Aortobifemoral Graft Research Articles

Laparoscopically Assisted Total daVinci Aorto Bifemoral Graft Bypass with a Unique System of Graft Delivery

We report the first known example of a fully robotic aortobifemoral graft and aortic endarterectomy using the daVinci Surgical System and a unique method for graft delivery using the Endo-Vein Harvester.

Long-Term Outcome following Stent Reconstruction of the Aortic Bifurcation and the Role of Geometric Determinants

We assessed the long-term patency of kissing stent reconstruction of the aortoiliac bifurcation and identified variables that may influence it. We retrospectively reviewed our experience with stent-reconstruction procedures of the aortoiliac bifurcation from January 1998 through June 2005. The impact of demographic variables, vascular risk factors, disease location and characteristics, stent material and design, and stenting configuration on stent patency was assessed using univariate and multivariate analysis. In particular, we evaluated the effect of geometric mismatch between the protruding segment of the stents and the distal aortic lumen. Sixty-six patients underwent aortobi-iliac stent reconstruction. Indications were bifurcation or bilateral proximal iliac disease in 52 patients and unilateral ostial disease requiring contralateral protection in 14 patients. Limited disease (TASC A and B) was present in 40 limbs in 19 patients; extensive/diffuse disease (TASC C and D) was present in 78 limbs in 47 patients. Complete occlusions were present in 37 limbs in 28 patients (bilateral in nine patients). Self-expanding stents were used in 56 procedures and balloon-expandable stents in 10. Crossing configuration was used in 43 procedures, while abutting configuration was used in 23 procedures. Technical success was achieved in 62 patients (94%), with all four failures due to inability to cross a chronically occluded limb. Three of these patients underwent aortomono-iliac stenting with a crossover femoral-femoral bypass graft, with the remaining one opting for no further interventions. Median combined follow-up was 37 +/- 27 months (range 0-102). Hemodynamically significant restenosis developed in nine patients (14%). The management of restenosis was endovascular in eight patients and was successful in all (balloon dilation in four, restenting in three, thrombolysis and stenting in one) and operative in one patient who developed aortic occlusion and underwent aortobifemoral grafting. Survival table analysis showed primary and assisted patency rates at 4 years of 81% and 94%, respectively. The mortality rate during follow-up was 19 (cardiac cause in eight, pulmonary cause in three, and malignancy in five). Univariate analysis showed radial mismatch (aortic lumen dead space around the protruding segment of the stents), female gender, prior occlusion, and residual stenosis to be significant predictors of restenosis. Multivariate logistic regression analysis showed radial mismatch to be the only significant determinant of restenosis, although the statistical power of the model was limited by the small number of restenoses. Stent reconstruction of the aortoiliac bifurcation for occlusive disease is effective and durable, even with complex aortoiliac disease and long segment occlusions. Most restenoses are amenable to endovascular treatment, with excellent long-term assisted patency. Geometric variables related to individual aortic anatomy and disease pattern (patient-dependent) and stenting configuration (operator-dependent) may have an impact on long-term patency.

Detection of an aortoenteric fistula in a patient with intermittent bleeding

A 57-year-old male with an aortobifemoral bypass graft presented to a gastroenterology clinic with a 3-month history of intermittent hematemesis, melena and fever. The patient had received antibiotic therapy 2 months before for the same symptoms; however, following brief regression ( approximately 3 weeks) the symptoms had returned. Physical examination; analysis of full blood count; measurement of erythrocyte sedimentation rate, C-reactive protein levels, liver enzymes, electrolytes, renal function, serum cholesterol and serum triglyceride; HIV serology; blood, sputum, urine and stool culture analysis; performance of esophagogastroduodenoscopy, colonoscopy, abdominal ultrasonography and multidetector CT scanning. Aortoenteric fistula with an inflammatory mass surrounding the aortobifemoral bypass graft. Laparotomy with removal of the aortobifemoral bypass graft, performance of an extra-anatomic right axillofemoral bypass graft and an extra-anatomic right-left femorofemoral bypass graft.

