Aortofemoral Bypass Grafting Research Articles

PRESENTATIONS AND OUTCOMES OF AORTOFEMORAL BYPASS GRAFTING

Objectives: The aim of the study is to study presentations and clinical outcomes in patients undergoing Aortofemoral Bypass Grafting Surgery (AFB). Design: This was a Hospital based prospective study. Materials And Methods: During 18 months period , 20 patients (mean age = 56 years) underwent AFB. Indications comprised of occlusive disease with Intermittent Claudication (IC) (n=10), Critical Limb Ischaemia (CLI)(n=4), Resting Pain (RP) (n=4) and Tissue Loss (TL) (n=2). Results: From Jan 2023 to June 2024, AFB was performed more frequently for IC (50%) vs rest of other indications. 30 day observations / follow up showed infection in 5%, Graft occlusion in 5% for which patient underwent emergency graft thrombectomy, Amputation in 10% due to gangrenous changes and 15% mortality. Graft patency was found to be triphasic in 90% cases. Hypertension was leading risk factor (85%) followed by Diabetes Mellitus(70%) and smoking (65%). Predictors of morbidity included CKD (25%), CAD (25%), COPD (20%), CVA (20%).90% Patients were operated via thoracotomy approach and 10% were operated via abdominal approach depending on level of aortic thrombus. 20% of patients had previous history of endovascular interventions followed by stent occlusion. Conclusion: In era of endovascular intervention, Aortofemoral Bypass Surgery is more likely to be performed for Intermittent Claudication and graft patency has a better outcome.

Outcomes of Surgical Revascularization in Trans-Atlantic Society Consensus (TASC II) Type C & D Aortoiliac Occlusive Disease

Introduction: Aortoiliac occlusive disease is a disabling illness. This study was conducted on the patients of Trans-Atlantic Society Consensus (TASC II) type C & D aortoiliac occlusive disease. Open surgical revascularization in the form of aortofemoral and aorto-bifemoral bypass grafting was done and the demography of patients of AIOD, the efficacy and outcomes of open surgical bypass in the patients of TASC II, type C & D aortoiliac occlusive disease was studied. Methods: in this study, total of 52 patients were revascularized and were observed for various parameters thoroughly throughout the course of diagnosis, preoperative, intra-operative and postoperative phase and until 6 months of follow-up. The demographics, clinical characteristics of the patients, co-morbid conditions, type of aorto-iliac occlusive disease (AIOD), the surgical procedure conducted and the outcomes of surgery in terms of limb salvageability, healing of ulcer, relief of claudication and graft patency were observed. Results: 50 (96.16%) out of 52 patients were males, with a mean age of presentation 55.01 + 8.58 years. 47 (90.38%) were smokers, 43 (82.69%) had hypertension, 17 (32.69%) had diabetes, 11 (21.15%) had CAD, 12 (23.07%) had COPD, 22 (42.30%) had type C and 30 (57.69%) patients had type D disease. Aorto-bifemoral bypass grafting was done in 42 (80.76%) . Mean duration of ICU stay was 1.9 days, 6 (11.53%) patients expired postoperatively. The graft patency and limb salvageability were 100% and 96.15% respectively during 1st, 3rd and 6th months of follow-up with complete healing of ulcers in 21 (91.30%) patients by the end of 6 months. Conclusion: Surgical revascularization is an important, high yielding, life changing intervention which serves as a boon for the patients with extensive or advanced aortoiliac disease. The surgery has excellent outcomes in terms of graft patency as well as limb salvageability.

Outcomes of axillofemoral and aortofemoral bypass for intermittent claudication may be similar

