Surgical treatment for primary infected aneurysm of the descending thoracic aorta,abdominal aorta,and iliac arteries

OBJECTIVE AND METHOD: In this retrospective review, we report the surgical results of infected aortic aneurysms treated at a single center over 5 years. RESULTS: From October 1996 to October 2001, 19 patients with infected aortic aneurysm were treated with surgery, nine with suprarenal infections (four proximal descending thoracic aortic aneurysms, two distal descending thoracic aortic aneurysms, and three suprarenal abdominal aortic aneurysms) and 10 with infrarenal infections (eight infrarenal abdominal aortic aneurysms and two iliac artery aneurysms). All had a positive blood or tissue culture; 89% were febrile, 89% had leukocytosis, and 32% were hemodynamically unstable. The most common responsible pathogens were Salmonella organisms (74%) followed by Streptococcus species (11%). Nine of 10 infrarenal infections were caused by Salmonella organisms. Both infrarenal and suprarenal infections were treated with wide débridement of infected aorta, in situ prosthetic graft or patch repair, and prolonged intravenous antibiotics. Hospital survival rate was 95%: 100% for infrarenal and 89% for suprarenal infections. There was no perioperative intestinal ischemia or perioperative limb loss. Acute renal failure occurred in two patients with suprarenal infection. Late deaths have occurred in three patients with one early graft infection (5%) resulting in the only one in-hospital death at 4 months. Sixteen patients remain alive at mean follow-up of 17.8 months (range, 4-47 months). There have been no late aortic or graft infections. During the same period, there were five unoperated patients, four of whom died of shock during hospitalization. CONCLUSIONS: Infected aortic aneurysm is common in Taiwan, and Salmonella species were the most common responsible microorganisms. With surgical intervention and prolonged intravenous antibiotics, in situ graft replacement provided a good outcome. The incidence of prosthetic graft infection was low, even in patients with infections due to Salmonella species and with in situ graft replacement.     

The management of aortoenteric and paraprosthetic fistulae

Aortoenteric and aortic paraprosthetic fistulae are devastating complications. Most authors recommend total excision of the graft and revascularization of the lower extremities by extra-anatomic bypass. We reviewed the University of Pittsburgh experience with these fistulae in 15 patients between 1977 and 1987. There were 9 aortoenteric fistulae (AEF) and 6 paraprosthetic fistulae (PPF). Seven of the 9 AEF had no abscess surrounding the graft, but communication of the intestine with the aortic anastomosis. One patient died during operation. Six patients underwent a local repair or in situ replacement of the graft. All 6 of those patients survived operation without limb loss. Two of the 9 patients with AEF had evidence of graft infection and underwent total excision of the graft and extra-anatomic reconstruction. Both patients died, one of sepsis and one of aortic stump rupture. All 6 patients with PPF had clinical and operative evidence of overt graft infection and underwent total graft excision and extra-anatomic bypass. Two of these patients died secondary to sepsis. We conclude that AEF, without evidence of graft infection, were safely treated by local repair. Patients with PPF had infected grafts requiring graft removal with significant morbidity and mortality.     

Graft excision and extra-anatomic revascularization: the treatment of choice for the septic aortic prosthesis

Graft excision and extra-anatomic revascularization is the treatment of choice for the septic aortic prosthesis. From 1979 to 1988, 20 patients underwent resection of aortic grafts and extra-anatomic bypass for the treatment of graft infections (No. 11) and aorto-enteric fistulas (No.9). The mean time interval from primary aortic surgery to the reoperative procedure was 65 months (range 1-192 months). Three patients died (one less than 30 days) after the secondary procedure for a mortality rate of 15%. One patient developed infection of the extra-anatomic bypass graft which resulted in an above-knee amputation. This was the only major limb loss in this series. A second patient developed contralateral buttock necrosis when he had unilateral axillary-femoral bypass without femoral-femoral bypass because of a previous above-knee amputation on the affected side. Major complications occurred in 7 patients (35%). Mean duration of follow-up after the reoperative aortic procedure was 44 months (range 6-120 months). One patient suffered aortic stump blowout 7 months after repair of an aortic duodenal fistula. Aortic graft excision and extra-anatomic revascularization of the lower extremities can be performed with low mortality and risk of limb loss and should remain the treatment of choice for aorto-enteric fistulas and infected aortic prostheses. Bilateral groin revascularization is important even in patients who have had a previous lower extremity amputation to provide pelvic blood flow.     

