Aortic Reconstructive Procedures Research Articles

Aortic arch replacement with simultaneous antegrade cerebral and systemic perfusion using a single centrifugal pump driven 'split arterial line' extracorporeal circuit design.

The ability to provide antegrade cerebral and systemic perfusion simultaneously may negate the requirement for any prolonged period of circulatory arrest during complex aortic arch reconstruction procedures, depending on the cannulation strategy. We describe the development and successful implementation of a custom 'split arterial line' extracorporeal circuit configuration to facilitate complex aortic surgery. This circuit design offers a wide range of cannulation and perfusion strategies, is safe, adaptable, simple to manage, and avoids the use of roller pumps for blood delivery, which are associated with deleterious haematological complications during prolonged cardiopulmonary bypass cases. The split arterial line approach has now become the standardised methodology for facilitating complex aortic surgery at our institution.

Precise moulded autologous pericardial configurations for aortic cusp reconstruction.

In order to facilitate surgical repair of complex aortic cusp deformities and restoration of aortic valve competence, new moulds were developed to shape the glutaraldehyde-treated autologous pericardium into precise cusp-like configurations that can be used in aortic cusp reconstruction. The new moulds embodied the natural geometry of single aortic cusps, and a series of moulds were made available to correspond with all potential aortic cusp sizes. Aortic valve reconstruction using moulded autologous pericardial cusps was performed in 2 patients (both males, aged 14 and 19 years) with large outlet-type ventricular septal defects, extensive deformation of prolapsed right coronary cusps and severe aortic valve insufficiency. In each patient, the diseased right aortic cusp was excised and was replaced by a moulded autologous pericardial cusp that equalled the size of adjacent undiseased native cusps. Excellent coaptation with adjoining native aortic cusps could be readily observed and intraoperative transoesophageal echocardiography confirmed satisfactory aortic valve repair (aortic insufficiency <1+ and low-transvalvular gradients). Follow-up transthoracic echocardiography confirmed that aortic valve function remained stable in both patients 2 years postoperatively. Initial clinical experience indicated that constructing geometrically perfect cusp-like configurations was uncomplicated and implantation of the moulded autologous pericardial cusps restored adequate aortic valve competence. We believe that the simplicity and reproducibility of this approach may assist in the dissemination of aortic cusp reconstruction procedures.

Analysis of Risk Factors for Early Type I Endoleaks After Thoracic Endovascular Aneurysm Repair

Purpose: To evaluate risk factors for early (<30 days) type I endoleak following thoracic endovascular aortic repair (TEVAR). Methods: A retrospective study was conducted of 439 consecutive patients (mean age 74.0±10.0 years; 333 men) who underwent TEVAR at a single center between June 2006 and June 2013. Pathologies included 237 aortic arch aneurysms and 202 descending thoracic aortic aneurysms (dTAA). Maximum TAA diameter was 63.6±13.7 mm. Among the distal aortic arch aneurysms, 124 required coverage of the left subclavian artery (LSA), while the remaining 113 arch aneurysms had debranching (n=40), the chimney technique (n=52), and a branched stent-graft (n=13). Eight patients with dilatation of the ascending aorta underwent arch replacement with elephant trunk prior to TEVAR. Predictive factors for type I endoleak were explored in univariate analysis and examined for each outcome using logistic regression models; results are given as the odds ratio (OR) and 95% confidence interval (CI). Results: Among 439 TEVAR cases, 37 (8.4%) had type I endoleaks on imaging at 1 month; 31 were in the 237 arch cases (13.1%). Endoleak investigation by site indicated a low incidence (3.0%) for dTAAs and markedly low (1.4%) in zone 4. Significantly more endoleaks were observed in zones 0–2 than in zone 4 (p<0.001). On univariate analysis, significant associations were found between endoleak and LSA coverage (OR 5.8, 95% CI 2.4 to 14.4, p<0.001), operative time ≥240 minutes (OR 3.7, 95% CI 1.5 to 6.2, p=0.002), and ≥270 mL of contrast (OR 2.8, 95% CI 1.4 to 5.8, p=0.004). Among the aortic branch reconstruction procedures, the chimney technique was the only maneuver associated with a significant risk of endoleak (OR 5.3, 95% CI 2.3 to 11.2, p<0.001). Arch state was not correlated with endoleaks, but ≥38-mm proximal neck diameter (OR 3.6, 95% CI 1.2 to 10.8, p=0.023), stent-graft diameter ≥40 mm (OR 9.9, 95% CI 1.4 to 30.5, p=0.015), and excessively oversized (≥14%) stent-grafts (OR 3.5, 95% CI 1.2 to 10.3, p=0.020) were; the proximal neck length was not correlated with endoleaks if a proximal neck length >10 mm can be secured. Conclusion: Risks for early type I endoleaks after TEVAR for aneurysm were landing zone 0–2, LSA coverage, large proximal neck and stent-graft diameters, excessive oversizing, and the use of the chimney technique.

