Aortoiliac Bypass Graft Research Articles

Submitted, Not Presented: Clinical Vignettes/Case Reports-GI Bleeding.

Aortoenteric fistula (AEF) is a pathological communication between the aorta and the gastrointestinal tract. We report a rare presentation of a secondary AEF diagnosed by esophagogastroduodenoscopy (EGD), after going unidentified on computed tomography angiography (CTA), in a patient with a history of bilateral aortoiliac bypass for peripheral arterial disease (PAD) who had a one month history of unexplained, intermittent gastrointestinal bleeding. An 85 year-old male, nursing home resident, with extensive history including dementia and PAD with remote bilateral aortoiliac bypass graft presented to the medical intensive care unit with one month of intermittent hematochezia and new onset hematemesis. The month prior, he had several admissions to a local hospital for hematochezia and anemia in which he was evaluated with both EGD and colonoscopy which failed to identify the source of bleeding. This presentation, patient had hematochezia and hematemesis. His presenting hemoglobin (Hgb) was 6.6 g/dL and nasogastric tube returned 550 mL of bright red blood. Upon transfer, his post transfusion Hgb was 12 g/dL and vitals were stable. CTA showed findings concerning for infected aortobifemoral bypass graft. Urgent EGD revealed a normal esophagus, stomach, duodenal bulb and second portion of the duodenum, but an exposed aortic graft was encountered in the third portion of the duodenum without active bleeding (Image 1 and 2). After further discussion with the patient's family detailing the risks and benefits of surgery, the decision was made to provide the patient with comfort measures only and inpatient hospice. He died one day later. An AEF is a conduit between the aorta and the gastrointestinal lumen. Primary AEF forms in patients with no preexisting aortal surgeries, while a secondary AEF occurs in patients with previous history of reconstructive surgery to the aorta. The most common presentation of an AEF is gastrointestinal bleeding. This can vary from herald bleeding to hemorrhagic shock. The diagnosis of AEF can be made using computed tomography. In our case, a secondary AEF was unidentified on CTA and a subsequent EGD was useful in the final diagnosis. Early recognition and diagnosis of AEF is essential as a delay is diagnosis and surgical exploration is almost always fatal (1).Figure: Secondary Aortoenteric Fistula.Figure: Secondary Aortoenteric Fistula.

Secondary Aortoenteric Fistula Causing Intermittent Gastrointestinal Bleeding

Introduction: Aortoenteric fistula (AEF) is a pathological communication between the aorta and the gastrointestinal tract (1). We report a rare presentation of a secondary AEF diagnosed by esophagogastroduodenoscopy (EGD) in a patient with a history of bilateral aortoiliac bypass for peripheral arterial disease (PAD) who had a one month history of unexplained, intermittent gastrointestinal bleeding.Figure 1Figure 2Case Presentation: An 85 year-old male, nursing home resident, with extensive history including dementia and PAD with remote bilateral aortoiliac bypass graft presented to the medical intensive care unit (MICU) with one month duration of intermittent hematochezia and new onset hematemesis. The month prior, he had several admissions to a local hospital for hematochezia and anemia in which he was evaluated with both EGD and colonoscopy which failed to identify the source of bleeding. This presentation, patient had hematochezia and hematemsis. His presenting hemoglobin (Hgb) was 6.6 g/dL and nasogastric tube returned 550 mL of bright red blood. Upon transfer, his post transfusion Hgb was 12 g/dL and vitals were stable. Computed tomography angiogram (CTA) showed findings concerning for infected aortobifemoral bypass graft. Urgent EGD revealed a normal esophagus, stomach, duodenal bulb and second portion of the duodenum, but an exposed aortic graft was encountered in the third portion of the duodenum without active bleeding (Image 1 and 2). After further discussion with the patient's family detailing the risks and benefits of surgery, the decision was made to provide the patient with comfort measures only and inpatient hospice. He died one day later. Discussion: An AEF is a conduit between the aorta and the gastrointestinal lumen. Primary AEF forms in patients with no preexisting aortal surgeries (2). A secondary AEF occurs in patients with previous history of reconstructive surgery to the aorta (3). In about one third of cases, the abdominal aorta forms a channel with the duodenum (4, 5). The most common presentation of an AEF is gastrointestinal (GI) bleeding which can vary from herald bleeding to hemorrhagic shock (6-7). The diagnosis of AEF can be made using computed tomography (CT) (9). An EGD is useful in patients with a history of surgical repair to the aorta who present with acute overt gastrointestinal bleeding (7 and 10). Early recognition and diagnosis of AEF is essential as a delay is diagnosis and surgical exploration is almost always fatal (11, 12).