Despite almost 40 years of experience with axillofemoral grafts, there remains an absence of clear guidelines for their use, especially in treating intermittent claudication (IC). This motivated Levin et al1Levin S.R. Farber A. King E.G. Beck A.W. Osborne N.H. DeMartino R.R. et al.Outcomes of axillofemoral bypass for intermittent claudication.J Vasc Surg. 2021; 75: 1687-1694Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar to examine the Vascular Quality Initiative (VQI) database to evaluate the appropriateness of axillofemoral bypass for IC. Although apparently their aim was not to compare axillofemoral bypass data with aortofemoral bypass grafts, much of their paper is devoted to such a comparison. On the basis of this evaluation, they first conclude that axillofemoral bypass is associated with significant perioperative morbidity, mortality, and long-term complications, and second, serious consideration should be given before its use for IC. Critical review posits that their second conclusion is correct and admirable, but the first may not be entirely accurate. In assessing an operative technique that involves a bypass graft, all preoperative, intraoperative, and postoperative variables and outcomes need to be considered to determine its efficacy and clinical benefit. Although the VQI is a formidable database, concerning axillofemoral bypass many confounding factors were not recorded. These include the status of the donor subclavian/axillary artery, the use of heparin surfaced grafts, postoperative surveillance protocols, and interventions to maintain patency of the donor artery. Indeed, recent papers2Samson R.H. Showalter D.P. Lepore M.R. Nair D.G. Dorsay D.A. Morales R.E. Improved patency after axillofemoral bypass for aortoiliac occlusive disease.J Vasc Surg. 2018; 68: 1430-1437Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar,3Hardouin S. Cheng T.W. Farber A. Kalish J.A. Jones D.W. Malas M.B. et al.Axillarybifemoral and axillary-unifemoral artery grafts have similar perioperative outcomes and patency.J Vasc Surg. 2020; 71: 862-868Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar have demonstrated excellent patency rates when heparin-bonded axillofemoral polytetrafluoroethylene grafts had been used or with axillary arteries that were proven normal or endovascularly treated to be, or remain, an acceptable donor vessel. Further, it is critical that if axillofemoral grafts are compared with the "gold standard" aortofemoral procedures, variables must be equivalent. In this report, patients undergoing axillofemoral grafts were more often older, female, had noncommercial insurance, ambulated with assistance, had a previous inflow bypass, ipsilateral leg bypass, peripheral endovascular intervention, and major amputation. Further, they were more often hypertensive, more likely to have coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, diabetes, anemia, and end-stage renal disease (P < .05 for all). Despite these significant risk factors, axillofemoral bypass was accompanied by a shorter length of stay, fewer pulmonary and renal complications, and, assuming these results, possibly lower cost. Further, despite these morbidities, they did not suffer more postoperative medical complications or operative mortality. Extensive comorbidities may also explain the difference in survivors’ amputation rate (5.2% vs 2%) and graft occlusion (7% vs 3.6%). However, the latter difference may also result from failure to use the more current heparin-bonded polytetrafluoroethylene or dual antiplatelet and statin therapy. Further, researchers must be leery of combined end points where one of its constituents significantly outweighs the others. For example, the authors reveal that 1-year ipsilateral reintervention/amputation/death was more likely with axillofemoral grafts, yet it is notable that occlusion/death and amputation/death were similar between cohorts. What then is the takeaway? First, appropriately surgeons who enter data into the VQI are more likely to use axillofemoral bypass grafts for high-risk patients. Second, even aortofemoral bypass grafts have significant morbidity and mortality. Therefore, the authors’ conclusion is correct that serious consideration should be given before axillofemoral bypass for IC. However, this conservative approach applies equally to aortofemoral bypass procedures. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Outcomes of axillofemoral bypass for intermittent claudicationJournal of Vascular SurgeryVol. 75Issue 5PreviewAlthough endovascular therapy is often the first-line option for medically refractory intermittent claudication (IC) caused by aortofemoral disease, suprainguinal bypass is often performed. Although this will often be aortofemoral bypass (AoFB), axillofemoral bypass (AxFB) is still sometimes performed despite limited data evaluating its utility in the management of IC. Our goal was to assess the safety and durability of AxFB performed for IC. Full-Text PDF

Hybrid revascularization in a patient with Covid-19 and chronic limb ischemia stage IV

The authors report hybrid treatment of a patient with angina pectoris class II, multiple previous reconstructive interventions on the aortofemoral segment and chronic ischemia of the left lower limb stage IV and concomitant COVID-19. Coronary angiography was performed after regression of infectious disease under antiviral therapy. Occlusion of the left anterior descending artery was observed that required LAD stenting. On the next day, hybrid revascularization of the lower extremities was implemented: thrombectomy and endarterectomy from the branch of the aorto-femoral bypass graft and deep femoral artery at the first stage, stenting of the orifice of proximal branch of aorto-femoral bypass graft at the second stage, endarterectomy from superficial femoral artery, recanalization and stenting of superficial femoral artery and popliteal artery at the third stage and prosthetic- femoral bypass with autologous vein at the fourth stage. Postoperative angiography revealed patent stents and no residual stenoses. The choice in favor of these procedures and step-by-step approach has been substantiated. The authors emphasized effectiveness and safety of this treatment strategy.

Living in a Food Desert is Associated With Increased Wound Complications After Major Vascular Procedures

