The assessment of pelvic circulation after internal iliac arterial reconstruction:—A retrospective study of the treatment for vasculogenic impotence and hip claudication

The standard surgical treatment of vasculogenic impotence or hip claudication involves repairing vascular lesions, especially in the internal iliac arteries. It is difficult, however, to make a definite diagnosis or an accurate judgement of the therapeutic effects of this treatment due to the trouble in ruling out any other disorders. During the last five years, 19 patients with impotence and associated apparent internal iliac artery stenosis or occlusion and 2 patients with hip claudication, underwent internal iliac arterial reconstruction. The patients’ ages ranged from 37 to 70 with a mean age of 63.7 and the main procedure performed in all patients was aorto-iliac to femoral bypass grafting, or abdominal aortic aneurysmectomy. A retrospective study revealed that 74 per cent of those treated regained penile erectile activity postoperatively, and that hip claudication disappeared completely in all cases. One of the patients received percutaneous transluminal angioplasty (PTA) for the treatment of vasculogenic impotence, after which his postoperative penile brachial pressure index (PBPI) improved, demonstrating a statistically significant difference compared to the preoperative value. Trans-anal Doppler measurement also proved useful in providing complication-free perioperative understanding of pelvic circulation.     

The assessment of pelvic circulation after internal iliac arterial reconstruction: a retrospective study of the treatment for vasculogenic impotence and hip claudication

The standard surgical treatment of vasculogenic impotence or hip claudication involves repairing vascular lesions, especially in the internal iliac arteries. It is difficult, however, to make a definite diagnosis or an accurate judgement of the therapeutic effects of this treatment due to the trouble in ruling out any other disorders. During the last five years, 19 patients with impotence and associated apparent internal iliac artery stenosis or occlusion and 2 patients with hip claudication, underwent internal iliac arterial reconstruction. The patients' ages ranged from 37 to 70 with a mean age of 63.7 and the main procedure performed in all patients was aorto-iliac to femoral bypass grafting, or abdominal aortic aneurysmectomy. A retrospective study revealed that 74 per cent of those treated regained penile erectile activity postoperatively, and that hip claudication disappeared completely in all cases. One of the patients received percutaneous transluminal angioplasty (PTA) for the treatment of vasculogenic impotence, after which his postoperative penile brachial pressure index (PBPI) improved, demonstrating a statistically significant difference compared to the preoperative value. Trans-anal Doppler measurement also proved useful in providing complication-free perioperative understanding of pelvic circulation.     

Aorto-iliac/femoral reconstructions in patients with vasculogenic impotence

One hundred and forty-eight patients out of 386 undergoing aorto-iliac or aortofemoral bypass had preoperative impotence, 37 of these were diabetics. In all of them Doppler studies revealed a penile/brachial pressure index less than 0.6 and an abnormal waveform analysis. Nocturnal penile tumescence was investigated in 44 cases and found to be abnormal. Angiography showed unilateral or bilateral obstructive lesions of the hypogastric arteries in 80%, in addition to aortic, common and external iliac and femoral lesions. One hundred and thirty patients (87.8%) had straight aorto-iliac/femoral bypass grafts inserted without a direct attempt to revascularise the hypogastric arteries but 24 had distal anastomoses to the bifurcation of the common iliac artery. In the remaining 18 patients the hypogastric artery was reconstructed on one side by an additional bypass or reimplantation on the graft. In 22 of 106 patients (20.7%) undergoing aortofemoral bypass, 18 of 24 (75%) with the distal anastomosis to the iliac bifurcation, and 14 of the 18 (77.7%) with revascularisation of the hypogastric arteries, erectile function was regained. A good result was obtained in only five of the diabetic patients (13.5%). Our experience suggests that: (1) impotence, as indicated by non-invasive investigations, was vasculogenic in origin since patients with the most effective revascularisation of the hypogastric arteries had the best results; (2) when it is feasible, revascularisation of the hypogastric arteries should be carried out more often, during the aorto-iliac or aortofemoral reconstructions, particularly in younger impotent patients; (3) aorto-iliac revascularisation restores potency in only a few diabetic patients.     

