Volume 26
’
Number 3
’
March
’
2015
Hg systolic within a 4-hour period. She was discharged the following morning, and all hypertensive medications were discontinued immediately after the procedure with the exception of clonidine and atenolol, which were tapered off over 2 weeks. A serum creatinine value was not obtained after the procedure because this is not routine practice at our institution. The patient was seen in the clinic 5 days after the procedure; at this time, her office BP was 82/50 mm Hg, and her doses of clonidine and atenolol were reduced. No blood work was obtained at that time. She was seen by her family physician 19 days after the procedure when her BP was observed to be normal, serum creatinine was 639 μmol/ L, and serum potassium was 8.9 mmol/L. The patient was transferred to the hospital immediately, where her BP was 82/54 mm Hg. Urinalysis was unremarkable. Random urinary sodium was 85 mmol/L and urinary potassium was 10 mmol/L, a pattern consistent with renal tubular dysfunction. Plasma renin mass was 623 ng/L (normal range, 6–20 ng/L), plasma aldosterone was 417 pmol/L, and serum cortisol was 424 nmol/L. Urine output and creatinine improved rapidly after resuscitation from hypovolemic shock with normal saline. Sphingomonas paucimobilis, a rare cause of nosocomial infection, grew in one of four blood cultures drawn in the emergency department. Although S. paucimobilis was considered a contaminant by the infectious diseases service, she received a 7-day course of oral ciprofloxacin as an outpatient. At no time, with the exception of decreased BP, did the patient exhibit clinical signs and laboratory findings of sepsis. Because BP remained low and serum potassium was high, she was started empirically on fludrocortisone. This medication was stopped after 3 weeks, when she developed fluid retention and hypertension, which was managed with furosemide and spironolactone. At 3-month follow-up assessment, office BP was 132/96 mm Hg, serum creatinine was 101 μmol/L, plasma renin mass was 18.3 ng/L, and plasma aldosterone was 378 pmol/L. Repeat renal imaging with computed tomography angiography was unremarkable. The clinical course of this patient suggests that catheter-based renal sympathetic denervation can impair renal sodium handling, which could lead to severe hypovolemia and acute renal failure. Renal sympathetic denervation decreases neurally mediated salt and water retention by the kidneys, reducing extracellular fluid volume (4). Patients with Parkinson disease, which has associated increased sympathetic activity, or other conditions associated with autonomic dysfunction may be particularly vulnerable (5). Clinicians performing this procedure should consider this potential complication. As a result of this experience, we now assess the renal function and volume status of all our patients who undergo renal denervation 72–96 hours after the procedure.
451
REFERENCES 1. Symplicity HTN-2 Investigators. Renal sympathetic denervation in patients with treatment-resistant hypertension (The Symplicity HTN-2 Trial): a randomized controlled trial. Lancet 2010; 376:1903–1909. 2. Schmieder RE, Redon J, Grassi G, et al. ESH position paper: renal denervation—an interventional therapy of resistant hypertension. J Hypertens 2012; 30:837–841. 3. Bhatt DL, Kandzari DE, OʼNeill WW, et al. SYMPLICITY HTN-3 Investigators. A controlled trial of renal denervation for resistant hypertension. N Engl J Med 2014; 370:1393–1401. 4. Esler M. The sympathetic nervous system through the ages: from Thomas Willis to resistant hypertension. Exp Physiol 2011; 96:611–622. 5. Biaggioni I. Parkinson’s disease. Autonomic neuronopathy with impaired cardiovascular regulation. Hypertension 2007; 49:21–22.
