Aortic Reconstructive Surgery Research Articles

IMPACT OF A WHOLE BODY PERFUSION STRATEGY DURING CIRCULATORY ARREST FOR AORTIC ARCH RECONSTRUCTIVE SURGERY

During aortic arch reconstructive surgery, continuous coronary and antegrade cerebral perfusion (ACP) has been shown to provide optimal myocardial and cerebral protection. However, hypothermia alone without perfusion is frequently trusted for lower body protection. When prolonged, visceral and lower body ischemia can result in metabolic debt, leading to significant lactic acidosis and end organ dysfunction. Between January 2008 and April 2014 a single surgeon at London Health Sciences Centre performed 83 consecutive proximal aortic arch reconstructive surgeries requiring hypothermic circulatory arrest (HCA). All operations were performed using ACP and moderate hypothermia (21°C to 28°C). Forty-two patients had their surgery using only ACP and HCA. Forty-one patients had their surgery using a whole body perfusion (WBP) strategy (ACP, HCA, and additional lower body perfusion through femoral artery cannulation or direct descending aorta cannulation). Baseline characteristics, clinical outcomes, and metabolic data were analyzed. There were no significant differences in patient demographics or comorbidities between the 2 groups. The WBP group contained a significantly higher number of patients undergoing total arch reconstruction (56% versus 19%, p<0.01) with a concomitant need for significantly longer bypass time (268±79 versus 205±55 minutes, p<0.01), cross clamp time (203±60 versus 131±57 minutes, p<0.01), and HCA time (43±29 versus 30±15 minutes, p=0.01). Both groups contained a similar proportion of aortic dissections and emergent cases. Despite the complexity of surgeries performed in the WBP group, there was not a significant increase in intraoperative or postoperative peak lactate levels. Similarly, there were no differences in bicarbonate levels; however intra-operative pH values were significantly lower in the WBP group but recovered within hours of ICU admission (see figure). Use of platelets (39% versus 59%, p=0.06) and FFP (37% versus 69%, p<0.01) was less in the WBP group, as was ICU length of stay (mean 5 days versus 8 days p=0.01). There were no differences between the groups in terms of postoperative outcomes including death (4.9% versus 7.1%, p=0.67) and any of 10 major postoperative complications (27% versus 31%, p=0.68). Aortic arch reconstructive surgery can be safely performed using a WBP strategy that combines moderate HCA and ACP with additional lower body perfusion. The technique may reduce metabolic debt in more complex arch cases and may be contributory to a reduction in the use of blood products and ICU length of stay. Further study is warranted.

LONG-TERM SURVIVAL FOLLOWING ENDOVASCULAR REPAIR OF THE DESCENDING AORTA

There were no differences between the groups in terms of postoperative outcomes including death (4.9% versus 7.1%, p1⁄40.67) and any of 10 major postoperative complications (27% versus 31%, p1⁄40.68). CONCLUSION: Aortic arch reconstructive surgery can be safely performed using a WBP strategy that combines moderate HCA and ACP with additional lower body perfusion. The technique may reduce metabolic debt in more complex arch cases and may be contributory to a reduction in the use of blood products and ICU length of stay. Further study is warranted. 400 LONG-TERM SURVIVAL FOLLOWING ENDOVASCULAR REPAIR OF THE DESCENDING AORTA

Mid-term results in patients having tricuspidization of the quadricuspid aortic valve