Effects of abdominal aneurysmectomy, aortoiliac bypass grafting and angioplasty on male sexual potency: a prospective study

The preoperative frequency and postoperative status of male sexual potency was studied prospectively in 46 patients who underwent abdominal aortic aneurysmectomy, aortoiliac and aortofemoral bypass grafting, or percutaneous transluminal angioplasty of the iliac artery. The patients with aortic aneurysms were older; approximately half of them were potent. The frequency of impotence was highest in patients who underwent aortoiliac bypass, and correlated well with their low penile to brachial pressure index. Patients who had angioplasty had more localized lesions, a higher penile to brachial pressure index and the lowest rate of impotence. Postoperatively, 13% of the patients regained nocturnal erection and 10% became functionally potent (defined as the ability to achieve penetration). The improvements were similar in bypass and angioplasty patients. No patient experienced deterioration in sexual potency and all showed a markedly improved thigh to brachial pressure index postoperatively. Routine aortoiliofemoral artery angiograms were of limited value in predicting the status and outcome of sexual potency in this series of patients.     

Aortoiliac Endarterectomy: A Lost Art?

Endarterectomy was first performed on a superficial femoral artery in 1946 by Cid dos Santos and subsequently on the abdominal aorta by Wylie in 1951. During the 1950s and 1960s, aortoiliac endarterectomy (AIE) was the standard procedure for treatment of aortoiliac occlusive disease. When prosthetic graft material became available, aortobifemoral bypass (ABFB) replaced AIE in most cases because occlusive disease commonly affects the external iliac arteries also, which were difficult to endarterectomize. As a result, aorto-common iliac endarterectomy became almost a lost art. However, we believe there is still a place for AIE in selected patients based on a review of our results with the procedure. We reviewed 205 patients who survived 10 years after undergoing operation for aortoiliac occlusive disease by either aorto-common iliac endarterectomy (n = 39) or ABFB (n = 166). Ten-year primary patency was 89.2% for AIE and 78% for ABFB. Graft infection or aneurysmal formation occurred in 5% of ABFB and 0% of AIE cases. Ten male patients who underwent AIE for leg and hip claudication with positive penile/brachial indices of ≤0.6 enjoyed improvement of erectile dysfunction. Twenty of the 39 AIEs were in female smokers with small vessels, localized disease, and elevated triglycerides. Three patients with end-to-side infected ABFB grafts, two with enteric fistula (one ours, two referred), had their grafts removed, followed by AIE with vein patching of their bypass sites. All three patients survived and at 10-year follow-up had patent reconstructed aortofemoral vessels. Since AIE avoids prosthetic material, it is preferable to ABFB in (1) patients whose aortoiliac occlusive disease does not involve the external iliac arteries; (2) male patients with aortoiliac occlusive disease who, in addition to claudication, have erectile dysfunction with penile/brachial indices of ≤0.6 and stenotic internal iliac origins; (3) patients with aortoiliac disease including the external iliac arteries who are not candidates for ABFB because of infection risk or small vessels; (4) patients with localized aortoiliac disease; and (5) patients after removal of an infected ABFB graft (with or without an enteric fistula) that had initially been placed end-to-side for aortoiliac occlusive disease.     

The effects of bilateral renal transplantation on pelvic hemodynamics and sexual function

Sexual function and internal iliac artery (IIA) patency were determined in 24 patients who had received at least two renal transplants, one in each iliac fossa, at the University of Maryland and Johns Hopkins Hospitals from 1975 to 1979. The pelvic hemodynamics of each patient were assessed with a penile/brachial blood pressure index (PBI). The rate of sexual dysfunction, as determined by questionnaires and personal interviews, was 46% (11 of 24 patients) compared with only 21% (five of 24 patients) after a single transplant. Nine of the 11 patients who were impotent had bilateral IIA occlusion and four of these nine had a PBI less than 0.70. One of the four patients regained full sexual function after a revascularization procedure, which confirmed that this impotence had a vascular etiology. Results of this study show that vascular insufficiency, but not necessarily vasculogenic impotence, was present in at least four of the 11 patients who were impotent (36%) and may have been avoidable by sparing at least one IIA during renal transplant procedures.     