Stent-Assisted Coil Embolization for a Traumatic Pseudoaneurysm of the Visceral Aortic Segment From: Chang Shu, MD, PhD Tun Wang, MD, PhD Quan-ming Li, MD, PhD Ming Li, MD, PhD Jason T. Lee, MD Department of Vascular Surgery (C.S., T.W., Q.-m.L., M.L.) The 2nd Xiang-ya Hospital of Central-South University Changsha, Hunan China Department of Vascular Surgery (J.T.L.) Stanford Hospital and Clinics and Lucile Packard Children’s Hospital Palo Alto, California
Editor: Pseudoaneurysm of the visceral aortic segment is rare and lethal. Open surgery with a retroperitoneal thoracoabdominal incision to reconstruct the lesion site is challenging, and surrounding vital visceral arteries present challenges for endovascular treatment. We describe a novel endovascular technique used to seal an aortic pseudoaneurysm and preserve all involved visceral arteries. Institutional review board approval was obtained for this study. A 41-year-old man sustained a gunshot wound to the left upper abdomen and underwent emergent laparotomy with vena cava, pancreas, and stomach repair. The patient presented 14 days later with complaints of sudden epigastric distention and pain. Computed tomography (CT) angiography demonstrated the presence of a 10 cm 6 cm pancreatic pseudocyst and a 1.5 cm 1.3 cm pseudoaneurysm in the visceral aortic segment, presumably traumatic in nature. The absence of fever, leukocytosis, and periaortic
None of the authors have identified a conflict of interest. C.S. and T.W. equally contributed to this manuscript. http://dx.doi.org/10.1016/j.jvir.2014.11.024
452
’
Letters to the Editor
inflammation on CT angiography did not support an infectious process. After conservative treatment for 16 days, the patient’s symptoms worsened, and CT angiography showed enlargement of the pseudoaneurysm to 3.5 cm 2.0 cm (Fig 1a, b). Considering the large pseudocyst, we anticipated that open surgery with a thoracoabdominal incision would risk complex complications, and so we chose an endovascular technique. First, aortography of the lesion area was performed (Fig 2a) to determine morphology of the pseudoaneurysm. The pseudoaneurysm was cannulated with a 6-F guiding catheter, and successive embolization was performed with two embolization coils (MWCE-358-12 and MWCE-35-5-8; Cook, Inc, Bloomington, Indiana) and a MReye Flipper patent ductus arteriosus closure detachable coil (IMWCE-5-PDA5; William Cook Europe ApS, Bjeaverskov, Denmark). Subsequent angiography indicated partial embolization of the pseudoaneurysm. To prevent microcoil migration and ectopic embolism and to induce thrombosis in the pseudoaneurysm, two stents (24 mm 80 mm and 24 mm 60 mm, Sinus-XL; OptiMed Medizinische Instrumente GmbH, Ettlingen, Germany) were advanced via the right femoral artery and deployed to overlap at the visceral aortic segment, covering the pseudoaneurysm and all visceral arteries. Angiography subsequently revealed almost complete disappearance of pseudoaneurysm perfusion and patency of all visceral arteries (Fig 2b). Antiplatelet therapy with aspirin (100 mg/d) was administered postoperatively. All of the patient’s symptoms gradually resolved. Duplex ultrasound and CT angiography were performed at 1, 3, and 6 months postoperatively and every 6 months thereafter. CT angiography performed at 1 month postoperatively showed complete pseudoaneurysm thrombosis. At the 25-month follow-up examination (Fig 3a, b), all visceral arteries were intact, and complete shrinkage of the pseudoaneurysm and pancreatic pseudocyst was
Shu et al
’
JVIR
observed. Duplex ultrasound detected normal peak systolic velocity, end-diastolic velocity, and resistance index in all visceral arteries (Table), which confirmed brisk visceral artery perfusion. Gunshot wounds to the aorta are lethal; 85% of victims die before hospital admission, and the overall mortality rate of victims who arrive at the hospital alive is about 87.5%. Tamponade of hemorrhage by surrounding tissue may result in development of silent pseudoaneurysm, and up to 25% of affected patients die of acute tamponade rupture (1). The endovascular technique offers an effective and microinvasive alternative to open surgery, but it is challenging when a pseudoaneurysm involves visceral arteries. Takahashi et al (2) described the use of a customized fenestrated stent graft to cover a paravisceral aortic pseudoaneurysm, while preserving involved branches. However, the customized nature of this method limits its widespread use. The use of a septal occluder is another option. Bornak and Milner (3) reported the successful treatment of a large saccular aneurysm involving the visceral segment of the abdominal aorta with an AMPLATZER Septal Occluder (St Jude Medical, Inc, St Paul, Minnesota). However, the risk of branching artery coverage by the metal disk should be considered. Chang et al (4) described the use of a bailout method with a chimney stent to reconstruct a left carotid artery that had been inadvertently covered during the placement of an atrial septal occluder to cover an aortic arch pseudoaneurysm. Percutaneous embolization with coils or thrombin injection via direct puncture or transcatheter can also be used. However, only selected patients with narrownecked saccular aneurysms or pseudoaneurysms are candidates for this treatment because of the risk of misembolization provoking acute ischemia in the distal or branching arteries (1). The use of two overlapping sinus stents across a pseudoaneurysm entry can segment the wide necks of saccular aneurysms or
Figure 1. (a, b) CT images obtained 16 days after conservative treatment show expansion of the pseudoaneurysm (arrow 1) with internal thrombosis (arrow 3), the bullet (arrow 2), and the huge pancreatic pseudocyst (arrow 4).
