Search Results (222)

Background/Objectives: Posterior inferior cerebellar artery (PICA) aneurysms are one of the most difficult cerebrovascular lesions to treat and account for 0.5–3% of all intracranial aneurysms. They have deep anatomical locations, broad-neck configurations, high perforator density, and a close association with the brainstem, which creates considerable technical challenges for either microsurgical or endovascular treatment. Despite its acceptance as the standard of care for most posterior circulation aneurysms, PICA aneurysms are often associated with flow diversion using a coil or flow diversion due to incomplete occlusions, parent vessel compromise and high rate of recurrence. This case aims to describe the utility of microsurgical clipping as a durable and definitive option demonstrating the value of tailored surgical planning, preservation of anatomy and ancillary technologies for protecting a genuine outcome in ruptured PICA aneurysms. Methods: A 66-year-old male was evaluated for an acute subarachnoid hemorrhage from a ruptured and broad-necked fusiform left PICA aneurysm at the vertebra–PICA junction. Endovascular therapy was not an option due to morphology and the center of the recurrence; therefore, a microsurgical approach was essential. A far-lateral craniotomy with a partial C1 laminectomy was carried out for proximal vascular control, with careful dissection of the perforating arteries and precise clip application for the complete exclusion of the aneurysm whilst preserving distal PICA flow. Results: Post-operative imaging demonstrated the complete obliteration of the aneurysm with unchanged cerebrovascular flow dynamics. The patient had progressive neurological recovery with no new cranial nerve deficits or ischemic complications. Long-term follow-up demonstrated stable aneurysm exclusion and full functional independence emphasizing the sustainability of microsurgical intervention in challenging PICA aneurysms. Conclusions: This case intends to highlight the current and evolving role of microsurgical practice for treating posterior circulation aneurysms, particularly at a time when endovascular alternatives are limited by anatomy and hemodynamics. Advances in artificial intelligence cerebral aneurysm rupture prediction, high-resolution vessel wall imaging, robotic-assisted microsurgery and new generation flow-modifying implants have the potential to revolutionize treatment paradigms by embedding precision medicine principles into aneurysm management. While the discipline of cerebrovascular surgery is expanding, it can be combined together with microsurgery, endovascular technologies and computational knowledge to ensure individualized, durable, and minimally invasive treatment options for high-risk PICA aneurysms. Full article

Modeling and simulation of aneurysm formation, growth, and rupture plays an essential role in a wide spectrum of application scenarios, ranging from risk stratification to stability prediction, and from clinical decision-making to treatment innovation. Unfortunately, it remains a non-trivial task due to the difficulties imposed by the complex and under-researched pathophysiological mechanisms behind the different development stages of various aneurysms. In this paper, we present a novel computational method for aneurysm simulation using smoothed particle hydrodynamics (SPH). Firstly, we consider blood in a vessel as a kind of incompressible fluid and model its flow dynamics using the SPH method; and then, to simulate aneurysm growth and rupture, the relationship between the aneurysm development and the properties of fluid particles is established by solving the motion control equation. In view of the prevalence of aneurysms in bifurcation vessels, we further enhance the capability of the model by introducing a solution for bifurcation aneurysms simulation according to Murray’s law. In addition, a CUDA parallel computing scheme is also designed to speed up the simulation process. To evaluate the performance of the proposed method, we conduct extensive experiments with different physical parameters associated with morphological characteristics of an aneurysm. The experimental results demonstrate the effectiveness and efficiency of proposed method in modeling and simulating aneurysm formation, growth, and rupture. Full article

