Durability of femorofemoral bypass grafting after aortouniiliac endovascular aneurysm repair

Midterm outcomes of endovascular treatment for infected aortic aneurysms: Single center experience

OBJECTIVE

The standard treatment of infected aortic aneurysms is open surgical repair but mortality rates remain high with the common cause of death being sepsis. Endovascular treatment of infected aortic aneurysms is another option and here we report the midterm outcomes of endovascular treatment for infected aortic aneurysms.

METHODS

Thirty-four patients with infected aortic aneurysms underwent endovascular and hybrid repair between December 2012 and June 2021. The patients were evaluated for early and midterm outcomes including postoperative mortality, morbidity, recurrent aortic infection, and midterm survival.

RESULTS

There were 34 patients who presented with infected aortic aneurysms with a mean age of 66.7 years (range, 26-89). Most of the patients presented with abdominal pain (94.1%) and fever (50.0%). The rate of positive blood culture for organisms was 32.4%. Salmonella was the most common organism. The procedures for treatment were endovascular repair using straight endograft, aorto-uni-iliac (AUI) endograft, bifurcated endograft, and thoracic endograft. Other procedures were endovascular repair with sandwich technique, chimney or periscope technique, and hybrid operation. The rate of in-hospital mortality and morbidity were 11.8% and 17.6%, respectively. Mean follow-up time was 21 months (range, 1-70). During the follow-up period, 7 (23.3%) patients had recurrent infection of aortic aneurysms and 5 patients required reoperation. Four patients died from septicemia and one patient died from cardiac disease. Male patients were more likely to have recurrent infection compared to females. The cumulative survival at 1 year and 2 years were 86.3% and 80.5%, respectively.

CONCLUSION

In this retrospective review of the endovascular treatment in the patients who presented with infected aortic aneurysms showed acceptable early and midterm outcomes.

Open Surgical Therapy for Peripheral Artery Disease

PURPOSE OF REVIEW

The surgical management of symptomatic peripheral artery disease (PAD) has changed in the last few decades. Improvement in endovascular technology has resulted in more complex lesion once reserved for open surgery being addressed in an endovascular fashion. Even with these advances, there are lesions and patients that are better managed with an open surgical procedure. The aim of this review is to describe the most commonly performed open surgical procedures for PAD.

RECENT FINDINGS

The recently published Best Endovascular versus Best Surgical Therapy (BEST-CLI) trial was an international, prospective, randomized controlled trial that aimed to investigate which revascularization (endovascular vs. surgical bypass) approach was superior for limb salvage. The evidence supports an open surgical bypass as an initial approach. The advancements made in the surgical management of PAD have provided options for patients who were once deemed poor surgical candidates. The goal continues to be utilization of the best available tools to address patient disease. In this current era, it is important to be familiar with the open surgical therapies.

Double-Barrel Technique With Reversed Gore Excluder Stent Graft Limb for Common Iliac Aneurysm Exclusion in a Patient With Prior Aortic Surgical Repair

Surgical repair of a common iliac artery aneurysm (CIA) after previous open aortic reconstruction is associated with significant morbidity and mortality. Endovascular repair is considered less invasive than surgery. However, if preservation of the internal iliac artery (IIA) is required, the applicability of endovascular techniques may represent a challenge and a limitation to the use of standard aortic endografts or iliac branch devices. In these cases, the off-label use of endovascular devices may be an effective alternative. Herein, we report a successful hybrid approach to treat CIA using a reversed iliac limb endograft coupled with a double-barrel technique with femoro-femoral crossover bypass in a patient who had previously undergone open aortic reconstruction.

Do Not Tunnel the Small Bowel during the Tunneling of a Femoro-Femoral Bypass

A 62-year-old male with a history of femoro-femoral crossover bypass surgery 31 months previously presented with recurrent symptoms of fever and chills, along with a previous positive blood culture. Computed tomography showed vegetation in the bypass graft located in the peritoneal cavity, closely abutting the small bowel and soft tissue lesions in the right proximal thigh and distal calf. Under high suspicion of graft-enteric fistula with metastatic infection, surgery was performed to remove the previous graft and insert a new femoro-femoral bypass graft subcutaneously. Small bowel resection and anastomosis were also performed because the graft penetrated the small bowel mesentery and eroded into the small bowel. The patient had a patent graft without infection for more than 10 years. This case demonstrates the importance of tunneling in femoro-femoral crossover bypass free from the small bowel or other intraperitoneal organs.

Results of adjunctive stenting with high-radial force stents to prevent or treat limb occlusion after EVAR

BACKGROUND

The aim of this study was to report the results of a multicenter experience on the use of adjunctive stents deployed inside abdominal aortic endografts with the purpose to prevent or treat limb occlusion after endovascular aneurysm repair (EVAR).

METHODS

Between 2010 and 2018, there were 35 patients with aorto-iliac aneurysm presenting one or more risk factors for endograft limb occlusion (narrow aortic bifurcation and/or stenotic, highly angulated or occluded iliac arteries), who were treated with standard bifurcated stent graft reinforced by the means of a single model of balloon-expandable platinum/iridium bare stent (CP Stent; NuMED, Inc., Hopkinton, NY, USA). Technical success, mortality, limb patency and reintervention rate during follow-up were the main endpoints assessed.

RESULTS

Technical success was 100%. No patients died perioperatively and no major complication was registered. During a mean follow-up of 48 months (range 1-87), neither aortic-related death nor secondary intervention was registered. At a mean follow-up imaging of 39.4 months (range 1-81) no endograft limb lost its patency.

