Femoral-femoral Bypass Research Articles

Fluoropolymer-coated Dacron Versus PTFE Grafts for Femorofemoral Crossover Bypass: Randomised Trial

To investigate whether patency of a thin walled 8 mm fluoropassivated Dacron graft was similar to that of a standard 8mm PTFE graft for femorofemoral crossover bypass surgery. A randomised multicentre clinical trial comparing two vascular grafts with participation of 10 departments of vascular surgery in Denmark, Sweden and Norway. 198 patients were randomised to PTFE (n=107) or fluoropolymer-coated Dacron grafts (n=91), 63% underwent surgery for claudication, 27% for ischaemic rest pain and 10% for tissue loss. The median follow-up time was 24 months (IQR 19-26 months). The primary patency rate of the two grafts was similar (log rank test: p=0.35). The primary patency rates (95% CI) for coated Dacron and PTFE grafts were 92% (86-98) and 94% (89-99) at 12 months and 87% (74-95) and 93% (87-99) at 24 months, respectively. In patients with unilateral iliac artery disease not amenable to angioplasty, the femoral-femoral bypass is durable and effective. No difference in patency was found between the two graft materials (fluoropolymer coated Dacron and PTFE).

Adjunctive primary stenting of Zenith endograft limbs during endovascular abdominal aortic aneurysm repair: Implications for limb patency

Endograft limb occlusion is an infrequent but serious complication of endovascular abdominal aortic aneurysm (AAA) repair. The insertion of additional stents within the endograft limb may prevent future occlusion. This study evaluates limb patency with and without adjunctive stenting of endograft limbs at the time of endovascular AAA repair. We performed a retrospective review of 248 patients who underwent endovascular abdominal aortic aneurysm repair with the Zenith AAA endovascular graft between 1999 and 2004. Among these patients, two groups were identified: 64 patients with adjunctive stents placed in 85 limbs and 184 patients without additional bare stent placement in endograft limbs at the time of endovascular AAA repair. Women comprised 23% of stented and 11% of unstented patients (P = .02). The mean length of follow-up in the stented and unstented groups was 2.0 years. There were 13 instances of limb thrombosis in 13 patients (5.2% of patients, 2.7% of limbs), all in the unstented group. No limb occlusions occurred in the presence of adjunctive bare metal stents. Seventy-three percent of the occlusions occurred < or = 6 months of endovascular AAA repair. Two patients (15%) had no symptoms of lower-extremity ischemia despite graft limb occlusion and did not undergo intervention. The others underwent thrombectomy (n = 2), thrombectomy with bare stent placement (n = 3), femoral-femoral bypass (n = 4), thrombolysis (n = 1), and thrombolysis with bare stent placement (n = 1). Of the seven who underwent thrombectomy or thrombolysis, three had no additional stents placed at the secondary procedure, and two of these three went on to rethrombose. By life-table analysis, primary patency at 3 years in the stented and nonstented limbs was 100% +/- 0% and 94% +/- 3%, respectively (P = .05). The intraoperative insertion of additional bare metal stents appeared to eliminate the risk of thrombosis and was without complication. Of the 85 stented limbs in this series, not one occluded. The overall rate of limb thrombosis was low, with most limb occlusions occurring < or = 6 months of stent-graft insertion, and would probably have been even lower had we been able to identify all high-risk cases for prophylactic adjunctive stenting. Limb occlusion denotes an underlying problem with the graft, which if left untreated after thrombectomy or thrombolysis will lead to rethrombosis. Postoperative imaging was of little value in detecting impending limb occlusion. Based on these findings, we believe one should identify and stent any limbs that appear to be at risk for thrombosis, but this study lacks the data to predict which limbs need stenting.

Returning reservoir blood to right atrium during extracorporeal circulation for descending aortic surgery

We report our techniques on conducting a closed-circuit femoral-femoral bypass during descending aortic surgery by which collected blood can be easily returned into the right atrium. The main circuit was composed of a centrifugal pump, an artificial membrane lung, and a filter. A reservoir with a roller pump was connected to the main circuit via a filter. Extracorporeal circulation was established by right atrial drainage via the femoral vein and femoral arterial return. On aortic cross-clamping, systemic blood pressure was controlled by activating the roller pump in reverse rotation and shifting the body blood into the reservoir temporarily. For a small amount of bleeding after aortotomy, the reservoir blood was returned via the femoral artery by activating the roller pump in normal rotation. When a large amount of bleeding was present making the systemic blood pressure fall, the main circuit was clamped just distal to the centrifugal pump and reservoir blood was directly returned to the right atrium to maintain systemic pressure. Confirming that bleeding was reduced, the clamp distal to the centrifugal pump was gradually released and blood was delivered to both the right atrium and the femoral artery. We believe that our system is a highly beneficial modality.

Initial experience with the AneuRx Stent Graft for the treatment of infrarenal abdominal aortic aneurysm.

