Endovascular aortounifemoral grafts and femorofemoral bypass for bilateral limb-threatening ischemia

Hybrid surgery for bilateral lower extremity inflow revascularization

OBJECTIVE

Aortobifemoral (ABF) bypass is the preferred method of bilateral inflow revascularization, with axillobifemoral (AXBF) bypass reserved for high-risk patients. Hybrid (HYB) surgery in the form of femorofemoral bypass and retrograde endovascular aortoiliac intervention is increasingly being used to achieve the same goal. This study compared the perioperative outcomes of HYB surgery with traditional surgery for bilateral inflow revascularization.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program files for the years 2012 to 2015 were reviewed, and all patients undergoing ABF bypass, AXBF bypass, and HYB surgery (femoral-femoral bypass and retrograde endovascular intervention) were included. Patients' demographics, comorbidities, and outcomes were compared between the three groups. A propensity-matched analysis was subsequently performed to compare HYB surgery with ABF bypass only. The χ² test and analysis of variance with post hoc analysis were conducted to evaluate between-group differences in risk factors and outcomes. SPSS statistical software (IBM Corp, Armonk, NY) was used.

RESULTS

There were 1426 patients (ABF bypass, 976; AXBF bypass, 257; HYB surgery, 193). There were significant differences in the three populations of patients, with ABF bypass patients significantly more likely to have age <70 years (ABF bypass, 84.2%; AXBF bypass, 49.8%; HYB surgery, 58%; P < .001) and more likely to be independent (ABF bypass, 98%; AXBF bypass, 89.1%; HYB surgery, 93.2%; P < .001). Patients undergoing AXBF bypass were significantly more likely to be treated for critical limb ischemia (ABF bypass, 46.5%; AXBF bypass, 72.4%; HYB surgery, 51.8%; P < .001) under emergent conditions (ABF bypass, 0.9%; AXBF bypass, 5.1%; HYB surgery, 3.6%; P < .001). There was no difference in mortality between the three groups (P = .178). After propensity matching, a total of 571 patients with ABF bypass were compared with HYB surgery patients. HYB surgery patients had significantly less pneumonia (ABF bypass, 8.7%; HYB surgery, 1.6%; P < .001), unplanned intubation (ABF bypass, 7.7%; HYB surgery, 3.1%; P = .032), cardiac arrest (ABF bypass, 3.7%; HYB surgery, 0.5%; P = .025), transfusion (ABF bypass, 44.4%; HYB surgery, 18.1%; P < .001), and composite morbidity (ABF bypass, 55%; HYB surgery, 32.6%; P < .001). Patients undergoing ABF bypass had significantly higher mortality (ABF bypass, 4.2%; HYB surgery, 1%; P = .043) and 30-day reoperation (ABF bypass, 17.5%; HYB surgery, 9.3%; P = .009) and longer total hospital length of stay (ABF bypass, 9.79 ± 10.69 days; HYB surgery, 5.79 ± 9.72 days; P < .001). There was no difference in major amputation (P = .607) and readmission (P = .495) between the two groups.

CONCLUSIONS

ABF bypass is the most common surgery for bilateral lower extremity revascularization in the American College of Surgeons National Surgical Quality Improvement Program database and continues to have good outcomes. In selected patients, HYB surgery was associated with improved perioperative, 30-day outcomes compared with ABF bypass.

Patency Rates of Femorofemoral Bypasses Associated with Endovascular Aneurysm Repair Surpass Those Performed for Occlusive Disease

Purpose:

To evaluate the patency rates of femorofemoral grafts performed in conjunction with aortomonoiliac or aortomonofemoral (AMI/F) endografts.

Methods:

Over the past 8 years, 110 patients (98 men; mean age 77 ± 7 years, range 57–90) underwent aortoiliac aneurysm repair with an AMI/F endograft. Follow-up data in these patients were prospectively collected for a mean 2.3 years (range 1–68 months).

Results:

There were 2 early (<7 days) AMI/F endograft thromboses with secondary femorofemoral graft occlusion. In both patients, patency of all grafts was restored by thrombectomy plus stenting of the endograft. Three late (4, 5, and 10 months) AMI/F endograft thromboses led to femorofemoral graft failure; 2 were successfully treated, but the third patient refused further intervention. No femorofemoral bypass failed in the absence of AMI/F endograft thrombosis. There were no femorofemoral graft infections. Four-year life-table primary and secondary patency rates were 95% and 99%, respectively.

Conclusions:

Femorofemoral bypasses with AMI/F endografts for aneurysmal disease are durable procedures and have better patency than femorofemoral grafts used to treat occlusive disease. Femorofemoral bypass patency rates alone are not a disadvantage of aortomonoiliac endografts.

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.

