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Carotid Artery Disease and Cognitive Functional Decline

Introduction A decline in cognitive function from ischemic, hypoperfused or hemorrhagic brain lesions has been termed “vascular cognitive impairment” (VCI). While memory dysfunction is an important correlate of classic dementias, VCI is generally associated with dysfunction in executive function and processing speed. Cognitive dysfunction after stroke is a well-recognized disability. This awareness has stimulated extensive research that has established standards of diagnosis, reporting, prevention and management…

Cerebrovascular Disease: The Unstable Carotid Plaque

Introduction Carotid artery disease is highly prevalent, with approximately 12.5% of men and 6.9% of women over the age of 70 years in the United States having asymptomatic carotid disease. The association between atherosclerotic disease of the carotid artery and ischemic stroke is well-documented. Carotid disease accounts for approximately 8%–37% of all strokes , (see Ch. 88 , Cerebrovascular Disease: Epidemiology and Natural History). Early randomized…

Cerebrovascular Disease: Epidemiology and Natural History

Background Until fairly recently, stroke was largely believed to be a result solely of intracranial pathology. William Osler attributed stroke mainly to intracranial hemorrhage or vasospasm and made no mention of carotid or vertebral artery occlusive disease. Yet the relationship between extracranial carotid disease and stroke had been surmised previously as early as 1875, when Gowers reported on a patient with carotid occlusion, left visual loss,…

Visceral Artery Aneurysms

Even though visceral artery aneurysms represent a rare pathology, they have important significance because of their potentially lethal clinical course. These lesions were described more than 200 years ago, and initial case reports consisted mostly of emergent interventions for rupture. Diagnosis in these cases was often made postmortem. The first reported successful operative repair was performed by Kehr in 1903; it consisted of ligation of a…

Upper Extremity Aneurysms

Upper extremity aneurysms are uncommon relative to other peripheral arterial aneurysms. Arch vessel aneurysms, the most frequent type of upper extremity aneurysm, can lead to life-threatening exsanguination as a result of rupture, as well as numerous other complications, including stroke, local nerve compression (leading to hoarseness or brachial plexus palsy), dysphagia from esophageal compression in cases of an aberrant right subclavian artery (ARSA) aneurysm, localized pain,…

Lower Extremity Aneurysms

Aneurysms occurring in the arteries of the lower extremity are second in frequency only to aneurysms of the infrarenal aorta and iliac arteries. Historically, lower extremity aneurysms were typically mycotic, syphilitic, or traumatic in origin. However, most aneurysms in the femoral, popliteal, and tibial arteries are currently either degenerative aneurysms or posttraumatic pseudoaneurysms related to catheterization or instrumentation. True aneurysms occur far more commonly in men…

Penetrating Aortic Ulcers

Introduction The presence of a penetrating aortic ulcer (PAU) often indicates a severely diseased aorta. Although first described as an incidental component of dissecting aneurysms in 1934, PAU was not clearly defined as an aortic pathology until 1986 and is now considered a subset of the acute aortic syndrome (AAS). , AAS entails three distinct, albeit related, pathologies – acute aortic dissection (AD), intramural hematoma (IMH),…

Aortic Dissection: Epidemiology, Pathophysiology, Clinical Presentation, and Medical and Surgical Management

Introduction Acute aortic dissection is the most common catastrophic event affecting the aorta, with an incidence exceeding that of ruptured abdominal aortic aneurysm. Without treatment, the majority of patients with aortic dissections will die within 3 months of presentation, and few survive the chronic phase more than 5 years due to aneurysmal degeneration and rupture of the outer wall of the false lumen. , Despite improvements…

Fenestrated and Branched Endograft Treatment of Juxtarenal, Paravisceral, Thoracoabdominal, and Aortic Arch Aneurysms: Device Selection and Technical Considerations

History of Fenestrated and Branched Endovascular Aortic Aneurysm Repair Fenestrated and branched endovascular aortic aneurysm repair (FBEVAR) uses endovascular aortic devices altered to preserve flow to the renal, visceral, or brachiocephalic vessels while excluding aortic pathology in the region of these vessels. The first description of this technique involved the treatment of short-neck infrarenal abdominal aortic aneurysms (AAAs) using fenestration for the renal arteries to extend…

Aortic Stent Graft and Endovascular Treatment of Thoracoabdominal and Aortic Arch Aneurysms: Strategies for Operative Repair

Most thoracic aortic aneurysms arise from medial degeneration or from chronic aortic dissection. The overall incidence of thoracic aortic aneurysms (TAA) is approximately 10.4 per 100,000 person-years with a significant increase with advancing age. In contrast to abdominal aortic aneurysms (AAA) which predominantly affect men, TAAs arise equally in women. Fortunately, aneurysms that involve the aortic arch (15%) or thoracoabdominal aorta (10%) are relatively uncommon compared…

