Conventional open repair for Thoracoabdominal aortic aneurysm (TAA) is associated with high morbidity and mortality. Spinal cord ischemia (SCI), renal failure, bowel ischemia and mortality are established complications following this procedure. With the advent of endovascular stent technology, various novel approaches have been described to reduce these complications, namely fenestrated stent graft and hybrid procedure. We present a case of hybrid procedure in a pseudoaneurysm of descending thoracic aorta done in Kuala Lumpur Hospital.
This is a case report of a pseudoaneurysm due to Salmonella aortitis in a 52 year old man. The condition is rare and represents one of the few cases reported in Malaysia. The diagnosis was made preoperatively by ultrasonography and computed tomography. This was confirmed at surgery where there was a 3 cm defect at the posterior wall of the aorta at L2/3 level. The aneurysmal sac extended to the retrocrural space at the 12th vertebra level cranially on the right side to the lower border of the 3rd lumbar vertebra caudally. It had a smooth fibrous wall and contained a mixture of organised haematoma and pus. At operation the aneurysm was excised, the affected region was carefully debrided and the aorta grafted with an in-situ in-lay graft. Antibiotic therapy was instituted until clinical response was evident, leukocytosis was reduced and blood culture was negative. However 4 months after surgery, the patient returned in irreversible shock and succumbed to disseminated intravascular coagulation secondary to massive upper gastrointestinal haemorrhage from an aortoduodenal fistula.
Uterine artery pseudoaneurysm (UAP) is a rare acquired vascular malformation associated with vaginal bleeding or intraabdominal haemorrhage occurring after pelvic surgery. Pseudoaneurysm may present with delayed, severe haemorrhage after a seemingly uncomplicated initial postoperative period. Treatment is therefore necessary to prevent further complications. We describe here a case of a 32-year-old mother, who presented with abdominal pain and intraabdominal bleeding, 20 days after Caesarean Section. Computerised Tomography (CT) scan showed the presence of haemoperitoneum, suggestive of pseudoaneurysm at the right cervical artery which was successfully managed with emergency angiographic embolisation.
A 62-year-old man presented with continuous, persistent backache shortly after completion of antituberculosis medication for tuberculosis (TB) of the spine. Computed tomography scan revealed a pseudoaneurysm involving the infrarenal aorta. He was restarted on anti-TB medication and underwent repair of the pseudoaneurysm with an in situ silver-coated bifurcated Dacron graft. His postoperative recovery was uneventful and he remained well up to 12 months of follow up. To our knowledge, this is the first case in the literature where an in situ silver-impregnated vascular graft has been successfully used in treating a tuberculous pseudoaneurysm.
Epistaxis is a common problem encountered in clinical practice. It is usually self-limiting and is usually controlled with conservative measures such as nasal compression or ice-packs. Occasionally nasal packing is required. It is rarely severe enough that surgical intervention is warranted. The following report illustrates a patient who presented to us with a rare cause of life-threatening epistaxis that is, a post-traumatic pseudoaneurysm who finally required surgical intervention to control the bleeding.
BACKGROUND: This is a single institutional review of aortoiliac pseudoaneurysm of various aetiologies managed with endovascular stent graft repair.
METHODS: From 2009 to 2014, 16 patients had endovascular stent graft inserted for pseudoaneurysm of the thoracic aorta, abdominal aorta and iliac arteries in Hospital Kuala Lumpur. Co-morbidity, causative agents, in-hospital mortality, complications and outcomes were examined.
RESULTS: The average age was 59.1 years (range 36-77). Comorbidities include hypertension, diabetes mellitus, tuberculosis, prior infection and previous open aneurysmal repair. All patients had raised WBC (>10.0x10(9) /L), ESR or Creactive protein on admission while 50% of patients had fever. Blood cultures were positive in 4 patients. All patients were given antibiotics. Only one in-hospital mortality was noted at day-47 post-procedure. Two patients died of aortoenteric fistula at district hospital eight and 16 months later. One patient died of chronic graft infection two years later. One died of unrelated cause. One patient developed type IB endoleak from internal iliac artery two years later and surgical ligation was performed. The average follow up was 15.8 months.
