Surgical Repair of Infected Peripheral Graft and Abdominal Aortic Aneurysm Using Arterial Homograft

We report a case of combined surgical repair including lower limb revascularization (below-knee bypass) and abdominal aortic aneurysm repair using cryopreserved arterial homograft. The patient experienced lower limb ischemia due to repeated thrombosis of a long-infected polytetrafluoroethylene (PTFE) graft, and was also shown to have a complicating abdominal aortic aneurysm. Infection was eradicated with total graft excision and intravenous antibiotics. Two-year patency of the in situ arterial homograft revascularization was demonstrated with hemodynamic and tomographic controls; no degenerations have been found to date. Benefits of the use of in situ arterial homograft for arterial reconstruction may include improved hemodynamics and greater resistance to infection compared to when alloplastic materials are used. Because of the risk of allograft deterioration, close follow-up of the patient is required.     

Fate of the iliac arteries after repair of abdominal aortic aneurysm with an aortobifemoral bypass graft

The objective of this study is to determine the fate of the iliac arteries after repair of abdominal aortic aneurysm with an aortobifemoral bypass graft. It is a prospective natural history study at a university-affiliated urban teaching hospital. Thirty-two patients with retrograde flow to the iliac circulation after repair of an abdominal aortic aneurysm by aortobifemoral bypass grafting were studied. All patients were followed prospectively with repeat CAT scans, clinical assessment, and selective angiography to determine the fate of the iliac circulation. We were particularly interested in subsequent vessel thrombosis or aneurysmal dilation. Patient survival was analyzed with a Kaplan-Meier life-table and survival curve. Graft patency was analyzed using life-table analysis. Primary outcomes included iliac artery size, graft patency, and patient survival. The iliac arteries remained constant in size or thrombosed in all study patients. Iliac expansion did not occur in any of the study patients. Secondary graft patency was 100%. The cumulative survival rate at 47 months was 0.55 (0.37–0.74,95% confidence interval). Retrograde perfusion of diseased iliac arteries after aortobifemoral bypass for repair of abdominal aortic aneurysm is safe. Iliac artery atherosclerotic, ectatic or small aneurysmal disease (≤3 cm) does not appear to be a contraindication to retrograde iliac artery perfusion.     

Successful Repair of an Aortoesophageal Fistula Caused by a Thoracic Aortic Aneurysm: Report of a Case

Aortoesophageal fistula occurring as a complication of a thoracic aortic aneurysm is difficult to repair because of the contaminated surgical field. We report the case of a 67-year-old man in whom an aortoesophageal fistula developed secondary to a dissecting thoracic aortic aneurysm. We performed in situ graft repair of the aneurysm, then covered the site with omentum and resected the esophagus to prevent graft infection. About 5 months later, the esophagus was reconstructed subcutaneously using an ascending colon pedicle. The patient recovered well and has resumed leading a normal life.     

Infrarenal aortic aneurysm repair by retroperitoneal approach combined with laparoscopic cholecystectomy: two case reports

Simultaneous repair of abdominal aortic aneurysm and treatment of cholelithiasis by the transperitoneal approach is controversial because of the risk of prosthesis infection. We report two patients who underwent a successful combined procedure using a retroperitoneal approach for the aortic aneurysm repair and a laparoscopic approach to the cholecystectomy. This combined approach reduces the risk of infection of the aortic prosthesis and is associated with a rapid return of normal peristalsis.     

Hybrid repair of thoracoabdominal aortic aneurysm in high-risk patients using a quadrifurcated graft