CONCLUSIONS

The use of high-radial force balloon-expandable stents deployed inside bifurcated endografts to prevent or treat limb occlusion is a safe and effective adjunctive procedure, with outstanding long-term outcomes in terms of patency and reinterventions.

An uncommon presentation and hybrid approach for the management of an unruptured 8 cm common iliac artery aneurysm

INTRODUCTION

Common Iliac Artery Aneurysms are rare in the general population and can be difficult to diagnose.

PRESENTATION OF CASE

An 82-year-old lady initially presented to her GP with non specific symptoms, but was found to have a right iliac fossa mass on examination. Initial Blood Tests and clinical observations were unremarkable. A CT scan demonstrated a large, 8 cm Isolated Right Common Iliac Aneurysm. She was admitted following the scan for monitoring and surgical intervention. In view of her mild frailty, she underwent a hybrid approach: Right Aorto-Uni-Iliac Stent Graft and Right to Left femoro-femoral crossover graft and right internal iliac artery embolization.

DISCUSSION

We discuss the rarity, variety of clinical presentations and aetiology of Common Iliac Artery Aneurysms. These aneurysms are at high risk of rupture and in the elective setting, many are repaired when they reach over 3.5 cm. With the advancement and preference of minimally invasive techniques, Endovascular Aneurysm Repair (EVAR) is replacing Open Surgery. In some instances, such as our case, the anatomy is unsuitable for a standalone EVAR procedure. Thus a hybrid operation was performed.

CONCLUSION

Common Iliac Artery Aneurysms should be considered in a differential diagnosis of lower abdominal mass. If presenting in this manner, the aneurysm can be of significant size and at high risk of rupture, requiring urgent surgical intervention.

The Society for Vascular Surgery practice guidelines on follow-up after vascular surgery arterial procedures

Although follow-up after open surgical and endovascular procedures is generally regarded as an important part of the care provided by vascular surgeons, there are no detailed or comprehensive guidelines that specify the optimal approaches with regard to testing methods, indications for reintervention, and follow-up intervals. To provide guidance to the vascular surgeon, the Clinical Practice Council of the Society for Vascular Surgery appointed an expert panel and a methodologist to review the current clinical evidence and to develop recommendations for follow-up after vascular surgery procedures. For those procedures for which high-quality evidence was not available, recommendations were based on observational studies, committee consensus, and indirect evidence. Recognizing that there are numerous published reports on the role of duplex ultrasound for surveillance of infrainguinal vein bypass grafts, the Society commissioned a systematic review and meta-analysis on this topic. The panel classified the strength of each recommendation and the corresponding quality of evidence on the basis of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system: recommendations were graded either strong or weak, and the quality of evidence was graded high, moderate, or low. The resulting recommendations represent a wide variety of open surgical and endovascular procedures involving the extracranial carotid artery, thoracic and abdominal aorta, mesenteric and renal arteries, and lower extremity arterial revascularization. The panel also identified many areas in which there was a lack of high-quality evidence to support their recommendations. This suggests that there are opportunities for further clinical research on testing methods, threshold criteria, and the role of surveillance as well as on the modes of failure and indications for reintervention after vascular surgery procedures.

Femorofemoral Crossover Bypass Graft Has Excellent Patency When Performed with EVAR for AAA with UIOD

OBJECTIVES

To compare the durability of the crossover femorofemoral bypass graft (CFFBG) in combination with aorto-uni-iliac stent graft (AUIS) for abdominal aortic aneurysm with the durability of CFFBG used in the treatment of unilateral iliac occlusive disease (UIOD).

METHODS

We analyzed the clinical records of 69 patients who underwent CFFBG from 1992 until 2010. Group I consisted of 34 patients who received CFFBGs in combination with AUIS. Group II consisted of 35 patients treated with CFFBG for UIOD. The mean period of follow up was 2.7 years. Outcomes analyzed included primary graft patency, secondary graft patency, and postoperative morbidity and mortality.

RESULTS

There was one death in each group. Wound infection complicated 11.4% of CFFBGs performed as a sole procedure for UIOD and 5.8% of cases in combination with AUIS (P = 0.673). Primary graft patency was 96.5% and 96.5% at 2 and 5 years in group I, compared with 76.6% and 53.7% in group II (P = 0.046, 0.009). Secondary graft patency at 5 years was 100% and 92.9% for groups I and II, respectively. No variables independently influenced primary graft patency. Patients in group I experienced complications that could be linked to the bypass graft in 20.5% of cases, after long-term follow-up.

CONCLUSIONS

The CFFBG possesses superior long-term durability and patency when implemented in combination with aorto-uni-iliac stent grafts and does not seem to compromise the endpoint success of endovascular treatment.

Aorto-Uni-Iliac Stent Grafting and Femoro-Femoral Bypass in a Patient with a Failed and Catastrophic Endovascular Aortic Aneurysm Repair

A 78-year-old man presented at Eulji University Hospital due to an abdominal aortic aneurysm with maximum diameter of 52 mm, which had been increased from 45 mm over 6 months. He underwent embolization of the left internal iliac artery with vascular plug, prior to endovascular abdominal aortic repair with a bifurcated stent graft system. Unfortunately, the inserted vascular plug was maldeployed and protruded into left external iliac artery, and caused acute limb ischemia. Because revascularization of the occluded segment was failed, emergent hybrid approach with aorto-uni-iliac stent grafting and femoro-femoral bypass was done, successfully.