Endovascular Revascularization of Diseased Native Arteries following Failed Aortoiliac and Femoropoliteal Grafts: Report of Two Cases

Arterial reconstructions for lower-extremity ischemia, comprising aortoiliac, aortofemoral, and femoropopoliteal bypasses, and other procedures, have an intrinsic tendency to fail as time elapses. Surgical approaches to arteries in patients who have failed bypass grafts are often rendered more difficult, or even impossible to use, by surgical scarring or infection. The authors report two cases in which the diseased native arteries treated with failed aortoiliac and femoropopliteal bypass grafts were successfully recanalized with primary stent placement. Our cases show that stent placement of the diseased native arteries can represent a possible option for the treatment of failed bypass grafts.

Modified Technique for Recovering Aortoiliac Homografts

Infection of the prosthetic aortic graft bypass remains one of the most serious complications of aortoiliac bypass grafts. Use of an aortoiliac allograft as a replacement for an infected prosthetic graft is an effective treatment for this problem. However, the availability of aortoiliac grafts is affected by the high rate of procurement errors experienced during recovery. This overall error rate nationally averaged 32.5% in 2006, of which nearly a third (9.6%) were related to tears of the intima at or below the bifurcation of the abdominal aorta. To analyze the potential of a new aortoiliac graft recovery method in reducing the error rate. A modified technique of aortoiliac graft recovery was used to minimize the possibility of intimal tears. The essence of this technique is to change the sequence of mobilization of the graft, starting from the zone of low resistance, which is at the iliac arteries, and continuing upward to the abdominal aorta, which has higher resistance because of the greater thickness of the aortic wall. An additional modification of the standard technique is to use a tourniquet to raise the aortic edges. The aortoiliac graft has various resistances to tearing owing to the different wall thicknesses of the aorta and the iliac arteries. Mobilization of the abdominal aorta before dissection of the iliac arteries creates a high risk of tears at and around the bifurcation of the aorta and the iliac arteries.

Modified technique for recovering aortoiliac homografts

Infection of the prosthetic aortic graft bypass remains one of the most serious complications of aortoiliac bypass grafts. Use of an aortoiliac allograft as a replacement for an infected prosthetic graft is an effective treatment for this problem. However, the availability of aortoiliac grafts is affected by the high rate of procurement errors experienced during recovery. This overall error rate nationally averaged 32.5% in 2006, of which nearly a third (9.6%) were related to tears of the intima at or below the bifurcation of the abdominal aorta. To analyze the potential of a new aortoiliac graft recovery method in reducing the error rate. A modified technique of aortoiliac graft recovery was used to minimize the possibility of intimal tears. The essence of this technique is to change the sequence of mobilization of the graft, starting from the zone of low resistance, which is at the iliac arteries, and continuing upward to the abdominal aorta, which has higher resistance because of the greater thickness of the aortic wall. An additional modification of the standard technique is to use a tourniquet to raise the aortic edges. The aortoiliac graft has various resistances to tearing owing to the different wall thicknesses of the aorta and the iliac arteries. Mobilization of the abdominal aorta before dissection of the iliac arteries creates a high risk of tears at and around the bifurcation of the aorta and the iliac arteries.

Ischaemic lumbosacral plexopathy following aorto-iliac bypass graft: case report and review of literature

A 77-year-old man had aorto-iliac bypass for an abdominal aortic aneurysm (AAA). This was complicated by occlusion that needed extension of the graft to the right femoral artery. He was unable to move his right leg with numbness after surgery. This was caused by extensive lumbosacral plexopathy on the right side. Lumbosacral plexopathy is uncommon because the plexus has a rich blood supply. The incidence of ischaemic lumbosacral plexopathy is higher with re-operative and emergency AAA reconstruction. This may predispose the lumbosacral plexus to ischaemic injury. Consideration should be given to maintaining retrograde perfusion of the internal iliac artery.