Surgical treatment for thoracoabdominal aortic aneurysm is still challenging and is associated with a high risk of paraplegia. Hybrid repair with stent graft insertion for the thoracoabdominal aorta excluding the branches of the lumbar and visceral arteries and bypass grafting to the visceral branches has been introduced as a less invasive treatment that reduces the risk of paraplegia. For hybrid repair, it is important to have appropriate management of the revascularized grafts to the 4 visceral arteries with sufficient inflow. We have recently adopted a knitted quadrifurcated graft applied inversely from the abdominal aorta or the iliac artery to the 4 visceral arteries; the celiac, superior mesenteric, and bilateral renal arteries. To date, we have used the graft in hybrid repair of thoracoabdominal aortic aneurysm in 2 high-risk elder patients who had disseminated intravascular coagulopathy and severe renal failure, respectively. We found that a knitted quadrifurcated graft was easy to handle and useful for reducing the number of anastomoses, which were expected to shorten the operation time. Postoperative courses were uneventful without paraplegia in either patient. Postoperative computed tomography showed excellent patency of the inversely applied quadrifurcated graft without any endoleak or migration in the thoracoabdominal stent. In conclusion, revascularization of 4 visceral arteries using a quadrifurcated graft should be considered a preferable option in hybrid treatment for thoracoabdominal aortic aneurysm.     

Aortoduodenal fistula and associated rupture of abdominal aortic aneurysm after endoluminal stent graft repair

The main complications of endovascular repair of abdominal aortic aneurysms are vascular leaks and rupture, although infection and aortoduodenal fistulas have also been reported rarely. We report a case of aortoduodenal fistula with separate retroperitoneal rupture of an abdominal aortic aneurysm after endovascular stent graft repair. The initial implantation was uneventful, without any leaks at 1 month. The patient underwent open repair and did well. To our knowledge, this is the first case report of aortoduodenal fistula and associated retroperitoneal rupture of the aneurysm after endovascular stent graft repair of an abdominal aortic aneurysm.     

Successful endovascular repair of juxtarenal and suprarenal aortic aneurysms with a branched stent graft

This case report describes a new technique for repairing pararenal aortic aneurysms with a transluminally placed triple-branched stent graft with sidearms extending into the superior mesenteric artery and renal arteries. Endovascular repair with the branched stent graft was attempted in two patients with a pararenal aortic Aneurysm. Stent grafting was technically successful in both patients. Although postoperative transient renal function impairment and paralytic ileus occurred in patient 2, these complications were gradually resolved in the perioperative period. A substantial shrinkage of the aneurysm was revealed by means of computed tomographic measurements in patient 1. In both patients, complete exclusion of the aneurysm and patency of the bilateral renal arteries and the superior mesenteric artery were confirmed by means of follow-up computed tomographic images at 2 years. This minimally invasive approach for pararenal aortic aneurysms appears to be a viable therapeutic option for patients who are at high risk for open surgery.     

Aortic endograft infection due to Pasteurella multocida following a rabbit bite

Abdominal aortic endograft infection is a serious complication after an endovascular abdominal aortic aneurysm repair. Pasteurella multocida, a gram-negative bacterium, is a commonly found organism in the mouth flora of many house pets. We report a case of an aortic endograft infection caused by P multocida after a rabbit bite. Successful treatment was performed by extra-anatomic revascularization followed by endograft removal.     

TEVAR and periscope graft technique to treatment of huge aneurysm of aortic isthmus: Case report

IntroductionThoracic endovascular aortic repair (TEVAR) has revolutionized the treatment of thoracic aortic aneurysms. Innovative techniques as chimney and periscope grafts can improve the outcomes of procedure. Herein, we report a case in emergency of huge Thoracic aortic aneurism.Presentation of caseAn 86-year-old male with hypertension, diabetes mellitus, was referred to our hospital for chest pain. CT-angiography showed a huge aneurysm of aortic isthmus with signs of rupture. The patient was considered unfit for open surgery and an endovascular approach was chosen. This patient underwent endovascular repair with TEVAR, using the periscope graft technique to preserve patency in left subclavian artery (LSA).DiscussionSymptomatic ischemia from LSA coverage has been reported to occur in only a modest 6–10% of patients and is often sacrificed with impunity given coverage rates between 10 and 50%. In this case reported the lack of revascularization of LSA increased the risk of neurological manifestations or stroke. Periscope technique is feasible and safe to maintain perfusion to the subclavian artery, with a 93% primary patency at 2 years.ConclusionsOur experience using TEVAR with periscope graft technique as solution to address thoracic aneurysm of aortic isthmus was feasible and safe.     

