Aortoiliac Disease Research Articles

Percutaneous Left Axillary Artery Approach for Impella 2.5 Liter Circulatory Support for Patients with Severe Aortoiliac Arterial Disease Undergoing High‐Risk Percutaneous Coronary Intervention

The use of the Impella 2.5 liter (L) device for hemodynamic support has been well described. The typical access site for the Impella 2.5 L device is the femoral artery. The use of the axillary and subclavian artery has been described via surgical cut down for the Impella 5 L device when femoral artery access is not possible. In patients with severe aortoiliac disease and difficult anatomy the femoral artery access for the Impella 2.5 L device is not feasible. We describe the successful percutaneous use of the Impella 2.5 L device for hemodynamic support via the left axillary artery in 2 patients undergoing high-risk PCI with concomitant severe aortoiliac disease.

Management of Aortic Valve Bypass Surgery

The 3 leading causes of aortic stenosis (AS) in adults are calcific degeneration of a normal trileaflet aortic valve (AV), calcific degeneration of a congenital bicuspid AV, and rheumatic AS. Therapeutic options in patients with severe AS include aortic valve replacement (AVR), transcatheter aortic valve implantation (TAVI), or aortic valve bypass (AVB). An AVB involves the placement of a valved conduit between the apex of the left ventricle and the descending thoracic aorta. AVB serves as a useful alternative to treat severe AS in patients deemed high risk for conventional AVR (ie, porcelain aorta, previous cardiac surgery) or TAVI (ie, severe aorto-iliac disease, limited experience, lack of hybrid operating room). Advantages of on-pump AVB include the avoidance of aortic cannulation, cross-clamping, and cardioplegic cardiac arrest. The procedure can also be performed without cardiopulmonary bypass. In this article, the authors review the circulatory physiology, perioperative anesthetic management, the role of intraoperative transesophageal echocardiography, and surgical considerations of AVB surgery through 3 cases.

Contemporary Outcomes After Endovascular Treatment for Aorto-Iliac Artery Disease

The patency and complications in aorto-iliac (AI) stenting remain poorly understood. The aim of this paper was to investigate the safety and efficacy after AI stenting. This study was performed as a large-scale multicenter, retrospective registry. A total of 2,147 consecutive patients with AI disease were enrolled. The safety endpoints were procedure success, complications and 30-day mortality. The efficacy endpoints were primary, assisted primary and secondary patency, overall survival, freedom from major adverse cardiovascular events (MACE; all-cause death, myocardial infarction and stroke), and major adverse cardiovascular and limb events (MACLE; any repeat revascularization for limb and leg amputation in addition to MACE). Procedure success, complication rate and 30-day mortality were 97.6%, 6.4% and 0.7%. Primary patency was 92.5%, 82.6% and 77.5% at 1, 3 and 5 years, assisted primary patency was 97.0%, 92.7% and 91.9% at 1, 3 and 5 years and secondary patency was 99.0%, 98.7% and 98.5% at 1, 3 and 5 years. The overall survival rate was 95.0%, 87.6%, and 79.3% at 1, 3 and 5 years. The cause of death was cardiovascular in 44.1%. Freedom from MACE (MACLE) was 93.3% (89.9%), 84.4% (76.7%), and 74.9% (66.8%) at 1, 3 and 5 years. Female gender, diabetes, renal failure, absence of aspirin, reference vessel diameter <8.0mm and outflow lesion were found to be independent predictors of primary patency. The safety and efficacy after AI stenting are feasible compared to surgical reconstruction.

