Aortoiliac Bypass Research Articles

Rectus Sheath Block Improves Patient Recovery Following Open Aortic Surgery

Postoperative pain management remains a barrier to recovery following aortic surgery. Although epidural catheters help in adjunctive pain management, less is known about the use of rectus sheath blocks. We compared patient recovery following open abdominal aortic surgery (OAS) with and without adjunctive rectus block. Adult patients undergoing open abdominal aortic aneurysm repair and aortobifemoral or aortoiliac bypass for occlusive disease were identified and stratified by use of general anesthesia alone (GA) versus adjunctive use of a rectus sheath block (GA+RB). A small number of patients with GA and concomitant epidural analgesia, along with patients that had retroperitoneal repairs, were not included in further analysis. Outcomes included time to extubation, intraoperative and postoperative morphine milligram equivalents (MME) utilization, length of stay, discharge MME, and postoperative complications. Categorial data were compared with Person Chi-Square tests or Fisher's exact tests. Continuous data were tested with independent t-tests or Mann-Whitney U-tests. From January 2017 to April 2022, there were 106 patients who underwent open aortic surgery, 55 patients with GA alone, 39 with GA+RB, and 12 patients who had a GA with concomitant epidural analgesia. Between GA and GA+RB, patients were comparable in both groups in terms of age, BMI (body mass index), smoking history, hypertension, diabetes, CAD (coronary artery disease), COPD (chronic obstructive pulmonary disease), and ASA (American Society of Anesthesiologists) class and prior opioid use. Patients with GA+RB were more likely to have scheduled elective procedures (80% GA cohort vs. 94.9% RB, P=0.040), and a lower incidence of retroperitoneal exposure (14.5% GA cohort vs. 0% RB, P=0.019). Patients with GA+RB had shorter time to extubation than GA (84.6%<12hr vs. 44.4%, P<0.001), greater rate of procedural ketamine usage (GA+RB: 61.5% vs. GA: 40.0%, P=0.049), lower MME at first postoperative day (median MME GA+RB: 25.0 vs. GA: 67.5, P=0.002), lower discharge MME (median MME GA+RB: 142.5 vs. GA: 225.0, P=0.036), and overall shorter length of stay (median stay GA+RB: 5 vs. GA: 6days, P=0.006). Postoperative complications were similar between groups. Similar findings were found in the comparison between elective-only GA and GA+RB patients and after exclusion of patients who only had a single shot of regional anesthesia. Patients that receive adjunctive rectus sheath blocks for pain control following OAS utilize fewer opioid medications during hospital stay and at discharge. Rectus sheath blocks represent an alternative option to other periprocedural analgesia following open aortic surgery.

Chronic Complete Distal Aortic Occlusion and Pulmonary Embolism—Atypical Antiphospholipid Syndrome?

Complete aortic occlusion is a rare pathology with various possible etiologies. According to current data, it is most frequently caused by atherosclerosis. However, thrombosis or vasculitis could also be involved. We present the case of a 42-year-old female with chronic complete distal aortic occlusion, associated pulmonary embolism and positive antiphospholipid antibodies. The patient had an obstetric history suggestive of antiphospholipid syndrome (APS). She presented with typical intermittent claudication symptoms persisting for approximately five years at the time of admission. Arteriography revealed complete infrarenal aortic occlusion and the presence of collateral arteries. Aortoiliac bypass surgery was performed. This case emphasizes an unusual, yet possible, etiology of chronic aortic occlusion-most probably, combining atherosclerosis and chronic thrombosis-in a relatively young patient, in which the diagnosis was significantly delayed due to the peculiar association of traits.