Aorto-Uni-Iliac Stent Grafts with and without Crossover Femorofemoral Bypass for Treatment of Abdominal Aortic Aneurysms: A Parallel Observational Comparative Study

We investigated the safety and efficacy of primary aorto-uni-iliac (AUI) endovascular aortic repair (EVAR) without fem-fem crossover in patients with abdominal aortic aneurysm (AAA) and concomitant aortoiliac occlusive disease. 537 EVARs were implemented between 2002 and 2015 in University Hospital Galway, a tertiary referral center for aortic surgery and EVAR. We executed a parallel observational comparative study between 34 patients with AUI with femorofemoral crossover (group A) and six patients treated with AUI but without the crossover (group B). Group B patients presented with infrarenal AAAs with associated total occlusion of one iliac axis and high comorbidities. Technical success was 97% (n = 33) in group A and 85% (n = 5) in group B (P = 0.31). Primary and assisted clinical success at 24 months were 88% (n = 30) and 12% (n = 4), respectively, in group A, and 85% (n = 5) and 15% (n = 1), respectively, in group B (P = 0.125). Reintervention rate was 10% (n = 3) in group A and 0% in group B (P = 0.084). No incidence of postoperative critical lower limb ischemia or amputations occurred in the follow-up period. AUI without crossover bypass is a viable option in selected cases.

Rates of adverse events and correction procedures after elective versus emergent aortouni-iliac endografting during mid-term follow-up: A prospective cohort study

BACKGROUND

Due to preferential implantation of bifurcated devices during endovascular repair of infrarenal abdominal aortic aneurysms (AAA), longer-term results following aortouni-iliac (AUI) endografting are scarce. The aim of this study was to determine the rate of endoleaks as well as frequency of secondary correction procedures after elective and emergent AUI endografting.

METHODS

A prospectively gathered database at a tertiary care university hospital was retrospectively reviewed from January 2000 until January 2012. This interrogation identified 61 patients who had undergone AUI endografting to treat their AAA. Data retrieval obtained 47 patients with elective AAA repairs while 14 patients received emergent AUI endografting in case of rupture. Procedural outcomes, endoleaks, complications, and secondary interventions during mid-term follow-up were recorded for analysis.

RESULTS

Fifty-five patients of the study cohort were male (90.2%) and mean age was 76.5 years (median: 77.2, Q1-Q3: 72.1-81.6). Patient demographics, comorbidities, procedural characteristics, as well as median follow-up length (39.8 months versus 34.9 months) were similar between groups. Endoleaks, complications, and rate of secondary correction procedures were not increased following emergent AUI endografting. The majority of these interventions comprised catheter-based or less invasive surgical procedures. All patients requiring major surgery (three open surgical conversions with endograft explantation and one open aortic banding) survived, while one patient sustained fatal myocardial infarction after a transluminal correction procedure.

CONCLUSION

Emergent AUI endografting was not associated with higher rates of adverse events or correction procedures during mid-term follow-up. Secondary interventions to maintain aneurysm exclusion could be carried out with low mortality.

Bilateral prevascular herniae - A rare complication of aorto-uniiliac endovascular abdominal aortic aneurysm repair and femoro-femoral bypass

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A case of a 78-year-old female with bilateral prevascular groin herniae following an emergency aorto-uniiliac EVAR and femoro-femoral bypass for a ruptured abdominal aortic aneurysm is presented.

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Primary repair of the herniae was achieved using a preperitoneal approach.

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The case emphasises a safe approach for dealing with this rare complication.

A case of a 78-year-old female with bilateral groin prevascular herniae following an emergency aorto-uniiliac EVAR and femoro-femoral bypass for a ruptured abdominal aortic aneurysm is presented. Primary repair of the herniae was achieved using a preperitoneal approach. The case emphasises a safe approach to dealing with this rare complication.

Reentry device aided endovascular aneurysm repair in patients with abdominal aortic aneurysm and unilateral iliac artery occlusion

BACKGROUND

We report 2 cases of patients undergoing endovascular aneurysm repair (EVAR) using reentry devices to recanalize unilateral iliac artery occlusions and complete a bifurcated endovascular repair.

METHODS

Patient 1 is a 70-year-old male with an enlarging 6.5-cm abdominal aortic aneurysm (AAA) and disabling left leg claudication with L external iliac occlusion with patent common and internal iliac arteries. Patient 2 is a 67-year-old male with an asymptomatic 4.0-cm AAA and L iliac chronic total occlusion (CTO) and disabling claudication. Both patients were poor operative candidates for open repair.

RESULTS

Both patients underwent elective percutaneous EVAR along with left iliac artery revascularization. Initial angiography in both cases showed a blind ending of the left common iliac artery. Retrograde subintimal dissection through the occluded iliac segment was attempted but in both cases the wire was unable to traverse back into the true aortic lumen. Using either the Outback LTD or Pioneer reentry catheter, direct visualization of the true aortic lumen was obtained to re-enter the true lumen. The subintimal iliac tract was then predilated to facilitate routine EVAR in both cases. Both patients were discharged the following day and 1-year and 6-month follow-up imaging revealed aneurysm exclusion, no endoleak, and patent bilateral common iliac arteries with resolution of claudication symptoms and normal ankle-brachial indexes. The previously patent internal iliac artery was preserved.

CONCLUSIONS

While not always technically possible, reentry device aided EVAR is safe, feasible, and durable in the mid-term and avoids the morbidity and mortality related to aortouniiliac/femoral-femoral bypass and open repair. This technique should be considered in patients with iliac artery CTO and concurrent AAA to allow total endovascular repair.

