Femoral Artery Bypass Research Articles

A Patient with the LEAD-Complicated Mid-Aortic Syndrome with Bilateral External Iliac Artery Hypoplasia Underwent Bilateral Common Iliac-Common Femoral Artery Bypass Surgery

A Patient with the LEAD-Complicated Mid-Aortic Syndrome with Bilateral External Iliac Artery Hypoplasia Underwent Bilateral Common Iliac-Common Femoral Artery Bypass Surgery

Investigation of center-specific saphenous vein utilization rates in femoral popliteal artery bypass and associated impact of conduit on outcomes

Investigation of center-specific saphenous vein utilization rates in femoral popliteal artery bypass and associated impact of conduit on outcomes

The Outcome of Sac Filling With Fibrin Sealant and Gentamicin After Endovascular Aortic Repair of Brucella-Related Aorto-Iliac Artery Aneurysms: A Retrospective Single-Center Study.

This study aimed to analyze the experience of our center and assess the efficacy of sac filling with fibrin sealant (FS) and gentamicin after endovascular aortic repair (EVAR) in patients with Brucella-related aorto-iliac artery aneurysms. All patients who received sac filling with FS and gentamicin after EVAR for Brucella-related aorto-iliac artery aneurysms between March 2019 and September 2022 were reviewed. Before and after sac filling with FS and gentamicin, aneurysm sac thrombosis and endoleak were evaluated using a preloaded catheter to monitor immediate repair outcome. Short- to mid-term outcomes were assessed by the incidence of vascular graft infection (VGI), all-cause mortality, maximum aneurysm diameter, aneurysm sac thrombosis, and other adverse events. There were 14 patients with Brucella-related aorto-iliac artery aneurysms who underwent sac filling with FS and gentamicin after EVAR. Perioperative death due to myocardial infarction in 1 patient resulted in a postoperative all-cause mortality rate of 7.1% (1/14). All patients received anti-Brucella drugs for a median of 6.0 (range: 3-12) months postoperatively. During a median follow-up period of 15.0 (range 0.5-36) months, the absolute and sagittal maximum diameters of the aorto-iliac aneurysm sac were significantly smaller than preoperation (from 46.3 ± 17.0 to 27.2 ± 16.3 mm, P<.001, and from 39.2 ± 13.1 to 24.0 ± 13.8 mm, P<.001). Two of these patients had a postoperative disappearance of the pseudoaneurysm. One patient was reintervened for bilateral femoral artery bypass surgery. Except for sac filling with gentamicin, all patients received anti-brucella medication for a median of 6.0 (range: 3-12) months. There were no allergic reactions, nephrotoxicity, endoleak, recurrence, VGI, aorta-related or infection-related deaths during the perioperative period and follow-up. Sac filling with FS and gentamicin adjunctive to EVAR, with targeted drug delivery to the sites of Brucella-related aorto-iliac artery aneurysm infection lesions, may be an effective solution to control pseudoaneurysm infection and rupture. Previous Brucella-associated aorto-iliac artery aneurysms have been limited to case reports. This study significantly increased the number of Brucella-associated aorto-iliac aneurysms by 19.7% (14/71) and extended the follow-up to 3 years. In this retrospective study of 14 patients with Brucella-associated aorto-iliac aneurysms treated endovascularly with fibrin sealant and gentamicin for sac filling and targeted administration to infection-related aneurysms, there were no aneurysm-related deaths or infection-related complications and may be an effective solution for controlling aneurysm infection and rupture. And, this approach is an attractive treatment for moving away from long-term dependence on antibiotics but still needs further evaluation.