Gastrointestinal: Aortoduodenal fistulae

An uncommon cause of major gastrointestinal bleeding is that of a fistula between the aorta and the adjacent bowel, usually the third part of the duodenum. The typical patient has been previously treated with a vascular prosthesis for an aortic aneurysm. Approximately 1–2% of these patients develop aortoenteric fistulae, usually after an interval of 2–10 years. Factors that predispose to fistulae include infection and further aortic dissection that result in duodenal damage and erosion of the duodenal wall by the graft. Case reports also describe aortoenteric fistulae without previous surgery in rare patients with atherosclerotic or mycotic aneurysms. The images shown below were from two patients with presumed aortoduodenal fistulae. Figure 1 is a contrastenhanced computed tomography scan from a 72-year-old man who was admitted to hospital with melena and subsequently had a major episode of gastrointestinal bleeding. The scan shows the lumen of the aorta, blood clot in an aneurysm and contrast around blood clot in the duodenum. The patient died despite multiple blood transfusions and emergency surgery. Figure 2 is an endoscopic image showing a segment of a Dacron graft that had eroded into the lumen of the third part of the duodenum. It was uncertain whether bleeding was a result of a direct communication between the graft and the duodenum or from erosion of vessels in the duodenal wall. The patient was a 69-year-old man who was investigated because of epigastric pain for 1 week and melena for 3 days. Twelve years previously, he had been treated with an aorto-iliac bypass graft because of distal aortic occlusive disease. Subsequent surgery involved resection of the graft as well as the third and fourth parts of the duodenum and the creation of an axillo-bifemoral bypass to revascularize the lower limbs.

Aortoiliac and aortofemoral bypass grafting are widely used operative treatment modalities of aortic reconstruction for both aortic occlusive disease and aneurysms of abdominal aorta. Graft occlusion,

Aortoiliac and aortofemoral bypass grafting are widely used operative treatment modalities of aortic reconstruction for both aortic occlusive disease and aneurysms of abdominal aorta. Graft occlusion,

Heparin-coated PTFE graft for aortoiliac bypass grafting inhibits intimal hyperplasia in baboons

Purpose: Intimal hyperplasia and graft thrombosis represent the major causes of graft failure. Heparin has been shown to prolong graft patency and inhibit intimal hyperplasia in animal models. The purpose of the study was to evaluate the effect of a heparin-coated expanded polytetrafluoroethylene (ePTFE) graft in a baboon model of aortoiliac bypass graft placement. Methods: Six adult male baboons (mean weight: 9.3 kg) underwent bilateral aortoiliac bypass grafting with ePTFE grafts (4 mm internal diameter × 5 cm length). In each animal, a heparin-coated ePTFE graft was placed on one side while the contralateral aortoiliac artery received an uncoated graft that served as a control. Platelet counts and activated partial thromboplastin time measurements were performed weekly. The grafts were harvested at 4 weeks and were subjected to morphometric analysis. Cell proliferation was assessed with bromodeoxyuridine immunostaining. Results: All the harvested grafts were patent. No differences were found in platelet counts or activated partial thromboplastin time measurements taken before and after the bypass procedure. There was a significant reduction of neointimal area at both proximal (0.06 ± 0.05 mm2) and distal (0.13 ± 0.07 mm2) anastomoses in the heparin-coated grafts as compared with proximal (0.16 ± 0.07 mm2) and distal (0.33 ± 0.12 mm2) anastomoses in the untreated control grafts (P < 0.05). In addition, neointimal cell proliferation assayed by bromodeoxyuridine (BrdU) incorporation was reduced in both proximal (2.03 ± 0.81%) and distal (3.12 ± 0.14%) anastomoses of heparin-coated grafts compared with proximal (3.54 ± 1.23%) and distal (5.58 ±1.15%) anastomoses of untreated control grafts (P < 0.05). Conclusions: Heparin-coated ePTFE graft significantly reduces anastomotic intimal hyperplasia and cell proliferation without measurable side effects in a baboon model. This approach supports a useful strategy for improving prosthetic bypass graft patency.

Endovascular repair as first-choice treatment for anastomotic and true iliac aneurysms.

To report our experience with the endovascular repair of iliac aneurysms secondary to aortoiliac bypass grafting. Thirteen patients (12 men; age range 62-86 years) with histories of aortoiliac reconstructions were treated with endovascular stent-grafts for 11 false and 2 true iliac aneurysms that averaged 5.2 cm in diameter (range 3.0-7.0). Via a percutaneous access and 9-F or 12-F sheaths, Passager or Wallgraft stent-grafts were delivered to exclude the aneurysms. Twelve (92%) of 13 interventions were completed satisfactorily; 1 procedure for a true iliac aneurysm was converted to traditional bypass grafting. Two patients underwent additional surgical procedures. The average hospital stay for the patients with endovascular repairs only was 3 days (range 2-5). After a mean follow-up of 28 months (range 17-40), no complication or endoleak has been detected in any patient, and all endografts are patent. Endovascular repair is an effective treatment for secondary aneurysms arising after aortoiliac surgery. It is less invasive and involves a shorter hospital stay. Endovascular repair should be the first choice treatment for iliac aneurysms.