Secondary modification into aortouniiliac configuration to salvage failed endovascular aneurysm repair is safe and effective but not associated with higher intervention rates during long-term follow-up

BACKGROUND

Reports of secondary modifications into aortouniiliac configuration to salvage-failed endovascular aneurysm repair (EVAR) are limited. We evaluated long-term results after these procedures and compared them with those after primary aortouniiliac endografting (AUE).

METHODS

A retrospective review of all EVAR performed from March 1995 until July 2011 was conducted. Patients were included when primary AUE (group I) or modification into aortouniiliac configuration (group II) was done.

RESULTS

Data analysis obtained 27 group I and 23 group II patients. Salvage of failed EVAR could be achieved in 96% of group II patients, and mortality was zero. Frequency of adverse events and amount of interventions to maintain aneurysm exclusion were not increased after secondary AUE. Kaplan-Meier estimates for long-term survival between groups were comparable (P = .36).

CONCLUSIONS

Secondary AUE allows correction of graft-related endoleaks potentially leading to late aneurysm rupture. Complications and adverse events throughout long-term follow-up were not necessarily increased when compared with primary AUE.

Crossover ilio-iliac bypass and removal of femoro-femoral graft as first treatment for the infection of crossover bypass in aorto-uni-iliac endovascular aneurysm repair

The crossover femoro-femoral bypass, classically used for the treatment of unilateral iliac arterial obstruction, has recently become an integral part of aorto-uni-iliac endovascular aneurysm repair. We therefore, reconsider the therapeutic problems related to thrombosis and in particular to infection of the femoro-femoral prosthesis, when many attempts have been made to preserve the bypass and treat the infection. Showing a case treated and well eight months later, we put forward the old technique of crossover ilio-iliac bypass, followed by the removal of the infected femoro-femoral graft. In our opinion, this technique circumvents the need for autologous tissue and allows for the use of prosthetics in a new, sterile, uncontaminated field. As this approach for these cases has so far not been reported in the literature, further cases and long-term follow-up are needed.

The impact of adjunctive iliac stenting on femoral-femoral bypass in contemporary practice

OBJECTIVES

Most reports of femoral-femoral bypass (FFB) were published before the era of endovascular intervention. This study examines the utilization and impact of adjunctive endovascular intervention on FFB in contemporary practice.

METHODS

We reviewed 253 FFB performed in 247 patients between 1984 and 2010. Primary endpoints, including graft patency, primary-assisted patency, limb salvage, and survival, were assessed using Kaplan-Meier life-table analysis. Univariate and multivariate analyses were performed to determine predictors of primary endpoints.

RESULTS

The indication for FFB included claudication (27%; n = 69) and critical limb ischemia (72%; n = 184). Forty-eight patients (19%) were treated urgently for acute ischemia. Mean follow-up was 5.6 ± 5.5 years. Over the study interval, adjunctive iliac percutaneous transluminal angioplasty (PTA)/stent placement increased significantly from 0% to 54% (P trend < .001), while the rate of axillofemoral bypass or no inflow procedure decreased from 100% to 46% (P trend < .001). Despite increased utilization, iliac PTA/stenting was associated with decreased 5-year primary graft patency of 44% compared with 74% for axillofemoral bypass patients and 71% in patients with no adjunctive inflow procedure (P = .004). Patients with inflow iliac PTA/stents also had diminished 5-year assisted primary patency of 61% compared with 85% for axillofemoral bypass patients and 87% in patients without inflow revascularization (P = .002). Adjunctive iliac PTA/stenting did not impact limb salvage or overall survival. Five-year primary patency among claudicants and critical leg ischemia patients was 65% and 68%, respectively.

CONCLUSIONS

The incidence of iliac PTA/stent placement in conjunction with FFB has increased significantly over time in contemporary practice. Reliance on iliac stent placement for FFB inflow is paradoxically associated with both diminished primary and assisted primary graft patency when compared with historical controls. These findings highlight the importance of patient selection and inflow consideration when performing FFB.

Placement of an aortomonoiliac stent graft without femorofemoral revascularization in endovascular aneurysm repair: a case report

Introduction

Endovascular aortic repair, if technically feasible, is the treatment of choice for patients with a contained ruptured aortic aneurysm who are unfit for open surgery.

Case presentation

We report the case of an 80-year-old Caucasian man who presented with an unusually configured, symptomatic infrarenal aortic aneurysm. His aneurysm showed an erosion of the fourth lumbar vertebra and a severely arteriosclerotic pelvic axis. A high thigh amputation of his right leg had been performed 15 months previously. On his right side, occlusion of his external iliac artery, common femoral artery, and deep femoral artery had occurred. His aneurysm was treated by a left-sided aortomonoiliac stent graft without femorofemoral revascularization, resulting in occlusions of both internal iliac arteries. No ischemic symptoms appeared, although perfusion of his right side was maintained only over epigastric collaterals.

Conclusions

The placement of aortomonoiliac stent grafts for endovascular treatment of infrarenal aortic aneurysms without contralateral revascularization is a feasible treatment option in isolated cases. In this report, access problems and revascularization options in endovascular aneurysm repair are discussed.

Endovascular repair of an abdominal aortic aneurysm in a patient with stenosis of bilateral common iliac artery stents

BACKGROUND

The explosion in endovascular interventions for peripheral vascular disease has resulted in procedures being used by a multitude of specialties. Nonvascular surgeons performing these interventions can create scenarios that may make future vascular interventions difficult. In this article, we present a case report illustrating this point.