Clinical analysis of surgical treatment of infection after interventional operation for major iliac artery disease in 6 cases

Objective: To explore the surgical treatment strategy of stent graft infection after interventional treatment of major iliac artery related diseases. Methods: Retrospective analysis was performed on the clinical data of 6 patients with secondary stent graft infection after interventional treatment for major iliac artery related diseases admitted to the Department of Vascular Surgery,Affiliated Drum Tower Hospital,Medical School of Nanjing University from November 2021 to August 2022.There were 5 males and 1 female,with a mean age of 64 years (range:49 to 79 years).The infection time was 53 to 3 165 days.All the 6 patients received surgical treatment,including 3 patients who underwent anatomic bypass grafting (axillary arterial-femoral artery bypass,femoral arterial-femoral artery bypass) using artificial vessels,and 3 patients who underwent in situ abdominal aorta reconstruction using bovine pericardium.The perioperative situation,postoperative infection and the occurrence of serious adverse events were recorded,and the safety of different treatment methods and materials was evaluated. Results: All patients successfully completed the operation and no death occurred during hospitalization.Intraoperative blood loss was 2 000~5 000 ml,and intraoperative blood transfusion was 1 600 to 5 350 ml.All the patients were followed up for 81 to 395 days after surgery,and the incision healed well,and no reinfection occurred.Postoperative gastrointestinal bleeding occurred in 1 patient,secondary surgery (retroperitoneal hematoma removal) was performed in 1 patient due to postoperative bleeding at the vascular anastomosis,both lower limb amputations were performed in 1 patient due to postoperative lower limb ischemia,and intermittent claudication occurred in 2 patients.All patients were alive at the last follow-up. Conclusion: For patients with aortic stent graft infection,when the infection is not serious and there is enough space to block the proximal and distal aorta,in situ aortic reconstruction is an effective treatment,and different materials can achieve satisfactory results in a short period of time.

Investigation of center-specific saphenous vein utilization rates in femoral popliteal artery bypass and associated impact of conduit on outcomes

ObjectiveThe purpose of this study is to investigate variation in great saphenous vein (GSV) use among the various centers participating in the Vascular Quality Initiative infrainguinal bypass modules. Further, differences in outcomes in femoral-popliteal artery bypass with single segment GSV conduit vs prosthetic conduit will be documented. Center GSV use rate impact on outcomes will be investigated. MethodsPrimary exclusions were patients undergoing redo bypass, urgent or emergent bypass, and those in whom prosthetic graft was used while having undergone prior coronary artery bypass grafting. The distribution of GSV use across the 260 centers participating in Vascular Quality Initiative infrainguinal bypass module was placed into histogram and variance in mean GSV use evaluated with analysis of variance analysis. Centers that used GSV in >50% of bypasses were categorized as high use centers and centers that used the GSV in <30% of cases were categorized as low use centers. Baseline differences in patient characteristics and comorbidities in those undergoing bypass with GSV vs prosthetic conduit were analyzed with χ2 testing and the Student t test, as were those undergoing treatment in high vs low use centers. Multivariable time-dependent Cox regression analyses were then performed for the primary outcomes of major amputation ipsilateral to the operative side and mortality in long-term follow-up. High vs low use center was a dichotomous variable in these regressions. Secondary outcomes of freedom from graft infection and freedom from loss of primary patency were performed with Kaplan-Meier analysis. ResultsAmong centers with >50 patients meeting inclusion criteria for this study, GSV use ranged from 15% to 93% (analysis of variance P < .001). When considering all centers irrespective of number of patients, the range was 0% to 100%. On Kaplan-Meier analysis, GSV conduit use was associated with improved freedom from loss of primary or primary assisted patency, improved freedom from major amputation after index hospitalization, improved freedom from graft infection after the index hospitalization, and improved freedom from mortality in long-term follow-up (log-rank P < .001 for all four outcomes). Both low use center (hazard ratio, 1.35; P < .001) and prosthetic graft use (hazard ratio, 1.24; P < .001) achieved multivariable significance as risks for mortality in long-term follow-up. Other variables with a multivariable mortality association are presented in the manuscript. Low use center and prosthetic bypass were significant univariable but not multivariable risks for major amputation after index hospitalization. ConclusionsThere is remarkably wide variation in GSV use for femoral popliteal artery bypass among various medical centers. GSV use is associated with enhanced long-term survival as well as freedom from loss of bypass patency and graft infection. The data herein indicate institutional patterns of prosthetic conduit choice, which has the potential to be altered to enhance outcomes.