Food deserts (FDs) are regions that lack grocery stores, have unaffordable healthy options, and/or have a density of poor-quality food choices. Living in a FD has been associated with metabolic risks; however, its relationship to wound complications after major vascular surgery remains unexplored. We hypothesized that FD status would be associated with an increased incidence of wound complications after major vascular surgery. We performed a single-center retrospective analysis of open vascular procedures from 2012 to 2020. FD status was determined by matching the patient census tract location to low- income and low-food access metrics from the U.S. Department of Agriculture Food Access Research Atlas. Major vascular procedures included infrainguinal bypass, femoral endarterectomy, aortofemoral bypass grafting, lower extremity bypass, open abdominal aortic aneurysm repair, and thoracoabdominal aortic repair. The Area Deprivation Index (ADI), a validated marker of socioeconomic status, was used to distinguish the effects of FD status from other markers of social disadvantage such as education and housing. Multivariable logistic regression was used to assess the independent association of FD status with wound complications. Among 1417 patients, 119 (8%) resided in a FD. Overall, wound complications occurred in 124 patients (9%): 15%, femoral endarterectomy; 14%, aortofemoral bypass grafting; 13%, infrainguinal bypass; 10%, thoracoabdominal aortic aneurysm repair; and 4%, open abdominal aortic aneurysm repair (P < .01). Patients in an FD were younger (61 vs 67 years; P < .01), more frequently had chronic obstructive pulmonary disease (28% vs 17%; P = .02), and had twice the incidence of wound complications (24% vs 12%; P < .01). On multivariable analysis, FD status was independently associated with increased odds of wound complications (1.9; 95% confidence interval 1.0-3.5; P = .04; Table). On sensitivity analysis, FD status and diabetes interacted, and FD and diabetes combined resulted in a 2.8-fold increased odds (95% confidence interval, 1.1-7.0) of wound complications compared with those without either risk factor. Living in a FD was associated with twice the odds of wound complications after major vascular operations. These results suggest that food insecurity can affect wound healing and should be considered as a potential modifiable perioperative risk factor. Future study of interventions aimed at addressing access to healthy foods is warranted.TableMultivariable analysis of wound complicationsCovariateaORa95% CIP valueFood desert1.91.0-3.5.04Obesity1.61.0-2.5.03CAD1.71.1-2.6.01Area deprivation indexb Medium1.71.0-2.9.03 High1.30.7-2.2.42aOR, Adjusted odds ratio; CAD, coronary artery disease; CI, confidence interval.Boldface P values represent statistical significance.aAdjusted for age ≥70 years, diabetes mellitus, coronary artery disease, area deprivation index, chronic obstructive pulmonary disease, obesity, aspirin, postoperative red blood cell transfusion, chronic kidney disease stage 5, operative indication, and procedure type.bCompared with an area deprivation index reference group of low. Open table in a new tab

Increased collateral flow by rescue femorofemoral bypass dissolved residual thrombus in implanted iliofemoral artery stents: a case report

BackgroundFailed aortofemoral and femoropopliteal bypass grafts in the lower extremity artery usually result in acute limb ischemia. Endovascular treatment and surgical revascularization have been reported for limb salvage.Case presentationA 72-year-old Japanese man was admitted with acute limb ischemia due to failed aortofemoral and femoropopliteal bypass grafts. Endovascular treatment with balloon angioplasty, thrombectomy, and stent implantation in the long chronic total occlusion from the right common iliac artery to the superficial femoral artery did not result in efficient flow due to thrombus transfer from a failed aortofemoral bypass graft. However, a rescue femorofemoral bypass (the left femoral to the right deep femoral artery) improved his symptoms, and implanted in-stent flow was gradually recovered. Lower extremity angiography performed 5 months later confirmed the patency of the iliofemoral in-stent flow. However, the femorofemoral bypass graft was unfortunately occluded due to the progression of left external iliac artery stenosis. The patency of the iliofemoral in-stent flow was confirmed at 1 year by ultrasonography.ConclusionsImprovement of the deep femoral artery flow plays an important role in the treatment of acute limb ischemia due to failed aortofemoral and femoropopliteal bypass grafts. Thus, increased collateral circulation to the periphery through the deep femoral artery dissolved the remaining in-stent thrombus in the iliofemoral artery.

Aorto Femoral Bypass Graft in Chronic Limb Ischemia Patient

A 44-year-old man was admitted to hospital to be performed re-thrombectomy after previously performed thrombectomy at the referring hospital but did not show clinical improvement. CT angiography results before re-thrombectomy showed a central thrombus measuring 1.1 cm in diameter, and an impression of 2.6 cm long at the branching of the right external Iliaca artery which caused total obstruction of the right illiaca external artery to the distal. Aortofemoral bypass graft surgery is a procedure utilized commonly for the treatment of aortoiliac occlusive disease. The treatment given to manage symptoms if medical management or minimally invasive therapy, such as balloon angioplasty and stenting, was unsuccessful or unsuitable for the patient. Aortofemoral bypass graft surgical procedure was performed on the patient. However, post procedure angiography showed no visible flow through the newly placed graft. A repair graft procedure was planned for the patient, but the patient refused to undergo further surgical procedures.

Prosthetic repair of the aorta with a cadaveric homograft for infection of bifurcated synthetic vascular prosthesis