Volume 26
’
Number 3
’
March
’
2015
453
Figure 2. (a) Angiography shows opacification of the pseudoaneurysm cavity and entry site (arrow 1) and the bullet (arrow 2). (b) After coil embolization and placement of overlapping stents across the orifices of all visceral arteries and the pseudoaneurysm, the pseudoaneurysm was almost completely obliterated, with little internal contrast (arrow 3) and intact perfusion of branching vessels. Black arrowheads indicate the ends of the 80-mm stents, and white arrowheads indicate the ends of the 60-mm stents.
Figure 3. (a, b) CT images obtained at 25-month follow-up examination show shrinkage of the pseudoaneurysm (arrow 2), good perfusion of all visceral arteries—right renal artery (arrow 1), superficial mesenteric artery (arrow 3), left renal artery (arrow 4)—with no stenosis at their orifices, and complete resolution of the pancreatic pseudocyst.
Table . Results of Duplex Ultrasound Examination to Assess Blood Flow in All Visceral Arteries 25 Months Postoperatively CA PSV (cm/s) EDV (cm/s) RI
62 23
SMA LRA RRA LRA Orifice* RRA Orifice* 83 14
51 22
68 32
0.62 0.84 0.56 0.54
45 18
32 10
0.60
0.66
CA ¼ celiac artery; EDV ¼ end-diastolic velocity; LRA ¼ left renal artery; PSV ¼ peak systolic velocity; RI ¼ resistance index; RRA ¼ right renal artery; SMA ¼ superior mesenteric artery. *Location where the bare stents segregated the aorta and visceral arteries and blood flow was not restricted.
pseudoaneurysms into small meshes to prevent microcoil migration and misembolization. Such stents do not reach the interstice size that would lead to flow diversion to branches, as the long-term outcome of intactness of all visceral arteries in the present case confirms.
In conclusion, the use of stents and microcoils can be considered as an effective option for the management of arterial pseudoaneurysms and saccular aneurysms near vital branches, regardless of the branch diameter or the presence of a wide neck. However, when the orifice of a vital branch, where it connects to the main trunk, is invaded, the use of this techsnique may be limited.
REFERENCES 1. Tucker S Jr, Rowe VL, Rao R, et al. Treatment options for traumatic pseudoaneurysms of the paravisceral abdominal aorta. Ann Vasc Surg 2005; 19:613–618. 2. Takahashi S, Takaya S, Fukuda I, et al. Stent graft treatment for abdominal pseudoaneurysm near the celiac artery. Thorac Cardiovasc Surg 2003; 126:600–602. 3. Bornak A, Milner R. Endovascular exclusion of a saccular aortic aneurysm using a septal occluder device. J Vasc Surg 2011; 53:1097–1099. 4. Chang G, Chen W, Yin H, et al. Endovascular repair of an aortic arch pseudoaneurysm by an atrial septal defect occluder combined with a chimney stent. J Vasc Surg 2013; 57:1657–1660.