Increasing incidence of midterm and long-term complications after endovascular graft repair of abdominal aortic aneurysms: a note of caution based on a 9-year experience

OBJECTIVE

To analyze the late complications after endovascular graft repair of elective abdominal aortic aneurysms (AAAs) at the authors' institution since November 1992.

SUMMARY BACKGROUND DATA

Recently, the use of endovascular grafts for the treatment of AAAs has increased dramatically. However, there is little midterm or long-term proof of their efficacy.

METHODS

During the past 9 years, 239 endovascular graft repairs were performed for nonruptured AAAs, many (86%) in high-risk patients or in those with complex anatomy. The grafts used were Montefiore (n = 97), Ancure/EVT (n = 14), Vanguard (n = 16), Talent (n = 47), Excluder (n = 20), AneuRx (n = 29), and Zenith (n = 16). All but the AneuRx and Ancure repairs were performed as part of a U.S. phase 1 or phase 2 clinical trial under a Food and Drug Administration investigational device exemption. Procedural outcomes and follow-up results were prospectively recorded.

RESULTS

The major complication and death rates within 30 days of endovascular graft repair were 17.6% and 8.5%, respectively. The technical success rate with complete AAA exclusion was 88.7%. During follow-up to 75 months (mean +/- standard deviation, 15.7 +/- 6.3 months), 53 patients (22%) died of unrelated causes. Two AAAs treated with endovascular grafts ruptured and were surgically repaired, with one death. Other late complications included type 1 endoleak (n = 7), aortoduodenal fistula (n = 2), graft thrombosis/stenosis (n = 7), limb separation or fabric tear with a subsequent type 3 endoleak (n = 1), and a persistent type 2 endoleak (n = 13). Secondary intervention or surgery was required in 23 patients (10%). These included deployment of a second graft (n = 4), open AAA repair (n = 5), coil embolization (n = 6), extraanatomic bypass (n = 4), and stent placement (n = 3).

CONCLUSION

With longer follow-up, complications occurred with increasing frequency. Although most could be managed with some form of endovascular reintervention, some complications resulted in a high death rate. Although endovascular graft repair is less invasive and sometimes effective in the long term, it is often not a definitive procedure. These findings mandate long-term surveillance and prospective studies to prove the effectiveness of endovascular graft repair.

Adverse outcome following transfemoral endovascular stent-graft repair of an abdominal aortic aneurysm in a patient with severe liver dysfunction: report of a case

We describe herein the case of a patient with severe liver failure in whom an abdominal aortic aneurysm (AAA) extending to the right iliac artery was diagnosed. Because the risk of performing a standard open repair was considered too high in this patient, the aneurysm was uneventfully repaired using a technique of transfemoral endovascular stent-grafting with femorofemoral bypass and occlusion of the left common and right internal iliac arteries. Unfortunately, multiorgan failure associated with adult respiratory distress syndrome (ARDS) and disseminated intravascular coagulation (DIC) suddenly developed on postoperative day (POD) 2 and the patient died on POD 9. Thus, although endovascular stent-grafting is generally assumed to be less invasive and therefore feasible for high-risk patients, patients with severe liver dysfunction may not be suitable candidates.

Endovascular grafts and other image-guided catheter-based adjuncts to improve the treatment of ruptured aortoiliac aneurysms

OBJECTIVE

To report a new management approach for the treatment of ruptured aortoiliac aneurysms.

METHODS

This approach includes hypotensive hemostasis, minimizing fluid resuscitation, and allowing the systolic blood pressure to fall to 50 mmHg. Under local anesthesia, a transbrachial guidewire was placed under fluoroscopic control in the supraceliac aorta. A 40-mm balloon catheter was inserted over this guidewire and inflated only if the blood pressure was less than 50 mmHg, before or after the induction of anesthesia. Fluoroscopic angiography was used to determine the suitability for endovascular graft repair. When possible, a prepared, "one-size-fits-most" endovascular aortounifemoral stented PTFE graft was used, combined with occlusion of the contralateral common iliac artery and femorofemoral bypass. If the patient's anatomy was unsuitable for endovascular graft repair, standard open repair was performed using proximal balloon control as needed.

RESULTS

Twenty-five patients with ruptured aortoiliac aneurysms (18 aortic, 7 iliac) were managed using this approach. Balloon inflation for proximal control was required in nine of the 25 patients. Twenty patients were treated with endovascular grafts. Five patients required open repair. The ruptured aneurysm was excluded in all 25 patients; 23 survived. Two deaths occurred in patients who received endovascular grafts with serious comorbidities. The surviving patients who received endovascular grafts had a median hospital stay of 6 days, and the preoperative symptoms resolved in all patients.