METHODS

A 68-year-old man with severe chronic obstructive pulmonary disease, coronary artery disease with prior myocardial infarction, and multiple abdominal operations presented with an abdominal aortic aneurysm. In our opinion, this patient was at a prohibitive operative risk for open repair. Review of his imaging results revealed a 6.7-cm infrarenal aneurysm with bilateral common iliac artery (CIA) stents (right: 8 mm; left: 6 mm) and 6-mm self-expanding stents extending from the right external iliac artery through the common femoral artery. A Cook Zenith Renu (30 × 108 mm) graft (Cook Medical Inc., Bloomington, IN) was advanced after serial dilation and balloon angioplasty of the stenotic right CIA stent. Left brachial access was used for arteriographic imaging. The left common femoral artery was accessed and the left CIA was coil-embolized to prevent backbleeding. A femoro-femoral artery crossover bypass was then performed after segmental resection of the right common femoral artery stent.

RESULTS

The patient tolerated the procedure well and was discharged home on postoperative day 3. Subsequent postoperative computed tomography arteriogram after 1 month showed palpable pulses and no evidence of endoleak with flow in the femoro-femoral graft on clinical exam.

CONCLUSIONS

This case demonstrates an endovascular intervention which limited the potential options available for aneurysm repair. Similar problems may become increasingly common as more providers offer endovascular interventions, thus emphasizing the importance of a collaborative approach to the patient with complex aorto-iliac occlusive disease and abdominal aortic aneurysm. It is the duty of the vascular surgeon to offer his vital expertise and leadership in the care of these patients.

Small bowel obstruction due to herniation into an extra-anatomical arterial bypass tunnel: a first case report

INTRODUCTION

We highlight the importance of considering rarer causes of small bowel obstruction in patients presenting after extra-anatomical arterial bypass.

CASE PRESENTATION

Our patient underwent a left common iliac-to-bifemoral bypass extra-anatomical graft for critical limb ischaemia. The patient developed mechanical small bowel obstruction on the 20th postoperative day. Emergency laparotomy revealed incarcerated, obstructed small bowel trapped in the graft tunnel. Recovery was satisfactory following small bowel resection.

CONCLUSIONS

To the best of our knowledge, small bowel herniation into an arterial bypass graft tunnel, with successful treatment outcome, has not been reported to date.

Long-term Results of Femoro-Femoral Crossover Bypass After Endovascular Aortouniiliac Repair of Abdominal Aortic and Aortoiliac Aneurysms

Aortouniiliac stent grafts allow the endovascular treatment of complex anatomy aortoiliac aneurysms. The main drawback is the need for femoro-femoral crossover bypass, with its complications and its patency limitations. However, some authors have shown good results of femoro-femoral crossover bypass in aneurysmal disease. In this article, initial and long-term results of our experience in femoro-femoral crossover bypass revascularization after endovascular aortouniiliac stent grafts repair of aortoiliac aneurysms is reported. Prospective collection, intention-to-treat, and retrospective analysis maintained database. Femoro-femoral crossover bypass patency assessment of all patients treated between January 1999 and September 2002, compared patients with or without associated occlusive arterial disease. Urgent indications were excluded. In total of 52 patients, with a mean age 72.6 years, 30.8% of patients were identified with associated occlusive arterial disease. Initial systemic and local, access site, complications were 7.7% and 7.7%, respectively, no early thrombosis or death is reported. Primary patency was 90.9% at 54 months, 66 months assisted primary and secondary patency were 97.7% and 100%, respectively. The 48-month survival rate was 84.2%. No significant differences between patients with or without associated occlusive arterial disease were found. Femoro-femoral crossover bypass after aortouniiliac stent grafts treatment of aortoiliac aneurysms shows excellent initial and long-term patency and low complication rate.

A novel hybrid approach to the treatment of common iliac aneurysms: antegrade endovascular hypogastric stent grafting and femorofemoral bypass grafting

A progressively enlarging left common iliac artery aneurysm developed in a 72-year-old man 7 years after open abdominal aortic aneurysm repair with a bifurcated Dacron graft. Because both the right hypogastric and inferior mesenteric arteries had been ligated at the initial operation, preservation of left hypogastric flow was critical to avoid pelvic or intestinal ischemia. He was a poor open surgical candidate owing to obesity, a hostile abdomen, and multiple medical comorbidities. Therefore, a novel hybrid approach was used consisting of left transbrachial selective left hypogastric artery catheterization, followed by deployment of two, overlapping, antegrade, covered stent grafts extending from the proximal left graft limb into the left hypogastric artery. A right-to-left femorofemoral crossover bypass was added to perfuse the left lower extremity and was performed in end-to-end fashion to the left common femoral artery to exclude and prevent retrograde flow into the iliac aneurysm. Also presented are potential procedural pitfalls and a detailed review of open, endovascular and hybrid options to preserve hypogastric flow when treating iliac aneurysms in complex, high-risk patients.

The Amsterdam Acute Aneurysm Trial: Suitability and Application Rate for Endovascular Repair of Ruptured Abdominal Aortic Aneurysms

PURPOSE

To evaluate anatomical suitability and application rate for endovascular repair of patients with a ruptured abdominal aortic aneurysm (RAAA).

METHODS

The Amsterdam Acute Aneurysm trial is a multicenter randomised trial comparing open with endovascular treatment in patients with a RAAA (International Standard Randomized Controlled Trial Number (ISRCTN) 66212637). Between April 2004 and January 2006, all consecutive patients with clinical suspicion of a RAAA at presentation were assessed prospectively. Anatomical suitability for endovascular repair was based on use of an aorto-uni-iliac endovascular graft and assessed in patients with a proven aortic rupture on CT angiography (CTA).