80-Year-Old Man With Vision Loss

An 80-year-old man presented to the emergency department with a 1-week history of progressive, transient, monocular vision loss, binocular diplopia, transient headache, and lightheadedness. Clinical comorbidities included obesity, hypertension, hyperlipidemia, former tobacco smoking, and femoral popliteal artery bypass surgery. He also had bilateral cataract surgery the month before presentation, which occurred without complications. Upon presentation, the patient’s medications included aspirin 325 mg daily (prescribed after bypass surgery), hydrochlorothiazide 25 mg daily, lansoprazole 15 mg daily, losartan 25 mg twice daily, metoprolol tartrate 100 mg twice daily, and simvastatin 80 mg daily. CORRECT ANSWERS: 1. b. 2. d. 3. a. 4. d. 5. e.

Right axillopopliteal artery bypass using a combined transiliac and lateral popliteal approach for groin infection and lymph fistula.

Wound infection in the groin is a serious complication after vascular bypass surgery. The combined treatment of critical limb ischemia and recurrent infection presents challenges for vascular surgery(1Lounes Y. Ozdemir B. Alric P. Canaud L. Trans-iliac Bypass for Critical Limb Ischaemia with Groin Necrosis: A Case Report.EJVES Short Reports. 2019; 42: 31-33https://doi.org/10.1016/j.ejvssr.2019.01.002Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 2Multon S. Jayet J. Javerliat I. Coscas R. Coggia M. Aortic–tibial transiliac wing extra-anatomic bypass with distal fistula for treatment of an infected deep femoral pseudoaneurysm.J Vasc Surg Cases, Innov Tech. 2022; 8: 201https://doi.org/10.1016/j.jvscit.2022.02.008Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 3Engin C, Posacioglu H, Ayik F, Apaydin A . Management of vascular infection in the groin. Texas Hear Inst J (2005) 32:529–534.Google Scholar). In this case, we successfully managed the wound infection in the groin after axillofemoral artery bypass grafting, using a combination of trans-iliac bypass and lateral popliteal approach(4Enzmann F.K. Nierlich P. Eder S. Aspalter M. Dabernig W. Aschacher T. et al.Trans-Iliac Bypass Grafting for Vascular Groin Complications.Eur J Vasc Endovasc Surg. 2019; 58: 930-935https://doi.org/10.1016/j.ejvs.2018.11.003Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 5Benzing C. Fellmer P. Lateral Approach to the Distal Femoral Artery in Femoro-Anterior-Tibial Bypass Surgery.Eur J Vasc Endovasc Surg. 2016; 52: 267https://doi.org/10.1016/j.ejvs.2016.04.024Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar). A 74-year-old man, having Buerger's disease and arteriosclerosis obliterans, presented with extensive lymphatic fistula and necrosis of the groin (Fig.1) after right axillary artery to the right deep femoral artery bypass, which had been patented for last five years after the several revascularizations of iliac arteries and femoral arteries. Due to the several open surgeries, such as aorto-right external iliac artery bypass, aorto-left popliteal artery bypass, cholecystectomy and resection of gastric cancer, we chose right axillopopliteal artery bypass grafting, through the iliac wing. The skin incision was made along the iliac crest and the external oblique muscle fascia was separated to reach the pelvis, and a longitudinal incision was made anterosuperior to the greater trochanter to create a gluteal pathway to bypass the infected groin. 10-mm hole was made by shaving the bone about 4 cm from the iliac crest, and the graft was passed through the hole. (Fig 2). A lateral popliteal approach was selected for revascularization owing to extensive groin and medial thigh infective wounds. After that the extensive lymphatic fistula and necrosis were controlled with using negative pressure wound therapy.Figure 2View Large Image Figure ViewerDownload Hi-res image Download (PPT) The postoperative course was uneventful, and contrast-enhanced computed tomography confirmed proper arrangement of the graft, without bending (Fig 3 and Fig 4). He was discharged from the hospital on the 14th postoperative day. The computed tomography which was taken one year later showed the patency of this graft. The combination of trans - iliac bypass and lateral popliteal approach was shown to be effective in this case of extensive groin and medial compartment infection, and can potentially be applied in similar future cases.Figure 4View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Open Surgical Insertion of TandemHeart Device for Left Ventricular Unloading.