BackgroundQuadricuspid aortic valve (QAV) is a rare congenital anomaly. We investigate the mid-term results of aortic valve reconstruction by tricuspidization in patients with QAV.MethodsWe analyzed the outcome of eight consecutive patients who underwent aortic valve reconstruction surgery (AVRS) with pericardial leaflets with symptomatic quadricuspid aortic valve (QAV) disease between December 2007 and May 2012. AVRS consists of leaflet reconstruction and fixation of the sino-tubular junction in order to maintain coaptation of the new valve.ResultsSix males and two females were included; ages ranged from 19 to 63 years (mean age, 51 years). According to Hurwitz and Roberts’s classification, three patients had type A, three patients had type B, one patient had type C, and one patient had type E. All patients had significant aortic regurgitation (AR): moderate in three patients, moderate to severe in one patient, and severe in four patients. Concomitant ascending aorta wrapping with an artificial vascular graft was performed in one case. There was no occurrence of mortality during the follow-up period (42.4 ± 18.0 months). No redo-operation was required. The NYHA functional class showed improvement from 2.1 ± 0.2 to 1.1 ± 0.2 (p = 0.008). The latest echocardiograms showed AR absent or trivial in seven patients, and mild in one patient. The aortic valve orifice area index (AVAI) was 1.03 ± 0.49 cm2/m2. Compared with preoperative echocardiograms, the left ventricular (LV) ejection fraction showed improvement from 57.6 ± 17.0 to 63.7 ± 13.2% (p = 0.036); the end-diastolic and end-systolic LV dimensions showed a significant decrease, from 63.5 ± 9.6 to 49.5 ± 3.1 mm (p = 0.012) and 43.6 ± 11.8 to 32.1 ± 5.4 mm (p = 0.012), respectively.ConclusionIn patients with QAV, AVRS with tricuspidization showed satisfactory early and mid-term results. Long-term follow-up will be necessary in order to study the durability of AVRS; however, it can be considered as a potential standard procedure.

Aortic Valve Reconstruction With Leaflet Replacement and Sinotubular Junction Fixation: Early and Midterm Results

Aortic valve reconstruction surgery (AVRS), consisting of aortic leaflet reconstruction with tailored pericardial patches and fixation of the sinotubular junction with properly sized fabric rings, is performed for the treatment of aortic valve diseases. The early and midterm outcomes of AVRS were analyzed. Between December 2007 and December 2012, 262 patients with isolated aortic valve disease underwent AVRS in one center. Clinical outcomes, effective orifice area, mean gradients, and left ventricular mass index were evaluated yearly. Mean follow-up duration was 36.0±17.1 months and was complete in 100% of surviving patients. There was no hospital mortality, but there were 3 late deaths (1.1% late mortality). Seven patients (2.7%) required reoperation: 5 because of endocarditis and 2 because of suture disruption of the leaflets. Ten patients (3.8%) experienced neurologic events. Aortic valve regurgitation was absent or trivial in 226 patients (87.3%) and mild in 29 (11.2%), mild to moderate in 3 (1.2%), and moderate to severe in 1 (0.4%). The mean valve gradient and valve orifice index were 10.6±5.3 mm Hg and 1.3±0.4 cm2/m2, respectively. The data from the first 5 years after AVRS reveal good clinical and hemodynamic outcomes, suggesting that AVRS is a new alternative technique to the practice of replacement with stented bioprostheses and mechanical prostheses. However, whether the reconstructed aortic valve represents a truly long-term valve remains to be demonstrated.

Different techniques for aortic valve repair and the associated root reconstruction - prospective long-term follow-up of the first 100 patients.

IntroductionThe advantages of aortic valve and aortic root reconstructive surgery include the provision of natural postoperative valve hemodynamics and the avoidance of prosthetic valve-related complications. A systematic approach based on functional classification of aortic regurgitation allows standardization and reproducibility. Its potential applicability, however, is limited by the relative lack of long-term follow-up data.AimTo achieve the long term results of aortic valve and root repair in prospectively recruited group of 100 patients operated on during first seven years.Material and methodsBetween the years 2003 and 2013, 225 consecutive patients (175 male, 50 female, mean age 51.3 years) with severe aortic regurgitation and aortic root enlargement underwent aortic valve repair or sparing surgery. The first 100 patients operated between 2003 and 2009 were prospectively enrolled in the study in order to achieve a 105-month follow-up. They underwent aortic valve repair and associated aortic root reconstruction. This prospective study is aimed at assessing the major endpoints of overall survival and freedom from reoperation. Additionally, log-rank testing for the risk factors associated with overall mortality, reoperation, and aortic valve repair failure was performed.ResultsAmong 225 patients, early mortality occurred in the case of 5 patients (2.2%), while 6 (2.5%) patients experienced early valve failure. In a prospective analysis performed on the first 100 patients, long-term results achieved with Kaplan-Meier analysis showed a survival rate of 93% and freedom from reoperation at the level of 91.3%. The risk factors for overall mortality included NYHA class, creatinine level, and perioperative root replacement as reimplantation. Redo operation was associated with bicuspid aortic valve and perioperative leaflet resection with pericardial patch repair.ConclusionsOne hundred and five month follow-up data from this prospectively analyzed cohort of patients prove that aortic valve repair associated with aortic root reconstruction can be performed with satisfactory results.

