Aortobifemoral Bypass Graft Research Articles

Para-Aortic Lymphoma Simulating Mycotic Abdominal Aortic Aneurysm

A 70-year-old man presented with 6 months’ history of progressively severe backache and left frank pain. Past history was significant for an aortobifemoral Dacron bypass graft performed 11 years ago for intermittent claudication attributable to aortoiliac occlusive disease. A contrast computed tomography (CT) scan showed a slight irregularity around the pararenal aorta without other abnormalities. Because of persistent symptoms, a positive emission tomography-CT scan was performed that showed a large pseudoaneurysm measuring 6.1×3.8×2.8 cm arising from the juxtarenal aorta above the previous aortic graft (Figure 1) with an associated retroperitoneal soft tissue mass encasing the left renal artery with a standardized uptake value of 22.5 (Figure 2). At this stage, the differential diagnosis was of juxtarenal aortic mycotic aneurysm or an anastomotic pseudoaneurysm with contained rupture, or retroperitoneal tumor with aortic invasion. The patient was referred to our tertiary vascular center for further management. Figure 1. Computed tomography scan …

V1857 CHALLENGING CASES OF ROBOTIC ASSISTED RADICAL CYSTECTOMY FOLLOWING RADIOTHERAPY OR VASCULAR SURGERY

You have accessJournal of UrologyBladder Oncology1 Apr 2013V1857 CHALLENGING CASES OF ROBOTIC ASSISTED RADICAL CYSTECTOMY FOLLOWING RADIOTHERAPY OR VASCULAR SURGERY Scott Leslie, Hamed Ahmadi, Andre Luis de Castro Abreu, Andre K Berger, R James Yu, Sheaumei Tsai, Steve Dong, Adrian S Fairey, Raed A Azhar, Mihir M Desai, Inderbir S Gill, and Monish Aron Scott LeslieScott Leslie Los Angeles, CA More articles by this author , Hamed AhmadiHamed Ahmadi Los Angeles, CA More articles by this author , Andre Luis de Castro AbreuAndre Luis de Castro Abreu Los Angeles, CA More articles by this author , Andre K BergerAndre K Berger Los Angeles, CA More articles by this author , R James YuR James Yu Los Angeles, CA More articles by this author , Sheaumei TsaiSheaumei Tsai Los Angeles, CA More articles by this author , Steve DongSteve Dong Los Angeles, CA More articles by this author , Adrian S FaireyAdrian S Fairey Los Angeles, CA More articles by this author , Raed A AzharRaed A Azhar Los Angeles, CA More articles by this author , Mihir M DesaiMihir M Desai Los Angeles, CA More articles by this author , Inderbir S GillInderbir S Gill Los Angeles, CA More articles by this author , and Monish AronMonish Aron Los Angeles, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2276AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robotic-assisted radical cystectomy (RARC) is increasingly utilized for the management of invasive bladder cancer. However, the feasibility of RARC in the setting of prior radiotherapy and vascular surgery has yet to be determined. We describe the technical challenges associated with these cases and compare outcomes with the entire RARC cohort at the University of Southern California. METHODS Between August 2009 and October 2012 58 patients underwent RARC at our institution. We compared the outcomes of 5 patients who had prior radiotherapy or vascular surgery with the rest of the cohort. The technique of RARC has been standardized at USC, and includes an extended pelvic lymph node dissection and intracorporeal urinary diversion. Demographic, perioperative and pathological parameters were collected. RESULTS All five patients were male with a median age of 75. Three patients received radiotherapy for prostate cancer and two patients with prior vascular surgery including abdominal aortic aneurysm repair in one patient and aorto-bifemoral bypass graft placement in the other one. Of the 5 patients, median EBL was 250 ml (range: 60 - 250), median operative time was 7 hrs (range: 6 - 8.9) and median hospital length of stay was 8 days (range: 5 - 19). There were no transfusions. One patient had a Clavien grade 1 and one patient had Clavien grade 3a complication. Comparing these 5 patients with the entire group undergoing RARC, there was no fifference in complications, estimated blood loss, or hospital length of stay. CONCLUSIONS RARC in the setting of prior radiotherapy or vascular surgery is safe and feasible. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e762 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Scott Leslie Los Angeles, CA More articles by this author Hamed Ahmadi Los Angeles, CA More articles by this author Andre Luis de Castro Abreu Los Angeles, CA More articles by this author Andre K Berger Los Angeles, CA More articles by this author R James Yu Los Angeles, CA More articles by this author Sheaumei Tsai Los Angeles, CA More articles by this author Steve Dong Los Angeles, CA More articles by this author Adrian S Fairey Los Angeles, CA More articles by this author Raed A Azhar Los Angeles, CA More articles by this author Mihir M Desai Los Angeles, CA More articles by this author Inderbir S Gill Los Angeles, CA More articles by this author Monish Aron Los Angeles, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Listeriosis infection of an abdominal aortic aneurysm in a diabetic patient