TandemHeart (Cardiac Assist Inc., Pittsburgh, PA) is a valuable mechanical circulatory support (MCS) device that provides left atrial to femoral artery bypass and directly unloads the left ventricle. The device is inserted under fluoroscopic guidance in the cardiac catheterization laboratory without requiring invasive surgical exposure. However, this device is unique because it directly unloads the oxygenated blood from the left atrium and may be needed for postoperative support in patients undergoing various open cardiac surgeries. In this article, we provide a detailed description of the open surgical insertion of a TandemHeart device.

External Iliac–Superficial Femoral Artery Bypass Surgery for Intractable Common Femoral Artery Infection

External Iliac–Superficial Femoral Artery Bypass Surgery for Intractable Common Femoral Artery Infection

Single-Center Experience of Treating Chronic Limb-Threatening Ischemia of Lower Limbs Combined with Diabetes

To summarize our hospital's single-center experience of and reflections on the treatment of chronic limb-threatening ischemia (CLTI) of lower limbs combined with diabetes in the past 5 years. We retrospectively analyzed cases of lower limb CLTI combined with diabetes diagnosed at our hospital from March 2017 to June 2021. The baseline data, surgical information, and follow-up results of the patients were collected. The primary outcome indicator was the patency rate of lower limb target artery within 1 year post-op, and the secondary indicators were the reoperation rate within 1 year post-op and the amputation rate within 1 year post-op. A total of 89 patients with lower limb CLTI combined with diabetes were included in the study. A total of 85 patients underwent percutaneous transluminal angioplasty and the operation of 7 patients ended in failure, with the operation success rate reaching 91.76% (78/85). Three patients underwent femoral popliteal artery bypass grafting with artificial blood vessels and one patient underwent iliac femoral artery bypass grafting with artificial blood vessels, with the success rate of the operations reachign 100% (4/4). Among 78 patients who successfully underwent percutaneous transluminal angioplasty, the median follow-up time was 33 months (13, 64). Two patients died within one year after operation, with the post-op one-year survival rate being 97.44% (76/78). The post-op 1-year reoperation rate was 19.23% (15/78), the 1-year target vascular patency rate (deaths not included) was 85.53% (65/76), and the 1-year amputation rate was 3.85% (3/78). Among the patients who underwent bypass surgery, the follow-up period was 13-48 months. No thrombosis in or re-occlusion of the artificial blood vessels were observed during the follow-up period, and the artificial blood vessels remained unoccluded. Transluminal angioplasty has a relatively ideal rate of postoperative vascular patency. In addition, it is a minimally invasive procedure involving low perioperative risks and is performed under local anesthesia. Therefore, it can be used as the preferred treatment for patients with CLTI. On the other hand, bypass surgery has good long-term patency rate, but it involves higher perioperative risks and the procedure is more invasive. Therefore, bypass surgery can be used as an alternative when transluminal angioplasty ends in failure.

Prevention of Spinal Cord Injury during Thoracoabdominal Aortic Aneurysms Repair: What the Anaesthesiologist Should Know.