Interleukin-10 Levels and Clinical Outcome: Comparison of Retroperitoneal versus Transperitoneal Approaches in Infra-Renal Abdominal Aorta Reconstruction

Background: To compare retroperitoneal (RP) vs. transperitoneal (TP) approaches in abdominal aorta reconstruction in terms of operative characteristics, plasma interleukin-10 levels and postoperative complications Methods: A total of 100 patients scheduled for elective abdominal aortic surgery for occlusive disease under general anesthesia from May 1005 to January 1010 were included in this prospective study with allocation of patients randomly to TP approach (n = 50; mean (SD) age: 64.3 (4.0) years; 76.0% were males) or RP approach (n = 50; mean (SD) age: 63.8 (5.6) years; 75.0% were males) for aortic surgery. Demographic data, risk factors, perioperative and postoperative data and IL-10 levels were analyzed in two groups.Results: TP approach was associated with higher levels for IL-10 measured at the time of T1 (before unclamping of aorta) [(8.4 (5.1) vs. 6.5 (4.9) pg/mL, p < 0.05)] and T1 (sixty minutes after declamping) [(11.7 (6.0) vs. 8.3 (6.1) pg/mL, p < 0.01)] compared with RP approach. Postoperative evaluation revealed a higher percentage of patients with postoperative ileus (10.0 vs. 0.0%, p < 0.001) and pulmonary complications (18.0 vs. 4.0%, p < 0.001) in the TP rather than RP groups. The TP and RP groups were similar in terms of mortality rates whereas TP approach was associated with longer mean (SD) length of hospital stay (6.1 (1.0) vs. 3.8 (1.0) days, p < 0.001) compared with the RP approach. Conclusions: Our findings revealed that the RP approach has significant advantages over the TP approach in aortic reconstruction surgery leading better pulmonary function and low ileus rate in the postoperative period as well as shorter length of hospital stay. While an increase in IL-10 levels was reported in both approaches, probably in relation to higher degree of tissue trauma, the increase was more profound in the TP approach.

Acute Kidney Injury and Renal Regional Oxygen Saturation During Aortic Arch Reconstruction in Infants

Acute kidney injury is a serious postoperative complication following cardiac surgery. The aortic arch repair technique using antegrade selective cerebral perfusion has been used, but it is unclear whether subdiaphragmatic organs such as the kidneys are perfused adequately. The authors compared intraoperative renal regional oxygen saturation using near-infrared spectroscopy between infants with and without postoperative acute kidney injury after undergoing aortic arch reconstruction. Retrospective medical records review. University medical center. Elective cardiac surgical infants. The author reviewed the perioperative clinical records of infants who underwent aortic arch reconstruction surgery using antegrade selective cerebral perfusion. During the operation, prestenotic (right radial or right brachial artery) and poststenotic (femoral or umbilical artery) invasive arterial blood pressure and cerebral and renal regional oxygen saturation were monitored continuously. Development of acute kidney injury within 72 hours of surgery was investigated. A total of 47 patients were enrolled in this study. Postoperative acute kidney injury occurred in 19 patients (40.4%). Intraoperative renal regional oxygen saturation was similar between patients with and without acute kidney injury. Intraoperative prestenotic and poststenotic mean arterial blood pressure and cerebral regional oxygen saturation also were similar between the 2 groups. The intraoperative renal tissue oxygen saturation was not different between the groups with or without postoperative acute kidney injury in infants who underwent aortic arch repair using antegrade selective cerebral perfusion.

Fístulas aorto-entéricas secundárias – caso clínico

Secondary aorto-enteric fistulas are a rare but potentially fatal complication after abdominal aortic surgery and remain one of the most challenging vascular disease.The authors present a case report of a female patient with past history of aortic reconstruction surgery (aortobifemoral bypass, performed 6 years previously) for treatment of peripheral artery disease, that was admitted in our hospital with a gastrointestinal bleeding. The Dacron® graft of the previous aortic procedure was visualized inside the 3rd portion of the duodenum in an esophagogastroduodenoscopy.A successful axillobifemoral bypass, with segmental duodenectomy, duodenal-jejunal bypass and a partial removal of the aorto-bifemoral was performed.The complications included irreversible ischemia of the right limb followed by above the knee amputation and the patient was discharged after a long hospital stay.