Aortic root morphology: a paradigm for successful reconstruction.

Aortic root (AoR) components provide synchronous and precise 3D deformation of the aortic root during the cardiac cycle in order to ensure closure and opening of the three leaflets over a lifetime. Any deviation from the natural 3D morphology, such as with AoR annulus dilatation, enlarged sinuses and/or dilatation of the sinotubular junction, as in the case of ascending aortic dilatation, may result in disruption of the natural AoR function. Surgical treatment of AoR pathology has two modalities: the replacement of the aortic valve by artificial prosthesis or by preservation of the three leaflets and reconstruction of the aortic root components. Currently, there are two basic aortic root reconstruction procedures: aortic root sparing and aortic valve reimplantation techniques. Regardless of the technique used, the restoration of adequate cusp coaptation, is from a technical point of view, the most important element to consider. To achieve this, there are two requirements that need to be met: (i) the valve coaptation should be superior to the level of the aortic root base by at least 8 mm and (ii) the coaptation height per se has to be ≥5 mm. Successful restoration of the aortic root requires adequate technical skills, detailed knowledge of aortic root anatomy and topography, and also knowledge of the spatial pattern of AoR elements. Recently, there has been growing interest in aortic root reconstructive procedures as well their modifications. As such, the aim of this review is to analyse aortic root topography and 3D anatomy from a surgical point of view. The review also focuses on potential risk regions that one should be aware of before the surgical journey into the 'deep waters area' of the AoR begins.

Prognostic implication of aortic regurgitation post transcatheter aortic valve implantation: A single centre experience

modifications but the two broad types are aortic root reimplantation and the aortic root remodelling procedure. We present the early and late outcomes following valve sparing aortic root reconstruction surgery in Australia and New Zealand. Methods: We reviewed the ANZSCTS database for patients undergoing these procedures. Preoperative, intraoperative and postoperative variables were analysed. Multivariable regression was performed to determine independent predictors of 30-day mortality. We also obtained 5and 10-year survival estimates by cross-linking the ANZSCTS database with the National registry of Births, Deaths and Marriages. Results: Between January 2001 and January 2012, 169 consecutive patients underwent valve sparing aortic root reconstruction procedures. The mean age of the study population was 54.4 years with 31.4% being females. Overall, 9 patients (5.9%) died within 30 days post procedure and 5 patients (3%) had permanent strokes. However, out of 132 elective cases, only 5 patients died (3.8%). Independent predictors of 30 day mortality were female gender (odds ratio [OR] 5.65, p=0.025), preoperative atrial arrhythmia (OR 6.07, p=0.035) and acute type A aortic dissection (OR 7.71, p=0.01). Long term survival was estimated as 85.3% and 72.7% at 5and 10-years, respectively. Discussion:Along with an acceptable rate of early mortality and stroke, valve sparing aortic root reconstruction procedures have good long term survival according to the ANZSCTS database. As promising procedures for pathologies that impair the aortic root integrity, they can be adopted more widely, especially in Australian and New Zealand centres with experienced aortic units. Future studies are planned to assess freedom from valve deterioration and repeat surgery.

Early and late outcomes following valve sparing aortic root reconstruction: The ANZSCTS database

Introduction: Valve sparing aortic root reconstruction has become an alternative to traditional aortic root replacement with a valved conduit. There have been various modifications but the two broad types are aortic root reimplantation and the aortic root remodelling procedure. We present the early and late outcomes following valve sparing aortic root reconstruction surgery in Australia and New Zealand. Methods: We reviewed the ANZSCTS database for patients undergoing these procedures. Preoperative, intraoperative and postoperative variables were analysed. Multivariable regression was performed to determine independent predictors of 30-day mortality. We also obtained 5- and 10-year survival estimates by cross-linking the ANZSCTS database with the National registry of Births, Deaths and Marriages. Results: Between January 2001 and January 2012, 169 consecutive patients underwent valve sparing aortic root reconstruction procedures. The mean age of the study population was 54.4 years with 31.4% being females. Overall, 9 patients (5.9%) died within 30 days post procedure and 5 patients (3%) had permanent strokes. However, out of 132 elective cases, only 5 patients died (3.8%). Independent predictors of 30 day mortality were female gender (odds ratio [OR] 5.65, p=0.025), preoperative atrial arrhythmia (OR 6.07, p=0.035) and acute type A aortic dissection (OR 7.71, p=0.01). Long term survival was estimated as 85.3% and 72.7% at 5- and 10-years, respectively. Discussion: Along with an acceptable rate of early mortality and stroke, valve sparing aortic root reconstruction procedures have good long term survival according to the ANZSCTS database. As promising procedures for pathologies that impair the aortic root integrity, they can be adopted more widely, especially in Australian and New Zealand centres with experienced aortic units. Future studies are planned to assess freedom from valve deterioration and repeat surgery.