Aortoduodenal Fistula and Streptococcal Myonecrosis

Pyomyositis is a rare primary bacterial infection of the skeletal muscles. Pyomyonecrosis is the most severe manifestation of this disease and is associated with a potentially devastating outcome. Patients with peripheral vascular disease presenting with pyomyositis may be difficult to distinguish from those with critical ischemia or synthetic graft sepsis. This article reports on a patient with aortobifemoral bypass graft and severe vitamin B(12) deficiency who developed pyomyonecrosis and aortoduodenal fistula. This article highlights the etiologic dilemma, diagnostic difficulties, and management challenges inherent in such cases. Pitfalls in our management of this patient are discussed.

Unilateral Gluteal Compartment Syndrome: A Complication of Open Abdominal Aortic Aneurysm Repair Using an Aortobifemoral Bypass Graft

Gluteal compartment syndrome following aortic surgery is a rare, often unrecognised complication. This report presents a case of unilateral gluteal compartment syndrome following an elective aortobifemoral bypass graft for an aortic aneurysm in a 58-year old male. Vascular surgeons and intensive care physicians should be aware of this potentially serious complication following aortic surgery and maintain a high index of suscpicion.

Aortofemoral graft limb–to–colon paraprosthetic fistula

A 58-year-old man presented with fever. During several hospitalizations in the preceding 3 months, bacteremia had been documented on seven occasions. Escherichia coli, Clostridium, and Candida spp were repeatedly recovered in blood cultures. The patient’s history was pertinent for tobacco abuse and severe claudication, which was initially treated with femorofemoral bypass graft. This failed, however, which prompted conversion to an aortobifemoral bypass (performed elsewhere), with resultant complete relief of claudication. The patient denied abdominal pain and had no evidence of overt or occult gastrointestinal (GI) bleeding. Fever and malaise persisted for 3 months. Abdominal computed tomography (CT) scans were performed on two occasions, and the results interpreted as negative. The Vascular Surgery Service was ultimately consulted and determined the patient’s clinical history and CT were highly suggestive of a secondary aortoenteric fistula (SAEF) involving the left aortobifemoral graft limb and the colon (A, arrow). The graft body, right limb, and both femoral regions appeared to be free of infection. An indium-111 white blood cell scan suggested isolated left midprosthetic limb involvement (B, arrow), and colonoscopy unequivocally established the diagnosis (Cover). Single-stage redo femorofemoral bypass and left aortofemoral graft limb excision was performed. At laparotomy, the left graft limb was densely incorporated to adjacent tissues, without gross contamination. The limb was transected and oversewn proximally. When followed distally, it was noted to traverse the sigmoid colon (C). Partial sigmoid resection with primary anastomosis was performed. The patient has since done well, without evidence of recurrent infection and with patent vascular reconstructions. SAEF is a direct communication between a vascular prosthesis and the GI tract. Most aortoenteric fistulas involve the graft-aortic suture line, with fistulization into the bowel lumen and resultant GI hemorrhage. A less common type of fistula, termed a paraprosthetic fistula, is defined as a communication between the surface of the graft body and the bowel lumen without suture line involvement or actual fistulization into the vascular lumen. The duodenum is the most frequently involved bowel segment for both types of SAEFs. Graft-colonic fistulae are much less common, comprising only 4.8% to 6.6% of cases in reported SAEF series. Because they do not involve the anastomosis, paraprosthetic fistulas do not result in GI hemorrhage, but rather sepsis, malaise, and other less specific symptoms. In patients who do not require emergency intervention, CT is the recommended initial diagnostic study of choice whenever SAEF is considered. A positive indium-111 white blood cell scan supports the diagnosis of SAEF. Endoscopy can be a definitive diagnostic tool, but may also serve to exclude other pathology in patients with GI bleeding. Traditional therapy for SAEF, especially for aortoduodenal fistula, is GI tract restoration, complete prosthetic graft excision, aortic stump closure, and extra-anatomic bypass. More conservative approaches such as partial graft preservation, excision of the involved limb, and extra-anatomic bypass, as used in this patient, are simpler, effective, and have potentially less morbidity in carefully selected, high-risk patients.