Comparison of Laparoscopic and Open Aortobifemoral Bypass in the Treatment of Aortoiliac Disease. Results of a Contemporary Series (2003–2009)

Objectives : The study objective was to describe and evaluate our single center (University Hospital Liège) experience with totally laparoscopic bypass surgery compared with conventional open surgery to treat aortoiliac occlusive disease.Material and methods : A retrospective database review of all patients undergoing aortobifemoral bypass for aortoiliac occlusive disease in our center, between 2003 and 2009, was performed. During this period, a total of 251 consecutive patients were identified. Among these patients, 95 underwent totally laparoscopic aortobifemoral bypass (group I) and 156 conventional open surgery (group II). Demographic data, operative data, postoperative recovery data, complications, two-year follow-up, morbidity and mortality were analysed according to the laparoscopic and conventional open group.Results : Patients included 160 men and 91 women. The mean age was 61 years (range, 40 to 88 years) in both groups. Indications for surgery were invalidating claudication in 87%, rest pain in 7%, trophic disorders in 5%, impotence in 1.6% and digestive claudication in 1.2%. Prior to bypass surgery, 11 (11.6%) for the group I and 41 (26.3%) for the group II had undergone one or more abdominal surgical procedures. A transperitoneal and retrocolic approach was preferred in all laparoscopic procedures. Laparoscopic aortobifemoral bypass (LABF) required an operative time of 242 minutes (range, 129 to 465) and open aortobifemoral bypass (OABF), 200 minutes (range, 105 to 430). The mean aortic cross clamping time was 62 minutes in group I and 33 minutes in group II. Mean blood loss was more important in group II (1010 ml) than in group I (682 ml). The average length of hospital stay was 8.1 days for LABF compared with an average of 12 days for OABF. In 21 cases (20%) conversion to open surgery was necessary in the laparoscopic group. Systemic morbidity was significantly higher in the OABF group. Thirty-day postoperative mortality was 2% for group II. There was no hospital mortality in the laparoscopic group. Twenty nine patients were lost to follow-up and the mean follow-up was 23.5 months.Conclusion : Analysis of the results shows that laparoscopic aortobifemoral bypass for aortoiliac occlusive disease is a safe procedure. The statistically significant advantages observed in the majority of our patients were decreased blood loss, faster post-operative recovery and shorter hospital stay. In the two groups, late morbidity attributable to the bypass prosthesis was minimal compared with other causes.

Supervised Exercise Versus Primary Stenting for Claudication Resulting From Aortoiliac Peripheral Artery Disease

Background— Claudication is a common and disabling symptom of peripheral artery disease that can be treated with medication, supervised exercise (SE), or stent revascularization (ST). Methods and Results— We randomly assigned 111 patients with aortoiliac peripheral artery disease to receive 1 of 3 treatments: optimal medical care (OMC), OMC plus SE, or OMC plus ST. The primary end point was the change in peak walking time on a graded treadmill test at 6 months compared with baseline. Secondary end points included free-living step activity, quality of life with the Walking Impairment Questionnaire, Peripheral Artery Questionnaire, Medical Outcomes Study 12-Item Short Form, and cardiovascular risk factors. At the 6-month follow-up, change in peak walking time (the primary end point) was greatest for SE, intermediate for ST, and least with OMC (mean change versus baseline, 5.8±4.6, 3.7±4.9, and 1.2±2.6 minutes, respectively; P &lt;0.001 for the comparison of SE versus OMC, P =0.02 for ST versus OMC, and P =0.04 for SE versus ST). Although disease-specific quality of life as assessed by the Walking Impairment Questionnaire and Peripheral Artery Questionnaire also improved with both SE and ST compared with OMC, for most scales, the extent of improvement was greater with ST than SE. Free-living step activity increased more with ST than with either SE or OMC alone (114±274 versus 73±139 versus −6±109 steps per hour), but these differences were not statistically significant. Conclusions— SE results in superior treadmill walking performance than ST, even for those with aortoiliac peripheral artery disease. The contrast between better walking performance for SE and better patient-reported quality of life for ST warrants further study. Clinical Trial Registration— URL: http://clinicaltrials.gov/ct/show/NCT00132743?order=1 . Unique identifier: NCT00132743.

A rare case of giant coronary artery aneurysm in the context of multiple arterial aneurysms

INTRODUCTIONWhilst the incidence of CAA has been reported as up to 5%, giant CAA (>2cm) is rare. PRESENTATION OF CASEWe present a rare case of 3cm×4cm giant coronary artery aneurysm (CAA) in the context of aorto-iliac aneurysmal disease, treated by staged open surgical repair. DISCUSSIONAbdominal aortic aneurysm (AAA) and CAA share risk factors and aetiological mechanisms, therefore should be considered, particularly when CAA is diagnosed in the first instance. CONCLUSIONSSurgical intervention for diagnosed giant CAA appears to be the treatment of choice in the reported literature, with the order of intervention when AAA co-exists remaining a point for debate.