Pelvic blood flow following aortobifemoral bypass with proximal end-to-side anastomosis

Nine patients with end-to-side aortobifemoral bypasses were studied in the first year after surgery using color duplex imaging to determine the source of pelvic blood flow. No patient had clinical evidence of postoperative pelvic ischemia. Six of nine patients were found to have occluded distal aortas by duplex studies performed at a mean of 4.4 months postoperatively (range 0.8–8.2 months). Of those six patients, postoperative duplex examination demonstrated two with no common or external iliac blood flow, two with bilateral retrograde external iliac flow, and two with unilateral retrograde external iliac flow. Of the three patients with patent distal aortas, two had no demonstrable external iliac blood flow, while the third had continued antegrade flow through one external iliac and retrograde flow through the other. Analysis of preoperative arteriograms failed to reveal accurate predictors of postoperative distal aortic patency or retrograde iliac blood flow. Despite the preoperative assumption that prograde common iliac artery blood was required to prevent pelvic ischemia, distal aortic patency was maintained in only three of nine patients. In the six patients with prograde iliac blood flow, no ischemic symptoms were present, including two patients with complete absence of antegrade aortic or retrograde external iliac blood flow. Our observations indicate that assumptions which underlie the decision to perform end-to-side aortic anastomoses are often not borne out in the months following aortobifemoral bypass.     

Laparoscopically Assisted Penile Revascularization for Vasculogenic Impotence

Young patients with impotence and cavernous arterial insufficiency resulting from trauma-induced arterial occlusive disease are ideal candidates for microvascular arterial bypass surgery. To avoid the long abdominal incision required to harvest the inferior epigastric artery, a laparoscopic approach was used. We report a case of laparoscopically assisted penile revascularization for vasculogenic impotence.     

Vasculogenic impotence and cavernosal oxygen tension

AIMS OF THIS STUDY: To determine the associations, if any, of cavernosal oxygen tension with vasculogenic impotence. MATERIALS AND METHODS: We evaluated penile cavernosal blood gas levels in men with suspected vasculogenic impotence during penile duplex ultrasonography and/or dynamic infusion cavernosometry and cavernosography (DICC). Patients with suspected impotence were evaluated from 1992-1996. Patient ages ranged from 24-75 y (mean 48 y). Eighteen men had arteriogenic impotence diagnosed by abnormal penile duplex ultrasound after injection of a vasoactive agent, and 23 men had venous leakage diagnosed by DICC. RESULTS: Eighteen men with arteriogenic impotence had the following mean blood gas values: pH = 7.38+/-0.01, PCO2 = 45.50+/-0.94, PO2 = 65.17+/-2.16. Twenty-three men with venogenic (venous leak) impotence had the following mean cavernosal blood gas values: pH = 7.41+/-0.01, PCO2 = 42.26+/-0.83, PO2 = 74.17+/-2.51. The differences in PO2 were significant (P<0.05). A subgroup of men with severe venous leakage had PO2 values that were similar to the low arterial PO2 values. CONCLUSION: The low PO2 in patients with arteriogenic impotence, and the subset of men with severe venous leak impotence, support a global concept of low cavernosal PO2 as a mechanism for both arteriogenic and venogenic impotence.     

The Role of Revascularization of the Profunda Femoris Artery in Vasculogenic Impotence

Introduction

Erectile dysfunction is a common disorder, but the underlying cause is difficult to clarify because the organic (endocrine, neurogenic, vasculogenic and iatrogenic) and psychological components are mixed. Vasculogenic impotence, due to penile vascular insufficiency, is a common symptom in patients with aortoiliac occlusive disease (Leriche’s syndrome).The aim of this clinical study was to investigate the hypothesis that revascularization of the profunda femoris artery in Leriche’s syndrome offers good results in vasculogenic erectile dysfunction.