A rare case of an abdominal aortic aneurysm (AAA) infected by Listeria monocytogenes in a 72-year-old male diabetic farmer, is reported. Our patient had a history of a recent pneumonia that could have been caused by Listeria too. Aneurysm infection was manifested by fever and abdominal and back pain, which prompted investigation with CT scanning that revealed a 4.9 cm AAA with typical signs of infection. He underwent urgent AAA repair with aortobifemoral bypass grafting and had an uneventful course. Aneurysm content microbiology revealed Listeria monocytogenes and following a 9-week course of antibiotics our patient remains asymptomatic 11 months later.

Aortoduodenal Fistula: Not Always Bleeding

1Division of Gastroenterology, Department of Medicine; 2Division of Vascular Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia Correspondence: Dr Michael F Byrne, Division of Gastroenterology, Department of Medicine, University of British Columbia, 5153-2775 Laurel Street, Vancouver, British Columbia V5Z 1M9. Telephone 604-875-5640, fax 604-875-5378, e-mail michael.byrne@vch.ca Received for publication March 17, 2013. Accepted May 12, 2013 Case Presentation A 73-year-old woman presented to a community hospital with three months of intermittent, followed by continuous epigastric pain. There was no gastrointestinal bleeding, nausea, vomiting or fever. A noncontrast abdominal computed tomography scan identified gas locules around an aortobifemoral bypass graft performed in 1992, with surrounding inflammatory fat stranding (Figure 1A). Graft infection was suspected. Metronidazole was prescribed with outpatient follow-up by a vascular surgeon who referred her for gastroscopy. At the third part of the duodenum, a wall defect 3 cm × 2 cm in size was replaced by a yellow-coloured foreign body suspected to be the external surface of an aortic Dacron graft (Figure 1B). The aortoduodenal fistula was treated with an axillofemoral graft, removal of the infected graft and a duodenal-jejunostomy, in which the lateral wall defect at the junction of the third and fourth parts of the duodenum was closed with a loop of proximal jejunum (Figure 1C). Cultures from the excised graft had growth of Candida lusitaniae and Streptococcus constellatus. Antimicrobials were commenced, with recovery in two months.

A novel endovascular technique in the management of a large internal iliac artery aneurysm associated with an arteriovenous fistula

To describe a novel endovascular technique in the management of a complex arteriovenous fistula between a large internal iliac artery aneurysm and the adjacent iliac vein in a 76-year old patient with previous aortobifemoral bypass graft with an occluded proximal common iliac artery. Due to the high risk of open surgery in this case, endovascular treatment with simultaneous venous and arterial access was performed, with implantation of 2 stent grafts in the iliac vein to cover the fistulous communication and embolisation of the native external iliac artery (inflow). The endovascular technique described enables thrombosis of the large internal iliac aneurysm and treatment of the arteriovenous fistula without exposing the patient to the high morbidity and mortality associated with open surgery.

Traumatic Nonanastomotic Pseudoaneurysm of Axillofemoral Bypass Graft

Traumatic nonanastomtic disruption of an axillofemoral bypass graft (AFBG) is a relatively rare entity. However, we are reporting on an 82-year-old female who presented with a pulsating mass on her left side, which was noticed about 2 weeks after she fell on her side. The patient had undergone an ABFG about 15 years earlier for limb revascularization, and she had an occluded aortobifemoral bypass graft. A diagnosis of localized rupture with pseudoaneurysm (PSA) was confirmed with arterial duplex ultrasound and computed tomograph (CT) angiogram scans. A 7-cm PSA with partial disruption of the polytetrafluoroethylene (PTFE) graft at the level of the fifth thoracic vertebrae was noted. An initial work-up to eliminate the possibility of sepsis and localized mycotic seeding was negative. The patient was taken to the hybrid angiogram room, and a percutaneous cut down of the AFBG was performed with local dissection below the site of rupture. A limited angiogram showed a focal PSA of the AFBG. An intravascular ultrasound (IVUS) was performed to calibrate the diameter of the AFBG, and a covered stent was deployed across the area of the disrupted graft. A completion angiogram showed complete exclusion of the PSA with good runoff throughout the graft. The authors will review the management of the traumatic PSA with an endovascular approach.

