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BACKGROUND: Multiple organ failure (MOF) is associated with poor outcomes and increased mortality in sepsis and trauma. There are limited data regarding MOF in patients after ruptured abdominal aortic aneurysm (rAAA) repair. We aimed to identify the contemporary prevalence and characteristics of patients with rAAA with MOF. METHODS: We retrospectively reviewed patients with rAAA who underwent repair (2010-2020) at our multihospital institution. Patients who died within the first 2 days after repair were excluded. MOF was quantified by modified (excluding hepatic system) Denver, Sequential Organ Failure Assessment (SOFA) score, and Multiple Organ Dysfunction Score (MODS) for postoperative days 3 to 5 to determine the prevalence of MOF. MOF was defined as a Denver score of >3, dysfunction in two or more organ systems by SOFA score, or a MODS score of >8. Kaplan-Meier curves and log-rank testing were used to evaluate differences in 30-day mortality between multiple organ failure and patients without MOF. Logistic regression was used to assess predictors of MOF. RESULTS: Of 370 patients with rAAA, 288 survived past two days (mean age, 73±10.1 years; 76.7% male; 44.1% open repair), and 143 had data for MOF calculation recorded. From postoperative days 3 to 5, 41 (14.24%) had MOF by Denver, 26 (9.03%) by SOFA, and 39 (13.54%) by MODS criteria. Among these scoring systems, pulmonary and neurological systems were impacted most commonly. Among patients with MOF, pulmonary derangement occurred in 65.9% (Denver), 57.7% (SOFA), and 56.4% (MODS). Similarly, neurological derangement occurred in 92.3% (SOFA) and 89.7% (MODS), but renal derangement occurred in 26.8% (Denver), 23.1% (SOFA), and 10.3% (MODS). MOF by all three scoring systems was associated with increased 30-day mortality (Denver: 11.3% vs 41.5% [P < .01]; DOFA: 12.6% vs 46.2% [P < .01]; MODS: 12.5% vs 35.9% [P < .01]), as was MOF by any criteria (10.8% vs 35.7 %; P < .01). Patients with MOF were more likely to have a higher body mass index (55.9±26.6 vs 49.0±15.0; P = .011) and to have had a preoperative stroke (17.9% vs 6.0%; P = .016). Patients with MOF were less likely to have undergone endovascular repair (30.4% vs 62.1%; P < .001). Endovascular repair was protective against MOF (any criteria) on multivariate analysis (odds ratio, 0.23; 95% confidence interval, 0.08-0.64; P = .019) after adjusting for age, gender, and presenting systolic blood pressure. CONCLUSIONS: MOF occurred in only 9% to 14% of patients after rAAA repair, but was associated with a three-fold increase in mortality. Endovascular repair was associated with a reduced MOF incidence.

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Internal thoracic artery aneurysms (ITAAs) are rare with wide variation in clinical presentation and a high risk of rupture. Endovascular techniques are increasingly being used for treatment of such aneurysms over surgical repair in recent times. A 34-year-old male presented with progressive swelling of the right anterior chest wall for 2 weeks and was diagnosed with right internal thoracic artery aneurysm with contained rupture. He underwent successful endovascular repair with coil embolization of ruptured right ITAA. Post intervention computed tomography (CT) angiography confirmed sealing of the ruptured aneurysm with no residual filling of the sac. At six months follow-up he is doing well with complete resolution of hematoma. This case demonstrates that an endovascular approach with coil embolization is a feasible and safe option for treating the rare ruptured ITAAs.

Os aneurismas da artéria torácica interna (ITAAs) são raros, com ampla variação na apresentação clínica e alto risco de ruptura. As técnicas endovasculares têm sido cada vez mais utilizadas para o tratamento desses aneurismas em relação ao reparo cirúrgico. Um homem de 34 anos de idade apresentou edema progressivo da parede torácica anterior direita por 2 semanas e foi diagnosticado com aneurisma da artéria mamária interna direita com ruptura contida. Ele foi submetido a reparo endovascular bem-sucedido, com embolização de ITAA direito roto. A angiotomografia computadorizada (angioTC) pós-intervenção confirmou o selamento do aneurisma rompido, sem enchimento residual do saco. No seguimento de 6 meses, ele estava bem, com resolução completa do hematoma. Este caso demonstra que a abordagem endovascular com embolização com molas é uma opção viável e segura no tratamento dos raros ITAAs rotos.