A one-stage operation for abdominal aortic aneurysm and intraductal papillary mucinous neoplasms of the pancreas: report of a case

Pancreatic surgery concomitant with abdominal aortic repair is rarely chosen due to concerns about prosthetic infection following pancreatic leakage and the poor prognosis of pancreatic neoplasms. We herein report a successfully treated case of infrarenal abdominal aortic aneurysm and intraductal papillary mucinous neoplasms of the pancreas treated by a one-stage operation. A 75-year-old male with a history of cerebral infarction and chronic subdural hematoma was referred to our department with a pulsatile abdominal mass. A 70-mm infrarenal abdominal aortic aneurysm with severe proximal neck angulation and a 28-mm multilocular cystic tumor with mural nodules in the pancreas body were detected. Abdominal aortic repair with a prosthetic graft and distal pancreatectomy were performed simultaneously. The postoperative course was mostly uneventful, and he was discharged to a rehabilitation facility.     

Repair of abdominal aortic aneurysms in patients with renal, iliac, or distal arterial occlusive disease

Appropriate preoperative vascular assessment of patients presenting with aortic aneurysms and arterial occlusive disease is essential to obtain the optimal results from aneurysm repair. The renal arteries should be evaluated in patients with hypertension or renal dysfunction, and stenosis must be addressed when seen on arteriograms. Hemodynamically significant lesions are candidates for bypass concomitant with aortic replacement. The stump pressure of a patent inferior mesenteric artery should be assessed intraoperatively, and bypass or reimplantation should be performed if colon ischemia might result from internal mesenteric artery ligation. If vasculogenic impotence is suggested by preoperative studies, meticulous nerve-sparing dissection and revascularization of the internal iliac arteries may result in recovery of erectile function in some patients. In all cases of aneurysm repair, the hypogastric circulation must be maintained through either direct revascularization or bypass to major collateral arteries. Iliac occlusive disease may be evaluated with several modalities, including physical examination, noninvasive laboratory testing, arteriography, and the papaverine test, to determine whether critical or subcritical stenoses are present. Aortic bifurcation grafts should be used to construct the distal anastomoses beyond areas of significant disease. The extent of lower-extremity occlusive disease directly affects the long-term patency of aortic replacement, and diligent follow-up is necessary for timely intervention to maintain patency of vascular reconstructions.     

Late iliac artery aneurysms and occlusive disease after aortic tube grafts for abdominal aortic aneurysm repair. A 35-year experience.

Controversy continues over whether patients treated with straight Dacron aortic tube grafts for an abdominal aortic aneurysm remain at significant risk for subsequent development of iliac aneurysm or occlusive disease. To address this issue, the authors performed a population-based analysis of 432 patients who had an abdominal aortic aneurysm diagnosed between 1951 and 1984. Aneurysm repair was performed eventually in 206 patients (48%). To ascertain differences in late development of graft-related complications, iliac aneurysms, and arterial occlusions, the authors compared all tube-graft patients with similar numbers of bifurcated-graft patients matched for age and year of operation. In the tube-graft group, no subsequent clinically evident or autopsy-proven iliac aneurysms or iliac occlusive disease were noted. Over a mean follow-up of 6 years (range, 4 to 18 years), new aortic aneurysms occurred in the proximal aorta in both tube and bifurcated-graft patients (5.0% and 2.5%, respectively). In contrast the cumulative incidence of graft-related complications was higher with a bifurcated prosthesis (12.8%) compared with a straight graft (5.0%) (p = 0.15). These problems generally occurred 5 to 15 years postoperatively and emphasize the need for long-term graft surveillance. The authors conclude that straight tube-grafts for repair of abdominal aortic aneurysms provide excellent late patency with minimal risk of subsequent iliac aneurysm development.     