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Number 3
’
March
’
2015
Hg systolic within a 4-hour period. She was discharged the following morning, and all hypertensive medications were discontinued immediately after the procedure with the exception of clonidine and atenolol, which were tapered off over 2 weeks. A serum creatinine value was not obtained after the procedure because this is not routine practice at our institution. The patient was seen in the clinic 5 days after the procedure; at this time, her office BP was 82/50 mm Hg, and her doses of clonidine and atenolol were reduced. No blood work was obtained at that time. She was seen by her family physician 19 days after the procedure when her BP was observed to be normal, serum creatinine was 639 μmol/ L, and serum potassium was 8.9 mmol/L. The patient was transferred to the hospital immediately, where her BP was 82/54 mm Hg. Urinalysis was unremarkable. Random urinary sodium was 85 mmol/L and urinary potassium was 10 mmol/L, a pattern consistent with renal tubular dysfunction. Plasma renin mass was 623 ng/L (normal range, 6–20 ng/L), plasma aldosterone was 417 pmol/L, and serum cortisol was 424 nmol/L. Urine output and creatinine improved rapidly after resuscitation from hypovolemic shock with normal saline. Sphingomonas paucimobilis, a rare cause of nosocomial infection, grew in one of four blood cultures drawn in the emergency department. Although S. paucimobilis was considered a contaminant by the infectious diseases service, she received a 7-day course of oral ciprofloxacin as an outpatient. At no time, with the exception of decreased BP, did the patient exhibit clinical signs and laboratory findings of sepsis. Because BP remained low and serum potassium was high, she was started empirically on fludrocortisone. This medication was stopped after 3 weeks, when she developed fluid retention and hypertension, which was managed with furosemide and spironolactone. At 3-month follow-up assessment, office BP was 132/96 mm Hg, serum creatinine was 101 μmol/L, plasma renin mass was 18.3 ng/L, and plasma aldosterone was 378 pmol/L. Repeat renal imaging with computed tomography angiography was unremarkable. The clinical course of this patient suggests that catheter-based renal sympathetic denervation can impair renal sodium handling, which could lead to severe hypovolemia and acute renal failure. Renal sympathetic denervation decreases neurally mediated salt and water retention by the kidneys, reducing extracellular fluid volume (4). Patients with Parkinson disease, which has associated increased sympathetic activity, or other conditions associated with autonomic dysfunction may be particularly vulnerable (5). Clinicians performing this procedure should consider this potential complication. As a result of this experience, we now assess the renal function and volume status of all our patients who undergo renal denervation 72–96 hours after the procedure.
451
REFERENCES 1. Symplicity HTN-2 Investigators. Renal sympathetic denervation in patients with treatment-resistant hypertension (The Symplicity HTN-2 Trial): a randomized controlled trial. Lancet 2010; 376:1903–1909. 2. Schmieder RE, Redon J, Grassi G, et al. ESH position paper: renal denervation—an interventional therapy of resistant hypertension. J Hypertens 2012; 30:837–841. 3. Bhatt DL, Kandzari DE, OʼNeill WW, et al. SYMPLICITY HTN-3 Investigators. A controlled trial of renal denervation for resistant hypertension. N Engl J Med 2014; 370:1393–1401. 4. Esler M. The sympathetic nervous system through the ages: from Thomas Willis to resistant hypertension. Exp Physiol 2011; 96:611–622. 5. Biaggioni I. Parkinson’s disease. Autonomic neuronopathy with impaired cardiovascular regulation. Hypertension 2007; 49:21–22.