Background: Cerebral aneurysm (CA) is a focal or diffuse pathological dilation of the cerebral arterial wall that arises due to various etiological factors. It represents a serious vascular condition, particularly affecting the elderly, and carries a high risk of rupture and neurological morbidity. Clonidine (CL), an α2-adrenergic receptor agonist, has been reported to suppress aneurysm progression; however, its underlying molecular mechanisms, especially in relation to cerebral endothelial dysfunction, remain unclear. This study aimed to investigate the potential of CL to mitigate CA development by modulating apoptosis, inflammation, and oxidative stress in an Angiotensin II (Ang II)-induced endothelial injury model. Methods: Human brain microvascular endothelial cells (HBMECs) were used to establish an in vitro model of endothelial dysfunction by treating cells with 1 µM Ang II for 48 h. CL was administered 2 h prior to Ang II exposure at concentrations of 0.1, 1, and 10 µM. Cell viability was assessed using the MTT assay. Oxidative stress markers, including reactive oxygen species (ROS) and Nitric Oxide (NO), were measured using 2′,7′–dichlorofluorescin diacetate (DCFDA). Gene expression levels of vascular endothelial growth factor (VEGF), matrix metalloproteinases (MMP-2 and MMP-9), high mobility group box 1 (HMGB1), and nuclear factor kappa B (NF-κB) were quantified using RT-qPCR. Levels of proinflammatory cytokines; tumor necrosis factor-alpha (TNF-α), Interleukin-6 (IL-6), and interferon-gamma (IFN-γ); were measured using commercial ELISA kits. Results: Ang II significantly increased ROS production and reduced NO levels, accompanied by heightened proinflammatory cytokine release and endothelial dysfunction. MTT assay revealed a marked decrease in cell viability following Ang II treatment (34.18%), whereas CL preserved cell viability in a concentration-dependent manner: 44.24% at 0.1 µM, 66.56% at 1 µM, and 81.74% at 10 µM. CL treatment also significantly attenuated ROS generation and inflammatory cytokine levels (p < 0.05). Furthermore, the expression of VEGF, HMGB1, NF-κB, MMP-2, and MMP-9 was significantly downregulated in response to CL. Conclusions: CL exerts a protective effect on endothelial cells by reducing oxidative stress and suppressing proinflammatory signaling pathways in Ang II-induced injury. These results support the potential of CL to mitigate endothelial injury in vitro, though further in vivo studies are required to confirm its translational relevance. Full article

Background/Objectives: There are no reports about the nationwide trends in abdominal aortic aneurysm (AAA) repair and mortality rates. This study aims to evaluate the trend in AAA treatment and related mortality, including ruptured AAAs (rAAAs) and intact AAAs (iAAAs) over the last 13 years. Methods: This serial, cross-sectional study investigated the time trends in patients who were treated for an AAA and underwent an aneurysm repair between 2010 and 2022. Data from the Health Insurance Review and Assessment Service (HIRA) and Statistics Korea were used. A linear-by-linear association and Poisson regression analysis were performed to determine the changes in the treatment of AAAs and related mortality. Results: The number of patients with an rAAA increased from 462 in 2010 to 770 in 2022 (relative risk, RR 1.57; p < 0.0001). The number of patients with an iAAA increased from 3685 to 12,399 in the same period (RR 3.16; p < 0.0001). Endovascular aneurysm repair (EVAR) has been more commonly performed since 2011. During the study period, EVAR increased from 406 to 1161 (RR 2.68; p < 0.0001). Although the annual mortality rates after iAAA treatment decreased from 1.4% to 0.7% (mean mortality rate, 1.1%), the mortality rates after rAAA treatment were similar, ranging from 34.6% to 34.2%, during the study period (mean mortality rate, 35.2%). Conclusions: During the last 13 years, the annual number of patients with rAAAs and iAAAs has increased. Since 2011, EVAR has been more commonly performed. The annual iAAA-related mortality rate decreased along with the increasing trend in EVAR. However, the annual rAAA-related mortality rate did not change. Full article

Background and Objectives: Visceral arterial pseudoaneurysms (VAPAs) are rare vascular lesions characterized by the disruption of partial disruption of the arterial wall, most commonly involving the intima and media. They have an estimated incidence of 0.1–0.2%, with the splenic artery most commonly affected. Their management poses unique challenges due to the high risk of rupture. Timely recognition is crucial, as unmanaged pseudoaneurysms have a mortality rate of 90%. This narrative review aims to synthesize current knowledge regarding the epidemiology, etiology, clinical presentation, diagnostic methods, and management strategies for VAPAs. Materials and Methods: A literature search was performed across Pubmed for articles reporting on VAPAs, including case reports, review articles, and cohort studies, with inclusion of manuscripts that were up to (date). VAPAs are grouped by embryological origin—foregut, midgut, and hindgut. Results: Chronic pancreatitis is a primary cause of VAPAs, with the splenic artery being involved in 60–65% of cases. Other causes include acute pancreatitis, as well as iatrogenic trauma from surgeries, trauma, infections, drug use, and vascular diseases. VAPAs often present as abdominal pain upon rupture, with symptoms like nausea, vomiting, and gastrointestinal hemorrhage. Unruptured pseudoaneurysms may manifest as pulsatile masses or bruits but are frequently asymptomatic and discovered incidentally. Diagnosis relies on both non-invasive imaging techniques, such as CT angiography and Doppler ultrasound, and invasive methods like digital subtraction angiography, which remains the gold standard for detailed evaluation and treatment. A range of management options exists that are tailored to individual cases based on the aneurysm’s characteristics and patient-specific factors. This encompasses both surgical and endovascular approaches, with a growing preference for minimally invasive techniques due to lower associated morbidity. Conclusions: VAPAs are a critical condition requiring prompt early recognition and intervention. This review highlights the need for ongoing research to improve diagnostic accuracy and refine treatment protocols, enhancing patient outcomes in this challenging domain of vascular surgery. Full article