The results of in situ prosthetic replacement for infected aortic grafts.

BACKGROUND: Treatment of aortic graft infection with graft excision and axillofemoral bypass may carry an increased risk of limb loss, aortic stump blowout, and pelvic ischemia. A review of patients with aortic graft infection treated with in situ prosthetic graft replacement was undertaken to determine if mortality, limb loss, and reinfection rates were improved with this technique. METHODS: The clinical data of 25 patients, 19 males and 6 females, with a mean age of 68 years (range 35 to 83), with aortic graft infection, treated between January 1, 1989, and December 31, 1998, by in situ prosthetic graft replacement were reviewed. Follow-up was complete in the 23 surviving patients and averaged 36 months (range 4 to 103). RESULTS: Twenty aortofemoral, 3 aortoiliac, and 2 straight aortic graft infections were treated with excision and in situ replacement with standard polyester grafts in 16 patients (64%), or with rifampin-soaked collagen or gelatin-impregnated polyester grafts in 9 patients (36%). Fifteen patients (60%) had aortic graft enteric fistulas, 8 patients (32%) had abscesses or draining sinuses, and 2 patients (8%) had bacterial biofilm infections. Thirty-day mortality was 8% (2 of 25). There were no early graft occlusions or amputations. There was one late graft occlusion. There were no late amputations. The reinfection rate was 22% (5 grafts). All reinfections occurred in patients operated upon for occlusive disease. Only one reinfection occurred in the rifampin-soaked graft group (11% versus 29%, P = NS). Reinfection tended to be lower in patients with aortoenteric fistulas and without abscess. Autogenous tissue coverage provided statistically significant protection against reinfection. There were no late deaths related to in situ graft infection. CONCLUSIONS: Patients treated with in situ graft replacement had an 8% mortality and 100% limb salvage rate. Reinfection rates were similar to those of extra-anatomic bypass, but a trend of lower reinfection rates with rifampin-impregnated grafts was apparent. Patients with aortoenteric fistula and without abscess appear to be well treated by the technique of in situ prosthetic grafting and autogenous tissue coverage.     

Surgical treatment of infected aneurysms and pseudoaneurysms of the thoracic and abdominal aorta

BACKGROUND: To review the outcome of infected aneurysms and pseudoaneurysms of the thoracic and abdominal aorta treated in a major teaching hospital. METHODS: Between December 1994 and January 2003, 13 infected aortic aneurysms and pseudoaneurysms (5 thoracic, 4 paravisceral, 4 infrarenal) in 10 consecutive patients were treated surgically. Aortic debridement with in situ reconstruction is our standard practice. Endovascular repair was offered to suitable patients with thoracic aortic involvement. RESULTS: There were six men and four women with a mean age of 63 years. The commonest pathogen was Salmonella species, accounting for 50% of the cases. Aortic debridement with in situ revascularization was performed for six patients with visceral reconstruction in four of them. One patient with aortic bifurcation involvement and gross purulent infection had ligation and debridement followed by right axillobifemoral bypass. Four infected thoracic aortic pseudoaneurysms in three other patients underwent endovascular repair. There was no hospital death, limb loss, renal failure, or intestinal ischemia. There were two late deaths from sepsis and pneumonia at 3 months and 77 months after operation. Eight patients were alive after a mean follow-up of 36 months and no late graft infection was evident. CONCLUSIONS: Surgical treatment for infected aortic aneurysms with in situ reconstruction is associated with favorable outcome and good long-term result. Endovascular repair has a potential role.     