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Introduction Weaning from external ventricular drainage (EVD) of cerebrospinal fluid (CSF) in hydrocephalus induced by aneurismal subarachnoid hemorrhage (SAH) had been proposed either through the rapid, gradual or intermittent approaches. There are no uniform guidelines for it. Given this, we planned to study the comparative outcome between EVD drainage with intermittent clamping versus EDV followed by Ommaya reservoir. Material and Methods The present retrograde observational study was conducted from July 2018 to March 2021 in the department of neurosurgery with 67 patients who developed hydrocephalus following SAH after aneurysm rupture. We divided the patients into two groups. Group 1 had only EVD placed for CSF drainage with intermittent clamping before the placement of the ventriculoperitoneal (VP) shunt, and, in group 2, an Ommaya reservoir was placed after EVD before the shunt. Result There were 38 patients in group 1 and 29 in group 2. They were age-matched, with a mild male predominance in group 1. Shunt dependency was significantly reduced in group 2 patients (p » 0.011), along with reduced length of stay in ICU (p » 0,001) and length of stay in Hospital (p » 0.019). We found improved Glasgow outcome score in group 2 patients (p » 0.006) together with reduced incidence of infarct (p » 0.0095). Conclusion We may infer from the present study that continuous drainage through EVD, initially, in hydrocephalus induced by SAH following aneurysm rupture, increases cerebral perfusion pressure (CPP) and decreases intracranial pressure (ICP) leading to decreased infarct rate and intermittent drainage through Ommaya following EVD reservoir, decreases shunt dependency, reduces ICU and hospital stay, with improved Glasgow outcome score on follow-up, but these findings need to be validated in a prospective randomized control trial.

Introdução O desmame da drenagem ventricular externa (DVE) do líquido cefalorraquidiano (LCR) na hidrocefalia induzida por hemorragia subaracnóidea aneurismática (HSA) foi proposto pelas abordagens rápida, gradual ou intermitente. Não há diretrizes uniformes para isso. Diante disso, planejamos estudar o resultado comparativo entre drenagem DVE com pinçamento intermitente versus DVE seguido de reservatório de Ommaya. Materiais e métodos O presente estudo observacional retrógrado foi realizado de julho de 2018 a março de 2021 no departamento de neurocirurgia com 67 pacientes que desenvolveram hidrocefalia após HSA consequente de ruptura de aneurisma. Dividimos os pacientes em dois grupos. O grupo 1 teve apenas DVE colocado para drenagem do líquor com pinçamento intermitente antes da colocação da derivação ventrículo-peritoneal (VP) e, no grupo 2, um reservatório de Ommaya foi colocado após a DVE antes da derivação. Resultado Havia 38 pacientes no grupo 1 e 29 no grupo 2. Eles eram pareados por idade, com leve predominância do sexo masculino no grupo 1. A dependência de shunt foi significativamente reduzida nos pacientes do grupo 2 (p » 0,011), juntamente com menor tempo de internação na UTI (p » 0,001) e tempo de permanência no Hospital (p » 0,019). Encontramos melhora no escore de Glasgow nos pacientes do grupo 2 (p » 0,006) juntamente com redução da incidência de infarto (p » 0,0095). Conclusão Podemos inferir do presente estudo que a drenagem contínua por DVE, inicialmente, na hidrocefalia induzida por HSA após ruptura de aneurisma, aumenta a pressão de perfusão cerebral (PPC) e diminui a pressão intracraniana (PIC) levando à diminuição da taxa de infarto e drenagem intermitente por Ommaya após DVE reservatório, diminui a dependência do shunt, reduz a permanência na UTI e no hospital, com melhora do escore de Glasgow no acompanhamento, mas esses achados precisam ser validados em um estudo prospectivo randomizado de controle.