Introduction: Primary extracranial vertebral artery aneurysms are sporadic in the general population. They are uncommon in individuals with neurofibromatosis type 1. During pregnancy or in the puerperium, the risk of aneurysm rupture in individuals with neurofibromatosis type 1 and extracranial aneurysms is elevated. Rupture of a vertebral artery aneurysm is an emergency condition and can be fatal. Case presentation: We present the case of a 33-year-old woman in the puerperium with neurofibromatosis type 1 who had a vertebral symptomatic artery aneurysm. During a previous hospitalization, two months before the treatment of the vertebral aneurysm, a same-sided aneurysm of the thyrocervical trunk was successfully treated with endovascular coiling because of aneurysm rupture. In this case report, the vertebral artery aneurysm was successfully managed using a flow diverter stent graft. Conclusions: This is the first reported case of a successfully treated symptomatic vertebral artery aneurysm with a flow diverter stent graft in a patient with neurofibromatosis type 1 during the early puerperium. Endovascular treatment with a stent graft is a minimally invasive, safe, and effective treatment for patients with vertebral artery aneurysms. Early diagnosis of non-ruptured vertebral artery aneurysms is a crucial as well as appropriate treatment, which should be undertaken in a timely manner to prevent serious complications or a fatal outcome. Full article

Background: The coexistence of extracranial arterial stenoses and intracranial aneurysms presents a unique clinical dilemma. While staged interventions are traditionally preferred to reduce procedural risks, recent advances have enabled single-stage endovascular treatment. This study evaluates the clinical outcomes, procedural strategies, and predictive factors associated with such combined interventions. Methods: This retrospective study included 47 patients treated with single-stage endovascular procedures for concurrent extracranial stenosis and intracranial aneurysm between 2016 and 2024. Clinical, angiographic, and procedural data were collected. Outcomes were assessed using the mmodified Rankin Scale (mRS), and statistical analyses were performed to identify associations between clinical variables and functional outcomes. Results: Of the 47 patients, 85.1% achieved favorable outcomes (mRS 0–2) at ≥6-month follow-up. The most commonly treated arteries were the internal carotid artery (70.2%) and the middle cerebral artery (34%). Stent-assisted coiling or flow diversion was performed in 93.6% of aneurysm cases, while 91.5% underwent carotid or vertebral stenting. Lesion laterality (left-sided aneurysms, p = 0.019) and stenosis length (p = 0.0469) were significantly associated with outcomes. Smoking was linked to multiple stenoses (p = 0.0191). Two patients experienced major complications: one aneurysmal rebleed after stenting, and one intraoperative rupture. Conclusions: Single-stage endovascular treatment for patients with concurrent extracranial stenosis and intracranial aneurysm is technically feasible and clinically effective in selected cases. Lesion configuration, anatomical considerations, and individualized planning are critical in optimizing outcomes. Full article

Aortic aneurysm is a vascular disease with a complex pathogenesis which is usually asymptomatic but can lead to high mortality with sudden rupture. This review comprehensively examines the molecular mechanisms of aortic aneurysms in the context of extracellular matrix destruction, smooth muscle cell apoptosis, chronic inflammation, oxidative stress, genetic mutations, and epigenetic regulations. In addition, the potential of molecular biomarkers in diagnosis and prognosis and targeted treatment strategies are evaluated. Animal models and translational findings form the basis for establishing a bridge between preclinical and clinical applications. This study aims to provide insight into the integration of molecular findings into clinical practice in light of the current literature and to guide future research. Full article