Adjunctive primary stenting of Zenith endograft limbs during endovascular abdominal aortic aneurysm repair: implications for limb patency

OBJECTIVE: Endograft limb occlusion is an infrequent but serious complication of endovascular abdominal aortic aneurysm (AAA) repair. The insertion of additional stents within the endograft limb may prevent future occlusion. This study evaluates limb patency with and without adjunctive stenting of endograft limbs at the time of endovascular AAA repair. METHODS: We performed a retrospective review of 248 patients who underwent endovascular abdominal aortic aneurysm repair with the Zenith AAA endovascular graft between 1999 and 2004. Among these patients, two groups were identified: 64 patients with adjunctive stents placed in 85 limbs and 184 patients without additional bare stent placement in endograft limbs at the time of endovascular AAA repair. RESULTS: Women comprised 23% of stented and 11% of unstented patients (P = .02). The mean length of follow-up in the stented and unstented groups was 2.0 years. There were 13 instances of limb thrombosis in 13 patients (5.2% of patients, 2.7% of limbs), all in the unstented group. No limb occlusions occurred in the presence of adjunctive bare metal stents. Seventy-three percent of the occlusions occurred < or = 6 months of endovascular AAA repair. Two patients (15%) had no symptoms of lower-extremity ischemia despite graft limb occlusion and did not undergo intervention. The others underwent thrombectomy (n = 2), thrombectomy with bare stent placement (n = 3), femoral-femoral bypass (n = 4), thrombolysis (n = 1), and thrombolysis with bare stent placement (n = 1). Of the seven who underwent thrombectomy or thrombolysis, three had no additional stents placed at the secondary procedure, and two of these three went on to rethrombose. By life-table analysis, primary patency at 3 years in the stented and nonstented limbs was 100% +/- 0% and 94% +/- 3%, respectively (P = .05). CONCLUSIONS: The intraoperative insertion of additional bare metal stents appeared to eliminate the risk of thrombosis and was without complication. Of the 85 stented limbs in this series, not one occluded. The overall rate of limb thrombosis was low, with most limb occlusions occurring < or = 6 months of stent-graft insertion, and would probably have been even lower had we been able to identify all high-risk cases for prophylactic adjunctive stenting. Limb occlusion denotes an underlying problem with the graft, which if left untreated after thrombectomy or thrombolysis will lead to rethrombosis. Postoperative imaging was of little value in detecting impending limb occlusion. Based on these findings, we believe one should identify and stent any limbs that appear to be at risk for thrombosis, but this study lacks the data to predict which limbs need stenting.     

Intermediate-term complications and problems after endovascular aortic stent prostheses

From August 1994 to December 1998 321 patients were treated with endovascular stentgrafts for aortic aneurysm exclusion in our hospital. Primary exclusion rate was 91% (primary leakage 8.7%) and hospital mortality was 3.7%. 6 different types of grafts were used, 5 of them commercially available. Midterm complications are due to configuration changes of the grafts, material deterioration, side branch reperfusion and changes in aortic morphology. The common pattern of clinical expression of these complications is secondary leakage (60 cases) and graft limb occlusion (37 occurrences in 30 patients). 50% of the secondary endoleaks have been treated up to now leaving the remaining patients under a thorough follow-up. Graft limb thrombosis was treated in all but three, well compensated, patients. Midterm results of the first commercially available endografts are not yet satisfying in contrast to conventional aortic repair. The recently available grafts are promising as they have a better kink resistance, no graft sutures and fewer modular components.     

Femorofemoral bypass graft: choice or compromise?

Thirty-one femorofemoral crossover graft procedures were performed in 27 patients who had unilateral limb ischemia either due to unilateral aortoiliac occlusive disease of due to thrombosis of one of the limbs of a previously placed aortic bifurcation graft. There was no operative mortality, and only two patients required late amputation. There have been two late deaths. Thrombosis of the femorofemoral graft occurred in five patients. Four patients had a second femorofemoral graft, three of whom have long-term patency. Grafts are patent in 23 of 25 surviving patients. The femorofemoral graft procedure is relatively simple and is associated with a low operative mortality and morbidity. Its late patency rates are comparable with those following conventional aortic bifurcation graft procedures. Therefore, we believe the indications for femorofemoral graft should be broadened to include all patients with unilateral aortoiliac occlusive disease where anatomic conditions are favorable and there is unilateral occlusion of an aortic bifurcation graft.     

