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mcatmemoranda · 1 year ago

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Abdominal aortic aneurysm – Abdominal aortic aneurysm (AAA) is a common and potentially life-threatening condition. Approximately 7000 deaths per year are attributed to ruptured AAA in the United States. Without repair, ruptured AAA is nearly uniformly fatal. For asymptomatic patients, elective repair of the aneurysm is the most effective management to prevent rupture.

●Asymptomatic small AAA – For most patients with asymptomatic infrarenal AAA <5.5 cm, we recommend conservative management (watchful waiting) rather than elective AAA repair (Grade 1A). The risk of aneurysm rupture does not exceed the risk of repair until the aneurysm diameter reaches 5.5 cm. However, there are situations for which elective repair of asymptomatic AAA <5.5 cm may also be appropriate. These may include rapidly expanding AAA (>0.5 cm in six months or >1 cm per year), coexistent aneurysm/peripheral artery disease, and female sex.

●Conservative management – Conservative management consists of periodic clinical evaluation and imaging surveillance to identify AAA that exceeds the threshold for repair or is rapidly expanding. Medical therapies for patients with AAA focus on the management of modifiable risk factors for AAA and cardiovascular disease with the goals of reducing the need for intervention due to aneurysm expansion or rupture, reducing morbidity and mortality associated with AAA repair, and reducing cardiovascular morbidity and mortality.

•Smoking cessation – For patients with AAA who smoke, we recommend smoking cessation (Grade 1A). Smoking is strongly associated with AAA expansion and rupture and is the most important modifiable risk factor. Even though reduced aneurysm expansion and rupture risk have not been clearly demonstrated among those who have stopped smoking, smoking cessation has other clear benefits.

•No medical therapies proven to limit AAA expansion – Although many pharmacologic therapies aimed at limiting AAA expansion and preventing rupture have been tried, no therapy has been proven successful at achieving these goals, and as such, we suggest not implementing any of the pharmacologic therapies discussed above for the sole purpose of treating AAA (Grade 2C).

●Asymptomatic large AAA – For good-risk surgical candidates (open or endovascular repair) with AAA >5.5 cm, we recommend elective AAA repair (Grade 1A). For patients with AAA >5.5 cm who have a short life expectancy (<2 years) due to advanced comorbidities, particularly cardiopulmonary disease or malignancy, we suggest no repair over endovascular aneurysm repair (Grade 2B). For these patients and others who elect not to undergo repair, ongoing AAA surveillance is not needed. The patient should be encouraged to create an advanced directive detailing their wishes for no repair of any kind in the event of rupture. Family members or other caretakers should be made aware of these wishes, given that the patient may not be able to report their wishes at the time of aneurysm rupture.

●AAA repair – The primary goals of aneurysm repair are to prevent rupture while minimizing morbidity and mortality associated with repair. We agree with guidelines from major medical and surgical societies that emphasize an individualized approach when choosing between an open or endovascular approach to AAA repair, accounting for aortic anatomy, patient age, life expectancy, and risk factors for perioperative morbidity and mortality. For patients with favorable anatomy for endovascular repair (as defined by the instructions for use of a given device) and a high level of perioperative risk, we recommend endovascular repair, rather than open surgical repair (Grade 1B).

●Surveillance schedule for unrepaired AAA – The optimal surveillance schedule for patients who are not undergoing AAA repair is not known for certain. The Society for Vascular Surgery (SVS) recommends surveillance every 6 to 12 months using ultrasound or CT for medium-sized aneurysms (4 to 5.4 cm in diameter) but less frequent intervals for smaller aneurysms. We frequently perform surveillance on small aneurysms annually to minimize imaging variability and alleviate patient anxieties. Annual clinical examination and risk reduction assessment can also be performed concurrently with AAA surveillance.

#AAA #abdominal aortic aneurysm

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irispublisherscasestudies · 4 years ago

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ABCD…Airway, Breathing, Circulation (and don’t forget Differentials) |Iris Publishers

Authored by Ashok Handa*

Abstract

Male patients over the age of 65, presenting with acute abdominal pain should be managed as a potential ruptured abdominal aortic aneurysm (AAA), until proven otherwise. Ruptured AAA is a commonly missed life-threatening diagnosis. This paper aims to recap over the diagnosis and management to aid doctors in training in their decision making.

Keywords:AAA; Aneurysm; Rupture; Epigastric pain; Collapse

Main Text

History

A 69-year old man presented to the emergency department with a three-week history of general malaise and diarrhoea, on a background of chronic kidney disease (baseline creatinine 250 μmol/L) and an abdominal aortic aneurysm (AAA;5cm). He was admitted with acute kidney injury (creatinine 1500 μmol/L) presumed to be secondary to severe hypovolemia, and commenced emergently on hemofiltration requiring heparinization, as well as aggressive fluid resuscitation. A few days later, he developed sudden onset of epigastric pain and syncope, with increasing abdominal girth and decreasing haemoglobin. Surgical review found a tender abdomen with a pulsatile epigastric mass, however he continued to be hydrated and anti-coagulated, as definitive diagnostic imaging and vascular referral was delayed until the following morning, some 5 hours later.