Material and Methods

We investigated 22 men aged 50–65 years (mean 57.5 years) with vasculogenic impotence due to Leriche’s syndrome. Exclusion criteria were: age >70 years, comorbidities, such as diabetes mellitus (DM), heart failure, HIV, history of perineal trauma and medication associated with erectile dysfunction (i.e., antidepressants, anxiolytics, antiandrogenics, anticholinergics). After clinical examination, measurement was made of the angle brachial pressure index (ABPI) and the penis brachial pressure index (PBPI) with duplex ultrasonography (U/S). All the patients underwent vascular imaging: 15 digital subtraction angiography (DSA) and 7 computed tomography angiography (CTA). Psychological investigation was carried out and the papaverine test was performed to exclude other causes of impotence. The patients underwent aorto-bifemoral bypass, with profundoplasty, if needed, and were followed for one year after operation with clinical examination and measurement of the ABPI and PBPI with duplex U/S.

esults

Preoperatively, all the patients reported absence of erectile function, with inability to achieve an erection of sufficient rigidity. Clinical examination revealed absence of pulses to peripheral arteries beyond the femoral arteries and absence of bruits in the iliac arteries. The ABPI ranged between 0.35 and 0.45 (normal: 1) and the PBPI between 0.2 and 0.32 (normal: 0.75). Aorto-bifemoral reconstruction (Y-Graft) with profundoplasty, if required, was performed on all patients. In 4 patients (group I) the peripheral arteries (common, profunda and superficial femoral artery) were not affected by atherosclerotic disease and profundoplasty was not required. In 18 patients (group II) profundoplasty was necessary because of atherosclerotic occlusion of the superficial femoral arteries and stenosis of the profunda artery.Postoperatively, in group I the ABPI became normal and the PBPI ranged between 0.5 and 0.6. In group II the ABPI ranged between 0.6 and 0.75 and the PBPI between 0.48 and 0.55. During the first month of the postoperative period 14 patients (4 from group I and 10 from group II) had normal erectile function (63.6 %) and during the late postoperative period (3-6 months of follow up) 5 more patients (2 from group I and 3 from group II) had improvement of the erectile function (22.7 %). No significant clinical improvement was observed in the other 3 patients (13.6 %).

Conclusion

In patients with Leriche’s syndrome, revascularization of the profunda femoris artery (profundoplasty) ameliorates vasculogenic impotence through the improvement of the pelvic blood flow via the collateral circulation.

     

Combined percutaneous transluminal angioplasty and extraanatomic bypass for symptomatic unilateral iliac artery occlusion with contralateral iliac artery stenosis

We have reviewed our experience with percutaneous transluminal angioplasty of contralateral iliac stenosis and extraanatomic bypass of the occluded iliac artery. Twenty-two men and nine women with a mean age of 65 years (range 46 to 84) presented with symptomatic iliac occlusive disease. Twenty-four (77%) had disabling claudication, four (13%) rest pain, and three (10%) ischemic tissue loss. Six (19%) had undergone previous vascular reconstructive procedures. All had an occluded iliac artery on the symptomatic side and greater than 50% stenosis of the contralateral iliac artery. Percutaneous transluminal angioplasty of the iliac stenosis was done prior to extraanatomic bypass, using polytetrafluoroethylene. There were six late deaths after discharge. The only significant complication was a femoral artery thrombosis which was corrected when the bypass graft was performed. Cumulative primary graft patency was 89% at one year and 81% at three years. The crossover graft occluded in six patients, five within 48 months of surgery, and one after nine years. One of these occluded grafts was salvaged by thrombectomy, for a secondary patency rate of 85% at three years. Two patients required aortobifemoral bypass, one an iliobifemoral bypass and one an ilioprofunda bypass. One patient operated upon for rest pain came to below-knee amputation. Mean resting ankle/brachial systolic pressure index increased significantly on the side of the iliac occlusion from 0.35 ±0.21 to 0.70 ± 0.20 (p < 0.05, paired t test) after the combined procedure. There was no significant difference in the mean resting ankle/brachial systolic pressure index on the contralateral side (0.60 ± 0.22 to 0.65 ± 0.27, ns). Combined iliac percutaneous transluminal angioplasty and femorofemoral bypass is a safe alternative to aortobifemoral bypass for selected patients with aortoiliac arterial occlusive disease. Presented at the Royal Australasian College of Surgeons, General Scientific Meeting, May 1989, Melbourne, Australia.     