Endovascular Treatment of a Ruptured Para-Anastomotic Aneurysm of the Abdominal Aorta

We report a case of a ruptured para-anastomotic aortic aneurysm treated with implantation of a bifurcated stent-graft. A 72-year-old patient, who had undergone aortobifemoral bypass for aortoiliac occlusive disease 16 years ago, presented with a ruptured para-anastomotic aortic aneurysm. A bifurcated stent-graft was successfully deployed into the old bifurcated graft. This is the first report of a bifurcated stent-graft being placed through an "end-to-side" anastomosed old aortobifemoral graft. Endovascular treatment of ruptured para-anastomotic aortic aneurysms can be accomplished successfully, avoiding open surgery which is associated with increased mortality and morbidity.

Drug Monitoring and Toxicology (DMT)

Tazocin is an injectable antibiotic preparation with broad-spectrum activity against aerobic and anaerobic gram-positive and gram-negative bacteria (1). Reported side effects that might prompt metabolic disease investigations include change in consciousness and encephalopathy (2)(3). We report 2 patients in whom interpretation of organic acid analysis was complicated by administration of tazocin. Case 1 was a 56-year-old man admitted for routine aortobifemoral bypass graft surgery. Past medical history included peripheral vascular disease, hypercholesterolemia, and epilepsy. Postoperatively the patient developed an acute abdomen and at laparotomy required extensive small bowel resection to treat a mesenteric infarction. His …

Iatrogenic sigmoid perforation by aortobifemoral left graft limb

A 76-year-old patient, submitted 10 months earlier to aortobifemoral bypass for abdominal aortic aneurysm repair at another institution, was admitted for sepsis likely due to graft infection. His medical history was also relevant for chronic renal disease (creatinine 1.6 mg/dL), previous myocardial infarction, and percutaneous coronary angioplasty, and chronic obstructive pulmonary disease. Two months after surgery, the patient had undergone surgical repair of an infected left femoral pseudoaneurysm.

Incidence and Treatment of Arterial Access Dissections Occurring during Cardiac Catheterization

Arterial access dissections may complicate cardiac catheterization and can often be treated percutaneously. The goal of this study was to examine the incidence, consequences, and the treatment of arterial access dissections at a tertiary referral hospital with an active training program. Patients experiencing arterial access dissection during coronary angiography or intervention at our institution between October 1, 2004, and January 31, 2007, were identified and their records were retrospectively reviewed. Thirteen of the 3,062 consecutive patients (0.42%) had arterial access dissection during the study period. The location of the dissection was in the common femoral artery (CFA) (n = 6), the external iliac artery (EIA) (n = 6), or in an aortobifemoral graft (n = 1). Three of the six patients with CFA dissection were diagnosed during coronary angiography, and because of significant comorbidities were treated with self-expanding stents. After a mean follow-up of 7 months, they experienced no stent fracture or other complication. Six patients had EIA dissections. In one such patient, the dissection was not flow limiting and was treated conservatively. The remaining five patients underwent successful implantation of self-expanding stents, and during a mean follow-up of 9.6 months, no patient had any symptoms or events related to lower extremity ischemia. Finally, one patient had an aortobifemoral graft dissection. Due to the patient's critical condition, secondary to sepsis, his family elected to withdraw care, and he subsequently expired. Arterial access dissections occur infrequently during cardiac catheterization. Routine femoral artery angiography may help identify vascular access complications, often allowing simultaneous endovascular treatment, with excellent short-term outcomes.

An unusual case of aortic graft infection: a case report and review of the literature

Graft-appendiceal fistula is a rare variation of aorto-enteric fistula. We report on the presentation and management of a 70-year-old lady who presented ten years after an aortobifemoral graft with a discharging sinus in her right groin. Investigations suggested aortic graft infection and she was taken to theatre for a laparotomy. An inflamed appendix with a necrotic tip was found in contact with the aortic graft. The infected graft was excised and an appendicectomy was performed. The distal organs were revascularised with an axillobifemoral graft. We review similar case reports.

Ruptured hepatic artery aneurysm: A novel approach to distal control

We describe a unique method for obtaining distal control in a ruptured hepatic artery aneurysm. A 34-year-old man with Ehlers-Danlos syndrome type IV presented with a ruptured left hepatic artery aneurysm. The distal aneurysm was within the parenchyma of the liver. Proximal control was obtained with pledgeted sutures. The distal hepatic artery was difficult to control. Injection of 5 mL of thrombin into the distal left hepatic artery resulted in hemorrhage control. This technique should be considered in select patients in whom distal arterial control is challenging.