Retroperitoneal Fibrosis with Duodenal Stenosis

Retroperitoneal fibrosis is a rare disease characterized by the formation of dense plaque of fibrous tissue covering the retroperitoneal structures. This disease is commonly presented as ureteral obstruction, but the involvement of duodenum is rare. We report a case of retroperitoneal fibrosis which was complicated with duodenal stenosis and was successfully treated with corticosteroids. A 58-yr-old man, who had history of aorto-iliac bypass graft due to arteriosclerosis obliterans with infrarenal aortic occlusion was admitted to the hospital with abdominal pain and a mass. Abdominal CT scan revealed the periaortic soft tissue mass encircling grafted aorta and stenosis of duodenal third portion. Retroperitoneal fibrosis with duodenal stenosis was diagnosed and prednisolone therapy was initiated. Follow-up CT scan showed that the patient responded to prednisolone therapy with eased pain, shrinking periaortic mass, and reduced duodenal stenosis.

Noonan's Syndrome Associated with Spontaneous Rupture of the Ascending Aorta

Noonan's syndrome associated with spontaneous rupture of the ascending aorta is rare. Review of the literature reveals only one such reported case. The authors describe a 41-year-old male with Noonan's syndrome who initially presented with lower extremity claudication. Computed tomography and digital subtraction angiography disclosed an abnormal dilation of the ascending thoracic aorta and a distal abdominal aortic dissection. The patient underwent successful aortoiliac bypass graft. Seven months later, he suffered rupture of his ascending aorta, resulting in death.

CHYLURIA AFTER RADICAL NEPHRECTOMY TREATED WITH N-BUTYL-2-CYANOACRYLATE

Chyluria is usually due to parasitic infection with Wuchereria bancrofti. Nonparasitic chyluria can be due to trauma, tuberculosis, surgery, for example aortoiliac bypass grafting, tumor or congenital lymphatic anomalies. We report a case of chyluria due to a lymphatic ureteral fistula after radical nephrectomy and lymphadenectomy. The fistula was treated successfully with ureteral occlusion using N-butyl-2-cyanoacrylate tissue adhesive. CASE REPORT A 42-year-old woman presented with severe left loin pain radiating to the iliac fossa. She had had 2 episodes of painless hematuria during the previous 4 months and was apyrexial with a large ballotable mass in the left loin. Erythrocyte sedimentation rate, serum albumin and creatinine were normal. Ultrasound and computerized tomography showed an 8 cm. heterogeneous solid lesion in the lower pole of the left kidney and suspiciously enlarged para-aortic nodes. Left radical nephrectomy was performed with the ureter ligated and transected at its mid third. The left para-aortic lymph nodes were 1 cm. in diameter and the entire lymphatic chain from the celiac axis to the pelvic brim was excised in continuity. Histology demonstrated Fuhrman grade II clear cell carcinoma without capsular invasion and reactive changes only in the lymph nodes. The patient noticed milky urine 3 weeks postoperatively. Urinalysis revealed 2.0 mmol./l. triglyceride concentration and 15.36 gm./l. proteinuria consistent with chyluria. There was post-prandial worsening of the chyluria and voiding was difficult due to obstruction from fibrin clots. Cystoscopy showed no chylous efflux. Retrograde assessment of the ureteral stump confirmed a fine communication with a lymphatic collection in the para-aortic space (fig. 1). There were multiple chyle clots in the bladder. Dilute povidone-iodine (0.2%, 15 ml.) was injected into the ureteral stump to sclerose the fistula.1 However, chyluria recurred 48 hours after the injection and persisted 2 months postoperatively, causing hypoproteinemia (albumin 27 gm./l.), ankle swelling, weight loss, lethargy and malaise. Under fluoroscopic guidance a catheter and long vascular sheath primed with 5% dextrose were advanced over a guide wire into the left ureteral stump. A mixture of 1 ml. N-butyl2-cyanoacrylate and 1 ml. iodized oil was injected into the upper half of the ureteral stump with immediate solidification (fig. 2). The chyluria resolved immediately and serial abdominal ultrasonography showed no evidence of intraabdominal lymphatic collection. At 1-year followup the patient was well with no recurrence of chyluria. DISCUSSION N-butyl-2-cyanoacrylate has been used to close minor superficial skin wounds as an alternative to sutures for many years. It has also been used by interventional radiologists for a wide variety of purposes, including embolization of intracranial arteriovenous malformations, spinal dural arteriovenous fistulas, uterine arteriovenous malformation, massive obstetric hemorrhage and high flow prapism due to blunt perineal trauma.2 In the urinary tract interventional radiologists have performed antegrade transrenal ureteral occlusion as palliative treatment of lower urinary tract fistulas, mainly in the presence of extensive pelvic malignancy or following radiotherapy. Gianturco coils with tissue adhesive and detachable balloons with or without tissue adhesive have also been used.3