We report our initial experience with the modular AneuRx Stent Graft System for the treatment of infrarenal abdominal aortic aneurysm (AAA) in National Taiwan University Hospital. From July 2002 to October 2003, 5 patients were recruited for stent graft repair. Patients were all male, and aged from 62 to 82 years. The stent grafts were deployed via the opened femoral arteries under fluoroscopic guidance. Endograft deployment was successful in all 5 patients. The average procedure time was 139 +/- 23 min, and mean blood loss was 310 +/- 167 mL. All patients had a smooth postoperative course. Type II endoleak was noted in 3 patients initially, which sealed spontaneously in 2 of them. One patient developed graft limb thrombosis 1 month after operation, which was treated by femoral-femoral bypass. Treatment was successful in all patients with no mortality during 1-year postoperative follow-up.

Endovascular Management of Ruptured, Mycotic Abdominal Aortic Aneurysm

Patients with mycotic aneurysms have a high mortality rate. The standard surgical approach can be exceptionally difficult and fraught with complications. There has been reluctance to insert an endograft into an infected field. We believe that this thought should be challenged and present a case of a successful endovascular repair of a ruptured, mycotic abdominal aortic aneurysm. The patient is a 63-year-old man with severe medical comorbidities and methicillin-sensitive Staphylococcus aureus. He required 6 units of red blood cells on admission. Magnetic resonance angiography (MRA) showed a contained rupture of his distal abdominal aorta, and he underwent emergent endovascular repair. An aortomono-iliac device (12 mm x 10 cm iliac extension limb) was inserted along with coil embolization of his right common iliac artery and a femoral-femoral bypass. He did not require additional transfusions after the procedure and was discharged in good condition. He is on antibiotics and doing well 1 year post-op. Endovascular management of ruptured, mycotic aneurysms is feasible. In fact, it is an attractive approach for a medically compromised patient subset that would carry an exceptionally high mortality rate with traditional surgical repair. Further follow-up is necessary to determine its long-term efficacy.

Initial management and outcome of aortic endograft limb occlusion

The purpose of this study was to determine the differences in outcome related to initial management of aortic endograft limb occlusion (ELO). During a 7-year period, 823 endovascular aneurysm repairs (EVARs) resulted in 25 ELOs in 22 patients. The initial management and outcome of these ELOs were reviewed. Median follow-up after ELO was 24.2 +/- 16.8 months. Initial EVARs included both unsupported unibody (n = 5) and supported modular (n = 17) devices. ELO was significantly more common in the unsupported unibody graft design (P <.024) and with extension of the graft limb to the external iliac artery (P <.001). ELO was managed with an endovascular approach (EVA), including some combination of mechanical thrombectomy (n = 8), angioplasty with or without stenting (n = 8), and thrombolysis (n = 2) in 12 patients and bypass procedures (femoral-femoral bypass, n = 11; axillofemoral bypass, n = 1; and aortofemoral bypass, n = 1) in 13. At 12-month follow-up, freedom from secondary procedures with EVA was 80.2 +/- 17.7% versus 53.2 +/-17.1% with extra-anatomic bypass (EB) (P = NS). Secondary patency was 100% with EVA and 80.6 +/- 14.4% with EB (P = NS). Of the 12 EVAs, there was 1 (8.3%) perioperative mortality with EVA and none with EB. EB failure was directly attributed to donor limb occlusion in 4 of 6 EVAs (67%), and when this occurred it resulted in bilateral lower extremity ischemia. Amputation was required in 2 of 12 (16.7%) EBs versus none of the 12 EVAs (P = NS). EVA never resulted in graft dislodgement or endoleak but did identify an underlying treatable cause in 8 of 12 (67%). Both EVA and EB are acceptable management strategies for ELO. The potential risk of graft dislodgement was not observed with an EVA. If EB is employed, assessment of the donor limb and treatment of any underlying lesions is advisable in an attempt to minimize future donor limb occlusion.

Acute Aortic Dissection Presenting as Rupture of the Femoral Artery

A 44-year-old male with Marfan's disease presented acutely with severe chest and left groin pain. A pulsatile mass was present in the left groin and the left leg was pale and pulseless. CT imaging demonstrated the presence of a distal thoracic aortic dissection (AD) involving the left iliofemoral segment with extravasation of contrast into the left groin. The patient was treated with an urgent femoral-femoral bypass, which repaired the femoral artery and restored perfusion to the left lower extremity. Whereas rupture of the aorta into the chest or pericardium is common, femoral artery rupture complicating AD has not been previously reported. This case illustrates the need for peripheral branch intervention when compromised by the dissection process including isolated iliofemoral segments, which are typically benign. Given frank femoral artery rupture, urgent surgical repair was required and resulted in a satisfactory outcome.

Secondary procedures after endovascular aortic aneurysm repair.