Acute thrombosis of an abdominal aortic aneurysm following intra-aortic balloon pumping

Acute thrombosis of an abdominal aortic aneurysm is a rare but devastating surgical emergency. We present the first case of a patient with sudden thrombosis of an AAA delayed (more than 24 h) after removal of an intra-aortic balloon pump. Treatment options include open surgical repair, axillobifemoral grafting or endovascular aortic repair. The patient received an aorto-bifemoral graft. The associations between intra-aortic balloon pump counter-pulsation and abdominal aortic thrombosis are discussed.

Simultaneous Off-Pump Coronary Artery Bypass Grafting and Ascending Aortobifemoral Bypass Graft via Ventral Abdominal Route

Aortoiliac disease often coexists with coronary artery disease. It is not uncommon to subject a patient to two separate interventions. We report two cases in which in simultaneous off-pump coronary artery bypass grafting was done with an ascending aortobifemoral bypass graft through the ventral abdominal route without any additional morbidity. Combining a technically simple method of limb bypass with an off-pump cardiac surgery is a promising procedure for revascularization of myocardium and lower limbs. We discuss the merits of combining an off-pump coronary artery bypass grafting procedure with a limb bypass.

Robot-assisted laparoscopic surgery of the infrarenal aorta

Recently introduced robot-assisted laparoscopic surgery (RALS) facilitates endoscopic surgical manipulation and thereby reduces the learning curve for (advanced) laparoscopic surgery. We present our learning curve with RALS for aortobifemoral bypass grafting as a treatment for aortoiliac occlusive disease. Between February 2002 and May 2005, 17 patients were treated in our institution with robot-assisted laparoscopic aorto-bifemoral bypasses. Dissection was performed laparoscopically and the robot was used to make the aortic anastomosis. Operative time, clamping time, and anastomosis time, as well as blood loss and hospital stay, were used as parameters to evaluate the results and to compare the first eight (group 1) and the last nine patients (group2). Total median operative, clamping, and anastomosis times were 365 min (range: 225-589 min), 86 min (range: 25-205 min), and 41 min (range: 22-110 min), respectively. Total median blood loss was 1,000 ml (range: 100-5,800 ml). Median hospital stay was 4 days (range: 3-57 days). In this series 16/18 anastomoses were completed with the use of the robotic system. Three patients were converted (two in group 1, one in group 2), and one patient died postoperatively (group 1). Median clamping and anastomosis times were significantly different between groups 1 and 2 (111 min [range: 85-205 min] versus 57.5 min [range: 25-130 min], p < 0.01 and 74 min [range: 40-110 min] versus 36 min [range: 22-69 min], p < 0.01, respectively) Total operative time, blood loss, and hospital stay showed no significant difference between groups 1 and 2. Robot-assisted aortic anastomosis was shown to have a steep learning curve with considerable reduction of clamping and anastomosis times. However, due to a longer learning curve for laparoscopic dissection of the abdominal aorta, operation times were not significantly shortened. Even with robotic assistance, laparoscopic aortoiliac surgery remains a complex procedure.

Surgical Management of Vascular Graft Infection in Severely Ill Patients by Partial Resection of the Infected Prosthesis

In the presented retrospective study, we report on our results with partial resection of infected prosthetic grafts after aorto-bifemoral graft placement in eight male and three female patients. In all 11 patients clinical signs of infection were observed and bacteriological cultures were positive. Three patients underwent immediate surgery for perforation of an aneurysm at the distal anastomosis, eight patients underwent elective surgery. In all cases silver-coated Dacron prostheses were implanted. Assessment of outcome was based on survival, limb salvage, persistent or recurrent infection, and prosthetic graft patency. In two cases, a partial wound dehiscence occurred which was treated with ambulant Vacuseal dressings for 16 and 21 days until secondary wound healing was achieved. In eight patients systemic markers of inflammation completed normalised within nine days. Follow-up CT-scans failed to demonstrate any signs of recurrent infection or peri-graft fluid collections. Patients were treated with specific antibiotic therapy for no more than three months. Post-operative bacteriological cultures were negative in all patients. The mean follow-up was 2.5+/-0.5 yrs. During follow-up, none of the patients died and there were no amputations. Despite only partial resection of the infected prostheses, the reported surgical procedure offers good results. This approach maybe particularly suitable for the treatment of elderly patients with prosthesis infections.