Thoraco-abdominal aortic repair is a high-risk surgery for both mortality and morbidity. A major complication is paraplegia-paralysis due to spinal cord injury. Modern thoracic and abdominal aortic aneurysm repair techniques involve multiple strategies to reduce the risk of spinal cord ischemia during and after surgery. These include both surgical and anaesthesiologic approaches to optimize spinal cord perfusion by staging the procedure, guaranteeing perfusion of the distal aorta through various techniques (left atrium–left femoral artery by-pass) by pharmacological and monitoring interventions or by maximizing oxygen delivery and inducing spinal cord hypothermia. Lumbar CSF drainage alone or in combination with other techniques remains one of the most used and effective strategies. This narrative review overviews the current techniques to prevent or avoid spinal cord injury during thoracoabdominal aortic aneurysms repair.

Experience of Patient-Specific CFD Simulation of Blood Flow in Proximal Anastomosis for Femoral-Popliteal Bypass

Femoral artery bypass surgery needs postoperative monitoring due to the high complication risks after bypass. Numerical simulation is an effective tool to help solve this task. This work presents the experience of patient-specific CFD simulation of blood flow in proximal anastomosis for femoral-popliteal bypass, including patient follow-up after bypass surgery. Six cases of proximal anastomosis of femoral-popliteal bypass 3–30 months after surgery were studied. A repeated study was performed for four patients to monitor geometric and hemodynamic changes. The blood flow structure variety in proximal anastomoses and the blood flow dynamics during the cardiac cycle are described in detail using CFD simulation. Special attention is paid to time-average wall shear stresses (TAWSS) and oscillatory shear index (OSI) distributions. Low and oscillatory wall shear stresses were registered in the graft downstream from the suture, especially in case of low inlet flow. It was shown that the postoperative geometry changes led to significant hemodynamic changes; thereby, neointima has grown in areas with initially low and oscillatory wall shear stresses.

Light-Activated Vascular Anastomosis.

Background. There have been few advances in technique since vascular anastomosis was performed with silk suture on a curved needle in 1902. This technique results in disruption of the endothelium with exposed intraluminal suture, both of which may lead to thrombocyte aggregation, intimal hyperplasia, and vascular stenosis. A variety of alternative techniques have been explored, with limited success. Photochemical tissue bonding (PTB) is a light-activated methodology of rapidly cross-linking tissue interfaces at the molecular level. Herein, we describe a new technique for anastomosis of venous interposition graft in an ovine model of femoral artery bypass utilizing PTB. Methods. Polypay specific pathogen free sheep (n = 5; 40-45kg) underwent femoral artery bypass utilizing saphenous vein. The femoral artery was transected and reversed saphenous vein was implanted as an interposition graft. The proximal anastomosis was created as a vein-over-artery cuff utilizing PTB, and the distal anastomosis was created with standard interrupted 8-0 polypropylene suture. Four weeks post-index operation, femoral angiogram was performed to evaluate patency, tortuosity, and luminal diameter. All bypass grafts were harvested and longitudinal and transverse histological sections from the proximal anastomosis were analyzed. Results. The PTB anastomoses (n = 5) were immediately watertight and patent. All animals survived the 28-day study duration. Angiography revealed patent grafts with no aneurysm or stenosis (n = 5). Histologic examination revealed integration of the venous endothelium with the arterial adventitia. Conclusion. Photochemical tissue bonding creates an immediate strong, watertight vascular anastomosis that can withstand physiologic arterial pressure and remains patent at 28days without the need for intraluminal suture.