Stent-Assisted Coil Embolization for a Traumatic Pseudoaneurysm of the Visceral Aortic Segment From: Chang Shu, MD, PhD Tun Wang, MD, PhD Quan-ming Li, MD, PhD Ming Li, MD, PhD Jason T. Lee, MD Department of Vascular Surgery (C.S., T.W., Q.-m.L., M.L.) The 2nd Xiang-ya Hospital of Central-South University Changsha, Hunan China Department of Vascular Surgery (J.T.L.) Stanford Hospital and Clinics and Lucile Packard Children’s Hospital Palo Alto, California
Editor: Pseudoaneurysm of the visceral aortic segment is rare and lethal. Open surgery with a retroperitoneal thoracoabdominal incision to reconstruct the lesion site is challenging, and surrounding vital visceral arteries present challenges for endovascular treatment. We describe a novel endovascular technique used to seal an aortic pseudoaneurysm and preserve all involved visceral arteries. Institutional review board approval was obtained for this study. A 41-year-old man sustained a gunshot wound to the left upper abdomen and underwent emergent laparotomy with vena cava, pancreas, and stomach repair. The patient presented 14 days later with complaints of sudden epigastric distention and pain. Computed tomography (CT) angiography demonstrated the presence of a 10 cm 6 cm pancreatic pseudocyst and a 1.5 cm 1.3 cm pseudoaneurysm in the visceral aortic segment, presumably traumatic in nature. The absence of fever, leukocytosis, and periaortic
None of the authors have identified a conflict of interest. C.S. and T.W. equally contributed to this manuscript. http://dx.doi.org/10.1016/j.jvir.2014.11.024
452
’
Letters to the Editor
inflammation on CT angiography did not support an infectious process. After conservative treatment for 16 days, the patient’s symptoms worsened, and CT angiography showed enlargement of the pseudoaneurysm to 3.5 cm 2.0 cm (Fig 1a, b). Considering the large pseudocyst, we anticipated that open surgery with a thoracoabdominal incision would risk complex complications, and so we chose an endovascular technique. First, aortography of the lesion area was performed (Fig 2a) to determine morphology of the pseudoaneurysm. The pseudoaneurysm was cannulated with a 6-F guiding catheter, and successive embolization was performed with two embolization coils (MWCE-358-12 and MWCE-35-5-8; Cook, Inc, Bloomington, Indiana) and a MReye Flipper patent ductus arteriosus closure detachable coil (IMWCE-5-PDA5; William Cook Europe ApS, Bjeaverskov, Denmark). Subsequent angiography indicated partial embolization of the pseudoaneurysm. To prevent microcoil migration and ectopic embolism and to induce thrombosis in the pseudoaneurysm, two stents (24 mm 80 mm and 24 mm 60 mm, Sinus-XL; OptiMed Medizinische Instrumente GmbH, Ettlingen, Germany) were advanced via the right femoral artery and deployed to overlap at the visceral aortic segment, covering the pseudoaneurysm and all visceral arteries. Angiography subsequently revealed almost complete disappearance of pseudoaneurysm perfusion and patency of all visceral arteries (Fig 2b). Antiplatelet therapy with aspirin (100 mg/d) was administered postoperatively. All of the patient’s symptoms gradually resolved. Duplex ultrasound and CT angiography were performed at 1, 3, and 6 months postoperatively and every 6 months thereafter. CT angiography performed at 1 month postoperatively showed complete pseudoaneurysm thrombosis. At the 25-month follow-up examination (Fig 3a, b), all visceral arteries were intact, and complete shrinkage of the pseudoaneurysm and pancreatic pseudocyst was
Shu et al
’
JVIR
observed. Duplex ultrasound detected normal peak systolic velocity, end-diastolic velocity, and resistance index in all visceral arteries (Table), which confirmed brisk visceral artery perfusion. Gunshot wounds to the aorta are lethal; 85% of victims die before hospital admission, and the overall mortality rate of victims who arrive at the hospital alive is about 87.5%. Tamponade of hemorrhage by surrounding tissue may result in development of silent pseudoaneurysm, and up to 25% of affected patients die of acute tamponade rupture (1). The endovascular technique offers an effective and microinvasive alternative to open surgery, but it is challenging when a pseudoaneurysm involves visceral arteries. Takahashi et al (2) described the use of a customized fenestrated stent graft to cover a paravisceral aortic pseudoaneurysm, while preserving involved branches. However, the customized nature of this method limits its widespread use. The use of a septal occluder is another option. Bornak and Milner (3) reported the successful treatment of a large saccular aneurysm involving the visceral segment of the abdominal aorta with an AMPLATZER Septal Occluder (St Jude Medical, Inc, St Paul, Minnesota). However, the risk of branching artery coverage by the metal disk should be considered. Chang et al (4) described the use of a bailout method with a chimney stent to reconstruct a left carotid artery that had been inadvertently covered during the placement of an atrial septal occluder to cover an aortic arch pseudoaneurysm. Percutaneous embolization with coils or thrombin injection via direct puncture or transcatheter can also be used. However, only selected patients with narrownecked saccular aneurysms or pseudoaneurysms are candidates for this treatment because of the risk of misembolization provoking acute ischemia in the distal or branching arteries (1). The use of two overlapping sinus stents across a pseudoaneurysm entry can segment the wide necks of saccular aneurysms or
Figure 1. (a, b) CT images obtained 16 days after conservative treatment show expansion of the pseudoaneurysm (arrow 1) with internal thrombosis (arrow 3), the bullet (arrow 2), and the huge pancreatic pseudocyst (arrow 4).