Risk factors for incisional hernia repair after aortic reconstructive surgery in a nationwide study

Abdominal aortic aneurysm disease has been hypothesized as associated with the development of abdominal wall hernia. We evaluated the risk factors for incisional hernia repair after open elective aortic reconstructive surgery for aortoiliac occlusive disease and abdominal aortic aneurysm. A retrospective analysis of prospectively recorded data in nationwide databases was carried out, with merged data from the Danish Vascular Registry (January 2006-January 2012), the Danish Ventral Hernia Database (January 2007-January 2012), and the Danish National Patient Register (January 2007-January 2012) to obtain 100% follow-up for incisional hernia repair in patients undergoing open elective aortic reconstructive surgery. The predefined risk factors of age, sex, American Association of Anesthesiologists score, body mass index, smoking status, type of aortic surgery, and type of incision were tested in a multivariate Cox regression model for the risk of incisional hernia repair. We identified 2597 patients, of whom 838 and 1759 underwent open elective surgery for an aortoiliac occlusive disease and abdominal aortic aneurysm, respectively. The median follow-up was 28.9 months (range, 0-71.6 months), and the cumulative risk of hernia repair after aortic reconstructive surgery was 10.4% after 6 years of follow-up. Body mass index >25.0 kg/m(2) (adjusted hazard ratio, 1.74; 95% confidence interval, 1.21-2.46) and abdominal aortic aneurysm repair (adjusted hazard ratio, 1.58; 95% confidence interval, 1.06-2.35) were significantly associated with incisional hernia repair. High body mass index and abdominal aortic aneurysm repair were independent risk factors for a subsequent incisional hernia surgery in patients undergoing aortic reconstructive surgery.

Incidental Detection of Gastrointestinal Bleeding From an Aortoenteric Fistula on 99mTc Leukocyte Scintigraphy

A 50-year-old-man with abdominal pain, who had undergone aortic aneurysm reconstructive surgery (aortic graft) 3 years before, was admitted to the hospital. A CT scan showed findings suggestive of perigraft infection. Scintigraphy with 99mTc-hexamethylpropylene amine oxime (HMPAO)-labeled leukocytes confirmed the diagnosis of aortic graft infection and documented an active concurrent bleeding in the gastrointestinal tract from a secondary aortoenteric fistula. This case illustrates the diagnosis of the precise location of the source of bleeding from aortoenteric fistula by leukocyte scintigraphy. The images aided the surgical team by revealing the aortic site of bleeding and the severity of the problem.

Preventive midline laparotomy closure with a new bioabsorbable mesh: An experimental study

BackgroundIncisional hernia formation is one of the most frequent complications of midline laparotomies requiring reoperation. The aim of this study was to evaluate the safety and efficacy of prophylactically placing a biodegradable mesh within the incision site at closure in a rat model. MethodsA 4-cm full-thick midline laparotomy was made in Sprague–Dawley rats along the linea alba and closed by inserting a commercially available web of synthetic polymers (polyglycolic acid–trimethylene carbonate) that are slowly degraded by the body. Host tissue reaction was evaluated ex vivo and compared with that obtained in suture-only–treated rats. Specimens were harvested at 1, 3, and 6mo after surgery and divided for histologic and zymographic analyses and uniaxial material testing. A group of intact nonoperated animals were included to serve as a reference. ResultsThe excised tissue explants revealed that the performance of the synthetic device was good and resulted in enhanced fibroproliferation, gelatinolytic activity, and angiogenesis within the repair site as compared with the suture-only procedure. Lastly, tensile strength augmented over the suture-only condition. ConclusionsThe preventive introduction of an absorbable mesh stimulates new tissue ingrowth and performance relative to suture repair without prosthesis, probably contributing to eventually reinforce the tension line. These results have a clinical potential in abdominal wall closure, especially in patients with multiple risk factors such as those treated for aortic reconstructive surgery, without the short- and long-term complications related to permanent grafts. However, data are preliminary and should be confirmed with longer follow-ups.