CONCLUSIONS

Hypotensive hemostasis is usually an effective means to provide time for balloon placement and often for endovascular graft insertion. With appropriate preparation and planning, many if not most patients with ruptured aneurysms can be treated by endovascular grafts. Proximal balloon control is not required often but may, when needed, be an invaluable adjunct to both endovascular graft and open repairs. The use of endovascular grafts and this approach using other image-guided catheter-based adjuncts appear to improve treatment outcomes for patients with ruptured aortoiliac aneurysms.

Utility and reliability of endovascular aortouniiliac with femorofemoral crossover graft for aortoiliac aneurysmal disease

OBJECTIVE

The purpose of this study was to determine the early efficacy of endovascular aortouniiliac stent grafts with femorofemoral bypass graft in the treatment of aortoiliac aneurysmal disease.

METHODS

We analyzed 51 consecutive patients from January 1997 to March 1999 with a mean follow-up of 15.8 months. Patients ranged in age from 44 to 93 years (mean, 75 years) with a mean aortic aneurysm diameter of 6.2 cm. Technical success was achieved in 50 patients; one patient required conversion to open repair intraoperatively. We placed 28 custom-made and 22 commercial devices. The mean operative time was 223 minutes. The endograft was extended to the external iliac artery in 42% of cases. The contralateral common iliac artery was occluded using either a closed covered stent or intraluminal coils.

RESULTS

The median hospital stay was 4 days with an average intensive care unit stay of 0.25 days. There were no operative mortalities. Two patients died during follow-up from unrelated conditions. Endoleaks occurred in 11 patients (22%); seven patients (14%) required intervention (four catheter based, three operative). Other complications occurred in 38% of patients but were largely remote or wound related. One femorofemoral bypass graft occluded immediately postoperatively as a result of an intraprocedural external iliac dissection yielding a 98% primary patency and 100% secondary patency. Clinical success was achieved in 88% of patients.

CONCLUSIONS

These data suggest that this strategy represents a reliable method of repair of aortoiliac aneurysmal disease and extends the capability of an endoluminal approach to patients with complex iliac anatomy.

Standard and new treatments for abdominal aortic aneurysms: the value of the Montefiore endovascular grafts for difficult aneurysms

The mortality rate following rupture of an abdominal aortic aneurysm (AAA) is 80-90% and the main goal of treatment is to prevent rupture. Treatment of the aneurysm is generally recommended for patients with an aneurysm larger than 5 cm in diameter, and the only effective treatment has been to replace the aneurysm with a prosthetic graft. Traditionally, this is performed through a major laparotomy; that is, open surgical repair, which itself carries a mortality rate of 4-8% and requires a hospital stay of 7-10 days. In addition, some sick patients are deemed a prohibitive risk for such major surgery and, therefore, treatment may be deferred. Endovascular grafts (EVGs) that enable treatment of patients with AAA without the need for laparotomy were developed in the hope of improving on the shortcomings of the standard repair technique. In addition to the various industry-made EVGs the authors have been using a surgeon-made Montefiore Endovascular Grafting System (MEGS). The recent introduction of several industry-made devices has prompted some to postulate that MEGS is no longer required. The 60 patients with AAA treated from 1 July 1997 to 30 June 1998 were evaluated for the inclusion criteria for industry-made EVG protocols. Those excluded from these protocols were evaluated for the MEGS. Open surgical repair was reserved for those unsuitable for any EVG repair or those not consenting to EVG repair. Thirty-seven percent of all cases could be treated with an industry-made device. By using the MEGS, an additional 43% of the cases could be treated endovascularly. In total, 80% of AAAs were able to be treated endovascularly. The reasons for excluding patients from industry-made devices were a combination of the following factors: (1) Short (<1.5 cm) or angulated (>60) proximal necks, (2) iliac artery aneurysms, (3) small, diseased or tortuous access arteries, and (4) small distal aortas. The mean length of stay for those treated endovascularly was 2.3 days, whereas it was 9 days for those treated by open surgery. There was no difference in the morbidity and mortality rates. EVG repair is feasible and safe for the majority of patients with AAAs; however, long-term durability is yet to be shown. Despite the availability of industry-made devices, there appears to be a continuing role for MEGS, especially for difficult aneurysms including those patients with complex anatomy and those with ruptured AAAs.

Midterm experience with the endovascular treatment of isolated iliac aneurysms

PURPOSE

This report describes our 5-year experience with the endovascular repair of isolated iliac aneurysms and pseudoaneurysms.

METHODS

Between June 1993 and July 1998, 40 isolated iliac aneurysms and pseudoaneurysms were treated with endovascular grafts in 39 patients. Thirty-seven aneurysms were treated with endovascular grafts composed of polytetrafluoroethylene grafts and balloon expandable stents, and the other three underwent repair with a polycarbonate urethane endoluminal graft.