Transcarotid artery endovascular reconstruction of the aortic arch by modified bifurcated stent graft for Stanford type A dissection

A 40-year-old man with Stanford type B dissection underwent his first endovascular repair (EVAR) in April 2004 by Talent thoracic stent graft. He had an uncomplicated recovery and maintained good blood pressure control. However, a new retrograde dissection appeared in September 2004. The new dissection involved his aortic arch and ascending thoracic aorta to the opening of the coronary arteries. To reconstruct the aortic arch, bypasses between the right common carotid artery (RCCA), left common carotid artery and left subclavian artery were performed before endovascular repair. A modified bifurcated Talent stent graft was deployed from the RCCA to the ascending thoracic aorta with a long limb in the innominate artery and a short limb in the aortic arch. A further two pieces of graft were deployed via the common femoral artery. The ascending thoracic aorta and aortic arch were reconstructed completely by the bifurcated stent graft. The final angiography confirmed that there was good stent graft configuration, normal blood flow, and stable haemodynamics. No endoleak or other major complications were encountered. This result indicated that it is possible to reconstruct the aortic arch with a bifurcated stent graft and could be a new endovascular repair model for complex thoracic aortic aneurysm and dissection.     

Evaluation of spinal cord ischemia in endovascular stent graft repair and surgical operation of descending thoracic or thoracoabdominal aortic aneurysms

Between October 1996 and June 2003, endovascular stent graft repair was performed in 87 patients with descending thoracic aortic aneurysms, graft replacement was performed in 24 patients with thoracoabdominal aortic aneurysms, and endovascular stent graft repair with concomitant surgical bypass of abdominal visceral arteries was performed in 3 patients with thoracoabdominal aortic aneurysms. The retrievable stent graft was inserted and evoked spinal cord potential were monitored in order to predict spinal cord ischemia for stent graft repair. There was no paraplegia or hospital death, although 3 patients had paraparesis in stent graft repair. Two of the 3 patients with paraparesis made a full neurologic recovery. There were no cases of paraplegia or paraparesis in surgical operations with thoracoabdominal aortic aneurysm. The concomitant surgical procedure was a good technique for patients in whom cardiopulmonary bypass could not be used. Our results of stent graft repair and surgical operation for descending thoracic or thoracoabdominal aortic aneurysms were acceptable. The retrievable stent graft was useful for prediction of spinal cord ischemia before endovascular stent graft repair of descending thoracic or thoracoabdominal aortic aneurysm.     

Endovascular graft limb occlusion

Endovascular aneurysm repair (EVAR) has undergone a tremendous evolution in the nearly 15 years since it was first described. Continual refinement of the technology and techniques associated with EVAR and the respectable short-term results of this procedure led the United States Food and Drug Administration to approve several devices for the endovascular treatment of abdominal aortic aneurysm (AAA). There has been a corresponding rapid dissemination of this technology throughout the vascular surgery community in the United States. Availability and critical analysis of mid- and long-term follow-up data on the increasing number of patients who have undergone EVAR has begun to raise questions about the long-term durability and effectiveness of EVAR. Numerous complications of EVAR are now recognized and well described in the literature. One of these is graft limb dysfunction. Graft limb occlusion occurs in a significant number of patients and it is imperative that physicians who perform EVAR have a thorough understanding of this condition. There are a variety of factors that predispose patients to development of graft limb occlusion. These factors can be classified as either anatomic or graft-related. When patients present with graft limb occlusion, endovascular treatment is usually possible and it is highly effective. Some cases require traditional surgical treatment. Prevention of graft limb occlusion is of paramount importance. It can only be achieved with an aggressive search for graft limb compromise and liberal use of angioplasty and/or stenting at the time of graft implantation.     