Clampless 2 Device: Experimental Study of a Lateral Aorto-Prosthetic Anastomosic Device Without Clamping or Suturing

To offer an alternative to conventional techniques of lateral prosthetic anastomosis on arteries which require a long training, and impose an extensive open surgery, we are proposing the clampless 2 device (C2D) implanted by a simple arterial puncture and allows a lateral implantation of a polytetrafluoroethylene (PTFE) vascular graft in an artery, without arterial clamping or suture. C2D is a "T" shaped 25-mm long and 8-mm diameter Nitinol stent with a 6-mm PTFE graft prosthesis mounted laterally on the stent, and implanted in an artery, via a 21-French sheath, and a compliant balloon inflation. Invitro testing of the C2D was first performed on a bench including a segment of a 7-mm internal diameter pig abdominal aorta. A series of 5 consecutive C2D implantation was analyzed with evaluation of the implantation time and the fluid losses at a fluid pressure of 80 and 150mm Hg. The C2D implantation was finally controlled by angioscopy. An aorto-iliac bypass was then secondly performed on 8 living sows, with a side-to-end C2D implantation in the infrarenal abdominal aorta, followed by a conventional end-to-end prosthetic left iliac trunk anastomosis. The C2D and distal conventional anastomotic times were evaluated, as well as the total operative time and blood loss. A postoperative angiogram was systematically performed. The C2D was successfully implanted in all 5 invitro tests, with an average implantation time of 2'58 (range: 2'25-3'22). The mean value of fluid losses was 84ml (range: 67-94ml), with no fluid leakage occurring at 80- and 150-mm Hg pressure. All anastomoses were patent after macroscopic study by angioscopy with a perfect application of the stent in the aortic wall. In 8 living sows (mean weight: 42kg, 37-50kg), an aorto-left iliac bypass was successfully implanted in all cases, with a total mean procedure time of 101min (range: 90-130min), and an average fluid loss of 77ml (range:20-120ml). The mean implantation time was 4'39 (range 3'29-5'52) for C2D and 16min (range 12-17min) to perform the conventional distal prosthetic-iliac anastomosis. Systematic arteriographic and angioscopy control showed perfect patency of the C2D implantations. Preliminary invitro and acute invivo testing of C2D implantation show good early results, allowing further long-lasting pig experiments on the way to human homologation.

In-Hospital Outcomes of Aortoiliac Versus Aortofemoral Bypass in Aortoiliac Occlusive Disease in Vascular Quality Initiative