Matériaux de reconstruction aortique résistants à la contamination bactérienne

Synthetic graft infection is a rare but extremely serious complication of aortic reconstruction procedures, with morbidity-mortality rates as high as 60 %. Some of the proteins (albumin, gelatin, collagen) used to coat polyester graft materials can establish ionic bonds with antibiotics or can capture antiseptics such as triclosan or ionic silver in their matrices. These active substances are then released from the graft, at varying rates, during the coating degradation that takes place during the weeks following polyester graft implantation in living tissues. Rifampin-bonded prostheses have proved effective against S. aureus and S. epidermidis in several canine models of synthetic aortic graft infection. Rifampin-bonded grafts have also been used successfully in patients with synthetic aortic graft infection by low-virulence bacteria. However, their effectiveness may be limited by the diverse and changing ecology of synthetic aortic graft infections, with an increasing prevalence of multidrug-resistant bacteria and polymicrobial infections. These include species that are naturally, or are likely to become, resistant to rifampin. We evaluated silver-ion-bonded prostheses in this setting but observed a disappointingly high mid-term rate of recurrent infections. Over the past few years we have been involved in the development of polyester vascular prostheses functionalized with a hydroxypropyl-β-cyclodextrin polymeric matrix that can capture and elute several therapeutic agents. The results are promising, as these prostheses enable the sustained release of various antibiotics in amounts several times their minimum inhibitory concentrations. This provides a unique opportunity to functionalize materials for aortic graft reconstruction, based on epidemiological data or individual bacteriological findings.

Invited commentary

Lin and coauthors have nicely described their experience with robotic-assisted laparoscopic aortic surgery. Because of the small number of patients, the diversity of operations, and the intraoperative selection process, their attempts to compare fully robotic reconstructions with those that included minilaparotomies are somewhat over-reaching. The authors do document, however, that with appropriate expertise and dedication, robotic aortic surgery is feasible. Whether it is practical or appropriate for prime-time vascular surgery is an entirely different question. Laparoscopic aortic surgery was introduced nearly a decade ago, yet it remains an operation largely relegated to small case series in the literature. Less invasive endovascular treatment of aortoiliac occlusive and aneurysmal disease has become the mainstay of therapy and will continue to grow as technology and skills evolve. Nonetheless, open operations for aortic occlusive disease and aneurysms remain an effective and essential part of the therapy we offer patients. However, it has become a major concern if vascular surgeons will perform enough open aortic operations in the future to maintain their skills. This is particularly true in that open operations are often performed in patients with the most complex anatomy. As such, is it unrealistic to assume that vascular surgeons will have sufficient skills and experience to conduct these more complex operations laparoscopically, with or without a robot? Furthermore, new training paradigms in vascular surgery with less general surgery exposure are unlikely to afford the next generation of vascular surgeons the necessary laparoscopic and robotic skills to perform these procedures safely. It is telling that four of the five authors of this article are urologists who routinely use the surgical robot in their operations. It is essential for vascular surgeons to remain in the vanguard, using and evaluating all available technologies to improve our care of patients. The authors are to be congratulated for their successful application of advanced robotic technology to the treatment of aortic disease. In those few centers where there is the constellation of appropriate interest, expertise, and equipment, the technique is feasible. It remains to be demonstrated in these centers if this approach will offer advantages over well-done open surgery. As endovascular therapy evolves and open surgery becomes more uncommon, the widespread feasibility and utility of this approach is more questionable. Robotic-assisted aortic surgery with and without minilaparotomy for complicated occlusive disease and aneurysmJournal of Vascular SurgeryVol. 55Issue 1PreviewPublished reports of robotic-assisted aortic surgery involve a combination of laparoscopy for aortic dissection and a robotic system for vascular reconstruction. The objective of this study is to determine the feasibility and advantage of a total robotic-assisted aortic dissection and vascular reconstruction vs robotic-assisted aortic procedures for aortoiliac occlusive disease (AIOD) and abdominal aortic aneurysm (AAA). Full-Text PDF Open Archive

Robotic-assisted aortic surgery with and without minilaparotomy for complicated occlusive disease and aneurysm