Transapical Aortic Valve Implantation in High-Risk Patients With Severe Aortic Valve Stenosis

Transapical aortic valve implantation (TA-TAVI) represents an alternative in patients with symptomatic severe aortic valve stenosis (SSAVS) who cannot be operated on or have a high surgical risk. The aim of this prospective multicenter observational study was to assess early and 2-year clinical and hemodynamic outcomes after TA-TAVI. From May 2008 to September 2010, 179 patients with inoperable conditions or high-risk patients underwent TA-TAVI at 4 institutions. Indications for TA-TAVI were SSAVS and logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) greater than 20% or porcelain aorta in patients with severe aortoiliac disease. Patients underwent clinical and echocardiographic follow-up visits at hospital discharge, 3 and 6 months after TA-TAVI, and every 6 months thereafter. The impact of the learning curve for the centers and of intraoperative complications on patient outcomes was also evaluated. Mean age was 81 ± 6 years. Mean logistic EuroSCORE was 22% ± 12%. Transapical delivery was successful in all patients. Seventeen severe intraoperative complications occurred in 13 (7.3%) patients. Thirty-day mortality was 3.9% (7 patients). Mean follow-up was 9.2 ± 6.5 months. Late mortality occurred in 9 patients. Two-year survival was 88% ± 3%. An intraoperative severe complication was identified as the only significant independent predictor of 1-year mortality. A significant benefit was found when comparing 2-year survival of the second versus the first 50% patients at each center (93% ± 2% versus 84% ± 3 %; p = 0.046). A significant reduction of both mean and peak gradients from the preoperative to the postoperative period, which remained stable during follow-up, was found. TA-TAVI provides excellent early and 2-year results in terms of survival, valve-related adverse events, and hemodynamic performance. Survival after TA-TAVI is affected by the center learning curve and by the occurrence of an intraoperative complication.

Systematic review of exercise training or percutaneous transluminal angioplasty for intermittent claudication

The aim was to summarize the results of all randomized clinical trials (RCTs) comparing percutaneous transluminal angioplasty (PTA) with (supervised) exercise therapy ((S)ET) in patients with intermittent claudication (IC) to obtain the best estimates of their relative effectiveness. A systematic review was performed of relevant RCTs identified from the MEDLINE, Embase and Cochrane Library databases. Eligible RCTs compared PTA with (S)ET, included patients with IC due to suspected or known aortoiliac and/or femoropopliteal artery disease, and compared their effectiveness in terms of functional outcome and/or quality of life (QoL). Eleven of 258 articles identified (reporting data on eight randomized clinical trials) met the inclusion criteria. One trial included patients with isolated aortoiliac artery obstruction, three trials studied those with femoropopliteal artery obstruction and five included those with combined lesions. Two trials compared PTA with advice on ET, four PTA with SET, two PTA plus SET with SET and two PTA plus SET with PTA. Although the endpoints in most trials comprised walking distances and QoL, pooling of data was impossible owing to heterogeneity. Generally, the effectiveness of PTA and (S)ET was equivalent, although PTA plus (S)ET improved walking distance and some domains of QoL scales compared with (S)ET or PTA alone. As IC is a common healthcare problem, defining the optimal treatment strategy is important. A combination of PTA and exercise (SET or ET advice) may be superior to exercise or PTA alone, but this needs to be confirmed.

324 The distribution of peripheral arterial disease in patients presenting to a community cardiology clinic

Our objective was to determine the prevalence of aorto-iliac disease, total inflow disease, superficial femoral disease and infra-popliteal disease in patients presenting for peripheral arterial disease testing and who were found to have an abnormal ABI.

