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Endovascular Treatment of Nonruptured Infrarenal Aortic and Aortoiliac Aneurysms

Endovascular aneurysm repair (EVAR) has become established as the first-line approach to treating abdominal aortic aneurysms (AAAs). Conceptually, the idea of using vascular endoprosthesis to exclude aneurysms dates back to the late 1960s with animal experimentation. The landmark first deployment of an aortic stent to exclude a human AAA was reported by Parodi and colleagues in 1991. Initially, straight grafts were used, with polyester tubes being…

Management of Small Abdominal Aortic Aneurysms

The introduction and propagation of screening programs for abdominal aortic aneurysm and the more frequent application of cross-sectional imaging has resulted in an increased detection of small-diameter abdominal aortic aneurysms (AAAs). Consequently, the management of these small aneurysms is becoming increasingly relevant in contemporary clinical practice. Recent large screening studies and randomized clinical trials of management of small AAA have improved our knowledge of this topic…

Selection of Patients with Aortic Aneurysms for Open Surgical or Endovascular Repair

An abdominal aortic aneurysm (AAA) is lethal; if associated with rupture, it carries an 85% risk of death. In patients with AAA, early diagnosis and prophylactic surgical intervention are essential to prevent rupture. Open AAA repair was originally pioneered in the 1950s, and surgical techniques have continuously improved since then. Endovascular aneurysm repair (EVAR) was pioneered in the 1990s and also has evolved significantly since then.…

Computed Tomography and Computed Tomographic Arteriography in the Evaluation of Abdominal Aortic Aneurysms

Computed tomography (CT) is an extremely powerful tool often used in evaluating a patient with aortic disease. However, a CT scan cannot simply be ordered with the expectation that an adequate and informative study will appear at the fingertips of the clinician. Imaging studies are best done in the context of the clinical need and mandate that the clinician understands the fundamentals of CT, and the…

Ultrasonography in the Evaluation of Abdominal Aortic Aneurysms

Medical ultrasonography was developed from principles of sonar exploration, pioneered in World War I. Sonographic images of abdominal disease were first published in 1958. This technology was widely adopted in radiology, cardiology, and obstetrics, and by 1966 reports of detection and measurement of an abdominal aortic aneurysm (AAA) by ultrasound began to appear. In 1983, Cabellon and colleagues used ultrasonography and abdominal palpation to find AAAs…

Vascular Complications of Marfan Syndrome, Ehlers–Danlos Syndrome, and Loeys–Dietz Syndrome

Inheritable connective tissue disorders have in common defects in collagen or elastin within the medial layer of the vascular wall causing loss of structural integrity, degeneration, aneurysmal development, and, as a final consequence, rupture of the wall with or without an underlying aneurysm or dissection. Three connective tissue abnormalities are of particular interest: Marfan syndrome, Ehlers–Danlos syndrome, and Loeys–Dietz syndrome. They are rare diseases, but because…

Arteriomegaly and Aneurysmosis

Arteriomegaly is defined as a diffuse ectasia involving multiple arterial segments including the aorta, iliofemoral, and femoropopliteal vessels. It is characterized by significant tortuosity, elongation, and luminal irregularities often resulting in diminished blood flow. It was originally described in 1971 by Thomas, with reference given to two cases described by Leriche in 1942 and 1943. These patients were noted to have “extraordinary elongation and dilatation of…

Pathophysiology of Aortic Dissection

The natural history of aortic dissections associated with aortic rupture or end-organ malperfusion invites a careful study of the structural properties of the false and true lumens (why the false lumen ruptures) and of the mechanisms of branch artery obstruction (how the dissection causes malperfusion). These same structural properties of the dissected aortic wall also have significant implications for effective open and endovascular treatment of aortic…

Pathogenesis of Inflammatory Aortic Aneurysms

Among the thousands of abdominal aortic aneurysms (AAAs) treated each year, the origin of a few are enigmatic. The inflammatory aortic aneurysm was originally described by Walker in 1972. One of the largest retrospective reviews consisted of 127 patients encountered over a 30-year period in Rochester, MN. Approximately 5% to 10% of all AAAs are of the inflammatory type. They share the same epidemiologic risk factors…

Genetics of Abdominal Aortic Aneurysms

A person’s genotype can have a significant role in the chance of that person’s developing of an abdominal aortic aneurysm (AAA). The principal observation that has led to this conclusion is the familial clustering of cases of AAA, with the first reported observation of this described in 1977. In the last decade of the 20th century, population-screening studies showed that the population prevalence of AAA was…

Pathogenesis of Abdominal Aortic Aneurysms

Abdominal aortic aneurysm (AAA) development is a complex, multifactorial process involving destructive remodeling of aortic wall connective tissue. Four interrelated factors involved in this process include: (1) chronic inflammation associated with neovascularization and increased proinflammatory cytokine production, (2) increased and dysregulated production of matrix-degrading proteinases, (3) destruction of structural matrix proteins, and (4) decreased medial smooth muscle cell (SMC) presence, resulting in impaired connective tissue repair.…

Hypothenar Hammer Syndrome

Hypothenar hammer syndrome (HHS) is a rare clinical condition that was first described in 1934 by von Rosen and was named in 1970 by Cone, Bergan, and Bell. HHS describes patients who experience signs and symptoms concerning for digital ischemia. Typically, patients have a history of blunt trauma to the palmar hypothenar eminence of the hand. Repetitive trauma to this area can disrupt the structural integrity…

Ergotism

Ergot is a parasitic fungal disease that is caused by the organism Claviceps purpurea and that has a particular prevalence for infecting rye plants. Ergot and the ergot alkaloids have been linked to epidemic poisonings that manifested as ergotism and resulted from consumption of rye. History shows that ergotism was more common in Germany and Russia than it was in the United Kingdom. The ratio of…

Buerger’s Disease

Thromboangiitis obliterans, or Buerger’s disease, is a relatively uncommon vascular disorder. It is considered a nonatherosclerotic, inflammatory occlusive disease that most commonly affects the intermediate and small arteries and veins of the extremities. Although there is a striking link with tobacco abuse, the specific etiologic mechanisms of Buerger’s disease remain unknown. Inflammatory, immunologic (including chronic periodontal infection), and prothrombotic factors as well as endothelial cell dysfunction…

Subclavian and Axillary Artery Aneurysms

Subclavian and axillary artery aneurysms account for less than 1% of all peripheral artery aneurysms. Among 1488 patients with atherosclerotic aneurysms reported from the University of Michigan by Dent and colleagues in 1972, only two subclavian and no axillary artery aneurysms were identified. Treatment of these aneurysms has evolved from ligation or exclusion, as first successfully performed by Smythe in New Orleans in 1864, to aneurysm…

Treatment of Arterial Complications in Thoracic Outlet Syndrome

Arterial thoracic outlet syndrome (TOS) can be defined as the anatomic condition that produces pathologic compression of the subclavian or axillary arteries in their course through the thoracic outlet. Arterial compression can occur as an anatomic state in which the artery is externally compressed in neutral position, which with the repetitive motion of the upper extremity accentuates the mechanical stress on the arterial wall, causing its…

Supraclavicular Operative Approach for Thoracic Outlet Syndrome

The supraclavicular approach is a mainstay in the surgical treatment of thoracic outlet syndrome (TOS), providing excellent exposure for safe and definitive decompression of the relevant neurovascular structures and the flexibility to manage the spectrum of circumstances that may be encountered with each type of TOS. Supraclavicular decompression is recommended for patients with neurogenic TOS when there is a sound clinical diagnosis, substantial disability (symptoms interfering…