Infection of arterial vascular grafts is a rare but utterly severe complication in vascular surgery. Therapeutic policy in patients with graft infection has not been standardized, to be determined individually. One of the variants of surgical treatment is considered to be repeat aortic repair using a cadaveric graft. Presented in the article is a clinical case report concerning a 60-year-old male patient previously subjected to aortofemoral bifurcation bypass grafting with stage IV ischaemia of lower limbs according to the Pokrovsky-Fontaine classification. In the early postoperative period the events of critical ischaemia were not arrested. Due to the presence of a block of the femoropopliteal segment, as the second stage 3 days after the primary operation, the patient underwent autovenous femoropopliteal bypass grafting with a reversed autovein above the knee-joint fissure. The clinical course of critical ischaemia of the limb was relieved. During subsequent 8 months of follow up his state remained stable. Eight months after the primary operation he developed purulent discharge from the postoperative scar on the left femur. In the setting of the Purulent Surgery Department, the patient was emergently subjected to opening and drainage of the abscess of the postoperative scar. On the bottom of the wound there was a freely lying branch of a synthetic vascular prosthesis. Computed tomography revealed infection of the entire synthetic prosthesis and aneurysms of distal anastomoses. Given extremely high risk for the development of arrosive haemorrhage, a decision was made on operative treatment - repeat prosthetic repair of the abdominal aorta with a cadaveric allograft. At the Vascular Department of the Clinic of Faculty Surgery, laparotomy was performed, with removal of the infected graft, followed by debridement of the retroperitoneal space and repeat aortofemoral bifurcation prosthetic repair of the abdominal aorta with a cadaveric allograft. The wound healed with first intention. There was no evidence of infectious process relapse. The patient was discharged on postoperative day 15 in a satisfactory condition. The duration of follow up amounted to 6 months. The control examination showed that the pain-free walking distance was 500 m. Doppler ultrasonography demonstrated that the graft was functioning, with no signs of either anastomotic aneurysms or suppuration of the retroperitoneal space.

Robotic-assisted operations for pathology of the aortoiliac segment: own experience

The present study was aimed at assessing the results of a total of 40 vascular operations carried out using the robotic-assisted da Vinci surgical system. Between January 2013 and September 2019, a total of 40 robotic-assisted vascular operations were performed at the Department of Vascular Pathology and Hybrid Technologies of the Centre of Vascular and Hybrid Surgery. Of these, 31 interventions were carried out for occlusion of the aortoiliac segment and 9 for removal of an aneurysm of the infrarenal portion of the abdominal aorta. The patients were arbitrarily divided into 2 groups: the first group included those subjected to aortofemoral bypass grafting procedures for atherosclerotic steno-occlusive lesions of the aorta and iliac arteries, whereas the second group comprised the patients who underwent aneurysmoectomies with linear prosthetic repair of the abdominal aorta. Altogether, elective robotic-assisted operations were successfully performed in 38 (95%) cases. Conversion to a laparotomic approach was required in 2 (5%) patients. The mean time of creating an anastomosis with the abdominal aorta amounted to 51 minutes (range 30-90), being 42±4.75 min for aortofemoral bypass grafting and 83±5.00 min for aneurysmoectomies with linear prosthetic repair of the abdominal artery. The average blood loss was 316 (range 50-1000) ml, amounting to 280±209 ml and 438±322 ml for group I and group II, respectively. With the exception of one case, all patients spent 24 hours in the intensive care unit to be then transferred to the specialized ward. The average length of hospital stay amounted to 9.8 days. One patient experienced haemorrhage from the central anastomosis in the early postoperative period and was emergently operated on from a laparotomic approach. Four (10%) patients developed nonlethal complications which were treated conservatively. During the 30-day follow-up period, no lethal outcomes, thromboses, nor infections of the prostheses were observed. From a practical point of view, the major advantages of using the robotic-assisted complex include minimal surgical trauma, reduced blood loss, a wide range of high-precision movements of the manipulators, 3-D visualization with a 5-fold magnification, thus making it possible to create a vascular anastomosis sufficiently fast in very tight spaces in the body. Our experience with laparoscopic robotic-assisted surgery demonstrated feasibility of using this technique for treatment of pathology of the aortoiliac segment.

Surgical policy in treatment of patients with infected aortofemoral bifurcation allografts

Described in the article are the results of treating a total of 44 patients who endured repeat operations for infection of aortofemoral bifurcation allografts over the period between 2001 and 2018. These patients had previously undergone reconstructive operations using various synthetic grafts for lower limb ischaemia on the background of lower-limb artery atherosclerosis and infrarenal aortic aneurysms. Infection of synthetic vascular allografts in these patients was observed both in the immediate and remote postoperative periods. The dominating infection in 70% of patients was methicillin-resistant Staphylococcus aureus. The main objective risk factors for infection of bifurcation grafts were found to be as follows: stage III-IV chronic lower limb ischaemia (according to the Fontaine-Pokrovsky classification), diabetes mellitus, and prior operations on lower-limb arteries. Two of the 44 patients were operated on for reinfection after repeat aortofemoral bypass grafting. 30% of patients underwent repeat surgery with symptoms of sepsis. After meticulous additional examination and preoperative preparation the patients were subjected to secondary simultaneous operation, i.e., removal of the synthetic aortofemoral bifurcation prosthesis and aortofemoral bifurcation autovenous repeat reconstruction (repeat bypass grafting) in situ. Aortofemoral bifurcation grafts were formed using superficial femoral veins from both legs. Four patients died in the immediate postoperative period. Other short-term complications included arrosive bleeding with or without sepsis, amputation of one leg due to graft limb thrombosis, and development of peritonitis resulting from perforation of the jejunum. In the remote period, patency of autovenous grafts was confirmed in 37 patients. Of long-term complications, mention should be made of the following: formation of aneurysms of distal anastomoses and thrombosis of one of the limbs of the autovenous graft. The patients were successfully operated on now using synthetic grafts in infection-free conditions. Hence, a method of surgical decision-making in patients with infected aortofemoral bifurcation grafts is the use of the technique of complete removal of the infected synthetic graft with simultaneous in situ replacement using autovenous grafts from superficial femoral veins, active pre- and postoperative antibiotic therapy. Such policy made it possible to decrease the mortality rate to 9%, with a limb-salvage rate of 97.5% and long-term graft patency rate amounting to 92.5%.