Background/Objectives: Physician-modified endografts (PMEGs) have emerged as a treatment option for complex aortic pathologies. Uncertainty remains regarding the modification techniques and the most suitable materials for customization of fenestrated endografts. The aim of this study was to evaluate CE-marked endovascular aortic repair (EVAR) devices and suitable materials for device modification in PMEGs for juxtarenal and pararenal aortic pathologies. Methods: This single-center observational study included patients treated with the physician-modified TREO (Terumo Aortic, Inchinnan, UK) device between April and December 2024. All patients had aortic ruptures or symptomatic aneurysms and unfavorable anatomy or severe comorbidities, making standard EVAR and open repair unsuitable. Procedural data were recorded and analyzed, including in-hospital outcomes. The “wire visibility” and “sheath–wire contrast” of endografts were assessed under fluoroscopy, and different resheathing techniques were compared. Results: Technical success was achieved in all five patients. The number of fenestrations per patient was 2.6 (range: 1–4). In one patient (1/5), type Ib and type IIIc endoleaks were observed postoperatively, requiring reintervention. No in-hospital mortality occurred. The ICU and hospital stay were 24 h (range: 18–40 h) and 8 days (range: 6–20 days), respectively. Moreover, the One SNARE wire was identified as the wire with the highest “wire visibility”, and Endurant II showed the best “sheath–wire contrast”. Resheathing with the dedicated crimping device was superior to the tape-assisted method. Conclusions: The TREO platform, in synergy with suitable additional materials, offers a viable solution for urgent aortic pathologies requiring PMEGs. Continued refinement of materials and procedural standardization could enhance the long-term outcome. Full article

The natural history of focal non-infected lesions of the abdominal aorta (fl-AA) remains unclear and largely depends on their aetiology. These lesions often involve a focal “tear” or partial disruption of the arterial wall. Penetrating aortic ulcers (PAUs) and intramural hematomas (IMHs) are examples of focal tears in the aortic wall that can either progress to dilatation (saccular aneurysm) or fail to fully propagate through the medial layers, potentially leading to aortic dissection. These conditions typically exhibit a morphology consistent with eccentric saccular aneurysms. The management of focal non-infected pathologies of the abdominal aorta remains a subject of debate. Unlike fusiform abdominal aortic aneurysms, the inconsistent definitions and limited information regarding the natural history of saccular aneurysms (sa-AAAs) have prevented the establishment of universally accepted practice guidelines for their management. As emphasized in the latest 2024 ESVS guidelines, the focal nature of these diseases makes them ideal candidates for endovascular repair (class of evidence IIa—level C). Moreover, the Society for Vascular Surgery just referred to aneurysm diameter as an indication for treatment suggesting using a smaller diameter compared to fusiform aneurysms. Consequently, the management of saccular aneurysms is likely heterogeneous amongst different centres and different operators. Endovascular repair using tube stent grafts offers benefits like reduced recovery times but carries risks of migration and endoleak due to graft rigidity. These complications can influence long-term success. In this context, the use of endovascular bifurcated grafts may provide a more effective solution for treating these focal aortic pathologies. It is essential to achieve optimal sealing regions through anatomical studies of aortic morphology. Additionally, understanding the anatomical characteristics of focal lesions in challenging necks or para-visceral locations is indeed crucial in device choice. Off-the-shelf devices are favoured for their time and cost efficiency, but new endovascular technologies like fenestrated endovascular aneurysm repair (FEVAR) and custom-made devices enhance treatment success and patient safety. These innovations provide stent grafts in various lengths and diameters, accommodating different aortic anatomies and reducing the risk of type III endoleaks. Although complicated PAUs and focal saccular aneurysms rarely arise in the para-visceral aorta, the consequences of rupture in this segment might be extremely severe. Experience borrowed from complex abdominal and thoracoabdominal aneurysm repair demonstrates that fenestrated and branched devices can be deployed safely when anatomical criteria are respected. Elective patients derive the greatest benefit from a fenestrated graft, while urgent cases can be treated confidently with off-the-shelf multibranch systems, reserving other types of repairs for emergent or bail-out cases. While early outcomes of these interventions are promising, it is crucial to acknowledge that limited aortic coverage can still impede effective symptom relief and lead to complications such as aneurysm expansion or rupture. Therefore, further long-term studies are essential to consolidate the technical results and evaluate the durability of various graft options. Full article