Secondary aortoduodenal fistula in the duodenal bulb: role of side-viewing endoscopy

Secondary aortoduodenal fistula is an uncommon but life-threatening complication of aortic reconstructive surgery [1]. Here we report on the diagnosis of an aortoduodenal fistula using an atypical endoscopic method.

Midline abdominal wall incisional hernia after aortic reconstructive surgery: A prospective study

To evaluate rate of formation of midline abdominal wall incisional hernia (MAIH) after elective open repair of abdominal aortic aneurysm (AAA) and revascularization for aortoiliac occlusive disease (AOD). AAA and AOD patients operated electively via a primary midline abdominal incision at our institution over a decade were entered in this prospective study. Patients who had already undergone midline laparotomy or had an MAIH after previous celiotomy were excluded. Patients were examined for MAIH 6-monthly for 2 years, then yearly. We included 1,065 patients who underwent aortic reconstructive surgery (412 with AAA and 653 with AOD). The follow-up (mean ± standard deviation) was 6.4 ± 3.8 years (range, 0.5-12.7). Wounds were closed with a suture length-to-wound length (SL:WL) ratio of at least 4:1 in 58% (239 of 653) of AAA patients and 66% (431 of 653) of AOD patients (P = .01). There were 124 (11.6%) MAIHs, with an incidence of 12.4% (51 of 412) in the AAA group and 11.2% (73 of 653) in the AOD group (P = .62), and 3 (0.4%) wound infections (all among the AOD patients), none of which resulted in MAIH. At multivariate analysis, a SL:WL ratio of <4:1 was the only independent predictor of MAIH in AAA (P = .004) and AOD patients (P < .001). AAA and AOD patients had a similar incidence of MAIH, which seems related to the wound closure technique. A SL:WL ratio of at least 4:1 is recommended. Further clinical studies are required to determine possible technical and perioperative variables that may be modified to decrease the incidence of MAIH development after aortic reconstructive surgery.

Aortoenteric fistulas: spectrum of CT findings

This article reviews the causes of aortoenteric fistulas, diagnostic options, and important CT findings. Aortoenteric fistula, a rare but potentially fatal entity, presents a significant challenge to radiologists in diagnosis, largely because of its subtle and nonspecific imaging findings. These fistulas can be divided into primary and secondary forms, depending on the presence or absence of prior aortic reconstructive surgery, but the secondary form is more common. Typical CT findings, which can overlap with those seen in perigraft infection, aortitis, infected/mycotic aneurysms, perianeurysmal fibrosis, and the immediate post-operative period after placement of a graft, include: Effacement of the fat planes around the aorta, perigraft fluid/soft tissue thickening, ectopic gas, tethering of adjacent thickened bowel loops towards the aortic graft, and in rare cases, extravasation of contrast from the aorta into the involved segment of bowel.

Combined general-epidural anesthesia with continuous postoperative epidural analgesia preserves sigmoid colon perfusion in elective infrarenal aortic aneurysm repair

Background:In elective open infrarenal aortic aneurysm repair the use of epidural anesthesia and analgesia may preserve splanchnic perfusion. The aim of this study was to investigate the effects of epidural anesthesia on gut perfusion with gastrointestinal tonometry in patients undergoing aortic reconstructive surgery.Methods:Thirty patients, scheduled to undergo an elective infrarenal abdominal aortic reconstructive procedure were randomized in two groups: the epidural anesthesia group (Group A, n=16) and the control group (Group B, n=14). After induction of anesthesia, a transanally inserted sigmoid tonometer was placed for the measurement of sigmoid and gastric intramucosal CO2 levels and the calculation of regional–arterial CO2 difference (ΔPCO2). Additional measurements included mean arterial pressure (MAP), cardiac output (CO), systemic vascular resistance (SVR), and arterial lactate levels.Results:There were no significant intra- and inter-group differences for MAP, CO, SVR, and arterial lactate levels. Sigmoid pH and PCO2 increased in both the groups, but this increase was significantly higher in Group B, 20 min after aortic clamping and 10 min after aortic declamping.Conclusions:Patients receiving epidural anesthesia during abdominal aortic reconstruction appear to have less severe disturbances of sigmoid perfusion compared with patients not receiving epidural anesthesia. Further studies are needed to verify these results.