Computed tomography angiography (CTA) of the abdomen showed a large infrarenal AAA, measuring 7.5 cm in maximal anterior-posterior diameter (Figures 1 & 2). Typical features of an aortic aneurysm include the calcified intimal layer of the arterial wall and the eccentric thrombus lining of the arterial lumen.

Of greater concern is the presence of an apparent contained rupture indicated by the presence of a significant retroperitoneal swelling due to a large contained haematoma, in this case unusually bilaterally and anteriorly displacing the posterior peritoneum; this can be verified by indicative Hounsfield’s units [1]. Quite remarkably, contrast can also be seen jetting from the intraluminal space into the haematoma anteriorly. The former is sufficient to demonstrate a ruptured aneurysm that has subsequently tamponaded, however the latter suggests ongoing bleeding into the retroperitoneal space.

Key Points

This case demonstrates that a high index of suspicion must always be exercised when patients over 65-years present with a history of epigastric pain and collapse. Certainly, a ruptured aneurysm constitutes one of several important differentials that must always be suspected and rapidly excluded (Table 1). In this case, a ruptured AAA could have been seen using a bedside ultrasound, including a FAST (focused assessment with sonography for trauma) scan [2]. Otherwise, in the setting of such severe acute renal failure, even a non-contrast CT would have sufficient features to suggest the diagnosis.

Management

Management of ruptured aneurysms includes early assessment and management with subsequent rapid access to definitive treatment (Table 2). If suspected or confirmed, all patients should have adequate vascular access, and “permissive hypotension” is key, such that low systolic blood pressures (>90mmHg) are tolerated as long as the Glasgow Coma Scale remains 15 and ST-T segment remains unchanged on electrocardiography. If the patient becomes haemodynamically unstable, volume resuscitation should be implemented cautiously with packed red blood cells, either previously cross-matched or O-negative if a crossmatch is not available. Simultaneously, early referral and rapid transfer to the nearest Vascular Unit should be facilitated [3].

Read More... Full Text

For More articles in Archives of Clinical Case Studies please click on: https://irispublishers.com/accs/

To Read More : Iris Publishers Linkedin

#Iris Publishers #Case Studies #clinical case studies

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aliceslantern · 5 years ago

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Beyond this Existence: Atonement, chapter 10

Ansem always had a penchant for strays, so it's not at all surprising when he takes in the orphaned child Ienzo. The boy's presence changes everything, far more than Even is willing to admit. Ienzo's brilliance seems promising, but the arrival of a young Xehanort pushes the apprentices onto a dark, cruel, inhumane path which will affect the future of the World. And even once it's all over with--once Xehanort is dead--they still must pick up the pieces, forgive one another, find a way to atone for their atrocities, and struggle to accept the humanity which has been thrust upon them.

Or: Even's journey from BBS through post-KH3

Chapter summary: Even offers the restoration committee a report of what the apprentices did, but it forces him to confront emotions long held at bay.

Read it on FF.net/on AO3

---

For an unknowable amount of time, Even writes. At first it is spurred on by anger; at Ansem, at the others, at himself most of all--but it seems that, once his fury cools, he can’t stop the words.

Even has never been a particularly poetic person. He tried, in the past, to keep all his journals and reports objective, clean, and to the point. Plainly worded, aside from the necessary technical terms--he himself remembered being incredibly frustrated with how wordy academics could be, so masturbatory in their writings--and neatly detailed.

These writings are clearly something else entirely. Emotion makes the pages bleed. He feels, above all, just a little deranged. He writes about guilt, about pain and remorse, about replicas who are now people, about how agonizingly raw he feels despite the fact that he is still not yet fully human , about DNA and boys from the past and boys from his memories. About what it felt like to be married and then widowed in seemingly an instant. About how his emotions color everything, despite his best attempts to remain reasonable, logical. If he were truly logical, he would’ve been able to end all this suffering before it happened.

When his wrist aches, he changes to a keyboard. He can plainly see spelling mistakes, grammatical aberrations; but he doesn’t edit, not yet. He writes himself into a stupor and falls asleep right on the keyboard, filling twelve pages with the letter F. When he rouses, he feels splitting pains in both hands, especially his dominant; he ices them, wraps them up tightly, and forces himself to sleep on the cot.

He doesn’t feel better, but he feels strangely relieved, like he’s released some pressure. He takes mild anti-inflammatories for his wrists, and drags himself towards his actual quarters.

His phone begins to ring. At first it seems to be from Ienzo; but then he notices the small forwarding icon, indicating the boy missed a call. They’ve set their phones up like this in case of emergency; Ienzo’s the one in contact with the restoration committee. Even blinks a little. Where’s the boy--is he alright? Or is he merely distracted? He hopes for the latter.

“Hello? Who’s this?”

“Oh, finally. I got someone.” A woman’s voice. “My name is Aerith. From the committee?”

He remembers. “I’m Even--apparently Ienzo has seen fit to make me his backup point of contact.”

“None of that matters right now. Demyx lives with you, right?”

Here it goes. How wonderful it would feel to tell the others he’s right. “Yes.”

“He’s very badly hurt.”

The satisfaction turns rank. He stops dead in his tracks. “How so? I’m a doctor--spare me no technicalities.” It feels odd to identify himself so after so long.

