Anastomotic arterial aneurysms. A continuing challenge.

Abstract

Aneurysms occurring at the site of arterial reconstruction continue to pose a challenge to surgical ingenuity. Our experience with the surgical treatment of 29 nontraumatic anastomotic aneurysms (AA) in 24 patients is analyzed. Twenty-two aneurysms presented in the femoral region. Dacron((R)) grafts and braided Dacron sutures had been used in 70 and 86% of AA, respectively. Immediate or late reoperation had been necessary 14 times in eight patients. Average time elapsed between the initial procedure and AA repair was 65 months. Indications for repair were expansion/rupture (nine patients), graft occlusions (12 patients), aortoenteric fistula (two patients) and presence of AA (six patients). The predominant operative finding was suture line dehisence due to an attenuated arterial wall (13 patients), problems with suture material (three patients), infection (two patients), and indeterminate (13 patients). The majority of the aneurysms (20) were partially excised and arterial limbs revascularized with interposition Dacron grafts, usually to the profunda femoris artery. Two of three postoperative deaths ensued in patients with aortoenteric fistulas. Omission of silk suture material has not eliminated AA and indeed, braided synthetic suture material had been used in most of the original procedures. A significant number of AA sites had had multiple reoperations. Operative findings suggested structural degeneration of the native artery as an important etiologic factor. Important technical principles in uninfected AA include: early control of inflow and outflow vessels, avoidance of dissection of the entire AA, and interposition of a new Dacron graft to the outflow vessel. No immediate limb loss and no recurrences occurred with this approach, with a maximum follow-up period of 72 months. Early elective repair of most AA is emphasized to avoid graft occlusion and potential technical mishaps associated with repair of large aneurysms.