Renal Transplantation With Arterial Inflow From an Axillofemoral Graft

Renal Transplantation With Arterial Inflow From an Axillofemoral Graft

Antegrade, Covered, Self-Expanding Stent as an Iliac Extension in a Bifurcated Endograft: A Feasible Technical Maneuver for Challenging Aortoiliac Aneurysmal Anatomy

Aneurysmal and occlusive aortoiliac disease can make the process of introducing large delivery catheters for endovascular repair challenging. We describe the case of a patient who could be treated by a bifurcated stent-graft despite having a unilateral external iliac occlusion. From a brachial access, a covered self-expanding stent was deployed antegradely through the distal gate of the stent-graft into the common iliac artery. This technical choice helped to overcome the problem of an external iliac occlusion, so as to maintain an antegrade flow into the internal iliac and avoid the need for an interfemoral bypass. Auto-expandable covered stent-graft with a thinner shaft can be used through a brachial access as an iliac extension of a bifurcated aortic endograft. However, a longer follow-up duration and more cases are necessary to warrant the safety and the durability of such an "off-label" endovascular material assemblage.

Combined Direct Repair and Inline Inflow Stenting in the Management of Aortoiliac Disease Extending Into the Common Femoral Artery

Describe a hybrid approach to simplify management of complex aortoiliac occlusive disease (AIOD) extending into the common femoral artery (CFA). Retrospective review of 56 patients who underwent hybrid management of AIOD extending into CFA between January 2003 and February 2007. Two distinct hybrid approaches were compared: Inline (iliac stenting continuous with an open CFA reconstruction, 38 limbs in 37 patients) and tandem (noncontiguous stenting of an upstream iliac segment, 20 limbs in 19 patients). The median follow-up duration was 15 ± 12 months in the inline group and 24 ± 12 months in the tandem group. Technical success was achieved in all but 1 procedure. Clinical and hemodynamic responses to the interventions and limb loss rates were comparable in both groups. Survival table analysis showed no significant difference between inline and tandem reconstructions. Inline stenting represents a lesser invasive revascularization choice in complex AIOD with contiguous involvement of the CFA.

Outcomes and Timing of Aortic Surgery in Renal Transplant Patients

Solid organ transplantation in elderly patients has become more common in recent years. An increasing number of patients present with renal failure requiring transplantation and comorbid occlusive or aneurysmal aortic pathology. The optimal strategy for the timing and management of the aortic disease and renal transplantation in these patients is unknown. Before the availability of endovascular therapies, our policy was to provide open repair of aortic disease before cadaveric transplantation, or by simultaneous aortic reconstruction with renal allotransplantation if a living donor was available. Since the wide acceptance of endovascular modalities, our strategy has changed to take advantage of endovascular treatment pre-transplant. This study examines the outcome of both approaches. We performed a retrospective review of 12 patients between 1996 and 2009 who underwent both renal transplantation and a major abdominal aortic procedure either simultaneously (n = 6), metachronous, with the procedures occurring within the same month (n = 2), or distant, with the aortic procedures occurring between 5 and 24 months before or after transplantation (n = 4). All patients with occlusive disease underwent an aortobifemoral bypass, one before transplant, one subsequent to transplantation, and four simultaneous with a renal allograft. To assess renal transplant status, patients' serum creatinine levels were followed up every 3 months. Of the 12 patients, eight underwent open aortic procedures, whereas four underwent endovascular aortic aneurysm repair. Patients who underwent endovascular aortic aneurysm repair were followed up with ultrasound examinations at 6-month intervals, and with contrast computed tomography scans every other year. Aortic reconstruction was performed successfully in all the 12 patients irrespective of timing strategy. All the patients who underwent endovascular repair had functional renal allografts for the duration of follow-up. Two patients had simultaneous aortobifemoral bypass and pancreas-kidney transplantation without complication. Among the patients with open aortic repairs, there was one 5-year mortality and one patient had failure of two renal allografts. None of the patients had limb loss, and aortic grafts (one limb required a secondary procedure) remained patent. The 5-year patient survival of 90% and kidney survival of 75% appeared similar to results in the general transplant population without aortic disease. Two significant complications related to the open procedures were observed: two renal transplants developed postoperative hematomas requiring evacuation and one aortobifemoral bypass (ABF) developed a femoral wound infection requiring evacuation and sartorius flap closure. The 30-day mortality rate in all patients was zero. The length of stay for patients receiving simultaneous procedures ranged from 5 to 14 days (median, 10.5) and was significantly lower than the 10-52-day (median, 18) combined length of stay in the metachronous and/or distant groups (p = 0.016). The coexistence of aortic disease and renal transplantation is an increasingly common clinical scenario. Exclusion from transplantation of patients with major aortoiliac disease is commonplace in many transplant centers as early registry data suggested a poor outcome. Appropriate planning with a vascular surgical team can lead to outcomes, which are comparable with the general transplant population without significant aortic disease.