“Yuffie--she’s on security detail--found him at the edge of town. Heartless, it seems like. They didn’t get his heart, thank god , but they’ve got him right in the infrarenal aorta. He’s lost something like three liters of blood. I’m trying everything in my power, but--”

“Don’t get my hopes up?” he finds his own heart beating heavily. “Can I be of any assistance?”

“The wound’s already closed--it’s the shock he has to recover from. I’ll… I’ll keep you updated, okay?” She hangs up before Even can say anything else.

Just because Even wants Demyx away from Ienzo doesn’t mean he wants him dead .

And now he has to tell the boy.

He has no idea where to find Ienzo. Not with Demyx, surely. But where?

The lab.

Even finds him in the hallway on the way back. “There you are. Why haven’t you answered your phone?”

The boy looks limp--Even realizes his eyes are red-rimmed. He’s been crying. Of course. Well, bigger fish to fry, in the moment. “Did you call me?” he asks tiredly.

“Perhaps you do not remember, but your phone is set up to forward calls to mine if marked urgent.”

“Whatever is the matter?”

Even hesitates. If they’ve fought or broken up--but the boy deserves to know. His time of hiding things from Ienzo is long over. “It’s Demyx.”

“What about him?” he asks, sourly but not without a trace of anxiety.

“He’s been injured. Mortally.”

His eyes widen; his hands flutter at his throat. Even explains what happened. “So you mean he’s--”

“We don’t know yet. What do you know of this woman’s abilities?”

He shakes his head, his eyes empty.

“You poor boy.” He embraces him, and to his surprise feels Ienzo hug back. He smells so the same as he once did, the slightly sweet scent of ink. “I worry, too. I know how much he means to you.”

He feels Ienzo shudder against him.

“Come. You mustn’t wait through this alone.”

He escorts the boy back to his quarters. Ienzo’s breathing oddly, heavily, and his eyes are so vacant. Even wants to press, to find out exactly what happened, but Ienzo doesn’t need that. He leads the boy over to the sofa; Ienzo immediately lays on his side and curls up. Even drapes a blanket over the boy. He knows nothing he can say or do will be of any use.

After what seems to be hours--hours where Even obsessively checks his gummiphone--Ansem arrives, breathless. “Have you any news? I heard a few moments ago. I was away from the phone."

He scowls. “Oh good, you’re here. Whatever would we do.”

Ansem ignores the barb. “What happened?”

“The usual. Heartless. Only he had no means to defend himself. He did not fall to darkness, but was wounded critically. That’s all we know.”

He shakes his head. “The irony of it. To survive all that, and to get wounded by shadows.”

“So things go,” Even mumbles.

Ansem kneels in front of Ienzo, who’s still supine. When he touches him, Even notices him flinch. “Have hope. I’ll get you two some tea.”

Even grits his teeth. Once he’s out of earshot, he snarls, “The man can take better care of a houseplant than a child.”

Ienzo raises an eyebrow.

“Oh, come off it. I’ve earned a few good digs at Master . He still does not understand people. As hard as he tries. It’s a miracle you came out as civilized as you did.” He sniffs. “Perhaps there is yet some bitterness in my new heart.” His phone started ringing; the boy’s eyes widen with something akin to panic. “Yes?”

“Even? Aerith again. Demyx is alive. He’s recovering well enough, but I had to put him to sleep for a while. The blood loss was really hard on his heart. Vitals seem to be stable, though.” Even can feel the boy’s eyes on him.

“Quite. Quite. I see. At least there’s that.”

Ienzo tenses.

“Merlin and I can bring him there. This isn’t really a good place for a person to recover. I figure you probably know what you’re doing.”

“Thank you. You’re a kind girl.” He explains it to Ienzo, but this doesn’t seem to placate him. Even chances a small smile. “If Demyx is anything, he’s resilient. I have a feeling he’ll be around to annoy us for a long time yet.”

When he’s back in his own bed, the boy is indeed in poor shape. There’s no wound, aside from a scar, and most of his blood has been replaced, but frankly he looks terrible. “So long as you don’t wake him, he’ll recover.” She too looks horrid. Even can remember his own endless days of patient care, how wearing it can be on the body. “When you take a person back from the brink of death, you have to let them sleep. But he should be okay. He’s got a will to live like I’ve never seen. Broke through several layers of sedation like it was nothing.”

“That’s what I’ve been saying,” Even says. “Poor Ienzo has been having conniptions.”

“Are you two close?” Aerith asks him.

He hesitates. “We’re partners,” he admits in a voice hoarse from hours of disuse. Interesting word choice.

She nods. “I’m sure this has been a harrowing experience. But we caught it in time. It’s lucky the Heartless didn’t want his heart.”

“...Lucky,” he echoes.

“Thank you for everything you’ve done,” Even says.

“Of course. I’m happy to help. Things have been so peaceful that this is the first major injury case I’ve seen in several weeks.” She sighs. “These things come and go in waves. Hopefully they don’t get much worse. I’ll come back tomorrow to check on him. Call me if you need to.”

“I shall. There was one thing left I wanted to discuss.” She follows him out the room, but Ienzo remains, taking the boy’s hand, an exact inverse of when he fell ill.