Erosion of Aorto-femoral Dacron Graft into Urinary Bladder Sixteen Years after Surgery, A Case Report

Dacron graft fistulation following aorto-iliac reconstruction into gastrointestinal tract is far commoner than fistulation into the urinary bladder. We reported the first case of erosion of an aorto-bifemoral Dacron graft into the urinary bladder, sixteen years after the initial aortic surgery. A high index of suspicion is necessary in patients presenting with significant urinary symptoms, who have had past history of vascular reconstruction.

Bilateral Symmetrical Ureteric Strictures following Aortobifemoral Grafting for Emergency Repair of a Ruptured Abdominal Aortic Aneurysm: A Case Report

Ischaemia of the abdominal organs is a potential complication of aortic aneurysm surgery. Ischaemic bowel strictures following aortic surgery have already been previously described but the authors believe this to be the first report of bilateral ureteric strictures of possible ischaemic origin following emergency aortobifemoral grafting for a ruptured abdominal aortic aneurysm.

Acute Thrombosis of an Aortobifemoral Graft after Cancer Surgery and Withdrawal of Clopidogrel: Thrombose aiguë d’une prothèse aorto bi-fémorale après chirurgie carcinologique et arrêt du clopidogrel

Acute Thrombosis of an Aortobifemoral Graft after Cancer Surgery and Withdrawal of Clopidogrel: Thrombose aiguë d’une prothèse aorto bi-fémorale après chirurgie carcinologique et arrêt du clopidogrel

Bilateral obturator bypass for combined aortic and femorofemoral graft infection

A 60-year-old man underwent end-to-end aortobifemoral (ABF) bypass for occlusive disease. 1,2 He subsequently underwent a right-to-left femorofemoral bypass (FFB) for occlusion of the left limb of the ABF. He was referred 4 years later with fever, malaise, and purulent drainage from the right groin. A computed tomographic scan demonstrated fluid surrounding the FFB and the right limb of the ABF (A). A segment of infrarenal aorta proximal to the ABF graft appeared normal. Standard inframesocolic exposure was obtained via the previous midline incision. No fluid was evident at the graft bifurcation, and it appeared well incorporated. The residual infrarenal aorta was dissected free and prepared for an anastomosis. Openings were made in the ventromedial aspect of the obturator membrane bilaterally while standard medial exposure of the above-knee popliteal arteries was performed. Expanded polytetrafluoroethylene grafts ((W.L. Gore & Association, Inc., Tempe, Ariz) Intering; 8 mm 40 cm) were tunneled from the popliteal sites through the obturator foramina into the abdomen. (B) The limbs of a bifurcated expanded polytetrafluoroethylene graft (Gore-Tex; 18 9 mm) were cut 1 cm from the graft bifurcation, and graft-to-graft anastomoses were performed bilaterally. After systemic anticoagulation, the infrarenal aorta and the limbs of the ABF were clamped. The limbs were then transected, ligated, and advanced antegrade along the iliac tunnels. The residual body of the ABF graft was excised. The new bifurcated graft was sewn end to end to the infrarenal aorta proximally. The graft-to-graft anastomoses were assessed for hemostasis before the grafts were pulled through the previously fashioned obturator tunnels. End-to-side anastomoses were performed distally. The wounds were closed and covered with occlusive dressings before complete excision of the residual ABF limbs and the FFB via bilateral femoral and suprapubic incisions. The femoral and suprapubic incisions were packed, and the patient was maintained on chronic oral antibiotic therapy. At 24 months, he had no evidence of recurrent infection and was ambulatory at home. A follow-up computed tomographic scan demonstrated no fluid collections and patent grafts (C; cover image). The treatment of infected ABF grafts is a difficult problem. Options include in situ reconstruction with femoral vein, cryopreserved allografts, or antibiotic-impregnated synthetic grafts. Extra-anatomic reconstruction to the popliteal level is not an ideal solution secondary to poor patency. We suggest that reconstruction with synthetic bilateral obturator bypass is a viable option if there is adequate residual infrarenal aorta. This procedure allows for complete treatment of the femoral pathology and should have improved patency compared with longer extra-anatomic bypasses.