Ureteral Obstruction Following Aortic Surgery: Guidelines for Successful Management

Ureteral obstructions following aortoiliac or aortofemoral bypass grafting for aortoiliac occlusive and aneurysmal disease are infrequently reported. Ureteral obstructions can be self-limiting and resolve without further treatment or can signify a more serious underlying complication such as graft infection or a pseudoaneurysm formation. The authors present a series of five patients with ureteral obstruction secondary to aortobifemoral bypass grafting. Different treatment options are described and an algorithm for the management of these complications is presented.

Local infusion of heparin reduces anastomotic neointimal hyperplasia in aortoiliac expanded polytetrafluoroethylene bypass grafts in baboons

Purpose: Recently, we designed and characterized a novel expanded polytetrafluoroethylene (ePTFE)-based local drug delivery approach that selectively concentrates infused pharmacologic agents specifically within those blood layers adjacent to the graft wall and at downstream anastomotic sites. In this study, we locally administrated standard heparin therapy and evaluated its effects on neointimal hyperplasia formation in a baboon model of aortoiliac bypass graft placement.Methods: Six adult male baboons underwent bilateral aortoiliac bypass grafting with ringed ePTFE (4 mm internal diameter × 5 cam length). In each animal, the distal anastomosis of one graft was continuously infused with heparin (50 U/h) and the distal anastomosis of the contralateral graft was infused with saline solution at the same rate (2.5 μL/h), with osmotic pumps implanted for 4 weeks. Platelet counts and activated partial thromboplastin time measurements were performed weekly. The specimens were harvested at 4 weeks and were subjected to morphometric analysis. Cell proliferation was assessed with bromodeoxyuridine immunostaining.Results: All the harvested grafts were patent except for one control graft. There were no significant differences in platelet counts or activated partial thromboplastin time measurements taken before and during heparin infusion. As expected, there were no significant differences in graft neointimal hyperplasia and cell proliferation at the proximal anastomoses between the heparin-infused and control grafts. In contrast, at the treated distal anastomoses, heparin infusion significantly reduced the graft neointimal area by 65% and the cell proliferation index by 47% as compared with the untreated control distal anastomoses.Conclusion: These results show that local infusion of heparin significantly reduces distal anastomotic neointimal hyperplasia and cell proliferation without measurable systemic anticoagulation or other side effects. Thus, this approach may represent an attractive strategy for prolonging ePTFE bypass graft patency.

Two aorto-iliac bypass graft infections associated with appendicitis

Two aorto-iliac bypass graft infections associated with appendicitis

Abstracts of Literature

Abstracts of Literature

Fibrin glue containing fibroblast growth factor type 1 and heparin decreases platelet deposition