“What’s up?” she asks wearily. He wishes he had an ether for her, but his stores are still decimated.

“What is the medical care situation like around here? You’re not the only one, are you?”

She shrugs, tiredly.

“Oh, no. You poor girl.”

“It’s alright,” Aerith says. “Like I said, it comes and goes in waves.”

“I don’t suppose you could use… an extra pair of hands?”

Her smile seems rather composed. “That’s a very generous offer, but…”

He nods. “It’d be rather disquieting to the patients?”

"Yeah. Kind of." She exhales, smoothing her braid. "I know Ienzo says you all want to atone, and that's only right. At the same time… the darkness has scarred everyone."

"...I see."

"Perhaps there are other ways you can help," she says. "You're all scientists--and the committee is run by largely uneducated people. I'm sure you can be useful. The one thing I'm sure you can do, though…"

"Name it and consider it done."

"You could give me a list of the victims."

She says it so earnestly. Even feels his heart drop.

"We've maintained a list of the missing and presumed dead for years. It might be nice… to be able to give the surviving families closure."

"...Yes. Of course. I will make it my priority. I can give a complete statement."

"That would make Leon very happy… well. Happy as he can be, anyway."

"The truth isn't easy, but it is necessary."

She nods.

"Now go sleep, woman. You look dead on your feet. I've been looking after these miscreants for years--I can handle it from here."

"Be well, Even."

"...I shall certainly try."

He peeks into the room once more before descending back into his lair. Ienzo touches Demyx's face, once, delicately. After all this… Even finds he no longer minds it so much. The boy needs love, and it's clear his own desiccated heart is not capable of providing it--nor anyone else's, save perhaps Demyx.

Love can be more than pain--he remembers that very distantly.

He allows himself to think about that person, slowly, unwinding the defensive chain around the memory. They too were in the sciences, the same doctoral class. They wanted to help people have children--in a roundabout way, inspiring him to consider the body, the replicas--the two of them must've discussed this for hours, the methods and the ethics, until the library closed. That person leaned over so carefully, their hair brushing Even's shoulder--and kissed him, his first.

The pregnancy wasn't necessarily intentional, ironically enough--neither was the following marriage, the proper thing to do at the time--but it was an arrangement that worked, an easy partnership. That period of his life seems long, but it was only seven years from start to finish. Gone.

Perhaps this is why, but when Even unseals his reports from the time before, he can feel the humanity, and despises the utter coldness with which he wrote about their victims. He reads their histories, their stories. He cries. How many children has he taken from their parents, spouses from their partners?

One hundred and twenty three.

From the initial, unharmed participants to the first artificial Heartless, there were one hundred and twenty three people they'd broken; one hundred Heartless.

He allows his wrists to ache as he types the report. In fact, the pain suits him. The document ends up being something like twenty pages, and he still has more to say. Even finds himself trembling, aching. This time he can feel it coming, and eases himself onto the cot before unconsciousness claims him. He wakes. Rather than bathing and sleeping, he resumes his work, trying to edit it into something reasonable. When he has a working draft of this impact statement, he sends it to Aerith, returns to his quarters, and sleeps.

He feels himself becoming… what?

He’s not well. He knows that much. But who dare he ask for help? Should he deserve it?

This is a dark place indeed, even darker because this is what they put their victims through.

He spends several days washing in and out of consciousness, hardly able to move aside from performing the most basic bodily functions. Despite it all, I live, I breathe. Why?

A knock at his door. He ignores it. His body, though underweight, seems to be dragging him down.

A voice, Aeleus’s--“Even? Are you in there?”

He forces himself to his feet, feeling the ground pitch, likely from low blood sugar. He smooths down his hair. “Do you need something?” he asks in what he hopes is a normal voice.

He cracks open the door and enters. “I… have not seen you in several days,” he says. “I… was worried.”

Even forces a smile. “What, about a wretch like me?”

“Yes.” He blinks. “I fear you are more volatile than ever.”

“You needn’t worry. I’ve merely been catching up on my sleep.”

Aeleus goes over to Even’s hot plate, opens up some of the cabinets above.

“What are you doing?”

“Feeding you,” he says. He pours water in a pot, begins making oatmeal.

“Aeleus, I’m a grown man. I can cook for myself.”

He grunts in response. “Because you can doesn’t mean you will.”

“I’m not sure I like what you’re implying.”

“You don’t take care of yourselves--any of you, but especially you, Master, and Ienzo.” He stirs the mixture. “Where do you think the boy gets it, Even? You’re more than your mind. I don’t think I’ve seen you looking healthy since we’ve all been back here.”

“My health doesn’t matter.”

“Yes. It does.” Aeleus turns to face him. “I’ll not have you doing anything reckless.”

Even feels vaguely caught; though why?

He starts making coffee, hands Even the steaming cup. In the winter weather, the warmth is incredibly welcome.

“I feel so cold,” he says softly.

“I know,” Aeleus says. “But you’re thawing.”

“...A lame pun if I’ve ever heard one.”

“It’s true.” He takes a deep breath. “My heart aches too, Even.”

He feels little emotion; but his eyes are watering. “It makes no sense,” Even says slowly. “I… my heart is still a mere fragment, yet I feel… all too much. Scientifically, it just doesn’t…”

Aeleus chuckles a little. “The heart is not bound to logic. Not even close.”

