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Introduction: The decision for active intervention for unruptured intracranial aneurysm patients are challenging due to most unruptured intracranial aneurysm patients are asymptomatic and they are reasonably healthy, but the procedure related risks such as stroke and mortality cannot be ignored. Selected high volume centers’ outcomes can potentially mislead the decision making process. Thus we aim to review the real-world clinical outcome of unruptured intracranial aneurysm treatment through a large national database. Methods: Unruptured intracranial aneurysm patients (18 to 86 years) from the 2007 to 2013 National Inpatient Sample Data were analyzed. Clinical outcomes evaluated include mortality, stroke, combined mortality and stroke, discharge home rate and complications except for mortality and stroke (M&S). Comparison of clinical outcomes between coiling and clipping were made through multivariate logistic regression and propensity-score matching. Also, hospital volume effects and over time trend of clinical outcomes per each intervention were analyzed. Results: Among 54,202 unruptured intracranial aneurysm patients, 37,050 (68.3%) were not treated, and either clipping or coiling was performed in 17,077 (31.5%). 6,120 (35.8%) patients had clipping and coiling was performed in 10,957 (64.16%). Unadjusted overall mortality, stroke, discharge home rate and complications except M&S were 0.5%, 3.27%, 2.2%, 84.24% and 11.05%, respectively. Coiling was favored for stroke and discharge home rate (p0.05). Complications except M&S favored clipping and was statistically significant (p Conclusion: Active interventions on unruptured intracranial aneurysm showed very low overall mortality. However, coiling showed lower stroke rate and higher home discharge rate than clipping. There was no significant difference in mortality between coiling and clipping.

Introduction: Comparison of real world clinical outcomes between clipping and coiling for ruptured aneurysm is challenging, mainly due to confounding case severity and variation in physician expertise. We sought to compare outcomes and costs of coiling and clipping by utilizing a large national database. Methods: Ruptured intracranial aneurysm patients age 18 to 86 years were identified from the National Inpatient Sample (NIS) from 2007 to 2013. The clinical outcomes evaluated were in-hospital mortality, in-hospital stroke, discharge destination and other complications. Also, the total hospitalization cost was compared. Multivariate logistic regression and propensity-score matching were used. Confounding factors such as specific neurovascular comorbidities (e.g. hypertension, diabetes), Charleson comorbidity index (CCI), all patient refined diagnosis related group (APR-DRG) risk of mortality, APR-DRG severity index, and NIS-SAH severity score were also controlled for. Results: 14379 patients with ruptured intracranial arterial aneurysms were identified (5966 clipping, 8413 coiling). Univariate analysis showed that coiling patients had higher preprocedural risks by CCI (p < 0.001) and APR-DRG mortality (p Conclusions: After adjusting for severity, there was no significant difference in mortality between coiling and clipping in ruptured aneurysm treatment. However, coiling patients had a lower chance of an in-hospital stroke and a higher chance of being discharged home. A limitation of the study is the possibility of unmeasured confounders.

Vascular Ehlers-Danlos syndrome (EDS) results from mutations in the formation of type III collagen. This leads to various potentially lethal complications including rupture of the arterial vessels, intestinal organs, and the uterus. This review summarizes recent cohort studies that have improved our medical and surgical management of complications associated with vascular EDS.Vascular EDS is associated with a shortened overall survival due to potential complications, namely loss of connective tissue integrity in blood vessels and increased risk of arterial rupture. The traditional approach has been to treat such complications conservatively unless they are life threatening. There have been challenges to this treatment paradigm based on recent reports. Treatment with the beta blocker Celiprolol was shown in a randomized study to be associated with a three-fold decrease in arterial rupture in vascular EDS patients. Furthermore, it was shown by observational studies that elective surgical repair of blood vessels at risk of rupture may be safely undertaken at tertiary referral centers that have expertise in managing connective tissue disorders. Novel approaches using endovascular therapy with coil embolization have also been attempted with good results in the treatment of ruptured pseudoaneurysms, visceral aneurysms, and carotid-cavernous fistulas.New evidence-based treatments have greatly expanded the medical and surgical management options for patients with EDS. These patients are best managed by multidisciplinary teams of interventionalists, cardiologists, and geneticists in tertiary centers with expertise in managing connective tissue disorders.

An 81-year-old man was incidentally found to have a large pericardial cyst on a chest computed tomography. Before surgical removal, an echocardiogram demonstrated that the cyst was more likely a large (7.5 cm) right coronary arterial aneurysm. A cardiac blood-pool study demonstrated a blood-filled structure adjacent to the heart, roughly the same size as the combined size of both the right and left ventricles. Coronary angiography confirmed the presence of a large right coronary artery aneurysm. A coronary aneurysm should be considered when a blood-filled structure is seen adjacent to the heart on a multigated acquisition scan.

A 71-year-old woman presented with dyspnea on exertion for one year. On auscultation, a grade 3/6 systolic murmur was heard at the upper sternal border. Chest radiographs (Figure 1, A and B) revealed a huge calcified lesion …

A 49-year-old man presented with right flank pain. Angiography revealed a giant right renal arterial aneurysm. Giant renal arterial aneurysms are typically treated by nephrectomy. In this patient the aneurysm was embolized successfully with multiple Gianturco-Wallace coils and polyvinyl alcohol. This case indicates that embolization may be a reasonable alternative to nephrectomy. (J. Urol., 144: 1227–1228, 1990)

Only 5 reports of cases of renal arteriovenous fistula appeared before or in 1953. Subsequently, 7 isolated reports brought the total to 12, and the 3 that we are reporting make 15. In reviewing the subject, the classification, incidence, causation, clinical features, diagnostic procedures, and pathophysiologic features were considered. Good evidence supports the thesis that in cases of congenital arteriovenous fistula an eroding renal arterial aneurysm is etiologic. Outstanding clinical features were hypertension (to group 4) and myocardial insufficiency; these contrast markedly with features of the usual peripheral arteriovenous fistula. Dramatic relief of heart failure and lowered reserve followed corrective operation in every case in which these features were recorded; relief of hypertension followed corrective operation in 11 of 12 cases in which this feature was mentioned. A loud, diffuse, continuous bruit invariably was present. Preoperative and postoperative catheterization and indicator-dilution studies, angiograms and aortograms are diagnostic measures emphasized in our 3 cases. Arterialization of blood in the vena cava, greatly increased cardiac output, and markedly shortened recirculation times of the dye were found. Excretory urograms were abnormal in 11 of the 12 cases in which they were made. The mechanism producing hypertension appears related to loss of pressure, decrease in flow, and loss of pulsatile character in the renal artery distal to the fistula, giving a Goldblatt-kidney type of end result. A vicious cycle of increasing hypertension followed by increasing flow through the shunt makes heart failure inevitable. Since 10 of the 15 cases were reported in the last 4 years, indicating that the lesion is commoner than previously supposed, we advise auscultation over the renal regions in patients with cardiac enlargement or failure of unknown causation, unexplained deformities in urograms, and renal tumors.

A false arterial aneurysm of a transplanted kidney was discovered by ultrasonography a few weeks after an open renal biopsy. The rapid increase in volume led to treatment of the lesion by bucrylate transcatheter embolization. The lesion disappeared without complications or sequelae. The renal transplant was functioning normally 30 months later.