The early success rates of endarterectomy and angioplasty are influenced by the thrombogenicity of the deendothelialized surface. We previously reported decreased platelet deposition after 30 and 120 minutes and after 28 days on expanded polytetrafluoroethylene (ePTFE) grafts coated with fibrin glue (FG) containing fibroblast growth factor type 1 (FGF-1) and heparin in canine aortoiliac bypass grafts when compared with control uncoated grafts. The FG/FGF-1/heparin coating has been shown to enhance spontaneous endothelialization at 28 days in canine ePTFE bypass grafts. The current study evaluates the thrombogenicity of this FG/FGF-1/heparin suspension applied to a balloon de-endothelialization model of endarterectomy in canine carotid arteries. Nine dogs underwent bilateral, deendothelialization balloon injury to 6-cm segments of their carotid arteries. Fibrin glue (fibrinogen 32.1 mg/mL + thrombin 0.32 U/mL) containing FGF-1 (11 ng/mL) and heparin (250 U/mL) was applied to the luminal surface of one carotid artery in each dog. Both femoral arteries were circumferentially dissected but not balloon injured; one femoral artery was clamped for the same period as the carotid arteries. In the 6 acute dogs, 10 minutes prior to the restitution of flow in both carotid arteries and one femoral artery, 4 to 8 x 10(9) (111)In-labelled autologous platelets were injected intravenously. Four-cm segments of both carotid and femoral arteries were excised after 15 or 120 minutes of circulation (n = 3/time/artery, 24 arteries). In the 3 chronic dogs, the radiolabelled platelets were injected 30 days after carotid injury. The carotid and femoral vessels were then excised after 120 minutes of perfusion. Radioactive platelet deposition was quantitated by gamma counting. After 2 hours, the injured carotid arteries demonstrated significantly more platelet deposition than either uninjured femoral artery controls (P < 0.001). There was also a significant 45.2% decrease (P = 0.008) in platelet deposition on the balloon injured carotid arteries treated with FG/FGF-1/heparin when compared with balloon injured carotid arteries alone. At 30 days there was an insignificant trend toward decreased thrombogenicity in the FG/FGF-1/heparin treated injured carotids. Surface coating with FG/FGF-1/heparin significantly decreases platelet deposition on balloon injured canine carotid arteries after 2 hours of perfusion and may be clinically applicable in endarterectomy and angioplasty procedures. The long-term induction of reendothelialization of arterial surfaces by this technique is under investigation.

Highly porous polymer matrices as a three-dimensional culture system for hepatocytes: Initial results

Background: The early success rates of endarterectomy and angioplasty are influenced by the thrombogenicity of the deendothelialized surface. We previously reported decreased platelet deposition after 30 and 120 minutes and after 28 days on expanded polytetrafluoroethylene (ePTFE) grafts coated with fibrin glue (FG) containing fibroblast growth factor type 1 (FGF-1) and heparin in canine aortoiliac bypass grafts when compared with control uncoated grafts. The FG/FGF-1/heparin coating has been shown to enhance spontaneous endothelialization at 28 days in canine e-PTFE bypass grafts. The current study evaluates the thrombogenicity of this FG/FGF-1/heparin suspension applied to a balloon de-endothelialization model of endarterectomy in canine carotid arteries.111In-labelled autologous platelets were injected intravenously. Four-cm segments of both carotid and femoral arteries were excised after 15 or 120 minutes of circulation (n = 3/time/artery, 24 arteries). In the 3 chronic dogs, the radiolabeled platelets were injected 30 days after carotid injury. The carotid and femoral vessels were then excised after 120 minutes of perfusion. Radioactive platelet deposition was quantitated by gamma counting.Results: After 2 hours, the injured carotid arteries demonstrated significantly more platelet deposition than either uninjured femoral artery controls (P < 0.001). There was also a significant 45.2% decrease (P = 0.008) in platelet deposition on the balloon injured carotid arteries treated with FG/FGF-1/heparin when compared with balloon injured carotid arteries alone. At 30 days there was an insignificant trend toward decreased thrombogenicity in the FG/FGF-1/heparin treated injured, carotids.Conclusion: Surface coating with FG/FGF-1/hep-arin significantly decreases platelet deposition on balloon injured canine carotid arteries after 2 hours of perfusion and may be clinically applicable in endarterectomy and angioplasty procedures. The long-term induction of reendothelialization of arterial surfaces by this technique is under investigation.

Anastomotic aneurysms following aortofemoral vascular replacement.

Despite the advances in reconstructive vascular surgery, anastomotic aneurysms,--particularly in inguinal position--have remained an unsolved problem. Between 1985 and 1992 in 46 patients who underwent aortoiliac or aortofemoral bypass grafting 58 anastomotic aneurysms were operated in our institution. The mean interval between primary reconstruction and onset was 65.0 months. In 54% we observed real suture aneurysms. Technical faults are supposed to be the most causative factor in development of anastomotic aneurysm. The rate of recurrence after repair was 10%. There was no postoperative mortality. It is concluded that comprehensive follow-up is required after aortofemoral grafting. Because of the risk of peripheral embolization and local disruption surgical repair has to be done soon after the diagnosis of anastomotic aneurysm.