“Aeleus… you have always been… a steady presence.” He takes a drink of the coffee, centering himself with its warmth and bitterness. “I fear I am rather… becoming mentally ill.”

“You’re beginning to process. It’s healthy.” He digs in Even’s barren cabinets for sugar. “I’m afraid the oatmeal is merely plain.”

“You believe this is healthy?”

“Better than absolute numbness, absolute repression.”

Even takes a few timid spoonfuls; he finds it goes down easily. “I feel so… horridly weak. I cannot even begin to…” A bite, a drink. It’s strangely foreign. “I’m giving that nice young woman a… report of what we did. It--”

“Remorse.”

“Yes.” More wetness warms his eyes, but he can’t blink it away this time.

“You should cry. It’s good for you.”

“I’m so humiliated, Aeleus.”

“Who will I tell?” It’s the earnestness that gets him. “We’re all in the same boat. I… myself, in my own quiet moments… I know you know what I did.”

“...What?”

“Ienzo. When he was a boy. Incapacitated him, so you could not take him.” He flinches just the slightest.

“Oh, Aeleus--”

“His eyes were full of such trust… I handed him that cake, knowing full well--” He shudders, almost imperceptibly. “All these years, I have tried to protect him. But I could not stop Axel from--” He trails off.

“Where would I have gone?” Even asks tiredly. “Without the power of darkness, I could not have taken us outside the city limits, where we no doubt would’ve starved, or died from dehydration. Else Xehanort would have found us… and disposed of witnesses.” It takes work, to finish the beverage and meal; once he’s done, he finds himself even more exhausted.

Rather than delve more deeply into this conversation, though, Aeleus looks out his window. “It’s snowing,” he says. “Even, look.”

He crosses over to the other man. Whiteness piles onto the windowsills, the ground. “So it is.”

“I’m… afraid I must tend to the steps, salt them and whatnot,” he says. “But I will be back in a few hours with another meal.”

He takes a breath. “Thank you,” he says softly.

Aeleus takes his hand and gives it a squeeze.

For a long while Even sits by the window, watching the slow fall so slowly. Briefly, he misses his element, his control over it; snow is much more natural than anything Vexen did. Cleansing. Gentle.

Out of the corner of his eyes, he sees movement. In the courtyard below his window he can see two figures in the snow; the boys. They’re throwing snowballs at one another, an endless volley. (He notes, with pleasure, that Ienzo seems to be winning.) Demyx is teaching him how to play; something they never did. With another swell of warmth, he notices Aeleus join in, pelting the two further.

He smiles a little. He realizes the boy is going to be fine; Demyx truly does care for him.

He bathes, for the first time in days, is able to give Aeleus a meal in turn, though it is flavorless and bland. He still lacks intellectual sharpness, but he’ll settle for simple functionality after all this.

Even begins to pull the shards of himself together.

#beyond this existence: atonement #even (kingdom hearts)#ienzo #aeleus #ansem the wise #aerith #beyond this existence

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imagecase · 3 years ago

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A 53-year-old female presented to the Internal Medicine clinic with a 2-year history of atypical chest pain and bilateral leg pain with nocturnal worsening. She had arterial hypertension diagnosed more than 10 years before and type 2 diabetes mellitus, with no end-organ damage documented, including coronary artery disease. Physical examination revealed a left periumbilical bruit and weak bilateral lower limb pulses. An abdominal computed tomography scan with contrast was performed for further evaluation, revealing a diffuse narrowing of infrarenal aortic artery (minimal diameter of 2 x 3 mm; arrow), stricture of the left common iliac artery and occlusion of the right common iliac artery with distal repermeabilization (*). Signs of collateral circulation were seen in the intervertebral arteries, and no occlusions of the renal arteries and superior and inferior mesenteric arteries were registered. She also underwent cervical doppler ultrasonography, documenting a sub-obliterative 80% stenosis of the proximal internal carotid artery with haemodynamic repercussion and significant intracranial collateralization to the right internal carotid vascular territory, through anterior and posterior communicating arteries. No elevation of acute phase reactants was detected. A diagnosis of mid-aortic dysplasia syndrome was made. This syndrome is a congenital disorder of unknown aetiology characterized by abdominal aortic stenosis and strictures of its main branches. Although it is rare, it represents a potentially curable cause of secondary arterial hypertension. During follow-up, no end-organ damage was identified with optimization of anti-hypertensive treatment and the patient was referred to Vascular Surgery clinics for further evaluation.

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marketresearchhealthcarefuture · 4 years ago

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Endovascular Aneurysm Repair Devices Market Industry Growth, Landscape and Demand by Forecast to 2027

Market Scenario

Global endovascular aneurysm repair devices market is likely to grow significantly over the forecast period. It is estimated that the global endovascular aneurysm repair devices market is expected to record a CAGR ~ 6.4 % during the forecast period of 2018 to 2023. The weakening and bulging of the aorta is called aortic aneurysm. The bulging can cause a leak that spills blood into the body. It can direct the blood flow away from the organs and tissues, causing severe complications, such as kidney damage, heart attacks, stroke, and even death. Thus, endovascular repair can be done by placing a stent-graft in an aneurysm through a small hole in the blood vessels in the groin area.