Size matters! A reliable endovascular method to avoid infolding and endoleaks when reconstructing aortic bifurcations using stent grafts

Conventional revascularization of the lower extremities secondary to aortoiliac atherosclerotic vascular disease (ASVD) involves major intra-abdominal surgery with aortobifemoral bypass grafting. Complication rates are as high as 10% and perioperative mortality can be as high as 5%; therefore, careful patient selection is paramount. Endovascular aortobifemoral bypass repair with aortic bifurcation reconstruction is an emerging option in patients deemed unsuitable for conventional surgical management. Emerging techniques such as snorkel/chimney method are expanding the number of patients who can undergo endovascular repair of abdominal aortic aneurysms and/or revascularization of the lower extremities. However, until now, objective criteria for stent size selection used in these hybrid techniques have not been described.

Secondary Aortoenteric Fistula: A Case Report of Acute Aortic Occlusion Following Cellulitis

A secondary aortoenteric fistula is a relatively rare complication of abdominal aortic reconstruction. The clinical manifestation of aortoenteric fistula is usually upper gastrointestinal bleeding. We report a patient who developed acute aortic occlusion following chronic cellulitis, which is an uncommon finding. A 50-year-old man with a history of aortobifemoral bypass grafting was admitted for tiredness, fever and swelling of his right leg. On the 40th day of admission, he developed acute aortic occlusion. Computed tomography revealed right distal aortic graft occlusion and the presence of gas surrounding the graft. Gastroduodenoscopy showed an underlying Dacron graft consistent with an aortoenteric fistula in the third part of the duodenum. We excised the infected graft and reconstructed the abdominal aorta with a new prosthetic graft in situ, which was wrapped with the vascularized pedicle of the omentum. The duodenal defect was repaired with segmental duodenal resection and end-to-end anastomosis. The patient recovered well after surgical management and has remained in good condition for 2 years without developing any signs of recurrence of infection.

Emergent endovascular treatment of a bleeding recurrent aortoenteric fistula as a “bridge” to definitive surgical repair

We report the case of a 59-year-old man who developed a recurrent aortoenteric fistula (AEF) following previous aorto-bifemoral bypass grafting and subsequent AEF open repair with aorto-bifemoral graft excision and extra-anatomic reconstruction. The patient was treated emergently by means of endovascular plug deployment via a left brachial approach into the infrarenal aortic stump, obtaining recovery of hemodynamic stability. Five days later, he underwent elective relaparotomy, aortic plug removal, infrarenal aortic ligature, and duodenal repair. Endovascular strategies to rapidly stop bleeding associated with recurrent AEF may serve as a "bridge" to definitive open repair, as in the case discussed herein. Even if rare, recurrent AEF following previous prosthetic aortic graft excision and extra-anatomic revascularization represents a dreadful event. Since surgical treatment is technically demanding and time consuming in emergent settings, we present an "unconventional" endovascular option to obtain quick cessation of aortic bleeding.

Femoral Artery Pseudoaneurysm and Sudden Death

Pseudoaneurysm formation may be a late complication of vascular grafting. A case of sudden death in an 83-year-old woman with a previous aortobifemoral bypass graft is reported that was due to spontaneous hemorrhage from a pseudoaneurysm of the graft site that had eroded through the overlying skin and subcutaneous tissues. Pseudoaneuryms do not have to be of a particularly large size for rupture to occur. Social isolation and age-related cognitive impairment may delay treatment in older individuals resulting in a lethal outcome. The elderly are also more vulnerable to serious morbidity and death under these circumstances owing to significant underlying cardiovascular and respiratory disease and/or anticoagulant medication. Rarer conditions that may cause pseudoaneurysms include tumors and vasculidites. The possibility of an infectious contribution to the pseudoaneurysm should be considered and microbiological sampling undertaken.