CONCLUSION: Endovascular stent graft repair for pseudoaneurysm is a viable option compared to open surgery. It is less invasive, has lower operative morbidity and fair outcomes. However, some cases may be due to inflammatory aortitis instead of infective pseudoaneurysm, given the frequent culture-negative results. In order to obtain high yield of bacteria culture for infected pseudoaneurysm, open repair with tissue culture is still the main mode of treatment especially for patients with low comorbidity.
Pseudoaneurysm of the ankle involving the posterior tibial artery is a rare presentation with only four paediatric cases previously reported in English literature. We report a new case following blunt trauma with the clinical presentation and management strategy. A 6-year-old boy presented with a pulsatile swelling at the medial aspect of ankle following a history of blunt trauma 3 weeks ago. Imaging confirmed pseudoaneurysm involving the distal posterior tibial artery. Excision of the pseudoaneurysm was performed without any complication.
Open surgical repair of axillosubclavian artery injuries is technically demanding and associated with significant morbidity and mortality. Endovascular intervention has emerged as a valuable alternative to open surgical repair. This report presents three cases with axillosubclavian artery injuries managed with endovascular intervention. All three cases had a pseudoaneurysm of the axillosubclavian artery with one case associated with an arteriovenous fistula. They were successfully treated with endovascular stenting and balloon angioplasty. There were no observed acute complications. No complications or recurrence have occurred, with a mean follow-up of 26 months. Endovascular intervention for axillosubclavian artery injuries is less invasive, safe and effective; however, data concerning the long-term effects and complications associated with this technique are lacking.
Bacterial arteritis is relatively uncommon and management of this condition, which carries high morbidity and mortality, is difficult and time-consuming. Common organisms implicated include Salmonella and Staphylococcus. Arteritis as a result of infection by Burkholderia pseudomallei (formerly Pseudomonas pseudomallei) has been rarely reported in the English literature. This organism, which is endemic in our part of the world, is well known to cause a wide spectrum of septic conditions. A review of cases managed at Hospital Kuala Lumpur revealed that bacterial arteritis due to melioidosis is not such a rare entity. We share our experience in the management of this condition using three cases as examples.
This is a study of 54 intravenous drug user's (IVDUs) with infected pseudoaneurysms undergoing ligation and debridement at the Vascular Unit, Hospital Kuala Lumpur (HKL) from February 1993 to February 1996. The median age was 37 years with a male preponderance (53:1). Chinese form the largest ethnic group with 57.4% of the cases. Staphylococcus aureus was the most common organism cultured. Human immunodeficiency virus (HIV) positive cases numbered 21 (38.9%). Four of the patients had to have an above-knee amputation after surgery. Simple ligation and debridement of all necrotic tissue is an acceptable mode of therapy in these patients with low amputation rates.
Epistaxis is commonly encountered in otorhinolaryngologic practice. However, severe and recurrent epistaxis is rarely seen, especially that originating from a pseudoaneurysm of the intracavernous internal carotid artery (ICA). We herein present the case of a 32-year-old man who was involved in a motor vehicle accident and subsequently developed recurrent episodes of profuse epistaxis for the next three months, which required blood transfusion and nasal packing to control the bleeding. Computed tomography angiography revealed a large intracavernous ICA pseudoaneurysm measuring 1.7 cm × 1.2 cm × 1.0 cm. The patient underwent emergent four-vessel angiography and coil embolisation and was discharged one week later without any episode of bleeding. He remained asymptomatic after three-month and one‑year intervals. This case report highlights a large intracavernous ICA pseudoaneurysm as a rare cause of epistaxis, which requires a high index of suspicion in the right clinical setting and emergent endovascular treatment to prevent mortality.
We describe a rare case of aorto-oesophageal fistula and aortic pseudoaneurysm in a middle-aged man, who presented with chest pain and haematemesis 1 week after swallowing a fish bone. Oesophagogastroduodenoscopy and computed tomographic angiography findings were consistent with oesophageal perforation, proximal descending aortic pseudoaneurysm, and aorto-oesophageal fistula. Thoracic endovascular aortic repair was performed. The patient died from severe mediastinal sepsis. Early surgical intervention and broad-spectrum antibiotic therapy are crucial in preventing life-threatening mediastinal infection.