Deep-penile-vein arterialization for arterial and venous impotence

Eleven impotent men underwent deep-penile-vein arterialization after preoperative assessment by a multidisciplinary team. Penile Doppler pressures, testosterone levels, and nocturnal penile tumescence were used to establish a vasculogenic etiology. Cavernosography, artificial erection by saline infusion, and selective hypogastric arteriography were obtained to delineate whether arterial, venous, or mixed (arterial/venous) factors predominated. Penile revascularization consisted of femoral artery to deep-penile-vein saphenous bypass, with ligation of superficial veins at the base of the penis in patients with venous leakage. Cumulative graft patency was 91% up to 20 months. There were no deaths. The average preoperative flow requirement of values greater than 250 mL/min was reduced to 59 mL/min postoperatively. Follow-up results of nocturnal penile tumescence were excellent in four of four patients with venous (venous leakage), two of three patients with arterial, and one of four patients with mixed factors. Deep-penile-vein arterialization appears to be beneficial for impotence secondary to venous leakage, with inconsistent results for arterial and mixed factors.     

Acute occlusion of the abdominal aorta with concomitant internal iliac artery occlusion

Acute aortic occlusion is a rare but catastrophic pathology with high mortality even after revascularization. We describe four patients who underwent thrombectomy or bypass surgery for acute aortic occlusion with concomitant internal iliac artery occlusion. Two patients (82- and 75-year-old men), who had insufficient reperfusion of bilateral internal iliac arteries after treatment (thrombectomy alone and axillobifemoral bypass, respectively), died on postoperative day three of uncontrollable hyperkalemia and multiple organ failure, respectively (mortality: 50%). The third patient (74-year-old man), in whom the left internal iliac artery was reperfused after an axillobifemoral bypass, underwent right lower limb amputation but survived. The fourth patient (63-year-old man) with sufficient internal iliac artery reperfusion bilaterally after aortobifemoral and right internal iliac artery reconstruction, had an uneventful postoperative course. Elevated creatine phosphokinase and myoglobinuria levels were observed in all four patients but were notably higher in the two patients with no reperfusion in either of the internal iliac arteries. Our results suggest that reperfusion of one or more internal iliac arteries may be a crucial factor in reducing mortality in revascularization treatment of acute aortic occlusion with concomitant internal iliac artery occlusion.     

Long-term results of combined iliac balloon angioplasty and distal surgical revascularization.

Long-term results of combined use of iliac artery percutaneous transluminal angioplasty (PTA) and distal surgical revascularization for the management of multilevel occlusive disease were evaluated over a 12-year period. A total of 79 combined procedures were performed in 75 patients. All patients had tandem occlusive disease, with the inflow lesion felt to preclude a distal revascularization procedure alone. Revascularization was performed for incapacitating claudication in 17 (22%) and limb salvage indications in 62 (78%) cases. A mean resting iliac artery pressure gradient of 29 +/- 11 mmHg pre-PTA was reduced to 0.9 +/- 0.4 post-PTA. Major complications of PTA occurred in five (6%) cases, but four were successfully corrected at the time of the distal surgical procedure without alteration of the operative plan. Infrainguinal operations included 55 femoropopliteal or tibial bypass grafts, 18 femorofemoral grafts, and 6 profundaplasties. Mean follow-up was 43 months. By life table analysis, the 5-year primary patency rate of the distal surgical procedures was 76%; a secondary patency of 88% at 5 years was achieved by various means of reintervention. Mean pretreatment ankle/brachial index of 0.31 +/- 0.14 increased to 0.80 +/- 0.16 after operation (p less than 0.0001). The 5-year limb salvage rate was 90%. There were no operative deaths. We conclude that in carefully selected patients, combined use of iliac PTA and distal surgical reconstruction is effective and durable, safely reducing the extent of surgical intervention while reliably increasing the comprehensiveness of revascularization.     