Modeling of Competitive Flow in Aortofemoral Bypass

Competitive flow places surgical bypasses at risk for thrombosis in certain vascular beds, such as coronary bypass. However, the anatomic configurations that may lead to flow stagnation in aortofemoral bypass remain poorly characterized. We aimed to model competitive flow and determine parameters placing bypass patency at risk. We created an aortofemoral bypass flow dynamics computer model using MATLAB software (MathWorks). Our standard model (Fig 1) included a native iliac artery of 8 mm diameter with patent superficial femoral artery (SFA, 6 mm) and profunda femoris artery (4 mm) outflow and bypass conduit (8 mm) positioned over the profunda femoris artery. Models included native iliac stenosis ranging from 0% to 100% across four time points throughout the arterial impulse cycle. Sensitivity analyses were performed for SFA and profunda femoris arterial occlusion as well as varying arterial and graft diameters. We created a total of 40 models. Fig 2 shows our base model with increasing severity of stenosis. As the severity of native iliac stenosis increases, the arterial impulse in the graft arrives more briskly. With little or no native iliac stenosis, the arterial impulse in the graft limb is delayed, but stagnation of flow does not occur as shown by the aqua coloration moving through the graft limb across time points. Sensitivity analyses demonstrated similar findings. No model demonstrated stagnation of flow portending high risk of bypass graft or native arterial thrombosis. Computer modeling did not demonstrate flow stagnation in aortofemoral bypass across a range of anatomic configurations. Our models suggest that competitive flow of a native iliac artery may not put the bypass graft at risk of flow stagnation and thrombosis.Fig 2Flow dynamics of aortofemoral bypass overlying the profunda femoris artery with increasing stenosis of the native iliac inflow artery across four time points of arterial impulse.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

How to Build OP-MEG: Specific Issues and Challenges

Symptomatic innominate artery stenosis presenting as hemodynamic bilateral cerebral ischemia is uncommon. We present a rare case of the severe stenosis of the origin of an innominate artery and severe stenosis of bilateral internal carotid artery that induced hemodynamic cerebral ischemia after ipsilateral axillary artery-bilateral femoral artery bypass and was treated with stent replacement of the innominate artery and right internal carotid artery.A 64-year-old woman who previously had undergone right axillary artery-bilateral femoral artery anastomosis for abdominal aorta high obstruction had been suffering from chronic dizziness and so visited our department. Findings of the examination included the severe stenosis of the origin of an innominate artery and severe stenosis of bilateral internal carotid artery, causing hemodynamic cerebral ischemia. She underwent stent replacement of the innominate artery and right carotid artery stenting via a right transbrachial approach. Her symptoms were relieved postoperatively.For the sake of improving the hemodynamic cerebral ischemia, we performed stent replacement for innominate artery stenosis and right carotid artery stenting. Endovascular treatment of subclavian and innominate artery disease is a safe procedure. In addition, for the protection of thromboembolic migration, we performed balloon protection of the external carotid artery and filter protection of the internal carotid artery.Stent replacement for these lesions can be performed safely with the right approach and protection methods, even when the only accessible route is the right brachial artery.

Rare cause of lower gastrointestinal bleeding: Iliac aneurysmo-colonic fistula after endovascular treatment.

A 59-year-old male visited our department for examination of positive fecal occult blood test. The patient was scheduled for colonoscopy. However, he was admitted to our hospital urgently for rupture of left internal iliac artery aneurysm (IIAA) (Fig. 1). IIAA was managed by coil embolization and stent graft. Two weeks after the discharge, the patient visited our department because of intermittent hematochezia. Colonoscopy revealed a submucosal tumor-like protrusion with a fistulous tract in the sigmoid colon (Fig. 2a). Computed tomography demonstrated an iliac aneurysm with thrombus and air bubbles, fistulizing to the sigmoid colon (Fig. 2b). The patient was treated by an iliac artery aneurysm resection, stent graft removal, right common femoral artery–left common femoral artery bypass, and colostomy. Although iliac aneurysmo-colonic fistula is a rare condition, it can cause acute and massive lower gastrointestinal bleeding. In addition to arterial intervention such as endovascular therapy, abdominal or pelvic surgery, pelvic malignancy, and infection are also known causes of fistula formation. For the secondary aneurysmo-colonic fistula that occurs after endovascular therapy, as in our case, surgical treatment is often selected instead of repeat endovascular treatment. Our case suggests that aneurysmo-colonic fistula should be considered as one of the differential diagnoses among acute lower gastrointestinal bleeding, in patients with a history of recent endovascular therapy in large vessels in proximity to the colon.