This study evaluated the in-hospital outcomes of patients undergoing aortoiliac bypass vs aortofemoral bypass for the treatment of aortoiliac occlusive disease using data obtained from the Vascular Quality Initiative. Surgeries listed in the Vascular Quality Initiative that occurred during the period from January 2009 to June 2021 were queried. The primary outcome was surgical site infection (SSI). The secondary outcomes included in-hospital mortality, postoperative myocardial infarction, postoperative congestive heart failure, return to the operating room, and postoperative major amputation. Logistic regression modeling was used to adjust for potential confounders. A total of 7006 aortofemoral bypasses (90.0%) and 781 aortoiliac bypasses (10.0%) were analyzed. Most of the surgeries were performed bilaterally (aortofemoral, 95.6%; aortoiliac, 92.3%). The patients in the aortofemoral group were older (age, 60.4 ± 8.7 years vs 58.0 ± 9.6 years; P < .001) and more likely to be male (60.1% vs 36.6%; P < .001) and non-White (13.7% vs 10.9%; P = .030) compared with the aortoiliac group. The patients in the aortofemoral group also had significantly greater rates of hypertension (80.5% vs 72.7%; P < .001), coronary artery disease (22.9% vs 19.3; P = .022), and prior cardiovascular interventions, including coronary artery bypass graft/percutaneous coronary intervention (22.2% vs 17.7%; P = .003), carotid endarterectomy/carotid artery stenting (7.9% vs 5.8%; P < .001), and peripheral vascular intervention (6.5% vs 3.1%; P < .001). Patients undergoing aortofemoral interventions had significantly greater rates of both previous lower extremity intervention (12.8% vs 8.6%; P = .001) and concomitant lower extremity intervention (6.4% vs 2.8%; P < .001; Table I). Aortofemoral procedures were significantly associated with higher rates of SSIs (adjusted odds ratio, 2.4; 95% confidence interval, 1.3-4.4; P = .006) and postoperative congestive heart failure (adjusted odds ratio, 2.2; 95% confidence interval, 1.1-4.5; P = .029) compared with aortoiliac procedures. Although aortofemoral procedures were associated with greater rates of myocardial infarction compared with aortoiliac procedures (3.3% vs 1.9%; P = .040), this association did not remain significant on multivariate analysis. In-hospital death, a return to the operating room, and postoperative major amputation did not significantly differ between the two surgical techniques (Table II). Patients undergoing aortoiliac bypass had significantly lower rates of SSIs compared with those undergoing aortofemoral bypass. This likely resulted from the avoidance of groin incisions, which is known to be associated with a significantly greater risk of infections in vascular procedures. If anatomically feasible, the aortoiliac configuration in aortic reconstructions should be preferred to reduce the risk of SSI.Table IBaseline and clinical characteristics stratified by distal bypass targetCharacteristicAortofemoral (n = 7006; 90.0%)Aortoiliac (n = 781; 10.0%)P valueAge, years60.4 ± 8.758.0 ± 9.6<.001Male sex4210 (60.1)286 (36.6)<.001Non-White958 (13.7)85 (10.9).030Ethnicity (Hispanic or Latino)159 (2.3)16 (2.1).694Obesity1465 (20.9)230 (29.5)<.001Insurance.053 Medicare2124 (34.0)218 (30.3) Medicaid884 (14.2)94 (13.1) Other3241 (51.9)407 (56.6)Smoking<.001 Never132 (1.9)35 (4.5) Prior2282 (32.6)268 (34.3) Current4585 (65.5)478 (61.2)HTN5629 (80.5)563 (72.7)<.001DM1766 (25.2)208 (26.6).395CAD1605 (22.9)151 (19.3).022Prior CABG/PCI1557 (22.2)138 (17.7).003CHF508 (7.3)37 (4.7).009COPD2336 (33.4)241 (30.9).155Dialysis32 (0.5)5 (0.6).481CKD1048 (15.1)122 (15.8).606Nonambulatory149 (2.1)14 (1.8).533ASA class.172 114 (0.2)1 (0.1) 2260 (3.7)43 (5.5) 35189 (74.2)572 (73.3) 41528 (21.9)164 (21.0) 51 (0.0)0 (0.0)Prior peripheral intervention461 (6.5)24 (3.1)<.001Prior CEA/CAS554 (7.9)45 (5.8)<.001Prior aneurysm repair73 (1.0)22 (2.8)<.001Prior major amputation101 (1.4)11 (1.4).945Aspirin5140 (73.5)551 (70.6).093P2Y12 inhibitor1291 (18.5)125 (16.0).093Statin5262 (75.2)560 (71.7).033Beta-blocker3202 (45.8)339 (43.5).222RAAS inhibitor2906 (46.3)302 (42.0).029Anticoagulant542 (8.6)63 (8.8).908Urgent787 (11.2)94 (12.0).505Anesthesia (general)6889 (98.4)768 (98.3).962Right side indication.001 Asymptomatic/claudication4301 (61.6)506 (64.8) CLTI2258 (32.3)213 (27.3) Acute ischemia310 (4.4)53 (6.8) Not treated117 (1.7)9 (1.2)Left side indication<.001 Asymptomatic/claudication4292 (61.4)538 (69.1) CLTI2315 (33.1)175 (22.5) Acute ischemia285 (4.1)53 (6.8) Not treated94 (1.4)13 (1.7)Previous inflow intervention1747 (25.0)175 (22.5).120Previous LE intervention894 (12.8)67 (8.6).001Concomitant LE intervention445 (6.4)22 (2.8)<.001Bilateral surgery6697 (95.6)721 (92.3)<.001ASA, American Society of Anesthesiology; CABG, coronary artery bypass graft; CAD, coronary artery disease; CAS, coronary artery stenting; CEA, carotid endarterectomy; CHF, congestive heart failure; CKD, chronic kidney disease; CLTI, critical limb threatening ischemia; COPD, chronic pulmonary obstructive disease; DM, diabetes mellitus; HTN, hypertension; LE, lower extremity; PCI, percutaneous coronary intervention; RAAS, renin-angiotensin-aldosterone system.Data presented as mean ± standard deviation or number (%). Open table in a new tab Table IIPostoperative outcomes of aortofemoral vs aortoiliac bypass for aortoiliac occlusive diseaseOutcomeUnadjusted, No. (%)AdjustedaAortofemoral (n = 7006; 90.0%)Aortoiliac (n = 781; 10.0%)P valueaOR (95% CI)P valueSurgical site infection271 (3.9)12 (1.5).0012.4 (1.3-4.4).006In-hospital death167 (2.4)14 (1.8).2971.1 (0.6-2.1).763Postoperative MI229 (3.3)15 (1.9).0401.4 (0.8-2.3).193Postoperative CHF216 (3.1)10 (1.3).0042.2 (1.1-4.5).029Return to operating room694 (9.9)65 (8.3).1561.1 (0.8-1.5).559Postoperative major amputation68 (1.0)9 (1.2).6280.5 (0.3-1.1).087aOR, adjusted odds ratio; CHF, congestive heart failure, CI, confidence interval; MI, myocardial infarction.aReference: aortofemoral. Open table in a new tab