Background/Objectives: Subarachnoid hemorrhage (SAH) due to ruptured intracranial aneurysms remains a critical neurosurgical emergency with high morbidity and mortality. The presence of multiple intracranial aneurysms (MIAs) in SAH patients presents a therapeutic challenge, particularly in choosing between single-stage and multiple-stage interventions. In patients with aneurysmal SAH and multiple intracranial aneurysms, we compared single-stage vs. multiple-stage interventions regarding vasospasm occurrence, complication rates, and short-term neurological outcomes in a retrospective cohort. Methods: This retrospective cohort study included 44 patients diagnosed with aneurysmal SAH and at least one additional unruptured aneurysm. Patients were categorized based on the intervention strategy. A “single-stage” intervention was defined as treatment of both the ruptured and all unruptured aneurysms in the same operative session. A “multiple-stage” intervention referred to a planned approach in which additional aneurysms were treated in separate, subsequent procedures. Clinical severity was assessed using scores. Aneurysm characteristics and treatment modalities were recorded. Outcomes were analyzed and compared between intervention groups. Statistical analysis was performed, with p < 0.05 considered significant. Results: The cohort included 44 patients with a total of 109 aneurysms. Most patients were female (68.2%), with a mean age of 54.5 years. The majority of aneurysms were small- to medium-sized and commonly located in the anterior circulation. Among the patients, 19.0% underwent single-stage interventions, and 28.6% underwent multiple-stage procedures. Vasospasm occurred significantly more often in the single-stage group (83.9% vs. 46.2%, p = 0.028). No significant difference was found in hospital stay duration between groups. The MRS scores showed a trend toward worse outcomes in the single-stage group (p = 0.060), as did the rates of post-operative neurological deficits (p = 0.079). Conclusions: In patients with SAH and MIAs, single-stage interventions may increase vasospasm risk. Although they offer logistical benefits, outcomes should be interpreted with caution given baseline differences and limited statistical adjustment. Full article

Abdominal aortic aneurysm (AAA) is the most common aortic disease occurring below the renal arteries, caused by multiple etiologies. Currently, no effective drug treatment exists, and the specific pathogenesis remains unclear. Due to its insidious onset and diagnostic challenges, AAA often culminates in aortic rupture, which has a high mortality rate. During AAA development, vascular smooth muscle cells (VSMCs) undergo significant pathological alterations, including contractile dysfunction, phenotypic modulation, cellular degradation, and heightened inflammatory and oxidative stress responses. In particular, emerging evidence implicates vascular smooth muscle cell (VSMC) metabolic dysregulation and mitochondrial dysfunction as key contributors to AAA progression. In this review, we systematically summarize the current understanding of VSMC biology, including their developmental origins, structural characteristics, and functional roles in aortic wall homeostasis, along with the regulatory networks governing the VSMC phenotype and functional maintenance. This review highlights the urgent need for further investigation into the aortic wall VSMC pathophysiology to identify novel therapeutic targets for AAA. These insights may pave the way for innovative treatment strategies in aortic disease management. Full article

Background/Objectives: The establishment of the first tertiary Neurointerventional Center at the University Hospital of Martinique in 2021, with full coverage of the populations of the French Antilles and Guyana, represents a paradigm shift in the treatment of intracranial aneurysms in the eastern Caribbean. We sought to evaluate the outcomes of the first cohort of patients treated for intracranial aneurysms from 2021 to 2024. Methods: We analyzed demographic, clinical, and angiographic data from a prospectively maintained database of patients treated from 1 January 2021 to 31 March 2024. The primary endpoint was the clinical outcome (mRS at discharge and at 4–6 months), and the secondary endpoint was the angiographic outcomes. Results: One hundred patients (mean age 56.7 ± 12.2 years old) with a total of 125 aneurysms (60.8% ruptured; 39.2% unruptured) were included from the following regions: 60% from Martinique, 21% from Guadeloupe, 13% from French Guyana, 1% from mainland France, 2% from St Martin, and 3% from abroad. The mean initial GCS value was 11.6 (median: 13; min: 4; max: 15); the mean mRS was 1.8 ± 1.7 before intervention, 1.8 ± 2 at discharge, and 1.7 ± 2 at 4–6 months. A total of 75% of the aneurysms were treated with coiling or remodeling, 23% received stents (20% FDs), and 0.8% were treated surgically. The procedure-related morbidity rate was 5.6% (7/125), and the mortality rate was 10.4%; both these percentages concerned only the ruptured cases. In the ruptured aneurysm subgroup, 32.8% (25/76) of complications were SAH-related, 9.2% (7/76) were hydrocephalus incidences, and 23.6% (18/76) were vasospasm cases. Satisfactory occlusion was obtained for 95.2% of the aneurysms post-procedure and for 96.7% at the last angiographic control. At the six-month control, 68% of the patients were independent in their everyday lives (mRS ≤ 2). Conclusions: The population was distinct in terms of the hyperexpression of risk factors, the multiplicity of IAs, and the severity of SAH. Female predominance was higher than usual in the population (81%). The organizational schema seemed effective; the treatments were safe and effective in terms of the clinical and angiographic outcomes. Full article