Migration of a bifurcated endovascular graft into an iliac aneurysm: endovascular salvage and future prevention--a case report

The FDA approval of endovascular grafts for the treatment of abdominal aortic aneurysms has been associated with a dramatic increase in the use of these devices. Major referral centers are reporting the treatment of 75% to 80% of their patients with infrarenal abdominal aortic aneurysms with endovascular devices. The large quantity of endovascular devices being used has produced a growing number of management issues that are often not predictable during the preoperative assessment. These issues require complex intraoperative decision making and innovative techniques for their management as reflected by the subsequent case report. An 82-year-old patient presented with a 7.8-cm abdominal aortic aneurysm. The aneurysm extended into the common iliac arteries bilaterally. The right common iliac artery was 6.5 cm and the left common iliac artery was 2.0 cm in maximal diameter. The preoperative work-up, including a computed tomography scan and arteriogram, suggested that he would be a potential candidate for endovascular repair. The plan was to extend the graft into the right external iliac artery after embolization of the right hypogastric artery and to seal the left limb in the ectatic left common iliac artery using an aortic extender cuff. During the endovascular repair of the aortoiliac aneurysms using the AneuRx bifurcated graft, the main device became dislodged from its infrarenal attachment site and migrated into the large right common iliac artery aneurysm with the iliac limb ending in the distal external iliac artery. A new bifurcated device was deployed from the left side to attempt an endovascular salvage of the difficult situation. The new graft was partially deployed down to the iliac limb. This allowed cannulation of the contralateral stump through the original endovascular graft that had migrated distally. The two grafts were connected with a long iliac limb. This allowed stabilization of the endovascular reconstruction by increasing its columnar strength. The deployment of the second bifurcated graft was completed and the central core with the runners removed safely without migration of the second bifurcated component. The reconstruction was completed with an aortic cuff in the left common iliac artery. The use of the aortic cuff was useful to preserve the left hypogastric artery. No intraoperative endoleak was noted. The patient did well and was discharged the day following the procedure. The follow-up computed tomography scan shows the abdominal aortic aneurysm excluded by the endovascular graft with a defunctionalized portion of one bifurcated graft within the right common iliac aneurysm. There is no evidence of endoleak and the abdominal aortic aneurysm had decreased in size at 6 months. This case demonstrates one of the unique management problems that may arise during endovascular graft placement. Events that initially would suggest failure of the endoluminal treatment may be corrected using advanced endovascular techniques by an experienced surgeon. However, there will be times that the prudent decision will be conversion to open repair. Only good clinical judgement and adequate training will prevent catastrophic outcomes.     

Endovascular repair of ruptured abdominal aortic aneurysms: experience in a community hospital

The endovascular technique has been recently used as an alternative procedure for selected patients with ruptured abdominal aortic aneurysm (RAAA) as a result of the potential for decreasing morbidity, mortality, and recovery time. We examined our institution's results with endovascular repair of RAAA. Between July 2005 and April 2006, four patients underwent endovascular repair of infrarenal RAAA. We performed a retrospective analysis of our comorbidities, operation time, length of intensive care unit and hospital stay, morbidity and mortality, blood transfusions, and secondary interventions on these patients at our institution. The median age was 73.2 years (range, 66-82 years); 75 per cent were male and 25 per cent were female. Mean operating time was 90 minutes. We had no operative or postoperative mortalities. Five complications occurred in three patients. These included acute renal failure, common femoral artery intimal dissection, graft thrombosis of the iliac limb, ischemic colitis, and chronic obstructive pulmonary disease exacerbation. Endovascular repair of RAAA by an endovascular team is feasible in the community hospital setting. Our limited number of patients in this study does not allow us to compare it directly with results from the standard open procedure. A larger, multicenter study may eventually show this method to be helpful in patients who require repair of RAAA.     

Surgical treatment of acute ascending aortic dissection.