RESULTS

In 128/256 patients, presenting with clinical suspicion of a ruptured aneurysm, RAAA was diagnosed. 105 patients were brought to a trial center and CTA confirmed RAAA in 83 patients. In 38 of 83 patients (45.8%) with positive CTA, the anatomy of the aorta and iliac arteries was considered suitable for endovascular repair. Exclusion from endovascular repair was due to unsuitable infrarenal neck or iliac anatomy (37 and 8 patients respectively). Overall, endovascular treatment was applicable in 38/128 patients (29.7%) with a RAAA in the Amsterdam region and in 38 out of 105 patients (35.5%) admitted to the trial centers.

CONCLUSION

In this prospective cohort of all patients with a RAAA in the Amsterdam Acute Aneurysm Trial region, the suitability for endovascular repair in patients with a RAAA confirmed on CTA is 45.8%, but the application rate was lower.

The Current Status of AAA Stent Grafting

It is now 16 years since the endovascular treatment of abdominal aortic aneurysm (AAA) was first described. It is probably true to say that, with current device technology, > 50% of all patients with an infrarenal aneurysm can be treated with an endograft. Endografting has become an important tool in the treatment of AAA. There are many reasons for this success. Rapid technical development followed the initial "homemade" devices, allowing easy accurate insertion. In early cohort series it was always the case that the operative mortality of endografting in AAA was lower than surgical treatment. In addition, postoperative management was easier and hospital stay was shorter after an endograft. No evidence indicated that quality of life improved after the perioperative period, however, and it was unclear whether the reduction in intensive hospital care requirement justified the considerable extra costs for an endovascular device. Despite these shortcomings, early widespread public awareness pushed endograft treatment forward. Patients started to ask for this new treatment option. But long-term outcome data then, and to some extent today, are still lacking.

Endovascular repair of an anastomotic leak following open repair of abdominal aortic aneurysm

This report describes the case of an early postoperative anastomotic leak following elective open repair of an infrarenal abdominal aortic aneurysm which was successfully treated by endovascular stent-grafting. A 71-year-old man underwent open tube graft repair of abdominal aortic aneurysm. Twelve days later he presented with a contained leak from the distal anastomosis, which was confirmed on CT scan. This was successfully treated with a bifurcated aortic stent-graft. This case illustrates the usefulness of the endovascular approach for resolving this rare surgical complication of open repair of abdominal aortic aneurysm and the challenges associated with the deployment of such a device within an aortic tube graft.

Fluoropolymer-coated Dacron Versus PTFE Grafts for Femorofemoral Crossover Bypass: Randomised Trial

OBJECTIVES

To investigate whether patency of a thin walled 8 mm fluoropassivated Dacron graft was similar to that of a standard 8mm PTFE graft for femorofemoral crossover bypass surgery.

DESIGN

A randomised multicentre clinical trial comparing two vascular grafts with participation of 10 departments of vascular surgery in Denmark, Sweden and Norway.

PATIENTS AND METHODS

198 patients were randomised to PTFE (n=107) or fluoropolymer-coated Dacron grafts (n=91), 63% underwent surgery for claudication, 27% for ischaemic rest pain and 10% for tissue loss. The median follow-up time was 24 months (IQR 19-26 months).

RESULTS

The primary patency rate of the two grafts was similar (log rank test: p=0.35). The primary patency rates (95% CI) for coated Dacron and PTFE grafts were 92% (86-98) and 94% (89-99) at 12 months and 87% (74-95) and 93% (87-99) at 24 months, respectively.

CONCLUSION

In patients with unilateral iliac artery disease not amenable to angioplasty, the femoral-femoral bypass is durable and effective. No difference in patency was found between the two graft materials (fluoropolymer coated Dacron and PTFE).

Duplex ultrasound criteria for femorofemoral bypass revision

PURPOSE

This study was conducted to evaluate the impact of duplex ultrasound surveillance on the patency of femorofemoral bypasses performed for symptomatic peripheral arterial occlusive disease (PAOD).

METHODS

A retrospective review was conducted of 108 patients (78 men, 30 women) with a mean age of 62 +/- 10 years who underwent femorofemoral prosthetic (n = 100) or vein (n = 8) bypass grafting for symptomatic PAOD (claudication, 38%; rest pain, 41%; tissue loss, 11%; infection, 10%) during a 10-year period. Prior or concomitant inflow iliac artery stenting was performed in 26 patients (24%), and a redo femorofemoral bypass was performed in 19 patients (18%). Duplex ultrasound surveillance of the reconstruction was performed at 6-month intervals to assess patency, graft (midgraft peak systolic flow velocity) hemodynamics, and identify inflow or outflow stenotic lesions. Repair was recommended for a stenosis with a peak systolic velocity (PSV) >300 cm/s and a PSV ratio >3.5. Life-table analysis was used to estimate primary, assisted-primary, and secondary graft patency.

RESULTS

During a mean 40-month follow-up (range, 2 to 120 months), 31 bypasses (29%) were revised: 19 duplex-detected stenosis involving the inflow iliac artery (n = 15) or anastomotic stenosis (n = 4), or both, 11 for graft thrombosis, and 1 for graft infection. Abnormal inflow iliac (PSV >300 cm/s) hemodynamics or a mid-graft PSV <60 cm/s was measured in eight of 11 grafts before thrombosis. Mean time to revision was 30 +/- 17 months. The primary graft patency at 1, 3, and 5 years was 86%, 78%, and 62%, respectively. Correction of duplex-detected stenosis resulted in assisted-primary patency of 95% at 1 year and 88% at 3 and 5 years (P < .0001, log-rank). Secondary graft patency was 98% at 1 year and 93% at 3 and 5 years.