Superficial Femoral Artery Occlusion Reduces Aortofemoral Bypass Graft Patency

Introduction - We examined the effect of superficial femoral artery (SFA) occlusion, at time of aortofemoral bypass (AFB) for aortoiliac occlusive disease (AIOD), on long-term patency of the bypass conduit.

Superficial Femoral Artery Occlusion Reduces Aortofemoral Bypass Graft Patency

The effect of superficial femoral artery (SFA) occlusion on long-term patency of aortofemoral bypasses (AFBs) for aortoiliac occlusive disease (AIOD) was examined. The AIOD database was reviewed to identify risk factors for AFB failure. The status of the SFA at AFB procedure was categorised as patent; diseased treated (DT), if the SFA occlusion was intervened on concomitant to AFB; or diseased untreated (DU), if the SFA was occluded but not revascularised. Censoring hierarchies for primary patency and patent graft survival time were constructed. Data were analysed by contingency table, Kaplan-Meier, and Cox regression analysis. Between 2004 and 2015, 122 AFB (9 unifemoral, 113 bifemoral) for AIOD were performed. Seventy-five (61%) were female and the mean age was 60±10 years. At the time of AFB, 50 (41%) had occluded SFAs (DT/DU). Of these, 15 had concomitant SFA revascularisation (i.e., DT) at the time of AFB. Patients with occluded SFAs had greater history of prior aortoiliac/infrainguinal procedures (aortoiliac 54% vs. 22%, infrainguinal 58% vs. 25%, both p<0.001), Trans-Atlantic Inter-Society Consensus II classification of femoropopliteal type D lesions (78 vs. 10%, p<0.001), Rutherford 4-6 categories (80% vs. 57%, p=0.011), and longer hospital stay (median 11 vs. 7 days, p<0.004). SFA status did not affect 30 day mortality (overall 9%); however, sub-analysis showed DT had significantly higher mortality than DU (p<0.03). Over a median follow up of 7.7 (IQR 4.3-11.4) years, primary patency at one and five years was 98.3% and 91.2% in patients with patent SFAs, 87.9% and 82.7% in DU, and 72.7% and 43.6% in DT (p<0.001), respectively. On multivariable analysis, low baseline glomerular filtration rate (HR 1.01, p=0.022), DT (HR 3.7, p=0.020), Rutherford 4-6 (HR 9.1, p=0.048), and occluded SFA (HR 3.9, p=0.009) adversely affected primary patency of AFBs. Long-term mortality was not different between the SFA status groups (p=0.279). Baseline SFA occlusion predicted a fourfold increased hazard of primary AFB failure. Concomitant SFA revascularisation did not improve AFB durability and was associated with increased in hospital mortality.

Simultaneous presence of massive chyloperitoneum and chylothorax and its successful management

The incidence of massive chylous ascites and chylothorax after aortofemoral bypass grafting (AFBG) procedure is unknown. Leakage of chyle results in severe malnutrition and infection which can be life threatening. Because of the rarity of disease, the definitive guideline on management of such extensive accumulation of chyle is lacking. We present a case of a 68- year-old gentleman who developed large chylous ascites and chylous pleural effusions causing respiratory distress. His history was significant for aortofemoral bypass graft procedure 8 weeks prior to index presentation. He was successfully managed with chylous fluid drainage, judicious use of diuretics, adherence to a low-fat diet, and supplementation with medium-chain triglycerides.