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Abstract Internal thoracic artery aneurysms (ITAAs) are rare with wide variation in clinical presentation and a high risk of rupture. Endovascular techniques are increasingly being used for treatment of such aneurysms over surgical repair in recent times. A 34-year-old male presented with progressive swelling of the right anterior chest wall for 2 weeks and was diagnosed with right internal thoracic artery aneurysm with contained rupture. He underwent successful endovascular repair with coil embolization of ruptured right ITAA. Post intervention computed tomography (CT) angiography confirmed sealing of the ruptured aneurysm with no residual filling of the sac. At six months follow-up he is doing well with complete resolution of hematoma. This case demonstrates that an endovascular approach with coil embolization is a feasible and safe option for treating the rare ruptured ITAAs.

Resumo Os aneurismas da artéria torácica interna (ITAAs) são raros, com ampla variação na apresentação clínica e alto risco de ruptura. As técnicas endovasculares têm sido cada vez mais utilizadas para o tratamento desses aneurismas em relação ao reparo cirúrgico. Um homem de 34 anos de idade apresentou edema progressivo da parede torácica anterior direita por 2 semanas e foi diagnosticado com aneurisma da artéria mamária interna direita com ruptura contida. Ele foi submetido a reparo endovascular bem-sucedido, com embolização de ITAA direito roto. A angiotomografia computadorizada (angioTC) pós-intervenção confirmou o selamento do aneurisma rompido, sem enchimento residual do saco. No seguimento de 6 meses, ele estava bem, com resolução completa do hematoma. Este caso demonstra que a abordagem endovascular com embolização com molas é uma opção viável e segura no tratamento dos raros ITAAs rotos.

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A ruptured abdominal aortic aneurysm after endovascular aneurysm repair with an arteriovenous fistula between the aneurysm sac and a retroaortic left renal vein is an extremely rare complication. This case describes an 81-year-old man who developed an aorto-left renal vein fistula owing to a type IB endoleak 2 years after endovascular aneurysm exclusion. The leak was repaired with a left endograft limb extension. Endovascular techniques are attractive and feasible alternatives and can play an essential role in reinterventions. This report is the first of an aorto-left renal vein fistula owing a type IB endoleak after an endovascular aneurysm repair.

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Pulmonary artery aneurysm is a disorder of varying etiology and should be diagnosed early for appropriate interventions. A 45-year-old man was hospitalized for chest pain, dyspnea, cough, chills, diarrhea, and vomiting, which had started 3 weeks before admission. Physical examination indicated a reduced vesicular murmur in the right hemithorax. A chest x-ray performed indicated a pneumothorax and pulmonary abscess in the right hemithorax. Thoracostomy released abundant purulent and fetid fluid. Direct examination of the pleural fluid using saline revealed structures similar to Trichomonas. Non-contrast chest computed tomography revealed right pneumothorax along with an irregular cavitation located at the pleuropulmonary interface of the posterior margin of the right lower lobe. A pleurostomy was performed. On the second postoperative day, the patient suffered a sudden major hemorrhage through the surgical wound and died on the way to the operating room. The autopsy revealed an abscess and ruptured aneurysm of the lower lobar artery in the lower right lung. Microscopic examination revealed extensive liquefactive necrosis associated with purulent inflammation and the presence of filamentous fungi and spores. This case can be characterized as a severe disorder that requires early diagnosis to achieve a good therapeutic response and to avoid fatal outcomes.

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Intracranial aneurysm rupture causes subarachnoid hemorrhage in 80% of the cases, and it may be associated with intracerebral hemorrhage and/or intraventricular hemorrhage (IVH) in 34% and 17% of the patients, respectively. However, on rare occasions, aneurysm rupturemay be present causing isolate intracerebral hemorrhage or IVH without subarachnoid hemorrhage. We describe an unusual case of an anterior communicating aneurysm rupture presented with IVH, without subarachnoid hemorrhage. Although isolated IVH is rare, aneurysm rupture is a possible condition. Patients presenting with head computed tomography revealing IVH without subarachnoid hemorrhage should be promptly investigated with contrasted image exam to identify and treat possible causes, even in the absence of subarachnoid hemorrhage.

