Temporary axillobifemoral bypass as an adjunct to endovascular aneurysm repair using fenestrated stent grafts

The Efficacy of Salvage Intervention with Emergency Transient External Arterial Bypass for Traumatic Artery Occlusion of Main Extremities

Even if the vascular repair is successful, the frequency of limb loss is still high when popliteal artery injury is associated with postischemic syndrome due to blunt trauma or a prolonged ischemic time. Because prolonged ischemia interferes with an injured foot rescue, shortening of the ischemic time is a major aim of surgeons. We present two types of transient external arterial bypass and two cases of ischemic extremities due to main arterial injury. Even though the injured extremities had no circulation for more than 6 h, a transient external arterial bypass supplied circulation immediately, and they were reconstructed successfully. Although transient external arterial bypass is a dated technique, it is a recommended option, especially in the management of acute traumatic ischemia of the extremities to shorten the ischemic time and provide immediate reperfusion, which will bring the opportunity to save the ischemic limbs.

Ischemia-induced lower extremity neurologic impairment after fenestrated endovascular aneurysm repair

OBJECTIVE

Placement of large sheaths in the iliac system during fenestrated endovascular aneurysm repair (FEVAR) leads to lower extremity (LE) ischemia that can be associated with serious neurologic complications. We sought to determine the effect of LE ischemic time on neurologic impairment after FEVAR.

METHODS

Consecutive patients who underwent FEVAR at a single institution were analyzed. LE ischemic time was calculated from the time of large sheath (≥18F) insertion to the time of sheath removal from the iliac arteries that led to continuous LE ischemia. The primary outcome was neurologic impairment defined as any new sensory or motor deficit in either LE. Outcomes were analyzed using descriptive statistics and modeled with logistic regression with interaction terms. Each individual LE was used as a unit of analysis.

RESULTS

We examined 101 patients (202 lower extremities) who underwent FEVAR over a 5-year period. The median LE ischemic time was 2.75 hours (range, 0.8-5.2 hours). Neurologic impairment developed in 18 extremities (9%). Of those, 12 (67%) developed mild sensory loss, 6 (33%) complete sensory loss, 4 (22%) loss of proprioception, and 2 (11%) motor dysfunction. Sensory deficit was permanent in four limbs (2%) and motor dysfunction in one limb (0.5%). In all other cases, the neurologic examination returned to baseline by postoperative day 15. Duration of LE ischemic time (odds ratio, 6.3; 95% confidence interval, 3.1-12.4; P < .001) and common iliac artery (CIA) stenosis to a lumen of 8 mm or less (odds ratio, 2.7; 95% confidence interval, 1.5-7.3; P = .002) were independent predictors for the development of neurologic impairment. An interaction term between LE ischemic time and CIA stenosis was statistically significant (P = .042), indicating that the presence of CIA stenosis modifies the effect of LE ischemic time. In those with CIA stenosis to a lumen of 8 mm or less, the risk of neurologic impairment increased rapidly after 2.5 hours of LE ischemia, and became nearly certain after 4 hours of ischemic time. By contrast, patients without CIA stenosis tolerated longer ischemic times and demonstrated a less steep increase in the risk for LE neurologic impairment.

CONCLUSIONS

LE neurologic impairment after FEVAR is strongly associated with LE ischemic time and CIA occlusive disease to a lumen of 8 mm or less. Our data indicate that, when the LE ischemic time is expected to exceed 2.5 hours (in patients with CIA stenosis) or 3 hours (in patients without CIA stenosis), measures to ensure LE perfusion should be given consideration.

Life over Limb: Lower Extremity Ischemia in the Setting of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a temporizing maneuver used to decrease hemorrhage, and thus perfusion, below the level of aortic occlusion (AO). We sought to investigate lower extremity ischemia in patients who received REBOA. Between February 2013 and September 2016 patients at a tertiary center that received REBOA and survived more than six hours were enrolled. Thirty-one patients were identified, the mean ISS was 40 ± 14 and inhospital mortality was 39 per cent. Twenty received REBOA in zone 1 (distal thoracic aorta). Three (15%) developed lower extremity compartment syndrome (LECS) after zone 1 REBOA. Injury of iliofemoral arteries and veins was each associated with calf fasciotomies (both P = 0.005). A longer duration of AO at zone 1 was associated with calf and thigh fasciotomy (P = 0.046 and P = 0.048, respectively). Iliofemoral arterial injury was associated with thigh fasciotomy (P = 0.04). Eleven patients received REBOA in zone 3 (distal abdominal aorta). Five (45%) patients underwent fasciotomy; four (36%) due to LECS. Femoral arterial injury was associated with calf fasciotomies (P = 0.02). There was no association with sheath size or laterality and need for fas-ciotomy. Neither groin access for REBOA or AO solely caused limb loss or LECS. The contribution to distal ischemia by REBOA remains unclear in patients with lower extremity injury.

Early experience with fenestrated stent grafts for treatment of juxtarenal aortic aneurysm

BACKGROUND

Fenestrated endovascular abdominal aneurysm repair (FEVAR) using branched arteries devices for visceral arteries is increasingly being used for the repair of juxtarenal aortic aneurysms (JAAs) in Europe, United States, Australia, New Zealand, and Asia. This study aimed to evaluate the technical feasibility and short-term results of FEVAR in treating JAAs in Japanese patients.

METHODS AND RESULTS

FEVAR with Cook fenestrated stent-graft (Cook Medical Inc., Bloomington, Indiana, USA) was performed for 5 patients at high risk for open repair of JAA. Seventeen visceral vessels were successfully accommodated with 12 fenestrations, and five visceral arteries with four scallops with a loss of renal artery. In one case, a type III endoleak occurred at a renal artery fenestration, and this had disappeared in the 1-month postoperative computed tomography (CT). The mean follow-up duration was 8 months. Iliac leg occlusion occurred in 1 case, which was treated with thrombectomy and additional leg device deployment. All patients had survived at the end of the follow-up period and continued their outpatient visits.

CONCLUSIONS

Implantation of a Cook fenestrated stent-graft incorporating the visceral arteries is technically feasible in high-risk Japanese patients with JAA and may be a viable alternative to current methods.

Techniques for removing bilateral renal artery stents prior to fenestrated endovascular aneurysm repair

PURPOSE

To demonstrate 2 endovascular methods for successful intravascular stent extraction.

TECHNIQUE

In preparation for fenestrated endovascular aneurysm repair, renal artery stents may be implanted for focal vessel stenosis at the ostium. In a recent case, bilateral renal artery stents were deployed with >50% protruding into the aortic lumen, thus rendering fenestrated endografting impossible. Two techniques were employed to extract the stents. In the left renal artery, the stent was extracted using an endovascular snare, but the right renal artery stent could not be removed with this method. Instead, an endoscopic forceps was advanced down a 16-F sheath, and the stent was grasped, extracted, and released into the aneurysm sac. The endovascular repair then proceeded in the usual fashion.

CONCLUSION

The need to remove a stent prior to endovascular aneurysm repair is not a common problem encountered by most endovascular specialists; however, these methods should be in their armamentarium should the need arise.