Coronary artery bypass grafting without cardiopulmonary bypass for high-risk patients

Between January 1991 and June 1993, coronary artery bypass grafting was performed without either cardiopulmonary bypass or cardiac arrest in 23 patients. Most patients had several surgical risk factors, including age ⩾ 70 years, poor left ventricular function, left main coronary artery stenosis, chronic renal failure, and aortic aneurysm. Distal anastomoses were made under temporary interruption of coronary flow. A total of 37 distal anastomoses to the left anterior descending coronary artery and/or right coronary artery (mean 1.6 per patient) were made, 24 of which were internal thoracic arteries. The coronary occlusion time ranged from 7–14 min (mean 9.8 min). Combined cardiac or vascular operations were carried out in six patients (abdominal aortic aneurysm repair, thoracic aortic aneurysm repair, carotid endarterectomy, and coronary endarterectomy). There was one hospital death. Postoperative angiography was performed in 22 patients and showed a patency rate of 89%. In summary, coronary artery bypass grafting without cardiopulmonary bypass may improve the postoperative outcome of high-risk patients.     

高外科风险腹主动脉瘤腔内修复术的近远期结果

目的 探讨高外科风险腹主动脉瘤患者接受腔内修复术治疗的近远期结果.方法 1997年7月至2011年7月,120例因肾下腹主动脉瘤行腔内修复术治疗的高外科风险患者纳入本研究.本组患者男性96例,女性24例;年龄52～95岁,平均74岁.平均动脉瘤直径(57±8)mm.术后1、3、6、12个月及此后每年进行CT血管造影或B超随访.主要研究内容是手术病死率及远期生存率,次要研究内容是二次手术率、动脉瘤体术后的变化以及支架的通畅率.结果 全身麻醉83例,局部麻醉37例.术后Ⅰ型内漏5例,Ⅱ型内漏25例,Ⅲ型内漏1例,技术成功率95％.手术病死率2.5％.随访6～144个月,平均(36±3)个月.术后1年生存率为92％,3年生存率为75％,5年生存率为43％.术后3年支架的一、二期通畅率分别为97％和100％.5年二次手术率为10％ (12/120),手术原因为:7例内漏,2例支架断裂,2例支架移位,1例支架内血栓形成.结论 高外科风险腹主动脉瘤患者接受腔内修复术治疗的近远期结果满意,证实该技术适用于这类人群.     

Aortic endograft infection with aortoduodenal fistula associated with adjacent vertebral body mycobacterial osteomyelitis (Pott's disease)

Aortoenteric fistulas (AEFs) are a rare complication of infrarenal abdominal aortic aneurysm repair. They occur in <1% of aortic grafting procedures, result from graft defects, foreign bodies, and trauma, and are associated with a high mortality rate. We report a complex AEF associated with vertebral body osteomyelitis, likely secondary to tuberculous infection. A 78-year-old man presented with a 2-week history of abdominal pain, fever, and anemia. Past surgical history is significant for open repair of infrarenal abdominal aortic aneurysm followed later by an endovascular repair of a proximal para-anastomotic aneurysm. Computed tomography angiography revealed air in the aneurysm sac, without evidence of endoleak. The posterior aspect of the aneurysm was noted to be in continuity with a destructive osteomyelitis of the second lumbar vertebral body and an adjacent psoas abscess. Percutaneous drainage revealed purulent fluid containing mixed enteric flora. With fluoroscopic guidance, injection of contrast in the aortic sac drainage catheter demonstrated complex fistulous communications from the aortic sac to the overlying small intestine. After a course of drainage, antibiotic therapy, and parenteral nutrition, the patient underwent a transperitoneal repair of the AEF with duodeno-duodenectomy and wide debridement of the aortic sac and Dacron graft. Pathology revealed giant cell granulomas, highly suggestive of tuberculosis.     

Clostridium septicum post-endovascular aneurysm repair stent-graft infection

Endovascular aortic aneurysm repair (EVAR) is establishing its role as a valid alternative for the treatment of abdominal aortic aneurysm. Post-EVAR graft infection is a rare and devastating complication. The incidence of post-EVAR graft infection is yet to be defined, and available data at this stage consist of case reports and small series. Possible etiologies for aortic stent-graft infection include perioperative contamination and hematogenous seeding. To the best of our knowledge, this is the first report of post-EVAR stent graft infection with Clostridium septicum. The possible mechanisms of this unusual hematogenous seeding have been discussed.     