Published reports of robotic-assisted aortic surgery involve a combination of laparoscopy for aortic dissection and a robotic system for vascular reconstruction. The objective of this study is to determine the feasibility and advantage of a total robotic-assisted aortic dissection and vascular reconstruction vs robotic-assisted aortic procedures for aortoiliac occlusive disease (AIOD) and abdominal aortic aneurysm (AAA). From February 2006 to August 2010, 21 patients were selected for robotic-assisted aortic procedures: aortobifemoral bypass in 12, AAA repair in 6, iliac aneurysm repair in 1, and ligation of type II endoleak after endovascular aneurysm repair in 2. Inclusion criteria included AAA >5 cm, iliac aneurysm >3 cm, and AIOD TransAtlantic InterSociety Classification (TASC) C or D lesions. The da Vinci S Surgical System (Intuitive Surgical Inc, Sunnyvale, Calif) was used for the abdominal aortic dissection in all cases and for the aortic anastomosis in three cases. The 21 patients (6 women, 15 men) were an average age of 65.7 years (range, 44-86 years), had a body mass index (BMI) of 27.23 kg/m(2), and 90.4% were American Society of Anesthesiologists (ASA) class 3 or 4. Robotic dissection of the abdominal aorta was successful in 20 patients (95.2%). One patient required full conversion to open AAA repair due to trocar injury. Of the remaining 20 patients, the average robotic dissection time of the infrarenal aorta was 113.1 minutes, and the average aortic clamp time was 86 minutes. The procedure in 15 patients was performed with a minilaparotomy using an average abdominal incision of 13 cm to implant the Dacron or polytetrafluoroethylene graft. Five patients underwent a total robotic-assisted procedure with robotic aortic reconstruction or ligation of a type II endoleak. The 30-day survival rate was 100%. Median length of stay was 7.5 days. All grafts were patent at a median follow-up of 32.0 months. For aortic procedures completed total robotically without an abdominal incision, the estimated blood loss was significantly less than in robotic-assisted procedures with a minilaparotomy. In these selected patients, robotic-assisted technology may be part of the armamentarium for the vascular surgeon as another less invasive method for the treatment of complicated occlusive disease or aneurysm.

Totally Robotic Aortic Surgery versus Robotic-Assisted Aortic Surgery with Mini-Laparotomy

Objectives: Safety and efficacy of totally laparoscopic aortic surgery and laparoscopic-assisted aortic surgery with minilaparotomy have been demonstrated in previous studies. Published reports of robotic-assisted aortic surgery involve a combination of laparoscopy for aortic dissection and robotic system for vascular reconstruction. The objective of this study is to determine the feasibility and advantage of a totally robotic aortic dissection and vascular reconstruction versus robotic-assisted aortic procedures for aortoiliac occlusive disease (AIOD) and abdominal aortic aneurysm (AAA). Methods: From February 2006 to August 2010, 21 patients were selected for robotic aortic procedures: 12 had aortobifemoral bypass, 6 had AAA repairs, 1 had iliac aneurysm repair, and 2 had ligation of type II endoleak after endovascular aneurysm repair. Inclusion criteria included AAA >5 cm, iliac aneurysm >3 cm, and AIOD TransAtlantic InterSociety Consensus C or D. The daVinci S Surgical System was used for the aortic dissection in all cases and the aortic anastomosis in three. Institutional Review Board approval and informed consent were obtained. Results: The 21 patients (6 women, 15 men) were an average age of 65.7 years (range, 44-86 years) and body mass index of 27.23 kg/m2, and 90.4% were American Society of Anesthesiology 3 or 4. Twenty patients (95.2%) underwent successful robotic dissection of the abdominal aorta. One patient underwent full conversion to open AAA repair due to trocar injury. Of the remaining 20 patients, the average robotic dissection of the infrarenal aorta was 113.1 minutes and average aortic clamp time was 86 minutes. Procedures in 15 patients were performed with a minilaparotomy using an average abdominal incision of 13 cm to implant the Dacron or PTFE graft. Five patients underwent a totally robotic procedure with robotic aortic reconstruction or ligation of type II endoleak. Thirty-day survival rate was 100%. Median length of stay (LOS) was 7.5 days. All grafts were patent with a median follow-up of 26.5 months. Conclusions: In this selected group of patients, totally robotic aortic surgery for aortic dissection and vascular reconstruction is feasible. For aortic procedures completed total robotically without an abdominal incision, the estimate blood loss was significantly less than robotic-assisted procedures with minilaparotomy.TableTotally robotic versus robotic-assisted aortic proceduresAortic clamp timeEstimated blood loss (mL)LOS (days)Mini-incision(min)(mL)(days)(cm)Totally robotic (n = 5)602006.6NoneRobotic-assisted (n = 15)89.51474. 411.713 Open table in a new tab

Larger aortic reconstruction corresponds to diminished left pulmonary artery size in patients with single-ventricle physiology