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Pulmonary artery aneurysm is a disorder of varying etiology and should be diagnosed early for appropriate interventions. A 45-year-old man was hospitalized for chest pain, dyspnea, cough, chills, diarrhea, and vomiting, which had started 3 weeks before admission. Physical examination indicated a reduced vesicular murmur in the right hemithorax. A chest x-ray performed indicated a pneumothorax and pulmonary abscess in the right hemithorax. Thoracostomy released abundant purulent and fetid fluid. Direct examination of the pleural fluid using saline revealed structures similar to Trichomonas. Non-contrast chest computed tomography revealed right pneumothorax along with an irregular cavitation located at the pleuropulmonary interface of the posterior margin of the right lower lobe. A pleurostomy was performed. On the second postoperative day, the patient suffered a sudden major hemorrhage through the surgical wound and died on the way to the operating room. The autopsy revealed an abscess and ruptured aneurysm of the lower lobar artery in the lower right lung. Microscopic examination revealed extensive liquefactive necrosis associated with purulent inflammation and the presence of filamentous fungi and spores. This case can be characterized as a severe disorder that requires early diagnosis to achieve a good therapeutic response and to avoid fatal outcomes.

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BACKGROUND: Previous studies have shown low rupture rates for small aneurysms (<10 mm), suggesting that the risk of treatment could exceed the benefits. However, evidence has changed, showing crescent rates of aneurysmal subarachnoid hemorrhage (aSAH) associated with small aneurysms. We report trends in size, localization, clinical characteristics, and outcomes of intracranial aneurysms (IAs). METHODS: In this retrospective study, a total of 200 clinical histories of patients diagnosed with IAs over an 8-year period were analyzed. Variables considered included age, sex, tobacco consumption, morphological characteristics of the aneurysm, complications, vasospasm, and mortality. Qualitative variables were assessed by measurements of absolute and relative frequency. Smoking behavior, aneurysm size, and aneurysm rupture (AR) were compared using 1-way analysis of variance. Categorical variables were analyzed using Pearson's χ2 test. RESULTS: The average age at presentation was 58 years. The average size of ruptured aneurysms in the general group was 2.5-7.5 mm, and AR was most common in women (76%) and in patients age 50-60 years (33%). The rate of vasospasm was 19%, and mortality was 37%. Smokers composed 32% of the cohort. Heavy smokers had a 57% rate of aSAH, with an average size of rupture of 5 mm. The most common location of aneurysms and AR was the AComA (33%). CONCLUSIONS: Our results suggest increasing AR rates in aneurysms smaller than 10 mm. This trend is seen especially in individuals with heavy tobacco consumption and in women of perimenopausal age. Our findings show a tendency of AR in accordance with previous results and are expected to serve as basis for further research on aneurysm management.

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Abstract Renal artery aneurysms (RAAs) are rare and usually asymptomatic; ~ 90% of them are unilateral. Once diagnosed during pregnancy, they may rupture, presenting a high maternal-fetal risk. The present study reports the case of a 32-year-old pregnant woman with a 30-week gestational age and a ruptured unilateral RAA.

Resumo Os aneurismas de artéria renal (AAR) são raros, normalmente assintomáticos, e ~ 90% dos casos são unilaterais. Uma vez diagnosticados durante a gestação, estes podem se tornar predisponentes a rotura e apresentar elevado risco materno-fetal. O presente artigo relata o caso de uma gestante de 32 anos, com idade gestacional de 30 semanas e quadro de AAR unilateral roto.