Mid-term results of robot-assisted laparoscopic surgery for aortoiliac occlusive disease

The aim of this study was to evaluate middle-term clinical results of robot-assisted laparoscopic surgery (RALS) to treat aortoiliac occlusive disease (AIOD). Between 2002 and 2007, 28 consecutive patients received robot-assisted laparoscopic aortobifemoral bypass grafting (n = 24) or aortoiliac endarterectomy (n = 4). Patients were followed prospectively. RALS could be completed successfully in 24 patients; conversion to open surgery was necessary in four patients (14%). Median operative time was 350 min. Median aortic clamping time was 70 min. Median hospital stay was five days. One patient died within 30 days. Non-lethal complications occurred in four patients (14%). Clinical symptoms improved in all patients. Primary and secondary limb-based patencies at 36 months were 89% and 91%, respectively. In conclusion, RALS is a feasible and durable technique for patients with AIOD. Although operative times are long, RALS allows rapid postoperative recovery.

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.

Endovascular Treatment of Common Carotid Artery Dissection Via the Superficial Temporal Artery

To describe the endovascular treatment of an iatrogenic common carotid artery (CCA) dissection using the superficial temporal artery (STA) as the principal access. An 83-year-old man with a post-carotid endarterectomy left CCA dissection was admitted for a transient ischemic attack involving the left cerebral hemisphere that occurred despite proper anticoagulation. After excluding redo surgery and transfemoral stenting (owing to a partially compromised aortobifemoral bypass graft), stenting of the left CCA dissection was planned using a right transbrachial approach, with the left STA as an additional access. However, intraoperative angiography showed an acute angle between the innominate artery and left CCA, so the STA was used as the primary access route owing to its straight course and 4-mm diameter. The 9-x40-mm self-expanding stent was inserted via a 5-F sheath in the STA and deployed directly at the CCA dissection. The procedure was successful, and all vessels involved were patent at 6-month follow-up. In selected cases, the superficial temporal artery may represent a valid alternative approach for the endovascular treatment of short CCA dissections.

Common iliac aneurysm rupture after previous aortic aneurysm resection.

Ruptured common iliac aneurysms present with diagnostic and therapeutic challenges. This case describes the successful outcome in a patient with complex vascular surgical history. An elderly patient presented with abdominal pain confirmed by CT as leaking iliac aneurysm. He had previously undergone an aorto-bifemoral bypass graft for ruptured abdominal aortic aneurysm. The iliac aneurysm was treated by simple ligation of the external iliac artery. Aorto-bifemoral bypass graft may be required for aortic aneurysm repair in severe iliac calicification. Iliac artery fed by retrograde blood flow from the aorto-bifemoral bypass graft contributed to aneurysm development here.

A 72-year-old man with intermittent fever, anemia and a history of coronary and peripheral artery disease

Dr. Del Pace: A 72-year-old man with history of coronary and peripheral artery disease was admitted to this hospital with fever, fatigue and loss of weight. He had hypertension, type 2 diabetes mellitus and hyperlipidemia. He suffered from an ischemic cardiomyopathy with a low ejection fraction (33%). Fifty years prior he had undergone subtotal gastroresection for peptic ulcer. Seventeen years prior to this current admission (PTA), he had an aortobifemoral bypass grafting for symptomatic peripheral artery disease, and 8 years prior he had a myocardial infarction. Three vessel coronary disease was detected and coronary-artery bypass grafting had been carried out. One year PTA, he experienced an episode of sustained ventricular tachycardia, treated with stenting of the anterior descending coronary artery, followed by an internal cardiac defibrillator (ICD) implantation. Ten months PTA, he had a massive enteric bleeding complicated by hemorrhagic shock. A colonoscopy revealed ulcerated cecal angiodysplasia that was treated with an application of metallic clips. During the following months, he was admitted several times for sideropenic anemia without evidence of acute gastrointestinal bleeding, and iron therapy was administrated. Two colonoscopies were performed but no source of active bleeding was detected. Two months PTA, he developed a low-grade fever resistent to a 2-week course of antibiotic therapy with levofloxacin. Laboratory tests showed a normocytic anemia (8.1 g/dL) with normal levels of B12 and folic acid, with low levels of sideremia (13 lg/dL), and a normal haptoglobin. An esophagogastroduodenoscopy was normal. Neoplastic markers (NSE, CA 125, CA 15-3, CA 72-4, CA 19-9, CYFRA 21-1, CEA, alfa-FP) were all in the normal range. Antinuclear antibody, ANCA, rheumatoid factor were negative as well as immunofixation in serum and urine. A computed tomography (CT scan) of the abdomen with contrast material confirmed ceacum angiodysplasia, but did not reveal active enteral bleeding. Transesophageal echocardiography was performed, and a vegetation on the ICD catheter was found. One blood culture was positive for Streptococcus intermedius. Treatment with amoxicillin was started, and during the hospital stay, the fever disappeared. Removal of the pacemaker was suggested, but the patient refused it. After discharge, he completed a 4-week cycle of antibiotic therapy, but after 1 week of withdrawal, fever developed again with malaise, fatigue and weight loss. He was readmitted to this hospital. On examination, the patient appeared in mild distress. He had low-grade fever (37.5 C). The Blood pressure was 100/50 mmHg, pulse rate 70 beats/min and oxygen saturation 98% while he was breathing ambient air. A grade 2/6 S. Del Pace A. Savino (&) G. F. Gensini Department of Heart and Vessels, Careggi Hospital, University of Florence, Viale Morgagni 85, 50139 Florence, Italy e-mail: savino.andrea@gmail.com