Short segment aortic endarterectomy - a technique to aid cannulation in donors with severe aorto-iliac disease

Cannulation of the abdominal aorta in older donors with advanced atherosclerotic disease is challenging and may lead to dissection or plaque embolization. We describe a different technique, short segment aortic endarterectomy, which can be a useful alternative during organ procurement. It permits safer cannulation and securing of atherosclerotic infrarenal aortas, thereby allowing us to flush and safely use organs that otherwise would have been discarded.

Hybrid Aortoiliac Revascularization to Avoid Nonautogenous Groin Reconstruction in an Intravenous Drug Abuser

Traditional methods for revascularization of an occluded aortoiliac system have necessitated either in-line aortic reconstruction through an aortobifemoral bypass or extra-anatomic bypass. However, both these approaches require artificial material to be placed in the groin. The consequence of groin infection can be devastating leading to high rates of both limb loss and mortality. One of the most feared patient populations presenting with groin complications is that of the intravenous drug abuser. We present the case of a patient with a long history of intravenous drug abuse with severe aortoiliac disease. Instead of resorting to a more traditional open surgical approach necessitating artificial reconstruction in the groin, we chose to proceed with a hybrid open and endovascular procedure through a direct open surgical access to the aortic bifurcation. This allowed for revascularization without the placement of artificial material in the groin.

Impact of Endovascular Technique in Vascular Surgery Training at a Large University Hospital in Brazil

The aim of this study was to determine the impact of endovascular surgery versus open vascular technique training in a Brazilian teaching service. Cross-sectional study. Hospital das Clinicas-Faculty of Medicine-University of Sao Paulo, a tertiary institutional hospital-Brazil. We reviewed 1,040 arterial operations performed during 2 distinct time periods: January 1995 to December 1996, and January 2006 to December 2007. Based on the disease treated, the procedures were classified into the following 5 groups: abdominal aortic aneurysms (AAA), aorto-iliac obstructive disease (AI), obstructive disease of the femoropopliteal-tibial segment (FP), carotid disease (C), and others (O). The operations were also divided into an endovascular surgery (ES) group and an open surgery (OS) group. We compared the number of open and endovascular procedures for each arterial disease group during both periods. During the 2006-2007 period, 654 patients were treated surgically, whereas over the 1995-1996 period, 386 arterial operations were performed. A significant increase in endovascular procedures (p < 0.001) was found from the 1995-1996 period to the 2006-2007 period (35 vs 351, respectively) in all groups, whereas open surgery showed a slight increase in the number of procedures in the AAA and O groups only. In the 1995-1996 period, OS was the primary surgical method for all groups, but in the 2006-2007 time frame, OS was performed more frequently than ES only in the AAA and O groups. Considering all vascular disease groups, OS was the technique used in 90.9% (351 of 386) of the operations during 1995-1996, whereas in 2006-2007, OS was performed in only 46.3% (303 of 654) of the procedures. The increase in the number of ES observed over the past decade has had little impact on OS procedures performed at our medical center, not bringing harm to open surgical training.