Iatrogenic aortocaval shunt treated by stent graft placement into the inferior vena cava

Fifty six year old male sustained an injury to the abdominal aorta during his 1992 lumbar disc surgery with subsequent aortocaval shunt formation. In order to close the shunt, his abdominal aorta and both common iliac arteries were ligated and bilateral aortoiliac bypass was implanted. Postoperatively the patient remained asymptomatic for several years. Subsequently he developed arterial hypertension, his exercise capacity diminished and he complained of exertional dyspnea. Intraarterial DSA demonstrated filling of the occluded aortic segment from intercostal and lumbar arteries as well and a shunt between this segment and the inferior vena cava. The hemodynamic significance of the shunt was confirmed using catheterization. Attempted reduction of the shunt flow by intercostal arteries embolization was not successful. We were successful in closing the fistula using a custom-made stent graft. CTA performed 18 years after the procedure confirmed absence of the shunt and patent inferior vena cava. The patient is now asymptomatic 23 years after the original surgery.

Ascending Aortoiliac Bypass for One-Stage Repair of Adult Aortic Coarctation With Concomitant Cardiac Lesions.

To evaluate the efficacy and safety of ascending aortoiliac bypass surgery for one-stage repair of adult coarctation of the aorta (CoA) and concomitant cardiac disease. From March 2012 to October 2018, 51 consecutive CoA patients were treated with ascending aorta to bilateral iliac artery bypass concomitant with and cardiac surgerical procedures performed for a variety of reasons. A Y-shaped graft was used for the bypass procedure. We evaluated early outcomes, including postoperative death, systolic blood pressure and differences between upper and lower limb blood pressure. The average age was 41years and 64.7% of patients were men. Simultaneous cardiac procedures included aortic valve replacement, ventricular septal defect repair, Bentall procedures and Wheat procedures. No deaths occurred in the early postoperative period. Three patients had delayed healing at the site of the abdominal lower quadrant incisions. The average systolic pressure in the upper limb and the average difference between the upper- and lower-limb blood pressure decreased significantly after surgery (162.7 ± 13.4mmHg vs 128.4 ± 6.7mmHg, P = .000; 69.6 ± 15.6mmHg vs 8.7 ± 7.6mmHg, P = .000, respectively); The systolic blood pressure in the lower limb increased after bypass surgery (93.1 ± 6.2mmHg vs 119.6 ± 7.7mmHg, P = .000). The follow-up rate was 100%, with an average follow-up time of 61months. Six patients (11.8%) had graft stenosis or occlusion. Three patients (5.9%) underwent endovascular embolectomy. In our small series, ascending aortoiliac bypass for one-stage repair of CoA with concomitant cardiac lesions appears safe and efficacious in effectively reduceing differences between upper and lower limb systolic blood pressure. Further study with larger sample size and longer follow-up is needed.

Spinal Cord Protection of Aorto-Iliac Bypass in Open Repair of Extent II and III Thoracoabdominal Aortic Aneurysm