Volume 26
’
Number 3
’
March
’
2015
453
Figure 2. (a) Angiography shows opacification of the pseudoaneurysm cavity and entry site (arrow 1) and the bullet (arrow 2). (b) After coil embolization and placement of overlapping stents across the orifices of all visceral arteries and the pseudoaneurysm, the pseudoaneurysm was almost completely obliterated, with little internal contrast (arrow 3) and intact perfusion of branching vessels. Black arrowheads indicate the ends of the 80-mm stents, and white arrowheads indicate the ends of the 60-mm stents.
Figure 3. (a, b) CT images obtained at 25-month follow-up examination show shrinkage of the pseudoaneurysm (arrow 2), good perfusion of all visceral arteries—right renal artery (arrow 1), superficial mesenteric artery (arrow 3), left renal artery (arrow 4)—with no stenosis at their orifices, and complete resolution of the pancreatic pseudocyst.
Table . Results of Duplex Ultrasound Examination to Assess Blood Flow in All Visceral Arteries 25 Months Postoperatively CA PSV (cm/s) EDV (cm/s) RI
62 23
SMA LRA RRA LRA Orifice* RRA Orifice* 83 14
51 22
68 32
0.62 0.84 0.56 0.54
45 18
32 10
0.60
0.66
CA ¼ celiac artery; EDV ¼ end-diastolic velocity; LRA ¼ left renal artery; PSV ¼ peak systolic velocity; RI ¼ resistance index; RRA ¼ right renal artery; SMA ¼ superior mesenteric artery. *Location where the bare stents segregated the aorta and visceral arteries and blood flow was not restricted.
pseudoaneurysms into small meshes to prevent microcoil migration and misembolization. Such stents do not reach the interstice size that would lead to flow diversion to branches, as the long-term outcome of intactness of all visceral arteries in the present case confirms.
In conclusion, the use of stents and microcoils can be considered as an effective option for the management of arterial pseudoaneurysms and saccular aneurysms near vital branches, regardless of the branch diameter or the presence of a wide neck. However, when the orifice of a vital branch, where it connects to the main trunk, is invaded, the use of this techsnique may be limited.
REFERENCES 1. Tucker S Jr, Rowe VL, Rao R, et al. Treatment options for traumatic pseudoaneurysms of the paravisceral abdominal aorta. Ann Vasc Surg 2005; 19:613–618. 2. Takahashi S, Takaya S, Fukuda I, et al. Stent graft treatment for abdominal pseudoaneurysm near the celiac artery. Thorac Cardiovasc Surg 2003; 126:600–602. 3. Bornak A, Milner R. Endovascular exclusion of a saccular aortic aneurysm using a septal occluder device. J Vasc Surg 2011; 53:1097–1099. 4. Chang G, Chen W, Yin H, et al. Endovascular repair of an aortic arch pseudoaneurysm by an atrial septal defect occluder combined with a chimney stent. J Vasc Surg 2013; 57:1657–1660.