Results from coronary artery bypass surgery combined abdominal aortic aneurysm repair.

OBJECTIVE: Complication from coronary artery disease is a major cause of mortality and morbidity in patients undergoing abdominal aortic aneurysm repair. We report our results from coronary artery bypass surgery performed in combination with abdominal aortic aneurysm repair in patients with coronary artery disease and abdominal aortic aneurysm, each being an indication for an emergency operation. METHODS: Seventeen patients underwent combined coronary artery bypass surgery and abdominal aortic aneurysm repair. The mean age of the patients was 67.6 +/- 5.2 years. Four had left main disease, 8 patients had triple-vessel disease, and 12 had a prior myocardial infarction. The average left ventricular ejection fraction was 0.49 +/- 0.13. The average abdominal aortic aneurysm diameter was 6.2 +/- 1.0 cm (range 4.5-8.0 cm). Thirteen patients underwent coronary artery bypass surgery followed by abdominal aortic aneurysm repair after discontinuation of cardiopulmonary bypass. In the remaining four patients, including one patient with severe left ventricular dysfunction, cardiopulmonary bypass was continued as a circulatory assist until the abdominal aortic aneurysm repair was completed. The left internal thoracic artery was used in 14 patients, and the right internal thoracic artery in one patient. RESULTS: Postoperative surgical complications occurred in three patients (bleeding in one patient requiring reoperation, abdominal subcutaneous wound infection in another and transient neural disorder in the others). There were no surgical or in-hospital death. There was no late cardiac complication and no late cardiac death after a mean of 29 months follow-up. CONCLUSIONS: We concluded that combined surgery was reasonable for selected patients with combined coronary artery disease and abdominal aortic aneurysm, each of which is an indication for an urgent operation. The aortic aneurysm repair during cardiopulmonary bypass for patients with severe left ventricular dysfunction was safe and effective.     

Endovascular stent graft repair for a Salmonella-infected aneurysm of thoracic aorta

Thoracic endovascular aneurysm repair using stent graft has been reported as a feasible and effective treatment for aortic aneurysm. However, its application for treating infected aortic aneurysms is still controversial and less reported. We report a 74-year-old male diabetic patient diagnosed with Salmonella-infected aortic aneurysm, who was successfully treated with endovascular stent graft repair followed by a 2-month course of intravenous antibiotics and long-term oral antibiotic therapy. Sequential computed tomography scans demonstrated the shrinkage of the aneurysm and no evidence of relapse 11 months later.     

Total videoscopic treatment of a type IV thoracoabdominal aneurysm

We performed a total videoscopic type IV thoracoabdominal aortic aneurysm repair. The postoperative course was uneventful, and the patient did well 10 months later. To our knowledge, a total videoscopic thoracoabdominal aortic aneurysm repair has not been previously described.     

Aseptic lysis L2–L3 as complication of abdominal aortic aneurysm repair

Osteolytic vertebral erosion is usually related to tumours, spondylitis or spondylodiscitis. Few reports in the literature describe lytic lesions of anterior lumbar vertebral bodies resulting from abdominal aortic aneurysm or false aneurysm. We report a case of abdominal aortic false aneurysm that caused lytic lesions of the second and third vertebral bodies in an 80-year-old man who underwent endovascular aneurysm repair. Fluoroscopy guided biopsy excluded infection or tumour. We performed a posterior spinal fusion and decompression because of bone loss of the second and third lumbar vertebral bodies and central stenosis. Postoperatively the patient showed satisfactory relief in low-back and thigh pain but, unfortunately, he died 1 month after surgery because of respiratory complications. This case suggests that when a lytic lesion of a lumbar vertebral body is discovered in a patient who has undergone endovascular aneurysm repair, an abdominal aortic false aneurysm may be the cause of the vertebral erosion even in cases without infective pathogenesis.