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Market Segmentation

The worldwide market for Endovascular Aneurysm Repair Devices Market has been segmented on the basis of indication, site, anatomy, and products.

The market, depending on the indication, has been considered for abdominal aortic aneurysm, thoracic aortic aneurysm, and others. The types of thoracic aortic aneurysm are ascending aortic aneurysm, descending aortic aneurysm, thoracoabdominal aortic aneurysm, and thoracic arch aortic aneurysm.

The market, site-wise, has been considered for infrarenal and pararenal. The market, with respect to the pararenal site, caters to juxtarenal and suprarenal.

The market, anatomy-wise, covers traditional and complex.

The market, with regard to the products, mentions percutaneous EVAR, fenestrated EVAR, aortic stents and TAA grafts, and others.

Regional Analysis

The market in the Americas is expected to dominate the global endovascular aneurysm repair devices market during the forecast period owing to the increasing geriatric population, and well-developed healthcare sector. The European market is expected to be the second-largest due to government funding and support of the healthcare sector coupled with the rising prevalence of aneurysms. Moreover, the market in Asia-Pacific is anticipated to be the fastest-growing during the assessment period owing to growing disposable income. The market in the Middle East & Africa is likely to account for the smallest share of the global endovascular aneurysm repair devices market.

Renowned Companies

Endospan Ltd., BiFlow Medical Ltd, Endologix, INC., Jotec GmbH, Medtronic plc, Terumo Corporation, W. L. Gore & Associates, Inc., Cardiatis SA, Boston Scientific Corporation, Cook Medical LLC, Endoluminal Sciences Pty Ltd, Cardinal Health, Braile Biomédica, Lemaitre Vascular Inc., Getinge AB, are the top players in the worldwide endovascular aneurysm repair devices market.

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Global Neurodiagnostics Market —Forecast till 2027

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mcatmemoranda · 2 years ago

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●Asymptomatic small AAA – For most patients with asymptomatic infrarenal AAA less than 5.5 cm, we recommend conservative management (watchful waiting) rather than elective AAA repair. The risk of aneurysm rupture does not exceed the risk of repair until the aneurysm diameter reaches 5.5 cm. However, there are situations for which elective repair of asymptomatic AAA less than 5.5 cm may also be appropriate. These may include rapidly expanding AAA (greater than 0.5 cm in six months or greater than 1 cm per year), coexistent aneurysm/peripheral artery disease, and female sex.:

•Smoking cessation – For patients with AAA who smoke, we recommend smoking cessation. Smoking is strongly associated with AAA expansion and rupture and is the most important modifiable risk factor. Even though reduced aneurysm expansion and rupture risk have not been clearly demonstrated among those who have stopped smoking, smoking cessation has other clear benefits.

●Asymptomatic large AAA – For good-risk surgical candidates (open or endovascular repair) with AAA greater than 5.5 cm, we recommend elective AAA repair (Grade 1A). For patients with AAA greater than 5.5 cm who have a short life expectancy (less than 2 years) due to advanced comorbidities, particularly cardiopulmonary disease or malignancy, we suggest no repair over endovascular aneurysm repair (Grade 2B). For these patients and others who elect not to undergo repair, ongoing AAA surveillance is not needed. The patient should be encouraged to create an advanced directive detailing their wishes for no repair of any kind in the event of rupture. Family members or other caretakers should be made aware of these wishes, given that the patient may not be able to report their wishes at the time of aneurysm rupture.

#AAA

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clinicalsurgery · 4 years ago

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Failure to Remove the Ruptured Balloon Catheter of a Balloon-Mounted Stent-Graft during Infra-Renal Aortic Stenosis Stenting in Open Access Journal of Medical and Clinical Surgery by Christian Warner*

Abstract

We report a case of a 72-year-old female patient who presented with disabling short distance bilateral buttock claudication due to severe calcific stenosis of the infrarenal aorta. A balloon mounted stent graft was deployed to treat the aortic stenosis. During deployment of the stent graft, the balloon burst, and only partial retrieval was achieved via the introducer sheath. Surgical groin exploration was performed in order to remove the retained balloon fragment. Attempts to retrieve the balloon had caused an iliac artery dissection which was treated with a self-expanding stent insertion. The procedure was further complicated by distal embolism into the superficial femoral artery which was manage with surgical embolectomy.

Keywords: Deployment failure; Stent-graft; Angioplasty; Retrieval

Introduction

Luminal narrowing of the aorta, or aortic stenosis, affecting the abdominal aorta is widely reported within literature despite being uncommon when compared to other aortic morphologies such as abdominal aortic aneurysms (AAA). In adults, abdominal aortic stenosis is often secondary to atherosclerotic disease. Other aetiologies include Takayasu arteritis, aortic dissection and iatrogenic secondary to intervention [1]. Historically, bypass surgery or endarterectomy were the preferred treatment options for these patients. Towards the end of the last century however, percutaneous transluminal angioplasty (PTA) has been shown to be safe and effective [2,3]. Despite those early findings, there is a distinct lack of randomised controlled trials comparing therapeutic management over the last 30 years as a result of the relative rarity of these lesions [4]. Due to their minimally invasive nature, endovascular treatments can be perceived as carrying a low or negligible risk. We would like to highlight a rare and unexpected complication of PTA in this case report which was successfully overcome.