V06-03 ROBOTIC DISTAL URETERECTOMY AND BOARI FLAP URETERONEOCYSTOSTOMY AFTER AORTO-BIFEMORAL BYPASS

You have accessJournal of UrologyAdrenal, Testis, UTUC Oncology & More1 Apr 2018V06-03 ROBOTIC DISTAL URETERECTOMY AND BOARI FLAP URETERONEOCYSTOSTOMY AFTER AORTO-BIFEMORAL BYPASS Jaya Sai Chavali, Daniel Sagalovich, Juan Garisto, Julien Dagenais, and Robert Stein Jaya Sai ChavaliJaya Sai Chavali More articles by this author , Daniel SagalovichDaniel Sagalovich More articles by this author , Juan GaristoJuan Garisto More articles by this author , Julien DagenaisJulien Dagenais More articles by this author , and Robert SteinRobert Stein More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1582AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We report our technique of distal ureterectomy with boari flap ureteral re-implantation in previous aorto-bifemoral bypass using the da-Vinci robotic surgical system. METHODS An 80 year old patient (BMI 38) with stage 4 chronic kidney disease (CKD) was noted to have a left mid-ureteral high grade transitional cell carcinoma (TCC) at the location that her ureter was passing between the native iliac artery and an aorto-femoral synthetic graft. Distal ureterectomy with preservation of the contralateral kidney was opted due to the patient's renal insufficiency. The descending colon was reflected medially. The left ureter was dissected proximal and distal to the left aortofemoral bypass graft which was crossing anterior to the ureter. The ureter was transected distally with a bladder cuff. The ureter at the level of the tumor was carefully dissected free of the posterior native iliac artery and the anterior graft. The ureter was transected proximal to the tumor and frozen section demonstrated no tumor at the margin.Due to the short length of ureter remaining, a boari flap ureteroneocystostomy was required for reconstruction. The ureter was able to reach the bladder in a tension-free manner and the ureterovesical anastomosis was completed with interrupted 3-0 polysorb sutures. A 7x24 double J ureteral stent was inserted robotically and the remaining bladder defect was repaired in a watertight fashion with a running 2-0 V-Loc suture. RESULTS Overall operative time was 450 min, estimated blood loss was 450 cc and there were no postoperative complications. The patient was discharged on postoperative day 5. Pathology was consistent with T3 high grade urothelial carcinoma. The Foley catheter was removed on postoperative day 14 and the ureteral stent was removed 4 weeks after surgery. CONCLUSIONS We demonstrate a robotic technique for management of a mid-distal ureteral tumor in the setting of a synthetic aorto-bifemoral bypass graft. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e661 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Jaya Sai Chavali More articles by this author Daniel Sagalovich More articles by this author Juan Garisto More articles by this author Julien Dagenais More articles by this author Robert Stein More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Unilateral inline replacement of infected aortofemoral graft limb with femoral vein

ObjectiveAortic graft infection remains a formidable challenge for the vascular surgeon. Traditionally, reconstruction with a neoaortoiliac system (NAIS) involves removal of the entire synthetic graft with in situ reconstruction using femoral vein. Whereas the NAIS procedure is durable with excellent graft patency and a low reinfection rate, it can take up to 10 hours and result in a high perioperative complication rate with significant mortality. Not infrequently, the infection is limited to a single limb. In addition, the patient may be too frail to tolerate aortic clamping for a complete graft excision. Under such circumstances, complete excision of the aortofemoral bypass graft (AFBG) may not be indicated. It is hypothesized that local control of infection and limited reconstruction using femoral vein may be acceptable. The objective of this study was to examine the outcomes of all patients who underwent partial AFBG resection and in situ reconstruction with femoral vein. MethodsA retrospective review of all AFBG infections from 2003 to 2015 treated at a tertiary care facility was undertaken. Patients who underwent unilateral partial graft excision with inline reconstruction using femoral vein at the distal (femoral) anastomosis were included. Complete excisions with bilateral revascularizations using any conduit or any extra-anatomic reconstructions were excluded. The primary end point was successful treatment of infection. Secondary end points were procedure-related mortality, graft patency, and perioperative complications. ResultsDuring a 12-year period, partial graft excision with bypass using the femoral vein was performed in 21 patients (24 limbs). Mean age was 61 ± 12 years. There were 13 men and 8 women. Mean follow-up was 53 ± 27 months. Successful treatment was achieved in 19 of 21 patients. The two treatment failures were due to persistent infection. One of these patients declined complete graft excision and is receiving lifelong suppressive antibiotic therapy. The other patient underwent complete graft excision and an NAIS reconstruction. There were no perioperative or procedure-related deaths. There were no major amputations, and primary graft patency was 92% at 72 months. The most common AFBG culture isolate was Staphylococcus species. Approximately one-third of cultures did not yield any growth. Patients underwent anywhere from 1 to 12 weeks of combined intravenous and oral antibiotic therapy. ConclusionsThis limited series demonstrates excellent graft patency with a low persistent infection rate. Thus, in patients with localized graft infection, partial excision with preservation of the proximal synthetic graft is an acceptable alternative when patient factors preclude complete graft excision.