Differential Expression of Sphingosine-1-Phosphate Receptors in Abdominal Aortic Aneurysms

Objective. Inflammation plays a key role in the pathophysiology of abdominal aortic aneurysms (AAAs). Newly discovered Sphingosine-1-Phosphate Receptors (S1P receptors) are critical in modulating inflammatory response via prostaglandin production. The aim of the current study was to investigate the expression of different S1P receptors in AAAs and compared with normal aortas at the protein level. Materials and Methods. Aortic specimens were harvested during aortic reconstructive surgery for the AAA group or during organ transplant for the control group. The protein expression of S1P1, 2 and 3 in AAAs and normal aortas was assessed by Western blotting and immunohistochemical analysis. Results. There were 40 AAAs and 20 control aortas collected for the receptor analysis. For Western blot analysis, S1P1 expression was not detected in either group; S1P2 protein was constitutively detected in both types of aortas but its expression level was significantly decreased by 73% (P < 0.05) in AAAs compared with the control group. In contrast, strong S1P3 expression was detected in AAAs aortas but not in normal aortas. Immumohistochemical staining showed similar results, except a weak S1P3 signal was detectable in normal aortas. Conclusions. Western blot and staining results consistently showed the down-regulation of the S1P2 protein with simultaneous up-regulation of the S1P3 protein in AAAs. Since those newly discovered receptors play an important role in the inflammatory cascade, the modulating of S1P signaling, particularly via S1P2 and S1P3, could represent novel therapeutic targets in future AAA treatments.

Elective visceral hybrid repair of type III thoracoabdominal aortic aneurysm

According to the classification given by Crawford et al. type III thoracoabdominal aortic aneurysm (TAAA) is dilatation of the aorta from the level of the rib 6 to the separation of the aorta below the renal arteries, capturing all the visceral branch of aorta. Visceral hybrid reconstruction of TAAA is a procedure developed in recent years in the world, which involves a combination of conventional, open and endovascular aortic reconstruction surgery at the level of separation of the left subclavian artery to the level of visceral branches of aorta. We presented a 75-years-old man, with elective visceral hybrid reconstruc tion of type III TAAA. Computerized scanning (CT) angiography of the patient showed type III TAAA with the maximum transverse diameter of aneurysm of 92 mm. Aneurysm started at the level of the sixth rib, and the end of the aneurysm was 1 cm distal to the level of renal arteries. Aneurysm compressed the esophagus, causing the patient difficulty in swallowing act, especially solid food, and frequent back pain. From the other comorbidity, the patient had been treated for a long time, due to chronic obstructive pulmonary disease and hypertension. In general endotracheal anesthesia with epidural analgesia, the patient underwent visceral hybrid reconstruction of TAAA, which combines classic, open vascular surgery and endovascular procedures. Classic vascular surgery is visceral reconstruction using by-pass procedure from the distal, normal aorta to all visceral branches: celiac trunk, superior mesenteric artery and both renal arteries, with ligature of all arteries very close to the aorta. After that, by synchronous endovascular technique a complete aneurysmal exclusion of thoracoabdominal aneurysm with thoracic stent-graft was performed. The postoperative course was conducted properly and the patient left the Clinic for Vascular Surgery on postoperative day 21. Control CT, performed 3 months after the surgery showed that the patient's vascular status was uneventful with functional visceral by-pass and with good position of a stent-graft without a significant endoleak. Visceral hybrid reconstruction represents a complementary surgical technique to that with open reconstruction of TAAA. This approach is far less traumatic to a patient, and is especially important in patients with lot of comorbidities, because there is no need for thoracotomy, and ischemic-reperfusion injury of the body is reduced to a minimum.