Spinal cord injury (SCI) is one of the serious complications of thoracoabdominal aortic aneurysm (TAAA) repair. Cardiopulmonary bypass (CPB) and left heart bypass (LHB) are well-established extracorporeal circulatory assistance methods to increase distal aortic perfusion and prevent spinal cord ischaemia in TAAA repair. Aorto-iliac bypass, a new surgical adjunct offering distal aortic perfusion without the need of complex perfusion skills, was developed as a substitute for CPB and LHB. However, its spinal cord protective effect is unknown. The perioperative data of 183 patients who had elective open Crawford extent II and III TAAA repair at our aortic centre from July 2011 to May 2019 were retrospectively analysed. Spinal cord protection was compared between the aorto-iliac bypass group (n=106) and the extracorporeal circulatory assistance group (n=77 [65 CPB, 12 LHB]), and the risk factors for SCI in these patients were explored. Eleven (11) patients had postoperative SCI: five (6.5%) in the extracorporeal circulatory assistance group (four with CPB and one with LHB), and six (5.7%) in the aorto-iliac bypass group. The incidence of SCI was 6.0% (11/183 cases). There was no difference between the aorto-iliac bypass group and the extracorporeal circulatory assistance group (p=1.0), while operation time, proximal aortic clamp time, intercostal artery clamp time, and length of intensive care unit stay were all increased in the latter group. Multivariate logistic regression analysis showed that cerebrospinal fluid pressure (odds ratio [OR] 1.270; 95% confidence interval [CI] 1.092-1.478 [p=0.002]) and lowest haemoglobin on the first postoperative day (OR 0.610; 95% CI 0.416-0.895 [p=0.011]) were the independent predictors of SCI in TAAA repair. Spinal cord protection of aorto-iliac bypass is comparable to that of CPB and LHB in open TAAA repair.

Descending thoracic aorta to bifemoral bypass grafting in Aortobiiliac occlusive disease

Introduction: The aim of this prospective study is to describe the clinical symptoms, investigation findings and surgical treatment of aortoiliac occlusive disease where abdominal approach not feasible or not possible for aortobifemoral bypass grafting. Method: From May 2013 to May 2019, ten patients were treated with descending thoracic aorto-bifemoral bypass for aortoiliac occlusive disease at Grant Medical College and JJ group of Hospitals, Mumbai (Maharashtra). Total 20 limbs were re-vascularized. Demographic data, co-morbid factors, per operative findings were noted. Indication for surgery is juxtarenal occlusion of the abdominal aorta, in most of the cases. In postoperative period, all patients were evaluated for appearance of distal pulsations, primary patency, warmness of foot, symptom relief, wound infection, healing of the ulcer, and complications. CT angiography was done in follow-up. Maximal followup of two years and minimum followup of one month was done after surgery. Results: No mortality. Mean duration of surgery was 2.5-5 h and mean blood loss was 250 - 400 mL. Major morbidity includes one graft occlusion. None of the patients developed proximal propagation of aortic thrombus. Ulcers showed healing. All patients had a good quality of life postoperatively. Postoperative angiography showed good re-vascularization. Conclusion: Majority of our patients are old age having juxtarenal aortic occlusion so we decided to use DTA as inflow for primary revascularization to avoid entering abdomen and renal injury. Some authors have recommended supraceliac aorta bypass surgery within the retroperitoneal space for juxtarenal aortic occlusive disease but is technically difficult and associated with morbidity. The major limitation to thoracic aorta bifemoral grafting technique is the morbidity rate associated with thoracotomy in a relatively high-risk vascular surgery population. Also, tunnelling in conventional DTA-to-femoral artery bypass is usually a “blind” procedure.For the cardiothoracic surgeon with experience, the use of descending thoracic aorta could be a very good alternative for infrarenal aortic occlusion or extra-anatomic aortoiliac bypass without any morbidity and mortality with good improvement in quality of life.

Middle Aortic Syndrome in a Child-Bearing Age Patient.

We report a rare case of a 30-year-old female who had a long-standing history of middle aortic syndrome that was being managed nonsurgically. She presented with hypertension and buttock pain with plans to become pregnant. She underwent an aortoiliac bypass.

Incidence of Ventral Hernia Repair after Open Abdominal Aortic Aneurysm and Open Aortofemoral or Aortoiliac Bypass Surgery: An Analysis of 17,594 Patients in the State of New York

