Editor's Choice - Nationwide Analysis of Patients Undergoing Iliac Artery Aneurysm Repair in the Netherlands

OBJECTIVE

The new 2019 guideline of the European Society for Vascular Surgery (ESVS) recommends consideration for elective iliac artery aneurysm (eIAA) repair when the iliac diameter exceeds 3.5 cm, as opposed to 3.0 cm previously. The current study assessed diameters at time of eIAA repair and ruptured IAA (rIAA) repair and compared clinical outcomes after open surgical repair (OSR) and endovascular aneurysm repair (EVAR).

METHODS

This retrospective observational study used the nationwide Dutch Surgical Aneurysm Audit (DSAA) registry that includes all patients who undergo aorto-iliac aneurysm repair in the Netherlands. All patients who underwent primary IAA repair between 1 January 2014 and 1 January 2018 were included. Diameters at time of eIAA and rIAA repair were compared in a descriptive fashion. The anatomical location of the IAA was not registered in the registry. Patient characteristics and outcomes of OSR and EVAR were compared with appropriate statistical tests.

RESULTS

The DSAA registry comprised 974 patients who underwent IAA repair. A total of 851 patients were included after exclusion of patients undergoing revision surgery and patients with missing essential variables. eIAA repair was carried out in 713 patients, rIAA repair in 102, and symptomatic IAA repair in 36. OSR was performed in 205, EVAR in 618, and hybrid repairs and conversions in 28. The median maximum IAA diameter at the time of eIAA and rIAA repair was 43 (IQR 38-50) mm and 68 (IQR 58-85) mm, respectively. Mortality was 1.3% (95% CI 0.7-2.4) after eIAA repair and 25.5% (95% CI 18.0-34.7) after rIAA repair. Mortality was not significantly different between the OSR and EVAR subgroups. Elective OSR was associated with significantly more complications than EVAR (intra-operative: 9.8% vs. 3.6%, post-operative: 34.0% vs. 13.8%, respectively).

CONCLUSION

In the Netherlands, most eIAA repairs are performed at diameters larger than recommended by the ESVS guideline. These findings appear to support the recent increase in the threshold diameter for eIAA repair.

Midterm results of autologous saphenous vein and ePTFE pre-cuffed bypass surgery in peripheral arterial occlusive disease

INTRODUCTION

The graft of choice in lower limb bypass surgery is the autologous saphenous vein (ASV). However, a prosthetic graft is needed in the absence of an ASV. In such situations, we used an expanded polytetrafluoroethylene (ePTFE) pre-cuffed Dynaflo graft as supragenicular bypass or Distaflo graft as infragenicular or femorocrural bypass. In respect to the expanding possibilities of percutaneous transluminal angioplasty (PTA), the indication for bypass surgery moved toward patients with advanced stages of peripheral arterial occlusive disease. For this reason, this study analyzed the current performances of these ePTFE grafts and ASV grafts with special attention to limb salvage.

METHODS

In a retrospective study all patients who underwent peripheral bypass surgery between 2004 and 2008 were included. Kaplan-Meier curves were used to express primary patency, secondary patency, and limb salvage rates at 1 and 3 years. Log-rank tests were performed to compare graft types.

RESULTS

A total of 272 grafts (ePTFE/ASV: 110/162) were performed in lower limb bypass surgery. The mean follow-up was 20.3 months. The secondary 3-year patency rates were for (n=78) supragenicular grafts (ePTFE/ASV: 45%/94%)*, for (n=124) infragenicular grafts (24%/74%), and 70 for femorocrural grafts (26%/52%). Limb salvage after 3 years was 59% in the ePTFE group versus 78% in the ASV group (P < .05).

CONCLUSION

In the current population of vascular patients where no PTA is possible and a peripheral bypass is necessary, the ASV remains the graft of first choice. However, the pre-cuffed ePTFE graft is a good alternative, especially in cases of critical limb ischemia, in respect to an acceptable limb salvage rate.

Surgical removal of an infected aortic endoprosthesis using a wire cutter

The purpose of this study is to report a new method of removing an infected endoprosthesis from the abdominal aorta using a wire cutter. A 65-year-old man with a ruptured abdominal aortic aneurysm was admitted to our hospital. He was treated with an endovascular abdominal endoprosthesis and discharged one week later. Three months after placement, the patient returned with an infection of the aortic endoprosthesis. The endoprosthesis had been fixed with barbs and hooks above the renal arteries and was surgically explanted by using a wire cutter to cut the hooks. The bare suprarenal stent was left in place. The patient was discharged one month after stent removal, and was treated with oral antibiotics for another ten weeks. At one year follow-up the patient showed no clinical, biochemical, or radiological signs of infection. In conclusion, infected endoprostheses should be surgically removed according to the medical literature. We recognize that removing a Zenith endoprostheses requires a dangerous operation because the hooks of the bare stent are engaged into the supra-renal aorta. This case report documents a new technique to safely remove an infected endoprosthesis with the help of a wire cutter.