Increasing efficacy of endovascular recanalization with covered stent graft for TransAtlantic Inter-Society Consensus II D aortoiliac complex occlusion

We compared the outcomes and the durability of endovascular recanalization (EVR) with the Viabahn (W.L.Gore and Associates, Flagstaff, Ariz) covered stent graft vs traditional aortobifemoral or aortofemoral bypass grafting for complex aortoiliac occlusions. Between 2008 and 2014, 11 unilateral iliac occlusions and 11 aortobiiliac occlusions were treated by EVR. Also collected were data from the last 21 consecutive patients treated in the same period by aortofemoral (n= 6) or aortobifemoral (n= 15) bypass grafting. In accordance with the TransAtlantic Inter-Society Consensus II (TASC II) document, only patients with type D lesions were considered. Kaplan-Meier estimates for patency were calculated, and Cox proportional hazard modeling was performed. The difference in risk factors between the groups was not significant. General anesthesia was required in 100% of the surgical group, and local or locoregional anesthesia was used for EVR. Suprarenal aortic cross-clamping was required in nine of the open surgical procedures (41%). A brachial percutaneous approach was performed in all patients undergoing EVR, and technical success was 100% in both groups. All of the attempts at EVR were successful. At the 2-year follow-up, primary patency did not differ significantly between the endovascular (91%) and surgical (95%) groups. This was seen in the univariate model (hazard ratio [HR], 0.27; 95% confidence interval [CI], 0.02-2.95; P= .28) and in the multivariate model (HR, 0.77; 95% CI, 0.06-10.07; P= .84) for group (HR, 0.58; 95% CI, 0.04-7.72; P= .68), age (HR, 0.89; 95% CI, 0.73-1.08; P= .24), symptoms (HR, 1.98; 95% CI, 0.42-9.46; P= .39), and occlusion (HR, 3.22; 95% CI, 0.51-20.35; P= .21). The average hospital length of stay was shorter for patients treated with ERV than for those treated with open surgery (3.9± 2.2 vs 5.8± 3.1days, respectively; P= .03). The complication rate was 4% for EVR vs 18% in the surgical group (P= .32). At 2years of follow-up, the results of endoluminal bypass grafting with the Viabahn stent to treat complex aortoiliac disease are promising. Longer-term results are needed to fully evaluate the potential benefits and longer-term patency.

PC14. The Impact of Combined Iliac Occlusive Disease and Aortic Aneurysm on Open Surgical Repair

Aortofemoral bypass (AFB) grafting for aortic aneurysmal disease necessitated by severe iliac occlusive disease may be associated with higher morbidity and mortality compared with standard intra-abdominal repairs (tube grafts and aortoiliac grafts; STD). We sought to compare the demographic and procedural characteristics and outcomes in these two cohorts using a single-center consecutive series of 1010 repairs. Using a prospectively maintained database, we retrospectively identified patients who underwent AAA repair from 1994 to 2014. A total of 1010 consecutive cases were performed consisting of 913 STD (638 tube graft, 275 aortoiliac) and 97 AFB cases. Standard medical and demographic data, procedural information, and postoperative complications and follow-up were extracted. Kaplan-Meier estimates of survival were calculated. The STD cohort had more men (77.7% vs 58.8%, P = .001) but was similar to the AFB group in race and age. Higher rates of hypertension (81.4% vs 68.3%, P = .008), chronic obstructive pulmonary disease (26.8% vs 16.1%, P = .008), and smoking (49.5% vs 34.4%, P = .003) were present in the AFB cohort. There were no differences in coronary artery disease, stroke, renal insufficiency, or heart failure rates. The AFB group had a smaller mean aortic diameter (5.16 vs 5.80 cm, P = .001) and required smaller mean aortic graft diameter (16.9 vs 17.8 mm, P = .001). Estimated blood loss and operative time were equivalent. Postoperative morbidity (40.2% vs 25.3%, P = .001) was higher in the AFB group. Renal failure (8.2% vs 3.4%, P = .047), wound infection (5.2% vs 1.3%, P = .005), and hematoma/seroma (6.2% vs 1.1%, P = .001) were also more likely. Hospital length of stay was higher for AFB (12 vs 10 days, P = .027). Despite differences in risk factors and morbidity, 30-day mortality was similar (1% AFB vs 1.4% STD, P = .75). Five-year survivals were not significantly different (64.0% AFB vs 71.3% STD. P = .078). Patients requiring AFB of AAA for associated iliac occlusive have more preoperative comorbidities, postoperative complications, and a longer length of stay. Nevertheless, 30-day and 5-year survival rates are similar to STD AAA repair.

Reinfection after resection and revascularization of infected infrarenal abdominal aortic grafts