The purpose of our study was to evaluate the rate of ventral hernia repair (VHR) after open abdominal aortic anneurysm in New York State compared with the rate of VHR after open abdominal aortic bypass procedures. The Statewide Planning and Research Cooperative System database was queried for all abdominal aortic aneurysm (AAA) and bypass procedures performed between 2000 and 2010. Social security death index was used to identify patients who died. The cause-specific Cox proportional hazard model was applied to compare the risk of having follow-up VHR between patients with AAA and bypass with death as a competing risk event. A multivariable model was used to explore independent relationship with the risk of having follow-up ventral hernia after adjusting for other factors. There were 9314 patients who underwent open AAA repair, 739 (7.93%) of which had subsequent VHR. Comparatively, 8280 patients underwent aortofemoral or aortoiliac bypass procedures, with 480 (5.8%) undergoing subsequent VHR. The observed one-year, five-year, and 10-year VHR rates for AAA versus bypass were 2.8 versus 1.8 per cent, 10.0 versus 8.0 per cent, 10.7 versus 9.38 per cent, respectively. After controlling for all other factors, patients undergoing AAA repair were more likely and elderly patients were less likely to undergo VHR (P < 0.0001). Patients with serious comorbid conditions such as valvular disease, diabetes mellitus, and neurologic disorders were less likely to undergo subsequent VHR controlling for other factors. VHR after AAA procedures is more common compared with bypass procedures for occlusive disease. Because this patient population has significant comorbidity, prophylactic mesh placement may play a role in preventing necessity for future procedures.

Aortobisiliac Bypass Using a Venous Homograft Concomitant With Kidney Transplantation in a Patient With Severe Bilateral Iliac Occlusive Disease: A Case Report

Aortoiliac occlusive disease (AOD) is a great threat for kidney transplantation (KT). Here we report the case of an aortoiliac bypass, performed simultaneously with renal transplantation using venous grafts obtained from the deceased donor. The recipient was a 68-year-old woman with significant stenosis of the aortoiliac axis. We performed an aortobisiliac bypass using donor’s femoral veins because presence of methicillin-resistant Staphylococcus aureus was detected on donor hemoculture and contraindicated a prosthetic implant on the recipient. KT was then carried out using standard technique. Operative time amounted to 330 minutes and cold ischemia time of the renal graft was 900 minutes. Delayed graft function was observed until postoperative day 12, but the patient showed a good urine output and a serum creatinine of 2.1 mg/dL at discharge. AOD is not an absolute contraindication to renal transplantation, and simultaneous surgical repair of aortoiliac lesions with KT seems feasible. The patient’s return to function after initial delayed graft function suggests that such interventions may allow transplantation to be offered to those patients who otherwise may be excluded for severe vascular comorbidities. Homologous vascular grafts are an excellent choice because prosthetic vascular replacement during immunosuppression must be avoided as long as possible, especially in patients with coexisting infective risk.

Results of hybrid procedures for treatment of aortoiliac Trans-Atlantic Inter-Society Consensus II D lesions with self-expanding covered heparin-bonded stent grafts.

According to the guidelines aortoiliac TASC D lesions should be treated by bypass. The purpose of this study was to examine the results of hybrid procedures with the use of a self-expanding covered heparin-bonded stent graft (Viabahn) in patients with extensive aorto-iliac lesions who were not considered to be suitable for open aorto-iliac surgery. All patients who received a hybrid procedure in combination with a Viabahn stent in our clinic to treat aortoiliac lesions between October 2011 and April 2017 were included in this retrospective analysis. Study endpoints were primary patency, amputation-free survival (AFS) and major adverse limb event (MALE) free survival after 2 years. We included 23 hybrid procedures (endarterectomy of the common femoral artery or cross over bypass and aortoiliac stent) in 20 patients (median age 59 years). Indication was critical limb ischemia in 70.0%. The reasons why patients were on high risk for alternative open aortoiliac revascularization were hostile abdomen in 35.0%, cardiopulmonary contraindications in 35%, cancer in 10.0%, age >80 years in 10.0% and alcoholic cirrhosis in 10.0%. The 30-day mortality was 15.0%, the major amputation rate was 4.3%. We had no early graft occlusion. After 2 years primary patency was 100%, AFS 58.2% and MALE free survival 95.7%. A hybrid procedure with the use of a Viabahn stent in severe aortoiliac pathologies showed good patency results in this selected patient group. Therefore, it should be considered a feasible alternative to aortoiliac bypass surgery in surgical high-risk patients.

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.