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.     

The noninvasive diagnosis of vasculogenic impotence

One hundred eleven impotent men and 25 potent men were prospectively evaluated with a standardized exercise treadmill test (SETT) used to noninvasively define their pelvic hemodynamics. Fifty-six men had vasculogenic impotence, whereas the remaining 55 had erectile dysfunction resulting from undetermined causes (31), psychogenic factors (10), or other identifiable reasons (14). Arteriography was performed on 40 (71%) of the patients with vasculogenic impotence without false positive results, as well as in 11 (44%) of the potent control patients and in six (11%) of the patients with nonvasculogenic impotence without false negative results, confirming the validity of the SETT. The distinction between vasculogenic and nonvasculogenic impotence can be accurately made with the SETT. Patients with vasculogenic impotence had a resting penile-brachial index (PBI) equal to 0.60 +/- 0.022 (mean +/- SEM) and a PBI after exercise equal to 0.45 +/- 0.019 with a fall in the mean PBI of -0.15 (p less than 0.001). Patients with nonvasculogenic impotence had a resting PBI equal to 0.80 +/- 0.024 and a PBI after exercise equal to 0.88 +/- 0.019 with a rise in mean PBI of 0.08 (p less than 0.001). This response was not significantly different between the control group and the nonvasculogenic impotence patients. The addition of PBI determinations after treadmill exercise revealed that 18% of the patients with vasculogenic impotence would have been incorrectly diagnosed, because their resting PBI was greater than the traditional standard of 0.70. Furthermore, 18% of the patients with nonvasculogenic impotence would have been incorrectly diagnosed as having vasculogenic impotence because their resting PBI was less than 0.70.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of the effects of on-pump versus off-pump coronary artery bypass surgery on serum prostate-specific antigen levels

AIM: To compare the effects of coronary artery bypass operation with or without extracorporeal circulation on serum total prostate-specific antigen levels. METHODS: Seventy-six men with a mean age of 57.04+/-9.27 years (range 44-77 years), who underwent coronary artery bypass surgery were enrolled to the study. In 50 patients (Group I), coronary revascularization was performed using extracorporeal circulation, and in 26 patients (Group II) coronary bypass grafting was performed on the beating heart without using extracorporeal circulation. All the patients had serum total prostate-specific antigen levels measured preoperatively and twice postoperatively in the first and fifth postoperative days. Differences in mean total prostate-specific antigen levels between the two groups in the postoperative period were analysed. RESULTS: The mean preoperative total prostate-specific antigen levels in Group I and Group II were 1.28+/-1.13 ng/mL and 1.11+/-0.93 ng/mL, respectively, and there was no significant difference in the preoperative total prostate-specific antigen values between the two groups (P=0.519). In Group I, postoperative means were 4.96+/-6.29 ng/mL and 5.86+/-9.09 ng/mL in the first and fifth days, respectively (P=0.0001, P=0.0001). Total prostate-specific antigen means in the same postoperative period for Group II were 2.13+/-2.72 ng/mL and 2.00+/-2.20 ng/mL, respectively (P=0.014, P=0.024). The comparison of total postoperative prostate-specific antigen levels between the groups showed significantly higher elevation in Group I (postoperative day 1: P=0.013; day 5: P=0.05). CONCLUSIONS: Coronary revascularization can cause a statistically significant rise in serum total prostate-specific antigen levels. This rise is more marked in patients undergoing conventional coronary revascularization.     

