IMAGES OF A COMPLEX CASE OF MULTIPLE ANEURYSMAL DISEASE IN A 58 YEAR OLD MAN IMMAGINI DI UN CASO COMPLESSO DI MALATTIA POLINEURISMATICA (Chirurgia Vascolare-ULSS 15 Alta Padovana) (Vascular Surgery -ULSS 15 Alta Padovana)

1. 1
A COMPLEX CASE OF MULTIPLE ANEURYSMAL DISEASE
IN A 58 YEAR OLD MAN
Salvatore Ronsivalle MD, Francesca Faresin, MD; Francesca Franz, MD; Carlo Rettore
MD*; Mario Zanchetta, MD, FSCAI**;
Department of Cardiovascular Disease – Vascular and Endovascular Surgery and
Angiology, Cittadella, Padua (Italy),*Department of Radiology, **Division of
Cardiology,***

2. 2
INTRODUCTION:
Aneurysms may be multiple and associated with generalized arteriomegaly in some
individuals.
For those older than 65 years of age, the prevalence of AAA is approximately 5% to 6%
in men and 1% to 2% in women, in 25% of these cases it involves iliac arteries 1,2,3
Aneurysms of the thoracic aorta (TAA) are about 5 times less common than in the
abdominal aorta 4
.
Aneurysms in most other arteries are either rare or exceedingly rare (upperlimb arteries)
and they do not appear to be associated with the more common aneurysms seen in larger
elastic arteries 1,5, 6,7, 8,9,10,11,12,13,14
.
CASE REPORT
In May 2009, a 58 year old man was admitted in our Department for an episode of chest
pain.
He had an anamnestic history of arterial hypertension, dyslipidemia, diabetes mellitus
type 2, HBV-related liver disease, benign prostatic hypertrophy, euthyroid cystic colloid
goiter, slipped disc, and a previous appendectomy.
The neck examination revealed a bilateral latero-cervical pulsating mass with murmur.
The abdominal examination and palpation revealed a pulsating mass with murmur in the
mesogastric region.
The lower limbs examination revealed the absence of the posterior right tibial pulse and
a right popliteal pulsating mass with murmur which was painful at palpation.
A complete cardiac investigation ruled out myocardial infarction or other ischemic heart
disease and pulmonary embolism; an echocardiogram showed aortic root dilatation.
A chest X ray showed a phrenic-left corner dehiscence and spirometry showed
reduction in forced expiratory volume.

3. 3
A CDU complete evaluation (performed with Siemens Acuson S2000, Siemens AG
Healthcare Sector, Henkestrasse 127 91052 Erlangen Germany) showed a multiple
aneurismal disease.
An angio CT scan ( ST : 0,6 mm) (performed with Light Speed VCT 64 GE
HEALTHCARE- Americas product Locator- W523 P.O. Box 414 Milwaukee, WI
53201-0414) demonstrated a lusoria right subclavian artery dilated in the proximal
segment with a thrombotic apposition and kinking in the pre-vertebral tract, a dilated
aortic arch (diameter 47 mm).
It also confirmed the fusiform aneurysm of the right common and carotideal bifurcation
(maximum diameter of 28 mm) a saccular aneurysm of the right internal carotid
(maximum diameter of 20 mm) and showed a regular distal right internal and external
carotid.
It also found the bifurcation aneurysm which involved the left carotid internal and
external origin (maximum diameter of 22 mm).
It established that there was an abdominal aorta aneurysm (maximum diameter of 63
mm) with normal iliac arteries.
It confirmed the right popliteal aneurysm (maximum diameter of 31 mm) with
thrombotic apposition, the stenosis of the tibial peroneal trunk with posterior tibial
artery occlusion at the origin and peroneal artery proximal subocclusion.
Intracranial and visceral artery were all normal.
A coronary angiography (performed with GE HEALTHCARE Innova 2000
Cardiovascular Imaging System) showed the presence of a moderate stenosis of the
right coronary artery and mild ectasia of the ascending aorta.
Blood tests revealed mild hyperglicemia, hypercholesterolemia, hypertrigliceridemia
PSA 7,99 ng/ml, PSA free 1,18 ng/ml; urinanalysis showed mild hemoglobinuria.