Thoracic Aortic Aneurysms: Endovascular Treatment

Since the US Food and Drug Administration (FDA) approved the first thoracic endovascular aortic endograft repair (TEVAR) in 2005, its use has rapidly increased. , In a relatively short period of time, TEVAR for descending thoracic aortic aneurysms (DTAA) and various other thoracic aortic pathology has not only become the preferred treatment method but also the standard of care. Recently, the Society for Vascular Surgery (SVS)…

Thoracic and Thoracoabdominal Aneurysms: Open Surgical Treatment

Introduction The surgical repair of descending thoracic (DTAA) and especially thoracoabdominal aortic aneurysms (TAAA) remains one of the major challenges in vascular surgery because of the technical demands of the surgery, which may require reattaching brachiocephalic, visceral, renal and intercostal arteries to a synthetic graft or aortic homograft, as well as the physiologic stress of the surgery and the risks of stroke, renal failure, and cardiac…

Thoracic and Thoracoabdominal Aortic Aneurysms: Etiology, Epidemiology, Natural History, Medical Management, and Decision Making

Introduction Aortic diseases, including aortic aneurysms, are the 17th leading cause of death in the United States. Descending thoracic aortic aneurysms (TAAs) and thoracoabdominal aortic aneurysms (TAAAs) occur with an estimated incidence of 5.9 cases per 100,000 person-years. A study by Clouse and others suggests that the incidence is increasing. During the last 20 years, the mortality for nonruptured and ruptured TAAs and TAAAs in the…

Isolated Iliac Artery Aneurysms and their Management

Introduction Iliac artery aneurysms (IAAs) commonly occur concurrently with more proximal arterial aneurysms. Isolated iliac aneurysms occur with an incidence of 0.4% to 1.9% in the general population. , Aneurysmal degeneration typically involves the common iliac artery (CIA, 70%–90%) and internal iliac artery (IIA, 10%–30%), or both of these segments contiguously; external iliac artery (EIA) involvement is extremely rare. , Bilateral common IAAs are present in…

Ruptured Aortoiliac Aneurysms and their Management

Introduction Rupture of an abdominal aortic aneurysm (RAAA) conveys a mortality risk 5- to 10-fold higher vs. elective repair. A major decline in RAAA incidence is now evident in both North America and Europe ( Fig. 76.1 ). , Despite improvements in perioperative management, service centralization, open RAAA survival rates have only marginally improved. However, ruptured endovascular repair (REVAR) has been associated with improved outcomes, with…

Aortoiliac Aneurysms: Endovascular Treatment

The first stent-based endoprosthesis with aortoiliac fixation was used in a human in May of 1985 to treat iliac artery stenosis. This technology was then used to treat aneurysmal disease in March of 1987, when a stent graft was delivered through the femoral artery to treat a post-traumatic pseudoaneurysm in the thoracic aorta. Four years later in 1991, Juan Parodi published his experience with deployment of…

Endovascular Aneurysm Repair Techniques

Introduction Current commercially available systems have a wide variety of configurations that are capable of treating the majority of infrarenal aortoiliac aneurysms. Various options exist for stent-graft fixation, sealing, patency, sizing, and durable exclusion of aortic aneurysms. Radiopacity, deployment precision, ease of use, and sheath size and flexibility are additionally important characteristics. Current commercially available infrarenal endografts and their respective US Food and Drug Administration (FDA)…

Abdominal Aortic Aneurysms: Open Surgical Treatment

Introduction Abdominal aortic aneurysm (AAA) is a common disorder with an estimated incidence of 4%–7% in western countries. It the 13th-leading cause of death in the United States, with 15,000 deaths yearly. Ruptured AAA (RAAA) continues to carry an operative mortality of 40%–70% and overall mortality of 80%–90%, which have not improved much over the past four decades despite major advances in surgical care and the…

Aortoiliac Aneurysms: Evaluation, Decision Making, and Medical Management

Introduction Ancient Egyptians were the first to recognize aortic aneurysms as early as 1550 bce, and Antyllus was the first to attempt treatment of aneurysms through ligation of the vessels, but this was met with poor results. , Through time our understanding of the anatomy, and pathophysiology of abdominal aortic aneurysms (AAA) has progressed and great advances have been made in the management of this complex…

Arterial Aneurysms: Etiology, Epidemiology, and Natural History

Introduction The term aneurysm describes dilatation of any blood vessel. Arterial aneurysms occur throughout the body but are most prevalent in the infrarenal aorta (AAA). These aneurysms represent the primary cause of the death and disability attributed to arterial aneurysms. In the United States, AAAs were directly responsible for 9928 deaths in 2017 and roughly 120,000 procedures are performed annually to prevent ruptured AAAs. , The…