RESULTS

All the patients underwent initially successful endovascular treatment of isolated iliac aneurysms and pseudoaneurysms and were followed from 1 to 51 months (mean, 18 months). The 4-year primary patency rate was 94.5% +/- 10%. The perioperative complications included one episode of distal embolization, an episode of colonic ischemia, five episodes of kinking or compression of the endovascular graft, and one early postoperative graft thrombosis. There was only one perioperative death in a patient whose aneurysm ruptured in the operating room just before endovascular repair. The median postoperative length of hospital stay was 3.0 +/- 1.3 days in this group of patients at moderate and high risk. The long-term complications included one graft thrombosis and two endoleaks. One small endoleak was followed until the patient died of unrelated causes, and the other one led to aneurysm rupture in the only patient temporarily lost to follow-up examination. This patient successfully underwent treatment in the standard open surgical fashion. To date, all the other aneurysms have remained stable or have decreased in size during the follow-up examinations with duplex or contrast-enhanced computed tomographic scans.

CONCLUSION

Endovascular repair of iliac aneurysms and pseudoaneurysms is a safe and effective technique with good midterm results in patients at standard and high risk. These grafts are particularly beneficial for patients with medical, surgical, or anatomic contraindications for open surgical repair.

Analysis of endovascular graft treatment for aortoiliac occlusive disease: what is its role based on midterm results?

OBJECTIVE

To analyze the authors' midterm results (up to 4 years) using endovascular grafts to treat aortoiliac occlusive disease in patients with limb-threatening ischemia.

SUMMARY BACKGROUND DATA

Endovascular grafts are being used to manage some aortoiliac lesions formerly treated by aortofemoral or extraanatomic bypass grafts. However, widespread acceptance of these new grafts depends on their late patency and clinical utility.

METHODS

Between January 1993 and December 1997, 52 patients with aortoiliac occlusive disease were treated with endovascular grafts. The primary indication for treatment was gangrene or ulceration in 42 patients (81%) and rest pain in 10 patients (19%). Sixteen patients had symptomatic contralateral limbs that were also treated, and 27 (52%) patients required a synchronous infrainguinal bypass. Results up to 4 years were evaluated by life table analysis.

RESULTS

Forty-six (88%) of the patients had complete follow-up of 3 to 57 months (median 22 months). Six patients were lost to follow-up at a mean of 20 months after surgery. The 4-year primary and secondary patency rates for the endovascular grafts were 66.1% and 72.3% respectively. Six patients required a major amputation, and the limb salvage rate was 88.7%. Four-year patient survival was 37%, with 23 patients dying during this follow-up period.

CONCLUSIONS

Endovascular grafts can often be used when conventional procedures are contraindicated or technically impractical. These grafts are a valuable alternative to extraanatomic and aortofemoral bypasses in high-risk patients with aortoiliac occlusive disease and critical ischemia.

Endovascular graft repair of ruptured aortoiliac aneurysms

BACKGROUND

The feasibility of endovascular graft (EVG) repair of ruptured aortoiliac aneurysms (AIAs) has yet to be demonstrated. There are inherent limitations in EVG repair, including the need for preoperative measurements of the aneurysmal and adjacent arterial anatomy to determine the appropriate size and type of graft and the inherent delay to obtain proximal occlusion. We developed an EVG system with broad versatility that largely eliminates these problems.

STUDY DESIGN

Between 1993 and 1998, within an experience of 134 endovascular AIA repairs, 12 ruptured AIAs were treated using EVGs that facilitated intraoperative customization and eliminated the need for preoperative measurements. The EVGs consisted of either a Palmaz stent and a PTFE graft deployed by a compliant balloon (n = 9) or a self-expanding covered stent graft (n = 3). Both grafts were cut to the appropriate length intraoperatively. The mean age of the patients was 72 years (range 40 to 86 years). The mean size of the aneurysms was 7.6 cm (range 3 to 16 cm). Preoperative symptoms were present in all patients and included abdominal or back pain (n = 9), syncope (n = 4), and external bleeding (n = 2). All patients were high surgical risks because of comorbid disease (n = 10) or previous abdominal operations (n = 6), and nine experienced hypotension.

RESULTS

All EVGs were inserted successfully and excluded the aneurysms from the circulation. The mean operating time was 263 minutes, the mean blood loss was 715 mL, and the mean length of hospital stay was 6.5 days. There were two deaths (16%), one from the preexisting acute myocardial infarction and one from multiple organ failure. There were three minor complications (25%). Two patients required evacuation of an intraabdominal hematoma from the initial rupture. All but one of the grafts was functioning at a mean followup of 18 months.

CONCLUSIONS

This study demonstrates the feasibility of EVG repair for ruptured AIAs using a graft that can be customized intraoperatively for each patient. Such repairs currently are valuable in patients with ruptured AIAs and serious comorbidities and may be applicable in other circumstances as well.