Metabolic Syndrome but not Obesity Adversely Affects Outcomes after Open Aortoiliac Bypass Surgery

Although the incident risk of peripheral artery disease increases in patients with metabolic syndrome, several authors report favorable outcomes in obese patients after arterial bypass surgery. We examine the effect of the so-called "obesity paradox" and metabolic syndrome on outcomes after open aortoiliac bypass surgery. We identified patients between 2004 and 2015 who had open surgical bypass for aortoiliac occlusive disease. We excluded patients with endovascular repair and those treated primarily for aneurysmal disease. Variables that were analyzed included preoperative medical history, Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease II classification, Rutherford classification, intra-operative, and postoperative outcomes. Metabolic syndrome was defined by World Health Organization criteria: diabetes and 2 or more of dyslipidemia, hypertension, and obesity (body mass index > 30kg/m2). Data were analyzed by stratified Kaplan-Meier and multiple Cox regression for outcomes including long-term mortality and reintervention rate. There were 154 open bypass surgery patients during the study period with a median age of 60years (interquartile range [IQR] 53-68), median glomerular filtration rate 76.1mL/min (IQR 54-102), and 58% female prevalence. In all, 53 patients had metabolic syndrome (4%), and 14 patients (9%) were obese but did not have metabolic syndrome. Primary bypass graft patency was 89.0±2.7% at 1 year and 77.4±4.1% at 5 years and was not significantly different between metabolic syndrome, obese, and nonmetabolic syndrome patients. Reintervention rate for the entire cohort was 25.3±3.7% at 1 year and 40.6±4.7% at 5 years. In those with and without metabolic syndrome, reintervention rate at 1 and 5 years was 33.0±6.8% vs. 21.1±4.2% and 56.1±7.9% vs. 30.7±5.4%, respectively (log-rank P=0.003). In multivariable analyses, metabolic syndrome (hazard ratio [HR] 1.8, P=0.036) and critical limb ischemia (CLI) (HR: 3.2, P=0.001) were the only independent predictors of reintervention. Neither obesity nor the individual components comprising metabolic syndrome was a risk for reintervention. Multivariate analysis demonstrated age, female gender, CLI, and nonobesity as the independent risk factors for long-term mortality. Our study supports the "obesity paradox" that obesity by itself is not a risk factor for reintervention and was a protective factor for mortality after open aortoiliac bypass surgery. Bypass graft patency and major amputation rates were not affected. Although the individual components do not predispose to worse outcome, metabolic syndrome is a constellation of factors that, together, are associated with adverse events.

Metabolic Syndrome but Not Obesity Adversely Affects Outcomes After Open Aortoiliac Bypass Surgery

Metabolic Syndrome but Not Obesity Adversely Affects Outcomes After Open Aortoiliac Bypass Surgery

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).

Surgical treatment of abdominal aortic aneurysms in infancy and early childhood

Pediatric abdominal aortic aneurysms (AAAs) are rare. The intent of this report was to review the presentation and surgical management of AAAs in infancy and early childhood. The clinical courses of young children undergoing AAA surgery were subjected to a retrospective review and analysis. Eleven children, nine boys and two girls, ranging in age from 2weeks to 6years, underwent surgical treatment of AAA at the University of Michigan from 2002 to 2014. Aneurysms were supraceliac (2), suprarenal (2), pararenal (2), or infrarenal (5). Associated iliac aneurysms (3) affected two children. Concomitant stenoses affected the renal (14), superior mesenteric (4), and celiac (3) arteries. AAAs were attributed to developmental defects (7), including three arising immediately beyond aortic narrowings; infection after umbilical artery catheterization (2); tuberous sclerosis (1); and trauma (1). Primary operative interventions included aneurysmectomy with a thoracoabdominal bypass (4), open aneurysmorrhaphy (2), closed aneurysmorrhaphy (2), and aneurysmectomy with an infrarenal aortoaortic bypass (1) or an aortoiliac bypass (2). Perioperative death occurred in one child who had preoperative heart and renal failure. Aortic graft occlusion affected two children at 1month and 3years postoperatively. The remaining children incurred no aortic reconstruction-related morbidity. Follow-up among the 10 survivors averaged 4.9years. Successful surgical treatment of AAAs in infants and young children requires careful execution of a diverse group of surgical techniques based on the etiology, the child's size and growth potential, and the aneurysm's location and coexisting branch involvement.