Case Report

A 72-year-old female presented with bilateral, very short distance, buttock claudication and lower back pain. Patient experienced symptoms on climbing single flight of stairs or walking less than 20 yards within her home. Past medical history included hypertension, hyperlipidaemia, CKD stage 3 and the patient is a non-smoker. Non palpable femoral or more distal pulses bilaterally. Unremarkable abdominal examination. Venous Duplex scan commented widely patent iliac arteries with reduced flow, monophasic signals in both common femoral arteries (CFA), superficial femoral arteries (SFA) and popliteal arteries with resting ABPIs of 0.49 bilaterally. CT Angiogram showed a severe focal stenosis of the infrarenal aorta approximately 3cm below renal arteries due to circumferential calcific atheromatous disease (Figure 1). The aorta was small in calibre, approximately 12mm. Distal to the aorta there were scattered calcifications present in the external iliac arteries with no focal stenosis. Bilaterally femoropopliteal and crural segment arteries were widely patent. A multidisciplinary team (MDT) decision recommended endovascular stenting of the infrarenal aorta using a covered balloon mounted stent graft.

The procedure was performed via a right common femoral artery approach under local anaesthesia. The infrarenal aortic stenosis was crossed and a 10 French long sheath advanced beyond the level of the stenosis (Figure 2). There was no pre-dilation of the vessel. A Bentley 12x59mm (un-sheathed) balloon mounted stent-graft was successfully deployed at its intended landing position (Figure 3), to protect the accessory renal artery and completion aortogram demonstrates good effect (Figure 4). During deployment of the stent graft, the balloon burst, on first inflation, at 10 atmospheres of pressure, below the rated burst pressure of 13 atmospheres (bar).

It was not possible to retrieve the stent delivery mechanism percutaneously through the vascular access sheath. The balloon had become wedged just outside the sheath. With some traction of the balloon catheter over a stiff Amplatz type wire. The lower portion of the balloon, attached to the outer catheter (silver/clear) of the balloon, was removed. At this point operators realised that the balloon was split into two and one half was still remaining inside the patient over the wire.

Several attempts, including trial of removing the balloon through the right CFA without a sheath, were made to remove the remaining part of the balloon, however these were not successful. Following discussion with the vascular surgeons, a decision was made to retrieve the balloon surgically. The patient was informed, and gave verbal consent to a right groin exposure, exploration and proceed under general anaesthetic. A longitudinal incision was made to the right groin and the femoral vessels exposed. The remaining portion of the balloon and the sheath were removed under direct vision.

Upon analysis of the retrieved delivery system, it was clearly evident that the balloon had burst radially and failed to reduce in axial diameter enough to be fit through the lumen of the sheath (Figure 5 & 6). Following removal of the device and sheath, blood flow was poor. A further 2000 units of IV Heparin were given in addition to the previously administered 3000 units. Surgical embolectomy of the iliac inflow was performed using a size 4 Fogarty catheter, however the inflow remained poor. Angiogram showed dissection of the right external iliac artery. Therefore, percutaneous left CFA access was gained in order to access the true lumen. A wire was snared from the right groin and stenting of the right EIA was performed with a 7 x 60 mm self-expanding bare metal stent with good angiographic result (Figure 7). However imaging of the femoropopliteal segment showed thromboembolism into the superficial femoral (SFA) and profunda femoris (PFA) arteries. Subsequent surgical SFA and PFA embolectomies were performed to establish a good outflow (Figure 8 left and middle).

A right femoral endarterectomy was performed and the arteriotomy was then closed using a VascuGuard bovine pericardial patch with a running 6.0 proline suture. Immediately prior to this, a small flap in the proximal superficial femoral artery was tacked with a 7.0 prolene suture. On clamp removal, the final diagnostic angiogram revealed excellent flow within the right lower limb arteries (Figure 8 right). The patient experienced an uncomplicated recovery on the vascular surgery ward and was discharged home on day 3 post operation. They were started on Apixaban and Aspirin for the initial 6 weeks, then a 6-week regimen of dual antiplatelet therapy (clopidogrel and aspirin) and finally followed by long term clopidogrel only. The patient was followed up 6 weeks post-op and reported walking “unlimited distances”, compared to her previous short distance claudication. On examination the patient had palpable peripheral pulses and on handheld Doppler triphasic pedal signals with normal resting ABPI’s.

Discussion

Focal infrarenal stenosis of the aorta is relatively uncommon and disproportionately affects women [5-7]. This classically presents with symptoms of bilateral claudication and is often also related to hypoplastic aortoiliac syndrome which can make surgical endarterectomy and bypass a more complex and challenging procedure with greater risks [7,8]. These patients are also typically younger and therefore more likely to require secondary intervention [9]. As a result of the relative rarity of these lesions [4], there is a lack of randomised controlled trials comparing therapeutic management.

