Coagulation and fibrinolysis in patients undergoing operation for ruptured and nonruptured infrarenal abdominal aortic aneurysms.
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PURPOSE: Hemorrhage and thrombosis predisposing to myocardial infarction, multiple organ failure, and thromboembolism account for the majority of the morbidity and mortality associated with repair of ruptured and nonruptured abdominal aortic aneurysms (AAAs). The aim of this study was to examine coagulation and fibrinolysis in patients operated on for ruptured and nonruptured infrarenal AAAs. METHODS: Ten patients operated on for ruptured and 9 patients operated on for nonruptured AAAs were studied. Tissue plasminogen activator (t-PA) antigen, thrombin-antithrombin (TAT), and D-dimer were measured before induction of anesthesia. Plasminogen activator inhibitor (PAI) activity, t-PA activity, and prothrombin fragment (PF) 1+2 were measured before induction of anesthesia, immediately before aortic clamp release, and 5 minutes and 24 hours after aortic clamp release. RESULTS: Preoperatively, ruptured AAA was associated with significantly elevated t-PA antigen (median 15.7 ng/mL, range 9. 0 to 22.1 ng/mL versus nonrupture: median 6.6 ng/mL, range 4.7 to 16. 4 ng/mL; P <.01, Mann-Whitney test), increased PAI activity (median 36.5 arbitrary units/mL, range 20.6 to 38.8 arbitrary units/mL versus nonrupture: median 8.2 arbitrary units/mL, range 3.2 to 21.7 arbitrary units/mL; P <.001), reduced t-PA activity (median 0.12 IU/mL, range 0.06 to 0.4 IU/mL versus nonrupture: median 0.49 IU/mL, range 0.14 to 3.2 IU/mL; P <.01), elevated TAT (median 135.5 microg/L, range 61.2 to 209.4 microg/L versus nonrupture: median 21. 6 microg/L, range 6.6 to 180.4 microg/L; P <.02) and elevated PF 1+2 (median 9.0 nmol/L, range 5.4 to 11.6 nmol/L versus nonrupture: median 2.2 nmol/L, range 0.7 to 7.1 nmol/L, P <.001). There was no significant difference in preoperative D-dimer levels (median 3460 ng/mL, range 1236 to 7860 ng/mL versus nonrupture: median 1642 ng/mL, range 728 to 5334 ng/mL; P =.07). The differences in PAI activity, t-PA activity, and PF 1+2 persisted throughout the course of surgery, but there was no significant difference between the groups at 24 hours. CONCLUSION: These novel data demonstrate that ruptured AAA repair is associated with inhibition of systemic fibrinolysis and intense thrombin generation. Similar changes are seen in nonruptured AAA but are of a lesser magnitude. This procoagulant state may contribute to the microvascular and macrovascular thrombosis that leads to myocardial infarction, multiple organ failure, and thromboembolism. (+info)
Asymptomatic rupture of an aortoiliac aneurysm.
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The rupture of an abdominal aortic aneurysm is one of the most feared complications confronted by cardiovascular surgeons. Such ruptures are usually catastrophic, but in some instances the rupture is posterior and remains sealed. These chronic ruptures may manifest with any of a variety of clinical presentations. This report describes an uncommon presentation of a chronic rupture of an aortoiliac aneurysm in a patient with generalized aneurysmal disease. The rupture presented as an asymptomatic giant pulsatile mass in the patient's abdomen. The mass had developed over a period of several years. The literature is also reviewed. (+info)
Disseminated coccidioidomycosis complicated by vasculitis: a cause of fatal subarachnoid hemorrhage in two cases.
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We describe two cases of disseminated coccidioidomycosis that were complicated by fatal subarachnoid hemorrhage. In the first case, a left middle cerebral artery aneurysm and long-segment vasculitis occurred. In the second case, MR imaging revealed an enlarging coccidioidal granuloma at the tip of the basilar artery, and the artery subsequently ruptured. Fatal intracranial hemorrhage is a rare complication of disseminated coccidioidomycosis. (+info)
Analysis of slipstream flow in two ruptured intracranial cerebral aneurysms.
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Replicas of ruptured posterior communicating and basilar artery aneurysms were created from cadaveric specimens and then were placed in a circuit of pulsating non-Newtonian fluid. Individual fluid slipstreams were opacified with isobaric dyes, and images were recorded on film. The slipstreams entered the distal aneurysm neck with impact against the distal lateral wall of the aneurysm. They then swirled slowly in a reverse vortical pattern within the aneurysm sac. Fluid exited the aneurysm at the proximal neck. The flow pattern clearly shows the impact zone of entering slipstreams (the point of aneurysm rupture) and provides information pertaining to aneurysm growth and formation. (+info)
Acquired pial arteriovenous fistula following cerebral vein thrombosis.