Pulmonary artery size is a crucial determinant of hemodynamic energy loss in total cavopulmonary connections. We investigated the effect of aortic arch reconstruction on left pulmonary artery size based on their anatomic proximity. Thirty-two patients undergoing the Fontan operation, 16 with hypoplastic left heart syndrome and 16 with non-hypoplastic left heart syndrome, were selected from the multicenter Fontan magnetic resonance imaging database at the Georgia Institute of Technology. The 16 datasets were consecutive with full anatomic reconstructions of the total cavopulmonary connection and aortic arch with no artifacts. The size of the aorta along the transverse arch and left pulmonary artery size in the region below the aortic arch was quantified by using a previously validated skeletonization technique. The transverse aortic and left pulmonary artery measurements (median, maximum, and minimum, respectively) for non-hypoplastic left heart syndrome were 2.2, 3.1, and 1.5 cm/m and 1.2, 1.6, and 0.2 cm/m, respectively, compared with 2.5, 4.1, and 2.0 cm/m and 0.9, 1.5, and 0.4 cm/m for patients with hypoplastic left heart syndrome. Thus the transverse aortic diameter of patients with hypoplastic left heart syndrome was, on average, 24% greater than that for patients with non-hypoplastic left heart syndrome (P < .05), whereas the left pulmonary artery diameter of patients with hypoplastic left heart syndrome was smaller than that of patients with non-hypoplastic left heart syndrome (P < .05). Regression analysis showed a significant negative correlation (P < .05) between aortic and left pulmonary artery diameters in both the hypoplastic left heart syndrome and non-hypoplastic left heart syndrome groups. However, when the study population was regrouped into reconstructed aorta and nonreconstructed aorta groups, the negative correlation was only significant for patients with reconstructed aortas, regardless of ventricular pathology (P < .02). Stage 1 aortic reconstruction procedures that result in a large aorta limit left pulmonary artery size in patients undergoing the Fontan operation.

"How I do it: utilization of high-pressure sealants in aortic reconstruction"

BackgroundSuture-line hemostasis, reinforcement of friable tissue, and adhesion prevention are key concerns for patients undergoing cardiac surgery for aortic reconstruction. Failure to secure hemostasis at anastomotic junctures and reinforce fragile tissue may lead to increased blood loss, additional blood product requirements, increased operative time, and, in extreme cases, reoperation. Patients with aortic pathology may also be at higher risk for reoperation, and adhesion formation from prior surgery is an added risk at resternotomy. The advent of high-pressure sealants has been of benefit in helping to alleviate these perioperative challenges.MethodsThe author utilizes two high-pressure sealants for aortic reconstructive procedures. The first is made of two polymers of polyethylene glycol (PEG) [Coseal®, Baxter Healthcare, Corporation], and is used to secure anastomotic suture-line hemostasis and for adhesion prevention. The second is a bovine serum albumin-glutaraldehyde (BSAG) glue [BioGlue®, CryroLife, Inc.], used for the repair of dissected aortic tissue and in reinforcing ("tanning") fragile aortic tissues. The techniques for application in select aortic reconstruction procedures are described.ResultsTo substantiate the hemostatic clinical benefit observed by the author, 60 consecutive major thoracic aortic operations in 57 patients in whom PEG sealant was used were retrospectively reviewed. Although comparisons with other agents were not performed for this descriptive report, bleeding results were very favorable for these types of operations. The strong clinical impression is that topical hemostatic application of PEG sealant to anastomotic suture lines is helpful in preventing bleeding.ConclusionIn major aortic reconstructive procedures the need for anastomotic sealing performance, reinforcement of friable tissues, and adhesion prevention should not be underrated. High-pressure surgical sealants represent an important surgical adjunct, and the author has found the use of both PEG sealant and BSAG glue advantageous in aortic reconstruction and repair.

Abdominal aortic coarctation: Surgical treatment of 53 patients with a thoracoabdominal bypass, patch aortoplasty, or interposition aortoaortic graft

Abdominal aortic coarctation is uncommon and often complicated with coexisting splanchnic and renal artery occlusive disease. This study was undertaken to define the clinical and anatomic characteristics of this entity, as well as the technical issues and outcomes of its operative treatment. Fifty-three patients, 34 males and 19 females, underwent surgical treatment of abdominal aortic coarctations from 1963-2008 at the University of Michigan. Patient ages in years ranged from 2-4 (n = 4), 5-8 (n = 17), 9-14 (n = 16), 15-20 (n = 11) and 25-49 (n = 5). The mean age was 11.9 years. Developmental disease (n = 48), inflammatory aortitis (n = 4), and iatrogenic trauma (n = 1) were suspected etiologies. Aortic coarctations were suprarenal (n = 37), intrarenal (n = 12), or infrarenal (n = 4). Patients often had coexisting occlusive disease of the splanchnic (n = 33) and renal (n = 46) arteries. Major clinical manifestations included: aortic and renal artery-related secondary hypertension (n = 50), symptomatic lower extremity ischemia (n = 3), and intestinal angina (n = 3). Primary aortic reconstructive procedures included: thoracoabdominal bypass (n = 26), patch aortoplasty (n = 24), or an aortoaortic interposition graft (n = 3). Primary splanchnic (n = 19) or renal (n = 47) arterial reconstructions were performed as simultaneous (n = 45) or staged (n = 13) procedures in relation to the aortic surgery. Benefits existed regarding improved control of hypertension (n = 46), as well as elimination of extremity ischemia (n = 3) and mesenteric angina (n = 3). Secondary renal or splanchnic arterial reoperations (n = 8) were performed without mortality 5 days to 12 years postoperative for failed primary procedures. Secondary aortic procedures, 5 to 14 years postoperative, were performed for patch aortoplasties that became stenotic (n = 2) or aneurysmal (n = 1), and when thoracoabdominal bypasses developed an anastomotic narrowing (n = 1) or proved inadequate in size with patient growth (n = 1). No perioperative mortality accompanied either the primary or secondary aortic reconstructive procedures. Abdominal aortic coarctation represents a complex vascular disease. Individualized treatment changed little over the period of study, remaining dependent on the pattern of anatomic lesions, patient age, and anticipated growth potential. This experience documented salutary outcomes exceeding 90% following carefully performed operative therapy.