CONCLUSIONS

Vascular laboratory surveillance after femorofemoral bypass that included duplex ultrasound imaging of the inflow iliac artery and graft accurately identified failing grafts. A duplex-detected identified stenosis with a PSV >300 cm/s correlated with failure, and repair of identified lesions was associated with excellent 5-year patency.

Endograft treatment of ruptured abdominal aortic aneurysms using the Talent aortouniiliac system: An international multicenter study

OBJECTIVE

To understand the potential of endovascular aneurysm repair (EVAR) in patients presenting with a ruptured abdominal aortic aneurysm (rAAA), the proportion in whom this procedure was applicable was assessed. Mortality and morbidity was also determined in patients treated with emergency EVAR (eEVAR) when anatomic and hemodynamic conditions allowed (ie, in the entire cohort with patients receiving endovascular and open repair combined). In addition, a comparison was made between the treatment group with eEVAR and open repair.

METHODS

Between February 2003 and September 2004, 10 participating institutions enrolled a representative sample of 100 consecutive patients in whom eEVAR was considered. Patients in the New Endograft treatment in Ruptured abdominal aortic Aneurysm (ERA) trial were offered eEVAR or open repair in accordance with their clinical condition or anatomic configuration. Written informed consent was obtained from all patients or their legal representatives. The study included patients who were treated by stent-graft technique or by open surgery in the case of adverse anatomy for endoluminal stent-grafting or severe hemodynamic instability, or both. Data were collated in a centralized database for analysis. The study was sponsored and supported by Medtronic, and eEVAR was uniquely performed with a Talent aortouniiliac (AUI) system in all patients. Crude and adjusted 30-day or in-hospital and 3-month mortality rates were assessed for the entire group as a whole and the EVAR and open repair category separately. Complication rates were also assessed.

RESULTS

Stent-graft repair was performed in 49 patients and open surgery in 51. No significant differences were observed between these treatment groups with regard to comorbidity at presentation, hemodynamic instability, and the proportion of patients who could be assessed by preoperative computed tomography scanning. Patients with eEVAR more frequently demonstrated a suitable infrarenal neck for endovascular repair, a longer infrarenal neck, and suitable iliac arteries for access than patients with open repair. The primary reason to perform open aneurysm repair was an unfavorable configuration of the neck in 80% of the patients. In patients undergoing eEVAR, operative blood loss was less, intensive care admission time was shorter, and the duration of mechanical ventilation was shorter (P < or = .02, all comparisons). The 30-day or in-hospital mortality was 35% in the eEVAR category, 39% in patients with open repair, and 37% overall. There was no statistically significant difference between the treatment groups with regard to crude mortality rates or rates adjusted for age, gender, hemodynamic shock, and pre-existent pulmonary disease. The cumulative 3-month all-cause mortality was 40% in the eEVAR group and 42% in the open repair group (no significant differences at crude and adjusted comparisons). The 3-month primary complication rate in the two treatment groups was similar at 59%.

CONCLUSIONS

In approximately half the rAAA patients, eEVAR appeared viable. An unsuitable infrarenal neck was the most frequent cause to select open repair. In dedicated centers using a Talent AUI system, eEVAR appeared to be a feasible method for treatment of a rAAA. The overall first-month mortality did not differ across treatment groups (patients with endovascular and open repair combined), yet was somewhat lower than observed in a recent meta-analysis reporting on open repair.

Complex iliac and bilateral common femoral artery aneurysms: a novel hybrid procedure

A 74-year-old man presented with a right common iliac artery aneurysm and bilateral common femoral artery aneurysms. These aneurysms were repaired by a hybrid procedure. A one-stage approach was chosen including an endovascular stent-graft and femoro-iliaco-femoral Y-bypass grafting. The authors describe a novel combined open and endovascular approach to repair these complex aneurysms.

Initial and Midterm Results for Repair of Aortic Diseases With Handmade Stent Grafts

BACKGROUND

The purpose of this study was to determine the initial and midterm results for repair of thoracic and abdominal aortic diseases using handmade stent-grafts (SGs).

METHODS AND RESULTS

Between 1999 and 2004, 41 consecutive patients (31 patients with thoracic and 10 patients with abdominal aortic disease) underwent endovascular stent-graft repair using handmade SGs. The follow-up averaged 24.8+/-17.6 months. The technical and initial clinical success rates were 82.9% (34/41) and 80.5% (33/41), respectively. Primary type I or III endoleaks occurred in 12.2% (5/41) of the patients. The hospital mortality rate was 4.9% (2/41). Persistent type I or III endoleaks occurred in 9.8% (4/41) and SG migrations occurred in 4.9% (2/41) of the patients. Open surgical conversion was undertaken in 12.2% (5/41) of the patients because of an endoleak and/or migration. The mean change observed in the aneurysm diameter was -6.2+/-10.5 mm, and shrinkage in the diameter occurred in 51.4% (18/35) of the cases. There was 1 patient death because of aneurysm rupture. Neither stent fracture nor graft hole was observed. The overall clinical success rate during follow-up was 78.0% (32/41).

CONCLUSION

The initial and midterm results obtained after repair of the aortic diseases using handmade SGs were considered to be satisfactory. More surgical experience and long-term patient follow-up are both required to further reassess the effect of this treatment.