Herald Bleeding: A Diagnosis of Aorto-Duodenal Fistula Treated with Graft Within a Graft Repair

Purpose: Introduction: An aortoenteric fistula is a communication between the aorta and an adjacent loop of the bowel. Secondary aortoenteric fistula is an uncommon but very important complication of abdominal aortic reconstruction. Herald bleeding sometimes precedes a catastrophic bleed. We report a case with this rare complication with typical herald bleeding treated with endovascular graft repair. Case report: An 80-year-old Caucasian male with a history of abdominal aortic aneurysm repair 18 years ago with a tube graft, presented with back pain, and vomiting “bloody slime.” He was on aspirin, but denied taking non-steroidal anti-inflammatory drugs or blood thinners. On examination, he was afebrile, his heart rate was 108/min and blood pressure was 101/53 mm Hg. His hemoglobin was 6.4 g/dL. He received packed red cells transfusion. An endoscopy was performed which revealed a large adherent clot in the third portion of the duodenum. This was not removed as there was a concern for aorto-enteric fistula. A review of previous CT scan revealed a closely adherent tube graft to the duodenum. Patient was deemed to be a poor surgical candidate and an endovascular graft repair was performed using a stent graft with CO2 angiography. A repeat upper endoscopy after removal of the adherent clot showed the previous aortic graft eroding through the duodenal wall, but there was no active bleeding. Patient had no further episodes of bleeding and was discharged with a close follow up. Discussion: Aorto-duodenal fistulas (ADF) after endovascular abdominal aneurysm repair are rare. Secondary ADF is an uncommon (0.3-2%) and life-threatening, long-term complication of aortic reconstructive surgery. The classic presentation of an aortoduodenal fistula is that of a “herald bleed” (brief, with spontaneous resolution), followed anywhere from hours to weeks later by a massive upper gastrointestinal bleed. Untreated cases have a mortality rate of up to 100%. In our patient, intermittent hematemesis was a warning symptom. Though laparotomy with repair is the treatment of choice, our patient was treated with graft within a graft repair in view of the comorbidities. In summary we report a rare case of aorto-duodenal fistula treated with endovascular graft repair.Figure: Visible aortic graft in the duodenum.

Surgical management of chronic total occlusion of the abdominal aorta

Background:­ In this study, we evaluated patients who underwent surgery for chronic total occlusion of the abdominal aorta in our clinic retrospectively. Methods: Twenty consecutive male patients (mean age 61.8±8.0 years; range 44 to 76 years) who underwent surgery in our clinic for chronic total occlusion of the abdominal aorta between March 2001 and December 2009 were included in this study. All patients were operated on electively. Four patients (20%) had undergone previous coronary artery bypass grafting surgery. The occlusion of the abdominal aorta was documented with angiography in all patients. Juxtarenal aorta occlusion occurred in six patients (30%), occlusion of the suprarenal aorta in three patients (15%), and occlusion of the infrarenal abdominal aorta in 11 patients (55%). An aortobifemoral bypass and abdominal aortic thromboendarterectomy were performed in all patients. The left kidney was revascularized with a saphenous vein graft in one patient (5%). Results:­ There was complete immediate success with no mortality. No complications occurred during or after the operation. The average duration of hospital stay was 7.1±1.4 (range 5 to 11 days) and an average intensive care unit stay was 2.4±0.6 (range 1 to 3) days. Neither revision nor reintervention was required during hospitalization. Conclusion:­ Considering our experience, aortic reconstructive surgery is a successful option for the management of chronic suprarenal, juxtarenal, and, infrarenal abdominal aortic occlusions.

Secondary aortoduodenal fistula identified by ultrasonography.

A 73-year-old man underwent coronary artery bypass grafting, abdominal aortic aneurysm resection, and prosthetic implantation as a single procedure in 2002. His progress was favorable until April 2008, when he was admitted to our hospital with melena. B-mode ultrasonography revealed a 5-mm defect in the abdominal aorta at the graft anastomosis, and an umbilicated lesion was seen projecting between the posterior wall of the third part of the duodenum and the abdominal aorta. A color signal was noticed at this site on color Doppler ultrasonography, leading to the diagnosis of a secondary aortoduodenal fistula (ADF). We resected the inflammatory mass comprising the graft and the third part of the duodenum, and performed prosthetic re-implantation, omentopexy, and duodenojejunostomy. We could not find any previous reports of successful identification of secondary ADF using ultrasonography. When a patient with gastrointestinal hemorrhage following reconstructive aortic surgery is encountered in the emergency department, ultrasonography may be considered to be a useful modality in the diagnosis of secondary ADF.