Since adopting a policy of immediate operation on patients with acute dissection of the ascending aorta, 42 men and 6 women (ages 18-67 years) have been managed surgically. Thirty-two patients had graft replacement of the ascending aorta and resuspension of the incompetent aortic valve. One of these had a coronary graft. There were five deaths in this group. Eight patients required aortic valve replacement because of a diseased aortic valve as well as grafting of the ascending aorta, with one death. Three patients had resuspension of the aortic valve and primary repair of their dissection without mortality. Two patients were managed successfully with an intraluminal prosthesis and resuspension of the aortic valve. Another patient had successful repair with a valved conduit and reimplantation of the coronaries. Two patients dissected 4 and 6 years after aortic valve replacement and neither survived operative repair. Of the surviving patients, one required dialysis, one a femoral-femoral bypass graft, and one an axillo-femoral bypass graft. One patient required a pacemaker for heart block, and two underwent successful repair of suture line aneurysms, both occurring three years after operation. On the basis of this experience, prompt surgical intervention for acute ascending aortic dissection is the treatment of choice. A variety of techniques are available to repair the dissected aorta. Long-term results for resuspension of the aortic valve in acute ascending aortic dissection have been excellent and emphasize that valve replacement should be reserved for those patients found at operation to have a primary abnormality of the aortic valve.     

Incidence of gross and microscopic carcinoma in specimens from patients with breast cancer after re-excision lumpectomy.

OBJECTIVE: This study reviews the outcome of 61 patients who underwent 66 reoperations for complications of aortic grafts. There were 25 patients with false aneurysm of an aortic anastomosis and 41 patients with graft infection, 17 of whom had involvement of the gastrointestinal tract. SUMMARY BACKGROUND DATA: Significant late complications of aortic grafting occurred in 2% of patients. The mode of clinical presentation, the clinical characteristics, and outcome in these patients has not been emphasized. METHODS: This study reviews our experience with patients with complications of aortic grafts requiring graft excision or replacement with a view towards identifying prominent and important clinical characteristics and predictors of successful treatment. CONCLUSIONS: Patients with involvement of the gastrointestinal tract have higher mortality and morbidity than patients with simple aortic graft infection or those who require aortic graft replacement for pseudoaneurysm formation at the aortic anastomosis. These patients require longer hospitalization, more blood transfusion, and have higher operative and long-term mortality. Revascularization of the lower extremities should be attempted and has a high rate of limb salvage although revision or thrombectomy may be required. The authors recommend complete graft excision and extra-anatomic bypass for patients with aortic graft infections.     

The role of aortic neck dilation and elongation in the etiology of stent graft migration after endovascular abdominal aortic aneurysm repair with a passive fixation device