The meandering mesenteric artery or central anastomotic artery

A 50-year-old woman who was a heavy smoker presented with intermittent claudication of both lower extremities. An abdominal aortogram with bilateral lower extremity runoff demonstrated marked arteriosclerotic occlusive disease of the superficial femoral arteries. It also demonstrated a huge meandering mesenteric artery as an important collateral system (A). Note that the inferior mesenteric artery (IMA) is dilated and may be seen in continuity with an enlarged left colic (LCA) and marginal artery (MA). Despite the excellent filling of the abdominal aortic branches, the superior mesenteric artery was not visualized. The lateral projection of the same abdominal aortogram (B) shows severe stenosis of the celiac artery (CA) at its origin (arrow) and of the superior mesenteric artery (SMA) just downstream from its origin (arrow). The origin of the inferior mesenteric artery is not stenotic but rather markedly enlarged as the beginning of the central anastomotic mesenteric artery or, as it is sometimes called, the meandering mesenteric artery. No symptoms referable to the abdomen were present. The recognition of a meandering mesenteric artery of the colon is sufficient evidence by itself to conclude that major abdominal arterial stenosis or occlusion is present. Such arterial disease is either severe stenosis or occlusion of the celiac and superior mesenteric arteries as seen only by a lateral aortic projection or a Leriche aortic occlusion just below the renal arteries. Its presence with mesenteric occlusive disease means that blood flow in the enlarged central anastomotic artery is upward from the open inferior mesenteric artery to supply the branches of the stenotic celiac and superior mesenteric arteries. When the disease is an occluded aorta, the collateral flow is from above downward to supply the lower extremities. Stenosis or occlusion of the celiac and superior mesenteric arteries is commonly associated with abdominal angina or loss of viability of the intestine. However, it need not cause symptoms as demonstrated in this patient. The central anastomosing mesenteric artery can enlarge enough to furnish adequate blood flow between the superior and inferior mesenteric circulations when the two major trunks are severely stenotic or even occluded.1Moskowitz M. Zimmerman H. Felson B. The meandering mesenteric artery of the colon.AJR. 1964; 92: 1088-1099Google Scholar, 2Connolly J.E. Abrams H.L. Kieraldo J.H. Observations on the diagnosis and treatment of obliterative disease of the visceral branches of the abdominal aorta.Arch Surgery. 1965; 90: 596-606Crossref PubMed Scopus (8) Google Scholar If this central anastomotic artery is interfered with during nonvascular abdominal surgery by thrombosis or division, acute ischemia and gangrene of the intestinal system will result. Likewise, division of an enlarged anastomotic artery without its reimplantation into the abdominal aorta or aortic graft may result in infarction of the bowel that it supplies. Its recognition on abdominal aortography or at laparotomy (C, Cover) is of great importance. This anastomotic pathway explains why surgical division of the inferior mesenteric artery has, on occasion, even resulted in gangrene of the legs when distal aortic or iliac artery obstruction was present. Our patient underwent bilateral femoral-popliteal bipasses for claudification and a subsequent nonvascular abdominal operation. At which time we obtain photo C, Cover. We also continued to monitor her for any symptoms of mesenteric ischemia. More commonly, the ability of the central anastomotic artery to enlarge may be limited, and in such patients, its presence is especially valuable in signaling impending bowel ischemia even before intestinal angina may appear. In such cases, we recommend prophylactic concomitant revascularization of the compromised mesenteric vessels during aortic reconstructive procedures.3Connolly J.E. Kwaan J.H. Prophylactic revascularization of the gut.Ann Surg. 1979; 190: 514-522Crossref PubMed Scopus (31) Google Scholar

Surgical Treatment of Subaortic Obstruction in Adolescent and Adults: Long-Term Follow-up

