of
right internal carotid artery with intimal thickening and 60–69% stenosis of the left internal
carotid artery. In July of 2017, a follow-up carotid
duplex study showed peak systolic velocity of
right internal carotid artery for 32 cm/sec with
end diastolic velocity of 155cm/sec. CTA of the
neck showed recurrent smooth 80% stenosis with
proximal right internal carotid artery secondary to
myointimal hyperplasia and 60–69% stenosis of
the left internal carotid artery (Fig. 81.1). Since
patient was asymptomatic, it was decided to continue medical management. Patient developed
recurrent (three episodes) of diminishing of the
vision of the right eye in March 2019, lasting
30–40 seconds. She was evaluated by a retinal
specialist who diagnosed ischemic retinopathy
secondary to severe extracranial carotid stenosis.
Procedure
Patient was taken to hybrid operating room for
placement of transfemoral placement of carotid
stent. Carotid arteriogram through the shuttle
81
Fig. 81.1 CTA showing smooth 80% recurrent ICA
stenosis
sheath revealed 80% smooth ICA stenosis at its
origin (Fig. 81.2). Intracerebral views showed
absent lling of the anterior cerebral artery
(Fig.81.3). Through the 7F shuttle sheath Xact
(Abbott, Temecula, CA), stent 6 × 8 × 40 mm
was deployed following pre-angioplasty followed by post dilatation with a 5 mm balloon
catheter. The procedure was performed using a
NAV6™ lter (Abbott). Completion arteriogram
showed satisfactory deployment of stent with no
intracerebral abnormalities (Fig.81.4).
Patient’s visual symptoms resolved follow-
ing carotid stenting, however patient developed
®
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_81
367
368
Fig. 81.2 Carotid
arteriogram showing
80% stenosis of the right
ICA and 60% stenosis of
the left ICA
81 Carotid Stenting forSymptomatic Carotid Restenosis Secondary toMyointimal Hyperplasia
Fig. 81.3 Intracranial view showing absent lling of the
right anterior cerebral artery
right femoral pseudoaneurysm. Because of its
wide neck, open repair of pseudoaneurysm
was preferred over thrombin injection. Carotid
duplex imaging in June 2019 showed a peak systolic velocity of right internal carotid artery
112 cm/sec with an end-diastolic velocity of
39 cm/sec. On the left side, the peak systolic
velocity of the left internal carotid artery is
303cm/sec and a diastolic velocity of 86cm/sec.
Since patient is not symptomatic, from the left
internal carotid artery stenosis, patient was recommended continuation of medical
management.
Discussion
The superiority of carotid angioplasty and stenting (CAS) over redo carotid endarterectomy for
recurrent carotid stenosis is uncertain. Arhuidese
et al. studied patients from Vascular Quality
Initiative Database (2003–2015) with prior ipsilateral carotid endarterectomy who underwent
2863 carotid interventions, 1047 (37%) redo
carotid endarterectomy, and 1816 (63%) CAS
[1]. The 30-day mortality was 1.3% for repeat
carotid endarterectomy versus 0.6% for CAS
(p=0.04). Both procedures had similar incidence
of perioperative stroke and myocardial infarction. Cranial nerve palsy occurred in 4.1% of
redo carotid endarterectomy patients, and excess
site complications occurred in 5.3% of CAS
cases as was the case presented in this report [1].
References
Fig. 81.4 Carotid arteriogram following placement of the carotid stent with residual stenosis and normal intracerebral
arterial circulation
369
DeBorst etal. performed 57 CAS procedures in
55 patients (36 men) with a mean age of 70years
[2]. The mean interval between carotid endarterectomy and CAS was 83 months (range
6–245months). Nine patients (16%) were asymptomatic. They did not observe any death or stroke
following CAS.A periprocedural transient ischemic attack occurred in two patients. During a
mean follow-up of 36 months (range
12–72months), two patients exhibited ipsilateral
cerebral symptoms (1 TIA, 1 minor stroke). In 11
patients (19%), in-stent restenosis (≥50%) was
detected post-CAS at month three (n = 3), 12
(n=3), 24 (n=2), 36 (n=1), 48 (n=1), and 60
(n=1). They concluded that CAS for recurrent
stenosis after carotid endarterectomy can be per-
formed with a low incidence of periprocedural
complications with durable protection from
stroke [2]. The rate of in-stent recurrent stenosis
is high, and the recurrent stenosis can occur early
as well as late.
References
1. Arhuidese I, Obeid T, Nejim B, Locham S, et al.
Stenting versus endarterectomy after prior ipsilateral
carotid endarterectomy. J Vasc Surg. 2017;65:1–11.
2. DeBorst GJ, Ackerstaff RGA, DeVries J-PM, Paroordt
ED, et al. Carotid angioplasty and stenting for post
endarterectomy stenosis: long term follow up. J Vasc
Surg. 2007;45:118–23.