Despite advances in perioperative care, long-term and amputation-free survival rates are poor after resection of infected abdominal aortic grafts. We reviewed our cases to determine the rate of reinfection and risk factors for mortality and limb loss. We reviewed cases with infrarenal aortic graft infection from 1999 to 2013. Cases requiring graft excision were included for analysis. Thoracic and thoracoabdominal aortic grafts were excluded. Reconstruction types included both extra-anatomic and in situ grafts. Patient comorbidities, surgical outcomes, and known reinfection rates were assessed. Univariate and Kaplan-Meier analysis were performed. Twenty-eight patients had resection of infected infrarenal abdominal aortic grafts during the study period. Most patients (26/28; 93%) had infected aortoiliac or aortofemoral prosthetic bypass grafts, but two of 28 patients had infected endovascular aortoiliac stent grafts. The median age was 69 years (range, 46-86 years), with 68% men and 32% women. Aortoenteric fistulae or graft-enteric erosions were noted in 12 of 28 (43%) patients at operation. There were 79% of patients who had in situ reconstruction, including 4 (14%) with polyester, 1 (4%) with polytetrafluoroethylene, 3 (11%) with cadaveric homograft, 3 (11%) with composite grafts, and 11 (39%) with native femoropopliteal vein grafts. Five (18%) patients had extra-anatomic bypass and one had excision without revascularization. In-hospital mortality after initial graft excision and revascularization occurred in two (7%) patients. Seven (25%) patients had evidence of reinfection after a median of 20 months, of whom five underwent reintervention with two additional in-hospital deaths. All in-hospital deaths occurred in patients with graft-enteric contamination. Overall limb salvage and survival at a mean follow-up of 2.5 years were 82% and 46%, respectively, and did not differ among revascularization types (P = .85 and .74). One-year amputation-free survival was 47% overall. Three patients with native femoropopliteal vein graft repair required amputation in follow-up. Diabetes was the only observed risk factor for amputation (P = .05). Risks for mortality included history of cerebrovascular disease (P = .05) and shock on presentation (P = .04). No other comorbid condition, type of revascularization, or perioperative complication was associated with limb loss or mortality on univariate analysis. Revascularization after excision of infected abdominal aortic grafts can be done with acceptable in-hospital morbidity and mortality. Reinfection is problematic, regardless of revascularization conduit, and is associated with limb loss and death. New and aggressive local anti-infective strategies are warranted.

Activation of T-lymphocytes and herpes viruses in atherosclerotic plaques

Aim: In our previous work we found that T-lymphocytes phenotypes in atherosclerotic plaques are different from those found in blood. T cells are more activated in plaque than in blood as judged by the expression of CD25, CD38, and HLA-DR. The purpose of this work was to evaluate the presence of herpesviruses (HHV) in these plaques and investigate whether their presence correlates with activation of resident lymphocytes. Methods: 27 atherosclerotic plaques from patients who underwent either carotid endarterectomy (22) or aortofemoral bypass grafting (5). The degree of carotid artery stenosis varied from 70% to 90% (median 80.0%, IQR 72.5–90). The phenotype of lymphocytes was analyzed using polychromatic flow cytometry, and HHVs DNA amount in plaques was measured by Real Time PCR. Results: We found a correlation between T lymphocytes activation and the presence of certain HHVs in atherosclerotic plaques. The fraction of CD4+ T cells expressing the late activation marker HLA-DR positively correlates with HHV-1 & -2 viral load (Spearman's r=0.438, p=0.0381). Also, there was a negative correlation between the fraction of naive CD8 T cells and HHV-7 viral load (Spearman's r= -0.7381, p=0.0366). And the viral load of HHV-4 correlated with the presence of late-differentiated effector memory CD4 T cells (Spearman's r=0.6364, p=0.0353) and effector memory CD8 T cells (Spearman's r=0.6636, p=0.026). Conclusions: The activation of T-lymphocytes in atherosclerotic plaque is correlated with the presence of different HHV types (1, 4 and 7). The presence of HHVs in atherosclerotic plaques may be an important factor of lymphocyte activation thus affecting plaques' maturation and rupture. This is the first study, which quantitatively associates activation of atherosclerotic plaques' resident lymphocytes with the presence of certain HHVs in theses plaques. The finding of this association may lead to the development of new targets for atherosclerosis preventive therapy and warrants further investigation.

Antibiotic Therapy of Aortic Graft Infection: Treatment and Prevention Recommendations

Surgical site infection (SSI) after aortic intervention, an uncommon but serious vascular condition, requires patient-specific antibiotic therapy. Effective treatment and prevention requires the vascular surgeon to be cognizant of changing SSI microbiology, advances in antibiotic delivery, and patient characteristics. The majority of aortic graft infections are caused by Gram-positive bacteria, with methicillin-resistant Staphylococcus aureus now the prevalent pathogen. Nasal carriage of methicillin-sensitive or methicillin-resistant S aureus strains, diabetes mellitus, recent hospitalization, a failed arterial reconstruction, and the presence of a groin incision are important SSI risk factors. Overall, the aortic SSI rate is higher than predicted by the Centers for Disease Control and Prevention's National Nosocomial Infections Surveillance risk category system; ranging from 5% after open or endovascular aortic interventions to as high as 10% to 15% after aortofemoral bypass or uni-aortoiliac grafting with femorofemoral bypass. Perioperative measures to reduce S aureus nares and skin colonization, administration of antibiotic prophylaxis, meticulous wound closure/care, and therapy directed to optimize patient host defense regulation mechanisms (eg, temperature, oxygenation, blood sugar) can minimize SSI occurrence. Antibiotic therapy for aortic graft infection should utilize bactericidal drugs that penetrate bacteria biofilms and can be delivered to the surgical site both parenterally and locally in the form of antibiotic-impregnated beads or prosthetic grafts.