Subaortic stenosis (SAS) is a wide spectrum of anatomical derangements ranging from a discrete fibrous membrane to tortuous fibrous tunnel with or without aortic annulus hypoplasia. We have reviewed 88 patients undergoing surgery for SAS over a 15-year period. There were 47 male and 41 female patients with a mean age of 19.8 +/- 10.6 years (range 11 to 39). Fifty-eight patients had discrete subaortic membrane, and 30 patients had diffuse tunnel subvalvular stenosis. The mean systolic pressure gradients were found to be 86.5 +/- 31.4 mmHg (range 48 to 145 mmHg). Ten patients had mild and 13 patients had moderate-to-severe aortic insufficiency (AI) preoperatively. Nine patients had bicuspid aortic valve. Forty patients (45.4%) had associated cardiac lesions. Isolated membranectomy was performed in six patients. Membranectomy associated with septal myectomy was done in 52 patients. Fifteen patients of them associated hypoplasia of the aortic orifice necessitated aortic valve replacement (AVR) using the Konno-Rastan procedure. Fifteen patients with tunnel SAS and normal aortic valves underwent a combined approach for valve sparing, a modified Konno procedure with patch septoplasty. Also eight patients required AVR because of the severity of AI and five patients aortic reconstruction procedures. Aortic commissurotomy was performed to relief of stenosis in four patients. There were three early deaths (3.4%) and one late death (1.1%) all after the Konno-Rastan procedure. Eight patients (9.1%) had permanent conduction abnormalities. Postoperative left ventricle-aorta gradient was significantly decreased at early postoperative period (p < 0.001) and ranged from 10 to 25 mmHg (mean 14.1 +/- 4.3). Fourteen patients (16.5%) were reoperated for recurrent obstruction or progression of AI. The mean reoperation interval was 4.4 +/- 1.7 years (range 2 to 8 years). Five-year reoperation-free survival was 88.0 +/- 3.6% and 12.5-year reoperation-free survival was 75.5 +/- 7.0%. Our results of aggressive surgical approach of subvalvular aortic stenosis produces relief of obstruction and frees the valve leaflets, significantly reducing associated AI with long-term survival and long-term adequate relief of left ventricular outflow tract obstruction.

Long-term survival after vascular surgery: Specific influence of cardiac factors and implications for preoperative evaluation

We sought to identify specific determinants of long-term cardiac events and survival in patients undergoing major arterial operations after preoperative cardiac risk stratification by American College of Cardiology/American Heart Association guidelines. A secondary goal was to define the potential long-term protective effect of previous coronary revascularization (coronary artery bypass grafting [CABG] or percutaneous coronary intervention [PCI]) in patients with vascular disease. Four hundred fifty-nine patients underwent risk stratification (high, intermediate, low) before 534 consecutive elective or urgent (<24 hours after presentation) open cerebrovascular, aortic, or lower limb reconstruction procedures between August 1996 and January 2000. Long-term follow-up (mean, 56 +/- 14 months) was possible in 97% of patients. The Kaplan-Meier method was used for survival data. Long-term prognostic variables were identified with the multivariate Cox proportional hazards model and contingency table analysis censoring early (<30 days) perioperative deaths. While 5-year survival was 72% for the overall cohort, cardiac causes accounted for only 24% of all deaths, and new cardiac events (myocardial infarction, congestive heart failure, arrhythmia, unstable angina, new coronary angiography, new CABG or PCI, cardiac death) affected only 4.6% of patients per year during follow-up. High cardiac risk stratification level (hazards ratio [HR], 2.2, 95% confidence interval [CI], 1.4-3.4), adverse perioperative cardiac events (myocardial infarction, congestive heart failure, ventricular arrhythmia; HR, 2.2; 95% CI, 1.2-4.1), and age (HR, 0.33; 95% CI, 0.2-0.6) were independently prognostic for latemortality. Preoperative cardiac risk levels also correlated with new cardiac event rates ( P < .01) and late cardiac mortality ( P = .02). Modestly improved survival in patients who had undergone CABG or PCI less than 5 years before vascular operations compared with those who had undergone revascularization 5 or more years previously and those at high risk without previous coronary intervention (73% vs 58% vs 62% 5-year survival; P = .02) could be demonstrated with univariate testing, but not with multivariate analysis. Type of operation, urgency, noncardiac complications, and presence of diabetes did not affect long-term survival. Despite cardiac events being a less common cause of late mortality after vascular surgery, perioperative cardiac factors (age, preoperative risk level, early cardiac complications) are the primary determinants of patient longevity. Patients undergoing more recent (<5 years) CABG or PCI before vascular surgery do not have an obvious survival advantage compared with patients at high cardiac risk without previous coronary interventions.