Carotid Artery Stenting
forSymptomatic RadiationInduced Carotid Stenosis
Physical Examination andHistory
A 78-year-old male was admitted to the hospital
from emergency room with recurrent episodes of
left upper extremity shaking. He denied any history of weakness of the left lower extremity or
slurring of the speech. He had undergone left
carotid endarterectomy (CEA) with history of
focal transient ischemic attack (TIA) in the distribution of left middle cerebral artery 2 months
prior to this admission. The left CEA was complicated by neck hematoma which needed drainage, and since then, patient has had no symptoms
pertaining to the left cerebral hemisphere. Patient
had history of radiation to the neck for carcinoma
of the tonsil about 15years ago. It was the opinion of the stroke neurologist that his symptoms
(shaking of the left upper extremity) represented
TIA in the distribution of right middle cerebral
artery. CTA of the neck showed severe stenosis
involving the right ICA and normal left CEA site
(Fig.82.1). Other comorbidities included hypertension and history of atrial brillation. Patient
was scheduled for carotid artery stenting (CAS)
on June 24, 2019.
Procedure
Patient was started on intravenous heparin for
atrial brillation in preparation for right CAS.
Carotid artery stenting was preferred to CEA in
82
Fig. 82.1 CTA showing bilateral radiation-induced right
carotid stenosis extending toward base of skull and satisfactory left CEA
this patient as the cephalad end of the plaque
extended to the junction of C1 and C2 vertebral
body.
Right femoral artery access was obtained by
percutaneous puncture, and 6 F sheath was
inserted. A headhunter catheter was used to gain
access to the right common carotid artery (CCA)
using a long angle stiff glidewire (035–260cm).
Right common carotid arteriogram showed
severe stenosis of the right internal carotid artery
(ICA) extending to the junction of the C1 and C2
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_82
371
372
82 Carotid Artery Stenting forSymptomatic Radiation- Induced Carotid Stenosis
vertebral body (Fig. 82.2). Using a Supracore
wire, a 7 F shuttle sheath was inserted, and
carotid arteriogram was observed showing severe
right ICA extending cephalad to the junction of
C1 and C2 vertebral body (Fig.82.2). Patient was
administered with heparin to keep the ACT close
to 300. Filter wire was advanced without difculty. Pre-dilatation was done by 3mm × 2cm
long balloon followed by deployment of a
6 × 8 × 40 Acculink stent. Post-dilatation was
done with a 6 mm balloon (Fig. 82.3). Postangioplasty arteriogram showed <10% residual
stenosis (Fig. 82.4). The lter was retrieved.
Carotid duplex study on July 2, 2009, showed a
peak systolic velocity 71cm/sec of the right ICA
and 74cm/sec left ICA.
Fig. 82.2 Carotid arteriogram showing severe long segment ICA stenosis with cephalad end of plaque at the junction
of C1 and C2
Discussion
373
Discussion
Limb shaking TIAs are unusual, they occur in
patients with severe carotid occlusive disease, and
often are mistaken for focal motor seizures. EEG
recordings during attacks are negative for epileptic
form discharges, and anti-seizure medications are
generally ineffective. Limb shaking TIAs do not
extend to the face; they often occur when patient is
standing up, as occurred in this patient while he
was taking a shower [1]. These patients are at high
risk for development of stroke [1]. The patient in
Fig. 82.3 Placement of right CCA stent with
post-angioplasty
this report was admitted to the Hospital On May
9th, 2020 with syncope secondary to rapid Atrial
Fibrillation. CT angiography of the neck showed
60% in-stent stenosis at the Cephalic end of the
shunt probably due to thrombus formation. Patient
was continued on medical management as he did
not experience any focal neurological symptoms.
Carotid stenting for radiation induced carotid stenosis has a propensity for recurrent disease and
thus the need for continued surveillance.
External radiation for head and neck cancer
may result in extracranial carotid stenosis; thus,
radiation indirectly poses a risk for a development of stroke [2–6]. The exact mechanism
underlying radiation-induced carotid stenosis is
not well established. The process is inammatory in type, and plaque characteristics are similar to those present in atherosclerotic disease.
However, the natural history of radiation-induced
stenosis is distinct [2]. Radiation-induced carotid
stenosis is often bilateral, and the plaque extends
to a considerable distance cephalad into the
internal carotid artery [2–6]. Carotid endarterectomy (CEA) in patients with history of neck
radiation is associated with slightly increased
incidence of cranial nerve injury, cervical hematoma, and wound complications. Carotid artery
stenting (CAS) is preferable in patients with history of head and neck cancer treated with prior
radiation with associated radical neck dissection
and tracheostomy. On the other hand, many
Fig. 82.4 Carotid arteriogram following stent placement