4. 4
On November 20 th
2009, after induction of general anesthesia, the patient underwent
endovascular aneurysm repair (EVAR) with placement of ANACONDA aorto bisiliac
stent graft (Vascutek, a Terumo Company Newmains Avenue, Inchinnan Renfrewshire
PA4 9RR, Scotland,GB).
Main stent graft body ANACONDA B 30 and its ipsilateral leg L17 x 120 were inserted
through a right femoral access.
Its contralateral left leg L16 x 120 was inserted through a left femoral access.
As prevention of EL type II, after deployment of main stent graft component with its
contralateral iliac extension, 4 COOK - IMWCE 35-20-20 MReye embolization coils
were introducted into the aneurysm sac followed by 10 cc of fibrin glue
(Tisseel/Tissucol; Baxter-Hyland Immuno AG, Vienna Austria) injection with good
results 15,16
.
After four days he underwent an abdominal X-ray and abdominal CDU control showing
regular aorto-bisiliac stent graft positioning without endoleaks.
He was then discharged with low molecular weight heparin therapy according to his
weight.
For the onset of right leg pain, probably caused by compression of neural structures,
without signs of ischemia or distal embolization , on January 22 th
2010 , after induction
of spinal anesthesia, through a back popliteal access, he underwent an aneurysmectomy
and popliteal intra joint termino- terminal graft sewing in autologous reversed
saphenous vein with positive results.
Vascular sutures were made with polypropylene monofilament non-absorbable 6/0
sutures (Premilene B/BRAUN).
Histological examination was evaluated by Hematoxylin-Eosin, Van Gieson, Masson
trichrome, and Periodic Acid Schiff stain tests that revealed an aneurysmal dilatation of
the wall with intraluminal thrombus, lymphocytic infiltrate, xanthomatosis,

5. 5
emosiderofagi, needle shaped cholesterol, foamy macrophages, fragmentation of elastic
fibers of tunica media, the margins free of disease showed hyperplasia of the tunica
intimate and fragmentation of elastic fibers of tunica media and atherosclerotic plaques
with intraplaque hemorrhage; all these findings are consistent with aneurysmal disease
in atherosclerosis and hypertension.
After five days he underwent an arterial lower limb CDU control, which showed graft
patency, non obstructive stenotic disease of the proximal and distal anastomosis, and
good flow.
He was then discharged with low molecular weight heparin therapy according to his
weight.
On February 24 th
2010, after induction of general anesthesia he underwent a right
carotid aneurysmectomy and a carotid–carotid graft sewing in autologous reversed
saphenous vein with positive results.
On April 16 th
2010, after induction of general anesthesia he underwent a left carotid
partial sacculectomy, along with angioplasty of left internal carotid artery with
autologous saphenous vein patch with positive results.
During both operations brain circulation was ensured by using a Pruitt- Inahara Carotid
External Shunt and vascular sutures were made with polypropylene monofilament non-
absorbable 6/0 sutures (Premilene B/BRAUN).
Both histological examinations noted findings similar to the previous ones and were
consistent with aneurismal disease in atherosclerosis and hypertension.
A supra-aortic vessels CDU control showed both graft patency, non obstructive stenotic
disease of the proximal and distal anastomosis, and good blood flow.
Five days after the first intervention and three days after the second intervention he was
discharged with low molecular weight heparin therapy according to his weight.

6. 6
One month after the second intervention, low molecular weight heparin was withdrawn
and replaced with acetilsalicilic acid therapy.
DISCUSSION
Aneurysms of the extracranial internal carotid artery are very uncommon; while their
rarity precludes the establishment of a precise natural history for these lesions,
significant risk for embolic events mandates urgent intervention 14
.
CONCLUSION
Given the complexity of the case, the sizes and characteristics of the aneurysms, we
decided to treat first, the abdominal aortic aneurysm and immediately after, the popliteal
and the carotid aneurysm.
The patient entered into a complete follow up programme which includes yearly
thoracic aorta angio CT control, abdominal CDU at discharge after 3, 6 and 12 months
from EVAR and once every 6 months thereafter. Two abdominal X-rays, the first at
discharge and the second a year later, a spiral CT scan at 6 months (fig C), and a CDU
inferior limb and supra-aortic vessel exam twice a year.

7. 7
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