Improved Intraoperative Management of Anastomotic Bleeding during Aortic Reconstruction: Results of a Randomized Controlled Trial

In a randomized controlled trial, the effectiveness of a polymeric surgical sealant (CoSeal) was compared to Gelfoam/thrombin for managing anastomotic bleeding after implantation of Dacron grafts during aortic reconstruction for nonruptured aneurysms. Each treatment was directly applied to the suture line after confirmation of anastomotic bleeding. The proportion of suture line sites that achieved immediate sealing and the proportion sealed within 5 minutes were determined among 37 experimental (59 sites) and 17 control subjects (27 sites). A significantly greater proportion of bleeding suture line sites treated with the polymeric sealant achieved immediate sealing following reestablishment of blood flow compared with control-treated sites [48 of 59 (81%) vs 10 of 27 (37%); P = 0.002]. The difference between treatment groups was maintained after 5 minutes with approximately 85 per cent (50 of 59) of CoSeal sites compared to just over one-half (14 of 27) of control sites demonstrating ultimate sealing (P = 0.01). There were no adverse events related to the use of the polymeric sealant in this study. These results support the use of this novel sealant for the intraoperative management of anastomotic bleeding during aortic reconstruction procedures.

Treatment of abdominal aortic anastomotic pseudoaneurysm with percutaneous coil embolization

Intraabdominal anastomotic pseudoaneurysms continue to be a late complication of aortic reconstructive procedures. Early surgical repair is critical but is associated with high operative mortality rates. We present a patient who was diagnosed with a distal anastomotic pseudoaneurysm 13 months after transabdominal repair of a symptomatic abdominal aortic aneurysm. Because of the poor operative risk, the patient was considered for a less invasive approach and underwent coil embolization of the abdominal aortic anastomotic pseudoaneurysm. The patient remains without recurrence of pseudoaneurysm 3.5 years later. (J Vasc Surg 2002;35:811-4.)

Prevention and management of sigmoid and pelvic ischemia associated with aortic surgery

Ischemia of the colon, rectum, and pelvis continues to be a significant source of morbidity and mortality after aortic reconstruction. Complications associated with colonic and pelvic ischemia are severe and include impotency, buttock claudication, colonic and rectal infarction, buttock and perineal necrosis, and spinal cord or lumbar plexus injury. To prevent these complications the vascular surgeon must make every attempt to guarantee the adequacy of colonic and pelvic blood supply after aortic reconstructive procedures. During open surgical repair of aneurysms or aortoiliac arterial occlusive disease, patent inferior mesenteric arteries must either be routinely reimplanted or selectively ligated on the basis of object intraoperative assessment of colonic perfusion. In addition, when possible, antegrade perfusion should be maintained in patent internal iliac arteries, and femoral reconstructions should include reconstruction of the deep femoral artery to assure adequate perfusion of potential pelvic collaterals. The rate of colonic and pelvic ischemia after endovascular aneurysm repair appears lower than after open repair, but all of the complications of colonic and pelvic ischemic seen after open repairs have been reported after endoluminal aneurysm repair. Thus, during stent-graft repair of abdominal aortic aneurysms, all attempts also should be made to preserve pelvic perfusion by maintaining antegrade flow to a least one patent internal iliac artery. The principle to remember in the management of complications of pelvic ischemia associated with aortic reconstruction is prevention because when complications of pelvic ischemia occur, the damage often is irreversible.

Intraoperative Use of Platelet-plasmapheresis in Vascular Surgery

Purpose: Acute platelet-plasmapheresis (APP) has been reported to decrease blood loss and homologous transfusions during cardiac [1] and vascular [2] surgery. However, there are no prospective, randomized trials using APP in vascular surgery. Our study examined APP use in aortic reconstructive surgery and the impact on blood loss and transfusion requirements. Methods: Preoperatively, patients undergoing elective aortic reconstruction were randomized to either a control (n=10) or a study (n=10) group. In the study patients, APP was performed subsequent to induction of anesthesia. Both platelet-poor plasma (PPP) and platelet-rich plasma (PRP) were administered at the completion of all graft anastamoses and after heparin reversal with protamine. Additional blood products were given as necessary. Perioperative blood loss, transfusion requirements, hematological and coagulation profiles were compared between the two groups. Means were compared using student's t-test. Results: Demographics, type of surgical procedure, and preoperative baseline laboratory values were similar for both groups. Intraoperative blood loss, fluid requirements, and total homologous transfusions were not different between the groups. (Table 1)Table 1Patients in the study group received a mean of 365 +/- 154 ml PRP/patient and 540 +/- 150 ml PPP/patient. Postoperative coagulation and hemotological studies were not different between the control and the study groups except for the platelet count (185,000 +/- 62,000 vs. 106,000 +/- 38,000; p=0.004). However, no clinical significance due to this difference was observed. Conclusions: This study failed to demonstrate any benefit from APP in elective aortic reconstructive procedures. This blood conservation technique needs to be considered on an individual basis and may play a significant role in patients who do not accept blood products on religious grounds or have major antigen-antibody reactions to donor blood.