VENOUS OUTFLOW AFTER HARVESTING OF FEMORAL VEIN FOR RECONSTRUCTION OF AORTOILIAC SEGMENT

Objective: to define the state of venous outflow after femoral vein harvesting for aortoiliac reconstruction. Material and methods. The distant results of 22 aortoiliac reconstructions with deep femoral veins performed at Gomel Regional Vascular Surgery Department over 2010-2015 have been studied. 5 patients were operated for late complications (false aneurisms) of previous aorto-femoral bypass, 8 patients were treated for acute prosthetic infection and 9 patients underwent initial surgery for terminal stage of critical limb ischemia. Results and discussion. The group of the patients after initial reconstructions revealed significant edema and lymphorea immediately after the surgery. It was not necessary to perform fasciotomy in all the cases. There were no signs of chronic venous insufficiency in all the patients in the remote postoperational period. Conclusion. The application of femoral vein for aortoiliac bypass is safe from the point of view of venous morbidity. Outflow disturbances were transient in all the cases and no additional treatment was needed.

Initial Experience in the Treatment of Extensive Iliac Artery Aneurysms With the Nellix Aneurysm Sealing System

Purpose: To assess the feasibility and effectiveness of the Nellix prosthesis in the treatment of common iliac artery aneurysms. Methods: Between May 2013 and June 2015, 230 patients underwent implantation of the Nellix device at 2 institutions. Fifty of these patients (mean age 76 years; 35 men) were identified as having 60 common iliac artery aneurysms (CIAAs) with a median diameter of 4 cm (range 3.5–7). The majority of patients had aortoiliac aneurysms (5, 70%), 10 (20%) had isolated CIAAs, and 5 (10%) had iliac anastomotic aneurysms after aortoiliac bypass. In 20 patients, the iliac aneurysm was the indication for the intervention; in the other 30 patients, the endovascular iliac repair was an adjunct procedure to endovascular aneurysm sealing (EVAS). An iliac branch device (IBD) was used when feasible to preserve flow to the internal iliac artery. Results: Seventeen (34%) patients underwent elective implantation of the Nellix graft in combination with an IBD, 33 (66%) patients underwent Nellix sealing of the CIAA using 1 (n=5), 2 (n=22), or 3 Nellix grafts (2 bilateral grafts and 1 graft as an extension to the external iliac artery in 6 patients). The technical success rate was 100%, and no graft-related complications were reported postoperatively. No buttock claudication, reinterventions, graft thrombosis, or endoleaks were observed during a mean follow-up of 12 months. Conclusion: Our initial experience demonstrates that Nellix grafts are feasible and safe for the treatment of extensive iliac artery aneurysms. The long-term durability of these grafts should be validated in larger patient cohorts before this promising alternative endovascular technique can gain widespread acceptance.

Male Sex Associated with Increased Long-term Cardiovascular Mortality after Peripheral Vascular Surgery for Atherosclerosis Despite Optimal Medical Treatment

The cardiovascular burden and consequences of peripheral atherosclerosis appear to differ between men and women. Data regarding long-term outcomes, including the impact of medical prophylactic treatment, are insufficient. This study examined long-term outcomes according to sex following primary vascular surgery, adjusted for multiple variables as well as recommended medical prophylaxis. All Danish patients who underwent peripheral vascular surgery from January 2000 to December 2007 were stratified into five procedural groups: (a) aorto-iliac bypass or thromboendarterectomy, (b) femoro-femoral crossover, (c) thromboendarterectomy of the femoral arteries, (d) infrainguinal bypass, or (e) axillo- uni-, and bifemoral bypass. Data were analyzed according to sex for differences in myocardial infarction, stroke, and death, individually and combined, after surgery. A total of 11,234 patients were included: 6,289 males and 4,945 females. The overall adjusted hazard ratio for male patients compared with female patients for death was 1.11 (95% CI 1.06-1.17), for MI was 1.16 (95% CI 1.04-1.29), for stroke was 0.99 (95% CI 0.89-1.11), and for any major adverse cardiovascular event was 1.10 (95% CI 1.05-1.16). These findings show that, despite indication, severity, and concomitant medical treatment of peripheral artery disease, men have a higher risk of mortality and adverse cardiovascular events following surgery for peripheral arterial disease.