Late ruptures of abdominal aortic aneurysms post-endovascular aneurysm repair present a significant risk, occurring in about 0.9% of cases. The typical timeframe leading to rupture is roughly 37 months, with the primary factors often linked to endoleaks, especially types I and III, which sustain pressure within the aneurysm sac. The approaches to managing late ruptures consist of endovascular approaches, open surgical interventions, and conservative care, each customised to the patient’s specific characteristics. When feasible endovascular repair is favoured, additional stent grafts are deployed to seal endoleaks and offer lower perioperative mortality rates compared to those for open surgery. Open repair is considered when endovascular solutions fail or are not feasible. Conservative management with active monitoring and supportive treatment can be considered for haemodynamically stable non-surgical patients. Endovascular repair methods like fenestrated/branched EVAR (F/BEVAR) and parallel grafting (PGEVAR) are effective for complicated anatomies and show high technical success with reduced morbidity compared to that with open repairs. Chimney techniques and physician-modified endografts may help regain and broaden the sealing zone. Limb extensions with or without embolisation, interposition endografting, and whole-body relining are helpful options for type IB and type 3–5 endoleaks. Open surgical repair carries a higher perioperative mortality but may be essential in preventing death due to rupture following failed EVAR. The choice depends on the patient’s clinical stability and fitness for surgery in the absence of a viable endovascular alternative. This article discusses the available options for treating late rupture after EVAR, emphasising the importance of individualised treatment plans and the need for rigorous postoperative surveillance to prevent such complications. Full article

Background/Objectives: Non-saccular aneurysms are a rare subtype of intracranial aneurysms with complex morphologies. Although treatment strategies for ruptured non-saccular and saccular aneurysms differ significantly, large-scale comparisons of the outcomes between the two types remain limited. We aimed to compare the clinical characteristics, procedure-related complications, and functional outcomes between patients with subarachnoid hemorrhage (SAH) caused by non-saccular or saccular aneurysms. Methods: We retrospectively analyzed 1176 consecutive patients with aneurysmal SAH from a population-based stroke registry in Kochi Prefecture, Japan. Aneurysms were classified as saccular or non-saccular based on the morphology, and clinical variables, radiological features, and treatment modalities were compared. Additionally, 840 patients who underwent intervention for their aneurysms within 3 days of onset were further investigated to evaluate the impact of the non-saccular aneurysm shape on poor functional outcomes, defined as a modified Rankin Scale score ≥ 3 at discharge. Results: Non-saccular aneurysms were more common in younger patients and located in the posterior circulation. Procedure-related ischemic complications were more likely to occur in non-saccular aneurysms than in saccular aneurysms (odds ratio [OR]: 2.57, 95% confidence interval [CI]: 1.56–4.97, p < 0.001). In a multivariable logistic regression analysis, a non-saccular morphology was an independent risk factor of poor outcomes (OR: 2.92, 95% CI: 1.34–6.32, p = 0.007) after adjustment for potential confounders. Interaction and subgroup analyses revealed that the negative effects of non-saccular aneurysms on functional outcomes were more prominent in younger patients aged ≤ 60 years. Conclusions: Non-saccular aneurysms are independently associated with ischemic complications and poor outcomes after SAH, particularly in younger patients. Full article