OBJECTIVE: Endovascular repair of abdominal aortic aneurysm (AAA) is complicated by the potential for stent graft migration over time. Factors including the type of fixation, initial proximal fixation length, and dilation and elongation of the infrarenal aortic neck may contribute to device migration. We sought to determine when device migration is a real phenomenon with actual device movement that compromises aneurysm exclusion. METHODS: Computed tomographic (CT) scans and computer reconstructions of all patients undergoing endovascular AAA repair with a passive fixation device at our institution from June 1996 to October 2004 were retrospectively reviewed. The distance from the distal renal artery to the proximal end of the stent graft at the time of initial deployment was determined for each patient. Migration was defined as a distance increase greater than 5 mm in the follow-up period; proximal fixation length, aortic neck enlargement and elongation, and neck angle were then measured. Data were further analyzed with respect to AAA growth, development of endoleak, AAA rupture, and the need for reintervention. RESULTS: A total of 308 patients with endovascular AAA repairs using a passive fixation device had complete postoperative imaging data sets; 48 patients (15.6%) with stent graft migration of 5 mm or more were identified, and 25 (8.1%) of these had a migration of 10 mm or more. Seventeen (35.4%) of 48 migration patients had a total loss of the proximal seal zone (loss patients); their average migration distance was 17.7 +/- 12.0 mm, with a mean neck shortening of 13.6 +/- 14.2 mm, and the average proximal fixation length loss was 14.0 +/- 7.6 mm. Those 31 patients with an intact proximal seal zone (nonloss patients) showed an average migration of 9.4 +/- 3.7 mm, with a mean neck lengthening of 9.6 +/- 8.4 mm and an average proximal fixation length change of 0.7 +/- 8.0 mm. Univariate analysis demonstrated significant differences between the loss and nonloss patients in follow-up duration (65.9 +/- 20.4 months vs 45.9 +/- 26.4 months; P = .01), neck dilatation at the distal renal artery (4.6 +/- 4.5 mm vs 1.8 +/- 1.9 mm; P = .026), stent graft migration distance (17.7 +/- 12.0 mm vs 9.4 +/- 3.7 mm; P = .001), change in aortic neck length (-13.6 +/- 14.2 mm vs 9.6 +/- 8.4 mm; P < .0001), change in proximal fixation length (-14.0 +/- 7.6 mm vs 0.7 +/- 8.0 mm; P < .0001), change in AAA size (1.8 +/- 7.1 mm vs -3.6 +/- 9.7 mm; P = .033), and use of a stiff body stent graft (47.1% vs 19.4%; P = .043). However, only change in aortic neck length was statistically significant on multivariate analysis (odds ratio, 0.75; 95% confidence interval, 0.591-0.961; P = .022). There were no differences between the loss and nonloss patients in time to migration discovery, initial AAA size, initial aortic neck diameter or length, initial device oversizing, initial neck angle, neck angle increase, type II endoleak, or AAA rupture. Eight of the 17 loss patients have been treated with proximal aortic cuffs; the remainder have refused reintervention, died of unrelated causes, or elected to have open repair. CONCLUSIONS: Postoperative elongation of the infrarenal aortic neck may create the radiographic perception of migration without necessarily causing a loss of proximal stent graft fixation. Patients with a total loss of the proximal seal zone actually have infrarenal aortic neck shortening, with a degree of neck dilatation beyond initial device oversizing that may compromise proximal fixation length. Conversely, those with an intact proximal seal zone demonstrate aortic neck elongation equivalent to migration, with no loss of proximal fixation length; these patients have a benign natural history without intervention. Thus, aortic neck dilatation beyond oversizing, aortic neck shortening, and loss of proximal fixation length are more clinically relevant predictors of proximal stent graft failure than simple migration distance.     

Technique for iliac artery reconstruction in abdominal aortic aneurysm repair.

The aim of this retrospective study was to evaluate the technique for iliac artery reconstruction in abdominal aortic aneurysm repair, when external and internal iliac arteries were required to reconstruct individually. Among 203 elective infrarenal abdominal aortic aneurysm repairs, 22 patients (10.8%) required individual reconstruction of bilateral or unilateral iliac arteries, including 56 external or internal iliac arteries. Mainly, three types of procedures were performed: (1) the external iliac artery was anastomosed to the end of the bifurcated graft limb in an end-to-end manner, and the internal iliac artery was attached to the side of the external iliac artery, (2) the external iliac artery was anastomosed to the end of the bifurcated graft limb in an end-to-end manner and the internal iliac artery was bypassed with the use of a straight prosthetic graft extending from the limb of the bifurcated graft, and (3) the internal iliac artery was anastomosed to the end of the bifurcated graft limb in an end-to-end fashion, and the external iliac artery was sewn to the side of the graft limb. In these three types of procedures, the third technique was the easiest and simplest anatomically.     

The influence of aortic cuffs and iliac limb extensions on the outcome of endovascular abdominal aortic aneurysm repair