Invited Commentary

Invited Commentary

Gasless Laparoscopic Aorto-Bifemoral Bypass Grafting Using Self-Designed Abdominal Lifting System

Severe aorto-iliac occlusive disease can cause disabling symptoms. The treatment of aorto-iliac occlusive disease has dramatically changed with the introduction of endoluminal techniques. However, according to the Trans-Atlantic Inter-Society Consensus for severe aorto-iliac disease, aorto-bifemoral bypass remains the therapy of choice. A recent addition to the open repair is laparoscopic-assisted aorto-bifemoral bypass, especially in occlusive arterial disease. In this article, we describe a new technique of performing gasless laparoscopic-assisted aorto-bifemoral bypass grafting with a self-designed abdominal wall-lifting system. We dealt with a patient who had a history of coronary artery disease and poor cardiopulmonary functional reserve. He had disabling symptoms of claudication and rest pain on bilateral lower extremities. Aorto-biliac-femoral occlusive disease was diagnosed in him, and he underwent the gasless laparoscopic-assisted aorto-bifemoral bypass. The total procedure time was 260 minutes. The patient was extubated 5 hours postoperatively. He was discharged home without complications 5 days after the surgery. This procedure is attractive not only to minimize the length of the wound and the time to extubation but also to avoid the possible lethal complications associated with the traditional laparascopic pneumoperitoneum. This device and technique can also provide a bridge for young or less-experienced surgeons to be familiar with total laparoscopic aortic surgery from traditional open repair.

Obesity and fat distribution as predictors of aortoiliac peripheral arterial disease in middle-aged men

Background Peripheral arterial disease (PAD) in the aortoiliac segment is found in nearly a half of patients with PAD. The aim of this study was to estimate the influence of obesity and fat distribution on the occurrence of aortoiliac PAD in middle-aged men. Methods This case–control study included 204 middle-aged men (mean 58 ± 7 years; range 45–70 years): 102 patients with aortoiliac PAD and 102 healthy controls without PAD. Aortoiliac PAD was diagnosed by ankle–brachial index (ABI) and angiography. Body mass index (BMI) was categorized as: normal weight, overweight, and obese. Percents of body fat were grouped according to quartile distribution. The relationship between anthropometrics and aortoiliac PAD was estimated by multivariate logistic regression. Results Patients with aortoiliac PAD had higher body mass index, waist circumference, waist–hip ratio and percent of body fat. A strong correlation between all anthropometric parameters and ABI index and mean angiographic score was shown among patients with PAD. Multivariate regression, adjusted for blood pressure and cholesterol level, identified being overweight, body fat over 26.5% and WHR over 1.02 as predictors for aortoiliac PAD. Body fat over 26.5% and WHR over 1.02 remained significant after further adjustment for blood pressure, cholesterol and body mass index. Conclusion This study has identified the quantity of fat tissue (body fat over 26.5%) and its visceral distribution (waist–hip ratio over 1.02) as predictors of aortoiliac PAD in middle-aged men. Body mass index, a crude indicator of obesity, should be combined with these parameters when assessing the risk for aortoiliac PAD.

Femoral/Axillary Volume Flow Ratio as a New Index for the Assessment of Iliac Atherosclerosis

To measure the arterial volume flow (VF) with duplex scan, calculate femoral/axillary VF ratio, and discuss its applicability as a new index for the hemodynamic significance of an aorto-iliac occlusive lesion. Several measures of VF were obtained consecutively with duplex scan in both common femoral and axillary arteries of healthy volunteers with no signs of atherosclerosis and patients with documented evidence of occlusive aorto-iliac disease with segmental pressure measurement. Then the patient group was sent to complimentary evaluation for a second confirmatory examination. There were a total of 635 measures of VF performed in 10 healthy volunteers and 8 patients with severe iliac stenoses or occlusion, 2 of then with bilateral disease. When comparing normal participants and patients with severe iliac stenoses or occlusion, there was statistical significant difference between these 2 groups (P < .01 Mann-Whitney). Similar result was found when comparing patient with diseased limbs with their own contralateral normal side (P < .05 Wilcoxon). And measuring the VF only during the systolic phase was a much more sensitive parameter for differentiating the normal from the diseased. Besides that a good correlation between proximal thigh pressure index and femoral/axillary systolic flow ratio was found in the patient group (P < .01 Spearman correlation). The femoral/axillary VF ratio is useful in assessing the hemodynamic significance of aorto-iliac disease, and the systolic femoral-axillary ratio may also be useful as a follow-up tool.