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BACKGROUND: We report a unique case of an acquired pial arteriovenous fistula occurring after an asymptomatic thrombosis of a superficial cerebral vein. CASE DESCRIPTION: A cerebral angiogram performed in a 51-year-old man with subarachnoid hemorrhage revealed a 10-mm ruptured anterior communicating artery aneurysm and a thrombosed left superficial middle cerebral vein. Coil embolization of the anterior communicating aneurysm was performed. Follow-up angiography 18 months later revealed a new, asymptomatic, pial arteriovenous fistula between the previously thrombosed left superficial middle cerebral vein and a small sylvian branch of the left middle cerebral artery. CONCLUSIONS: This case provides evidence that pial arteriovenous fistulas may develop as acquired lesions and furthermore may rarely follow cerebral vein thrombosis. Several cases of dural arteriovenous fistulas, as well as a single case of a mixed pial-dural arteriovenous fistula, occurring after dural sinus thrombosis have been reported previously. However, to our knowledge, this is the first report of an acquired pial arteriovenous fistula following a cerebral vein thrombosis. (+info)
Flow dynamics in a lethal anterior communicating artery aneurysm.
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We describe and analyze the flow dynamics in replicas of a human anterior communicating artery aneurysm. The replicas were placed in a circuit of pulsating non-Newtonian fluid, and flows were adjusted to replicate human physiologic parameters. Individual slipstreams were opacified with isobaric dyes, and images were recorded on film and by CT/MR angiography. When flow in the afferent (internal carotid) and efferent (anterior and middle cerebral) arteries was bilaterally equal, slipstreams rarely entered the aneurysm. When flow in either the afferent or efferent vessels was not symmetrical, however, slipstreams entered the aneurysm neck, impinged upon the aneurysm dome, and swirled within the aneurysm. Unequal flow in carotid or cerebral systems may be necessary to direct pathologic, fluid slipstreams into an aneurysm. (+info)
Treatment of intradural paraclinoidal aneurysms.
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Intradural paraclinoidal aneurysm still presents conceptual confusion and technical surgical problems. The clinical features of 68 consecutive patients with paraclinoidal aneurysms were analyzed. The pterional approach was used in all patients. Subarachnoid hemorrhage (SAH) occurred in 37 patients from the paraclinoidal aneurysm and in 10 patients from another associated aneurysm. Thirty-four of the 37 ruptured paraclinoidal aneurysms were clipped, two blister-like aneurysms required trapping, and one blister-like aneurysm was coated. Thirteen of the 31 unruptured paraclinoidal aneurysms, consisting of 10 with ruptured associated aneurysm, four symptomatic, and 17 incidental, were clipped and 18 were coated. Favorable outcomes were obtained in 38 of 47 patients with SAH and 17 of 21 patients without SAH. Nine unfavorable outcomes in SAH patients were caused by primary brain damage (5), vasospasm (2), cerebral infarction after trapping (1), and pneumonia (1). All four unfavorable outcomes in non-SAH patients were due to surgical procedures for giant aneurysms or associated basilar artery aneurysm. Removal of the anterior clinoid process was performed to secure the proximal neck in 15 patients with large or giant aneurysms. Multiple clips with or without fenestrated clips were required in all giant aneurysms, and exposure of the cervical internal carotid artery (ICA) in 17 giant or large aneurysms. Fenestrated clips were also useful for one small aneurysm projecting posteriorly. A favorable outcome was achieved in 17 of 19 patients undergoing coating. Coating without clipping might be better for some blister-like ICA aneurysms, even if ruptured. Paraclinoidal aneurysms can be clipped with favorable results using these techniques except for giant aneurysms and associated basilar artery aneurysm. (+info)
Endovascular treatment of ruptured posterior circulation cerebral aneurysms. Clinical and angiographic outcomes.
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BACKGROUND AND PURPOSE: We sought to describe the clinical outcome and angiographic results obtained in the endovascular therapy of ruptured posterior circulation cerebral aneurysms using Guglielmi detachable coils (GDC) over a 7-year period. METHODS: A retrospective analysis was performed of 112 patients evaluated at the University of California at San Francisco Medical Center between June 1991 and August 1998. The Hunt-Hess grade at presentation of treated patients was I in 26 patients (24%), II in 24 (22%), III in 27 (25%), IV in 24 (22%), and V in 8 (7%). Clinical follow-up for the total population was achieved in 104 of 109 patients (96%), with a mean duration of 13.1 months. Angiographic follow-up for the subset excluding parent vessel occlusion cases was obtained in 93% of cases, with a mean duration of 7.2 months. RESULTS: Technical success, defined as the ability to catheterize and embolize the aneurysm with GDC, was achieved in 109 of 112 of cases (97%). The mean angiographic occlusion rate, or projected area of the aneurysm occluded by the coils, for all 110 successfully treated aneurysms was 94.6%. At latest clinical follow-up, 81 of 109 patients (74%) achieved good recovery with Glasgow Outcome Scale (GOS) score of I, 10 of 109 (9%) were moderately (GOS II) and 5 of 109 (5%) were severely (GOS III) disabled, 1 of 109 (1%) remained in a vegetative state (GOS IV), and 12 of 109 (11%) were dead. Of the subset of 77 patients with Hunt-Hess grades I to III, 68 (88%) achieved a good clinical outcome (GOS I). A statistically significant correlation was demonstrated between Hunt-Hess grade at presentation and final GOS outcome score (chi(2)=41.4, P<0.0005). Procedure-related permanent morbidity was 2.8% (3/109 patients). Repeated hemorrhage was observed in a single patient (0.9%) with a partially treated aneurysm. CONCLUSIONS: The observed favorable outcome and low morbidity in this group of high-risk patients point to GDC embolization as an effective method for the endovascular management of patients with ruptured posterior circulation aneurysms. (+info)