PubMed · 10840310
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D Külling. 2000. Aortoenteric fistula.. https://doi.org/10.1067/mge.2000.103672
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OBJECTIVE AND IMPORTANCE: An innovative stenting technique to treat a difficult case of a fusiform aneurysm of the intracranial vertebral artery (VA), with restoration of the vessel lumen, is described. CLINICAL PRESENTATION: A 58-year-old patient experienced sudden pain in the upper cervical spine, followed by a severe headache. He underwent computed tomographic evaluation, which demonstrated subarachnoid hemorrhage in the prepontine cistern. A fusiform aneurysm of the distal right VA and critical stenosis of the left VA were detected in digital subtraction angiograms. The patient experienced a new subarachnoid hemorrhaging episode, and urgent endovascular treatment was planned. INTERVENTION: The patient underwent angioplastic and stenting procedures in the left VA, with good results. Forty-eight hours later, an endovascular procedure was performed to treat the right VA aneurysm. We decided to use a graft stent (Jostent graft stent; Jomed, Conroe, TX) instead of a balloon to preserve the arterial lumen. The complete procedure was well tolerated by the patient, and he was discharged, without symptoms, 48 hours later. CONCLUSION: The patient was discharged, without neurological deficits, 48 hours after completion of the endovascular procedure, with clopidogrel (75 mg/d) and aspirin (325 mg/d) therapy. This treatment was discontinued after 4 weeks. According to our search of the medical literature, this is the first clinical case in which an intracranial fusiform aneurysm was permanently sealed with a graft stent.
OBJECTIVE: An aneurysm can produce large defects in the parent vessel if the aneurysm tears at the neck of the vessel. The authors present a technique to repair a tear at the base of a blister-like aneurysm encountered during microsurgical clipping of an anterior wall aneurysm of the internal carotid artery. METHODS: The repair technique involved suturing and covering the aneurysm with an encircling aneurysm clip. A large tear had destroyed the vessel's tubular structure, and repair was not sufficient using an encircling clip alone. Two microsuture stitches were placed on the tear, so that a split artery re-formed a tubular structure. The lesion was then covered with Surgicel (Ethicon, Inc., Somerville, NJ) and fibrin glue. When the Surgicel and fibrin glue were applied, the temporary clip on the distal internal carotid artery was removed for a moment, allowing retrograde blood flow to provide the counterforce necessary to maintain the vessel's tubular structure. An encircling clip was then applied to cover the entire circumference of the lesion. RESULTS: This method required only a short occlusion time for arterial repair, thus helping avoid ischemic complications. The patient awoke with transient hemiparesis, but recovery was prompt. CONCLUSION: This technique is useful for repairing an aneurysmal tear at its base, especially if the tear is large.
OBJECTIVE: Many practitioners favor early operation after aneurysmal rupture, but sound data supporting this practice are lacking. A systematic review was conducted to compare early aneurysm surgery (Days 0-3), intermediate surgery (Days 4-7), and late surgery (more than 7 d after subarachnoid hemorrhage). METHODS: We performed a MEDLINE search of the literature published between January 1974 and December 1998 and an additional manual search of selected journal titles from January 1998 to December 1998. Main outcome measures were death and poor outcome (defined as death or dependency) at the end of the follow-up period. Risk ratios (RRs) and corresponding 95% confidence intervals (CIs) were calculated; patients planned for late surgery were used as the reference. RESULTS: Identified were 1 randomized clinical trial and 268 observational studies, of which only 10 studies (assessing a total of 1814 patients) fulfilled a set of minimum requirements for methodological quality. In the trial, the RR of poor outcome was 0.42 (95% CI, 0.17-1.04) for patients planned for early surgery and 1.07 (95% CI, 0.56-2.05) for intermediate surgery. In analyses with data from the 11 included studies, the RR of poor outcome for patients in good clinical condition at admission was 0.41 (95% CI, 0.34-0.51) for early surgery and 0.47 (95% CI, 0.32-0.69) for intermediate surgery. For patients in poor clinical condition at admission, the RR of poor outcome was 0.84 (95% CI, 0.67-1.05) for early surgery and 0.54 (95% CI, 0.24-1.22) for intermediate surgery. Adjustment of the RRs for year of publication, study design, and aneurysm location yielded essentially the same results, as did a sensitivity analysis after exclusion of the data from the randomized trial. CONCLUSION: This meta-analysis suggests that both early and intermediate surgical treatment improve outcome after aneurysmal subarachnoid hemorrhage--in particular for patients in good clinical condition at admission. However, this impression is derived only from an indirect comparison between different cohorts of patients. Sound evidence on the best timing of surgery is still lacking. Observational studies with better methods--and ideally a new randomized trial--are needed.