Use of a Percutaneous Ventricular Assist Device/Left Atrium to Femoral Artery Bypass System for Cardiogenic Shock.

The left atrial to femoral artery bypass (LAFAB) system is a mechanical circulatory support (MCS) device used in cardiogenic shock (CS) that bypasses the left ventricle by draining blood from the left atrium (LA) and returning it to the systemic arterial circulation via the femoral artery. It can provide flows ranging from 2.5-5 L/min depending on the size of the cannula. Here, we discuss the mechanism of action of LAFAB, available clinical data, indications for its use in cardiogenic shock, steps of implantation, post-procedural care, and complications associated with the use of this device and their management. We also provide a brief video of the procedural component of device therapy, including the pre-placement preparation, percutaneous placement of the device via transseptal puncture under echocardiographic guidance and the post-operative management of device parameters.

Use of a Percutaneous Ventricular Assist Device/Left Atrium to Femoral Artery Bypass System for Cardiogenic Shock

Use of a Percutaneous Ventricular Assist Device/Left Atrium to Femoral Artery Bypass System for Cardiogenic Shock

Descending thoracic aorta\u2013abdominal aortic bypass and bilateral renal arterial blood circulation reconstruction are effective in atypical coarctation of the aorta with heart failure: a case report

BackgroundThere are a lot of reports of the renal failure and heart failure due to coarctation of the aorta. However, there are no case reports in which revascularization dramatically improved left ventricular function in patients with progressive decline in left ventricular function. Herein, we present a rare case in which the left ventricular function was dramatically improved by surgical treatment for progressive left ventricular dysfunction due to atypical coarctation of the aorta.Case presentationA 58-year-old man underwent left axillary artery-bilateral femoral artery bypass at another hospital for atypical coarctation of the aorta due to Takayasu’s arteritis. Approximately 10 years later, he was re-hospitalized for heart failure, and the left ventricular ejection fraction gradually decreased to 28%. Computed tomography showed severe calcification and stenosis at the same site from the peripheral thoracic descending aorta to the lower abdominal aorta of the renal artery, and aortography showed delayed bilateral renal artery blood flow. An increase in plasma renin activity was also observed. Despite the administration of multiple antihypertensive drugs, blood pressure control was insufficient. We decided to perform surgical treatment to improve progressive cardiac dysfunction due to increased afterload and activated plasma renin activity. Descending thoracic aorta-abdominal aorta bypass and revascularization of the bilateral renal arteries via the great saphenous vein grafts were performed. Postoperative blood pressure control was improved, and the dose of antihypertensive drugs could be reduced. Plasma renin activity decreased, and transthoracic echocardiography 1.5 years later showed an improvement in contractility with a left ventricular ejection fraction of 58%.ConclusionIn atypical coarctation of the aorta in patients with decreased bilateral renal blood flow, heart failure due to renal hypertension, and progressive decrease in left ventricular contractility, descending thoracic aorta-abdominal aortic bypass and bilateral renal artery recirculation can be extremely effective.

A Case of Effective Balloon Fenestration for Localized Aortic Dissection Complicated with Acute Renal and Bilateral Limb Ischemia in a Thoracoabdominal Aortic Aneurysm.

An 85-year-old man visited our hospital with bilateral leg weakness. Blood tests revealed an abrupt deterioration of renal function. Computed tomography revealed a 53-mm aortic aneurysm at the level of the diaphragm with an aortic dissection after branching of the superior mesenteric artery. An emergency left axillary–left femoral artery bypass surgery was performed to secure blood flow to the kidneys and lower limbs. Five days later, a transcatheter balloon fenestration for the stenosis was performed, and the blood pressure of the infrarenal aorta was improved. Both the dorsal pedis and posterior tibial arteries became palpable, and renal function was improved.