VS 6. Combined Endovascular and Surgical Treatment of Severe (TASC D) Aortoiliac Occlusive Disease

Aortobifemoral bypass grafting has been the traditional treatment for extensive aorto-iliac occlusive disease (AIOD). We present a case of recanalization, percutaneous transluminal angioplasty and stenting (R/PTAS) of the iliac vessels combined with femoral endarterectomy in a patient with severe AIOD. We have performed nearly 100 of these procedures with good mid-term resolution of symptoms and durability. Concomitant treatment of femoral disease often needed. R/PTAS is a suitable, less invasive alternative to aortic reconstruction for treatment of patients with severe AIOD.

Uso do azul de metileno na reversão de vasoplegia refratária ao uso de catecolaminas após bypass aortobifemoral

Há evidências de que o óxido nítrico (NO) tem importância na vasodilatação associada a reações vasoplégicas. O objetivo deste relato de caso é documentar um caso de vasoplegia refratária ao uso de catecolaminas após bypass aortobifemoral revertida com o uso de azul de metileno. Mulher, 50 anos, submetida a bypass aortobifemoral. Sem comorbidades. Saiu de sala cirúrgica extubada, estável e com pulsos distais presentes. Duas horas após a cirurgia, evoluiu com choque circulatório. Iniciada noradrenalina e investigadas causas de choque. Manteve-se com necessidades crescentes de aminas e parâmetros estáveis. No sexto dia pós-operatório, com a hipótese de vasoplegia refratária, optou-se pelo uso do azul. Resposta imediata, com queda nos níveis de aminas, sendo desligada a noradrenalina no dia seguinte. O azul de metileno inibe a guanilato ciclase, produtora de guanosina monofosfato cíclico. Especula-se que haja um sinergismo entre essas drogas, já que a sua associação permite a atuação do sistema adenosina monofosfato.

Unilateral Lower Limb Paralysis After Aortobifemoral Bypass Graft for Ruptured Abdominal Aortic Aneurysm: A Case Report

An 81-year-old man underwent an aortobifemoral bypass graft because of a ruptured abdominal aortic aneurysm. His postoperative recovery was complicated by unilateral lower limb paralysis caused by perioperative ischemia of the lumbosacral plexus. Ischemic lumbosacral plexopathy is an uncommon complication after infrarenal aortic surgery with serious morbidity. Despite a good surgical technique and knowledge of the vascularization of the spinal cord, its occurrence remains unpredictable.

Severe Valvular Regurgitation and Late Prosthesis Embolization After Percutaneous Aortic Valve Implantation

We report the case of a 79-year-old man with low-flow, low-gradient aortic stenosis who underwent transapical aortic valve implantation. The deployment of a 26-mm Edwards SAPIEN valve (Edwards Lifesciences Inc, Irvine, CA) was complicated with the occurrence of severe central aortic regurgitation that was successfully treated with the implantation of a second valve ("valve-in-valve"). Postoperative progress was satisfactory but 2 days after the procedure he suddenly developed cardiogenic shock secondary to the migration of the aortic bioprothesis into the left ventricular outflow tract. Open-heart surgery was undertaken to remove the valves and perform standard aortic valve replacement, but the patient died perioperatively.

Aortoentric Fistula Following Ruptured Abdominal Aortic Aneurysm Surgery: Aortobifemoral Dacron Bypass Graft is Detected by Colonoscopy

Aortoenteric fistula is a dramatic and rare complication, which may occur following abdominal aortic surgery. In this report, we present images of a 65-year-old patient who presented with acute peritonitis two months after aortobifemoral bypass grafting operation with a bifurcated dacron graft. Colonoscopy clearly showed the pathology leading to acute abdomen: Intestinal fistulization of the graft.