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OBJECTIVE: The aim of this study was to describe our early experience in the treatment of ruptured abdominal aortic aneurysms with bifurcated endografts. We report on our initial twelve-month experience using this approach. METHODS: Clinical data on patients with ruptured abdominal aortic aneurysms treated at a single tertiary center in Brazil were prospectively recorded. The eligibility for endovascular treatment was evaluated by computed tomography scanning and anatomical features were determined based on the method of treatment. RESULTS: From February 2012 to January 2013 (12 months), 28 consecutive patients (mean age 67.2 years, range 45-85 years) underwent treatment for ruptured abdominal aortic aneurysms at our hospital. Eighteen patients (64.3%) were suitable for and underwent endovascular treatment with bifurcated endografts (16 patients) or aortouniiliac endografts (two patients). Ten patients who were considered unsuitable for endograft repair underwent open repair. Seven patients were classified as hemodynamically unstable (Endovascular, 5; Open, 2), and 21 were classified as stable (Endovascular, 13; Open, 8). The overall 30-day mortality rate associated with endovascular treatment was 27.8% (stable, 18.7%; unstable, 40%) and the rate associated with open repair was 50% (stable, 37.5%; unstable, 100%). CONCLUSIONS: In this study, the suitability of patients for endovascular repair of ruptured abdominal aortic aneurysms was high and the overall results of endovascular treatment remain encouraging. Indeed, bifurcated endografts are a feasible option for treating anatomically eligible ruptured abdominal aortic aneurysms. .

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Introducción: El aneurisma del seno de Valsalva es una dilatación que se origina por adelgazamiento de la unión de la capa media aórtica y el anillo fibroso; de origen adquirido y más frecuentemente congénito. El seno coronario derecho es el más afectado y la rotura es la complicación más común. Casos clínicos: Presentamos dos casos de aneurisma del seno de Valsalva roto a cavidades derechas con insuficiencia cardiaca severa, que constituyeron 0.4 % del total de cirugías cardiacas realizadas en un año en el Hospital de Especialidades, Centro Médico Nacional de Occidente, Guajalajara, Jalisco. Caso 1: hombre de 27 años con disnea de pequeños esfuerzos, disnea paroxística nocturna, ortopnea, fibrilación auricular paroxística, soplo diastólico, hepatomegalia y edema de miembros inferiores. Caso 2: hombre de 33 años con disnea de pequeños esfuerzos, disnea paroxística nocturna, ortopnea, soplo diastólico, insuficiencia renal aguda e insuficiencia hepática congestiva. La resolución quirúrgica consistió en resección del aneurisma y cierre del defecto con parche de dacrón, preservando la válvula aórtica. Ambos casos sobrevivieron. Conclusiones: La presencia de insuficiencia cardiaca y cambios auscultatorios súbitos obligan a sospechar aneurisma del seno de Valsalva roto. La ecocardiografía es suficiente para diagnosticar aneurisma del seno de Valsalva, sus complicaciones, repercusión y orientación quirúrgica. Cuando es asintomático existe riesgo de expansión, rotura, insuficiencia cardiaca, endocarditis, embolia y muerte súbita, lo que justifica la resolución quirúrgica, la cual tiene baja mortalidad a corto y largo plazo.

BACKGROUND: The sinus of Valsalva aneurysm (SVA) is a small dilatation caused by a separation between the aortic media and annulus fibrosus. Its origin may be either acquired or congenital. The right coronary sinus is most frequently affected, with the most common complication being rupture. CLINICAL CASES: We report two cases of SVA complicated with rupture to the right cavities with severe cardiac failure, which represents 0.4% of the total cardiac surgeries performed during the past year in our hospital. Case #1: We present the case of a 27-year-old male with low-effort dyspnea, nocturnal paroxysmal dyspnea, orthopnea, paroxysmal atrial fibrillation, diastolic murmur, hepatomegaly and edema of the lower extremities. Case #2: We present the case of a 33-year-old male with low-effort dyspnea, nocturnal paroxysmal dyspnea, orthopnea, diastolic murmur, severe kidney insufficiency and congestive hepatic insufficiency. Surgical resolution in both cases consisted of aneurysm resection and closure of the defect with a Dacron patch, preserving the aortic valve. Both patients survived. CONCLUSIONS: Cardiac failure and sudden auscultation changes suggest the possibility of SVA rupture. Echocardiography is sufficient to diagnose SVA, its complications, repercussions, and surgical options. SVA, even if asymptomatic, has potential risks of expansion, rupture, cardiac failure, endocarditis, embolism and sudden death. This justifies surgical correction, with a low mortality rate in both the short- and long-term.

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