Primary stent placement is preferred over a surgical approach for its lower major complication and mortality rates, along with its shorter recovery period and when making consideration of potential secondary intervention in the future [5,8-10]. It also holds a an advantage over percutaneous transluminal angioplasty (PTA) for aortic disease, which was previously the low risk option for selected cases [8,11], due to the infrequent but associated risk of thrombus formation and restenosis, intimal dissection, acute aneurysm formation and rupture, and distal embolization with PTA alone [4,7-13]. For these reasons and results from several case series compared by Simons et al. demonstrating good patency rates it has been suggested as the first-line management for distal aortic occlusive disease since the early 2000s [5,9]. Stenting without predilation of the aorta reduces the risks of the PTA associated complications9 by preventing the elastic recoil of the vessel and associated stenosis and outward pressure between the intima and media layers [11].

Both bare and covered stents have been used for treatment of narrowing of the aorta, with each having their own relative drawbacks. Bare stents are reported to have a greater re-stenosis rate, whereas covered stents pose a greater risk of occlusion of the main branches of the abdominal aorta [11,12]. A preference for balloon mounted stents, and their greater radial force, are when calcified lesions are present in the vessel, which can be problematic when placing self-expanding stents and potentially lead to incomplete deployment or create difficulty advancing balloon catheters into the stent after deployment [9]. This is the rationale of using a balloon mounted stent graft in our case. However, a recognised fallibility of balloon mounted stents is their susceptibility to compression and deformation which was observed early in their use [14]. Rupture of the delivery balloon and vascular damage using balloon-mounted stents is suggested due to be to the more rigid nature of the stent itself [11,13] and correlated to the relative lengths of the balloon and stent in use [15]. Self-expanding stents comparatively result in fewer incidences of damage against the vessel wall, however are more difficult to site and prone to “jumping” on deployment [11,12].

Horton et al. present their findings of sharp vascular calcifications causing recurring and reliable balloon rupture with apparent abrasions and focal puncture point during their embolization procedures [16]. Blame has often been ratified on the irregularities of the vessel, be it a calcified or angular lesion or tortuous vessel or technical factors such as over inflation of balloon pressure, or subsequent incomplete deflation, in cases of retention or entrapment of the balloon portion of devices [17-19].

The authors present a case where a balloon mounted stent graft was used to treat a focal infra-renal aortic stenosis. The post procedure results were satisfactory with good clinician and patient reported outcome measures at 6 weeks follow up. Despite following national guidelines, we experienced an expected and potentially severe complication which was rectified with a multidisciplinary approach. At our local hospital, all endovascular aortic work is performed in close collaboration with the interventional radiology, vascular surgery and anaesthetic departments, as well as the manufacturing companies. We believe it is this safety infrastructure that allows for the timely evaluation and action of any potential problems that may arise during the procedure.

Our case was reported to the manufacturer and the summary of their investigation was the severity of the calcification at the point of deployment caused the balloon to burst . Though not a novel finding in itself, it was the mechanism of burst which led to the complications experienced and outlined in this report. A detailed review by the manufacturer (Bentley) follows below. In an overview statement, the company said “[The] product was produced within the defined specifications…The lot passed all in-process controls…as well as the determination of the balloon burst pressure and burst mode… A device malfunction is not assumed but cannot be completely excluded.”

The balloons are designed to burst longitudinally in the event of a burst of up to three atmosphere (ATM) above rated burst pressure (RBP) for this balloon diameter. Above three ATM they can also burst radially. It is not known at which pressure the balloon bursts and what the burst mode looks like, though it appears to be longitudinal and radial (Figure 9). The failure mode occurred most probably due to a damage during use and an interaction with difficult anatomical conditions (heavy calcification). Therefore, the most probably root cause of the burst balloon is the inflation of the balloon in the severe calcified lesion.

As part of a review of the case we identified that the ultimate management was suitable and in following with the literature. The authors acknowledge however, that such invasive methods of retrieval should only be used when absolutely necessary and in future, retrieval using a snare from the top of the balloon or contralateral side would be attempted in the first instance.

Figure 9: BeGraft Aortic balloon catheter fragments. The main part of the balloon is still attached to the inner tubing and a small part to the outer tubing. A statement from Bentley said: “The split of the balloon was found not to be at the tip of the catheter but in the proximal balloon cone…the main balloon part is still attached to the inner tubing (at the catheter tip). The guide wire is stuck in the guide wire lumen of the inner tubing.

Conclusion

PTA has established itself as the preferred method of treatment for focal infrarenal aortic stenosis. Balloon rupture is a potentially dangerous complication that may occur, and endovascular retrieval is not always possible. Clinicians must be aware of the different balloon burst mechanisms, and how to identify and manage them.

Regarding our Journal: https://oajclinicalsurgery.com/ Know more about this article https://oajclinicalsurgery.com/oajcs.ms.id.10005/ https://oajclinicalsurgery.com/pdf/OAJCS.MS.ID.10005.pdf

#Infra-Renal Aortic Stenosis #Stent-Graft #Christian Warner*#Angioplasty #retrieval #OAJCS #Clinical surgery

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clinicamed · 4 years ago

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Infrarenal abdominal aortic aneurysms https://www.instagram.com/p/CLosh-3HOwu/?igshid=1ocr37pmh4pbn

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sachincmi · 4 years ago

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