Femorofemoral bypass with femoral popliteal vein

BACKGROUND

The femoropopliteal vein (FPV) has been used successfully for vascular reconstructions at multiple sites. To date, there have been no studies documenting patency of the FPV graft in the femorofemoral position. Our goal was to assess long-term patency of the FPV graft used for femorofemoral bypass (FFBP).

METHODS

Patients undergoing FFBP over a 10-year period were studied. Those in whom the FPV was used as a conduit were analyzed for runoff resistance score to assess how patients with poor runoff fared. Poor runoff was defined as a runoff resistance score of > or =7 (1 = normal runoff, 10 = total occlusion of all runoff vessels).

RESULTS

Fifty-four patients underwent FPV FFBP as a sole procedure (n = 16, 30%) or as a portion of an aortofemoral reconstruction with a FFBP component (n = 38, 70%). Mean (+/- SD) follow-up was 47 +/- 33 months. The 1-, 3-, and 5-year primary patencies were 97%, 93%, and 76%. The 5-year assisted primary and secondary patency rates were 85% and 90%. Among 27 patients with poor runoff (runoff resistance score of > or =7), the cumulative 40 month patency rate was 90%. Among patients in whom FPV FFBP was performed as a primary procedure (no aortofemoral component), there were no graft failures.

CONCLUSIONS

FFBP performed with FPV has excellent 1-, 3, and 5-year patency rates. FPV has sustained patency for FFBP in patients with poor runoff.

Endovascular AAA Repair With the Aortomonoiliac EndoFit Stent-Graft: Two Years' Experience

PURPOSE

To evaluate the feasibility and efficacy of a specific aortomonoiliac endograft and the durability of the femorofemoral bypass for treatment of abdominal aortic aneurysm (AAA).

METHODS

From 2002 to 2004, 39 high-risk (ASA III/IV) patients (36 men; median age 74 years, range 63-84) with AAA (n = 33) or AAA and common iliac artery aneurysm (n = 6) were treated with an EndoFit aortomonoiliac endograft and femorofemoral crossover bypass. The contralateral iliac axis was obstructed with an endoluminal occluder. Patients were followed with contrast-enhanced computed tomography at 1, 6, 12, and 24 months.

RESULTS

EndoFit AMI stent-grafts were implanted successfully in all patients. Perioperative mortality was zero. Endoleak occurred in 3 (7.7%) cases. A proximal type I endoleak was identified at 1 month and was treated with a proximal cuff. Two type II endoleaks are under surveillance because the aneurysm sac shows no enlargement. Thrombosis of the femorofemoral graft occurred in 1 case during the immediate postoperative period due to insufficient inflow from a residual stenosis of the endograft (primary patency 97.5%). The deficit was treated successfully (secondary patency 100%). Two (5.1%) tunnel hematomas were treated conventionally. Median follow-up was 14 months (range 6-30). All patients are alive. None of the aneurysms has ruptured or been converted to an open procedure. Graft migration, serious infection, paraplegia, distal embolization, or any other serious complication has not been observed.

CONCLUSIONS

In high surgical risk patients with complex iliac anatomy, aortomonoiliac endograft with femorofemoral crossover bypass is feasible and efficacious. Moreover, the midterm patency of the extra-anatomic bypass appears quite satisfactory.

Critical appraisal of femorofemoral crossover grafts

Background

The aim of this study was to determine how often femorofemoral crossover grafting for critical ischaemia or intermittent claudication gives an ideal result. An ideal result is an uncomplicated operation with primary wound healing, relief of ischaemic symptoms without recurrence and no need for further intervention.

Methods

All patients undergoing primary femorofemoral crossover grafting between January 1988 and December 2003 were studied.

Results

Some 144 operations were analysed; 51 patients had critical ischaemia and 93 claudication. There was one postoperative death (0·7 per cent). Complications occurred within 30 days in 32 patients (22·2 per cent), including graft occlusion in three (2·1 per cent); six patients (4·2 per cent) required early reoperation. Primary patency for patients with critical ischaemia was 88, 82 and 74 per cent at 1, 3 and 5 years respectively. Respective figures for those who presented with claudication were 93, 92 and 90 per cent (P = 0·034). Late symptoms included graft occlusion (20 patients), disease progression (25), ongoing ulceration (six), graft infection (nine), false aneurysm formation (two) and late donor-site stenosis (two).

Conclusion

When obtaining informed consent, simply describing patency and limb salvage rates does not provide an accurate picture of the outcome of femorofemoral grafting.

A temporary hemostatic valve in the short limb of a bifurcated stent-graft to facilitate endovascular repair of ruptured aortic aneurysm: experimental findings

PURPOSE

To evaluate a homemade tricuspid valve placed in the short limb of a bifurcated aortic stent-graft to facilitate endovascular treatment of ruptured abdominal aortic aneurysms (AAA).

METHODS

A valve consisting of 3 polytetrafluoroethylene cusps was constructed in the short limb of a bifurcated stent-graft. The endoprosthesis was placed into an in vitro circulation model with pulsatile flow. Angiography was performed before and after insertion of the second graft limb.

RESULTS

Angiographically, there was complete occlusion of the short limb before and normal patency after deployment of the second graft limb. Cannulation of the short limb with a guidewire was performed without technical difficulty.

CONCLUSIONS

Addition of a temporary hemostatic valve in the short limb of a bifurcated stent-graft can potentially reduce blood loss during endovascular treatment of ruptured AAAs.