Intraoperative monitoring of penile and buttock blood flow during endovascular abdominal aortic aneurysm repair.

OBJECTIVE: The purpose of this study was to assess the pelvic circulation during endovascular abdominal aortic aneurysm repair (EVAR) with a new monitoring system measuring penile and buttock blood flow. METHODS: We measured penile brachial pressure index (PBI) during EVAR by pulse-volume-plethysmography (form PWV/ABItrade mark). We also measured bilateral gluteal tissue oxygen metabolism with near-infrared spectroscopy to provide a gluteal tissue oxygenation index (TOI). Twenty-two men who underwent aortouni-iliac stentgraft with crossover bypass for exclusion of abdominal aortic aneurysm were studied. Twelve patients underwent aorto-uni-common iliac artery stentgraft (CIA) and ten underwent aorto-uni-external iliac artery stentgraft (EIA). RESULTS: In all patients, there was an immediate reduction in PBI during the EVAR procedure. After revascularization of the ipsilateral limb of the stent graft, the recovery of PBI was significantly less in EIA group. After the completion of crossover bypass, PBI in both groups recovered to the baseline values. In both groups there was a bilateral reduction in gluteal TOI during malperfusion of the internal iliac artery. After revascularization of ipsilateral limb of the stent graft, the ipsilateral TOI recovered to the baseline level in CIA patients, but recovery was incomplete in EIA patients. In contrast, contra-lateral TOI remained low in both groups after revascularization of ipsilateral limb of the stent graft. Only after completion of crossover bypass did the contra-lateral TOI recover to baseline level in both groups. CONCLUSIONS: Both TOI at the buttocks and PBI are a sensitive reflection of pelvic haemodynamics. Penile blood flow and bilateral gluteal blood flow are supplied via different circulations and both should be monitored for full assessment of the pelvic circulation.     

Emerging role of endovascular grafts in complex aortoiliac occlusive disease

BACKGROUND: Aortobifemoral bypass is the standard therapy for complex aortoiliac occlusive disease. The purpose of this study was to examine the use of endovascular grafts as an alternative to aortobifemoral bypass in patients with advanced aortoiliac occlusive disease at high risk. METHODS: Endovascular grafts were placed in 23 limbs in 22 patients with TransAtlantic Inter-Society Consensus document (TASC) type C and D lesions. All procedures were performed in the operating room, and images were obtained with portable digital fluoroscopy. Surgical exposure of the ipsilateral common femoral artery was performed to enable safe closure of 9F to 12F sheath sites and to facilitate ipsilateral interventions in the distal external iliac artery. Concomitant infrainguinal outflow procedures were performed in 6 patients. RESULTS: Twenty of 22 patients were men; mean patient age was 63.2 +/- 3.2 years. Indications for intervention were rest pain in 12 of 23 limbs and tissue loss in 9 of 22 limbs. Risk factors included hostile abdomen or pelvis in 8 patients, coronary artery disease in 11 patients, end-stage renal disease in 3 patients, and severe chronic obstructive pulmonary disease in 3 patients. Each patient received a mean of 1.6 grafts. Initial technical success was 95.2%, with one technical failure. There was no 30-day mortality. All patients experienced at least one grade improvement per Society for Vascular Surgery reporting standards. Primary patency at 24 months was 84.2% +/- 8.0%, with a limb salvage rate of 95.3% +/- 5.0%. Mean (+/- SD) ankle brachial index improved from 0.49 +/- 0.22 to 0.87 +/- 0.26 (P <.001). CONCLUSION: Endovascular grafting to treat advanced aortoiliac occlusive disease can be accomplished with good clinical outcome and acceptable short-term patency. This endovascular technique can be a viable alternative to conventional surgical revascularization in patients with advanced aortoiliac occlusive disease at high risk.