BACKGROUND: In a proportion of patients with an endovascular abdominal aortic aneurysm repair (EVAR), aortic cuffs or iliac graft limb extensions are required to enhance sealing or to fix the position of the device. This requirement arises when these goals are not primarily obtained with the basic stent-graft configuration. The aim of this study was to assess the influence of the use of endograft extensions during the primary EVAR procedure on the short- and long-term outcome. METHODS: The study was based on the data of the EUROSTAR registry. Patient and anatomic characteristics, data regarding the procedure, postoperative complications, and the mortality of patients undergoing EVAR were retrieved from the database. Patients were divided into three groups: (1) no extensions, (2) proximal aortic cuffs, and (3) iliac limb extensions. Logistic regression and Cox proportional hazards models were used to compare significant influences of the use of cuffs or extensions on different outcomes relative to control patients, adjusted for patient and anatomic factors. RESULTS: The overall cohort comprised 6668 patients: 4932 (74.0%) without extensions, 259 (3.9%) with an aortic cuff, and 1477 (22.2%) with an iliac endograft extension. Both the 30-day (2.3%-3.9%) and the all-cause mortality rates (23%-27% at 4 years) were similar in the three study groups. The use of proximal cuffs or iliac extensions did not have an effect on the incidence of endoleaks of any type (24%-32% at 4 years). The incidences of device kinking (P = .0344) and secondary transfemoral interventions (P = .0053) during follow-up were increased in patients in whom iliac limb extensions were used. In patients with aortic cuffs, no significant associations with altered outcome were observed. CONCLUSIONS: The use of iliac graft limb extensions at EVAR was associated with a higher incidence of kinking and secondary transfemoral interventions, whereas proximal aortic cuffs did not influence outcome.     

Redo aortic grafting after treatment of aortic graft infection

Purpose: This study was performed to determine the indications, operative strategy, and hemodynamic benefit of redo aortic grafting procedures after earlier excision of an infected aortic graft.Methods: Among 164 patients treated for aortic graft infection, 15 later underwent redo aortic grafting procedures an average of 18 months (range, 1 to 59 months) after removal of an infected aortic graft. Redo grafting procedures were performed for leg ischemia (n = 11) or infection (proven, n = 3; suspected, n = 1). The new aortic graft originated either from the distal thoracic aorta (n = 5) or from the juxtarenal aortic stump (n = 10). Follow-up averaged 56 months (range, 7 to 110 months).Results: All patients survived the redo grafting procedure. In the eleven patients who had ischemic symptoms, redo grafting procedures uniformly resulted in symptomatic improvement with an increase in ankle-brachial indexes (0.78 ± 0.34 vs 0.50 ± 0.29; p = 0.02). A graft limb occlusion developed in two of these patients (3 and 6 months), but no limbs were amputated. In the four patients who had proven or suspected extraanatomic bypass graft infection, there was one graft limb occlusion (29 months) and one amputation (17 months). Overall, recurrent graft infection occurred in three of 15 patients and may be more frequent in patients who have a proven extraanatomic bypass graft infection (2 of 3 vs 1 of 12; p = 0.08). Infection accounted for two of the three graft limb occlusions and two of the three late deaths. Recurrent infection was not associated with early (<1 year) regrafting procedures, and culture results did not correlate with the microbiologic features of the primary infection.Conclusions: Redo aortic grafting procedures can be performed safely and at relatively early intervals (6 to 12 months) after removal of the infected aortic graft. The procedure reliably relieves ischemic symptoms of the hemodynamically inadequate extraanatomic bypass graft. Reinfection remains a risk after redo aortic grafting procedures, particularly when treating established extraanatomic bypass graft infection. (J Vasc Surg 1996;24:328-37.)     

Primary repair of traumatic aortic rupture: a preferred approach.

Eighty patients with traumatic rupture of the thoracic aorta were treated. Seven patients died during the initial resuscitation. Forty-three patients underwent surgical repair using the clamp-and-sew technique; 14 patients had a heparin-bonded shunt placed, and 16 patients were repaired using cardiopulmonary bypass. An interposition Dacron graft was used in only 19 patients (26%). The last 32 consecutive patients underwent primary repair of the ruptured aorta. Overall mortality was 19.2% (14 of 80); 9 of 14 patients (64%) had laparotomies along with the aortic repair, and 13 of 14 patients (92%) had three or more associated major injuries. Paraplegia occurred in four cases (5.6%). Traumatic aortic rupture remains a difficult surgical problem. Primary repair, without graft interposition, is the preferred technique and can be accomplished even when the two aortic ends have retracted several centimeters.