The purpose of this study was to evaluate the incidence, distribution, and indications of secondary procedures after endovascular aortic aneurysm repair (EAR). At a single institution, 179 patients underwent EAR with four different endografts (AneuRx, n = 117; Zenith, n = 49; Ancure, n = 12; and Talent, n = 1). The vascular section database was queried for patients who needed secondary procedures after the original EAR. The mean time from EAR to the termination of the study was 27.0 +/- 16.7 months. Type I or III endoleaks were treated aggressively. Type II endoleaks were treated only in the presence of aneurysm expansion. Thirty-five (35/179; 19.6%) secondary procedures were performed in 32 patients. Indications for secondary procedures included 14 limb occlusions or stenoses (40.0%), 13 endoleaks (37.1%), six endograft migrations (17.1%), one delayed aneurysm rupture (2.8%), and one device malfunction (2.8%). Seven of the 10 early (<90 days) limb failures (70%) occurred within the first 60 patients. At that time, a protocol with aggressive external iliac artery evaluation was adopted. In the next 125 patients, the rate of early limb occlusion or stenosis was 2.4% (P =.025, with Fisher exact test). Distribution of secondary procedures included 23 endoluminal interventions (65.7%; angioplasty +/- stent placement, thrombolysis, endocuff placement, embolization), eight traditional peripheral procedures (22.9%; femoral-femoral bypass, thrombectomy), two laparoscopic interventions (5.7%; inferior mesenteric artery ligation), and two laparotomies (5.7%; delayed conversions). Interventions for limb occlusion or stenosis occurred earliest (3.5 +/- 5.4 months; P <.05, with analysis of variance), followed by treatment of endoleaks (14.3 +/- 12.9 months) and migration (27.5 +/- 10.4 months). The one delayed rupture occurred at 15.3 months. Secondary procedures after EAR are common. Reinterventions can be grouped temporally on the basis of indication. Treatment for limb ischemia is predominately early (>/=3 months), whereas treatment for endoleaks occurs at approximately 1 year and interventions for migration predominate after 2 years.

Occlusion of an intraluminal endovascular stent graft after treatment of a ureteral-iliac artery fistula

Ureteral-arterial fistulas are rare causes of intermittent and often massive hematuria. We report the case of a patient presenting with massive hematuria and shock caused by a ureteral-iliac fistula initially treated with a covered endovascular stent graft. Eight months after deployment, the stent occluded, and the patient required a femoral-femoral bypass. This is the first known case of endovascular stent graft occlusion when used for this purpose.

Predicting iliac limb occlusions after bifurcated aortic stent grafting: Anatomic and device-related causes

Graft limb occlusion may complicate endovascular abdominal aortic aneurysm repair. The precise etiologic factors that contribute to the development of these graft limb thromboses have not been defined. We evaluated our experience with bifurcated aortic endografts to determine factors that may predict subsequent limb thrombosis. The management of the thrombosed limbs and the results after treatment were also investigated. During a 4-year period, 351 patients with aortic aneurysms underwent treatment with bifurcated endografts (702 graft limbs at risk). These 351 bifurcated devices included AneuRx (Medtronic, Minneapolis, Minn; n = 35), Ancure (Guidant, Menlo Park, Calif; n = 8), Gore (W.L. Gore & Associates, Sunnyvale, Calif; n = 25), Talent (World Medical, Sunrise, Fla; n = 255), Teramed (Teramed, Minneapolis, Minn; n = 10), and Vanguard (Boston Scientific Vascular, Natick, Mass; n = 18). Details regarding the type of device, mechanism of deployment, and aortoiliac artery anatomy were collected prospectively and analyzed. Graft limbs were analyzed for diameter, use of additional endograft iliac extensions, deployment in the external iliac artery, and endograft to vessel oversizing. Follow-up included physical examination, duplex ultrasonography, and spiral computed tomographic scans at 1 month, 6 months, and 12 months and annually thereafter. The follow-up period ranged from 2 to 54 months, with a mean follow-up period of 20 months. Twenty-six of 702 limbs (3.7%) had an occlusion develop. The risk of limb thrombosis was associated with a smaller limb diameter. Mean graft limb diameter was 14 mm in the occluded population, and patent limbs had a mean diameter of 16 mm. Thrombosis occurred in 16 of 291 limbs (5.5%) that were 14 mm or less and in 10 of 411 limbs (2.4%) that were greater than 14 mm (P =.03). Extension of a graft to the external iliac artery was performed in 96 of the 702 limbs. Eight of these 96 limbs (8.3%) had thrombosis develop as compared with 18 of 606 (3.0%) that extended to the common iliac artery (P =.01). No significant association was present between limb thrombosis and the contralateral or ipsilateral side of a device, the configuration of the iliac graft limb end (closed web, open web, or bare spring), or the degree of iliac graft limb oversizing. AneuRx, Ancure, Vanguard, and Talent grafts each sustained limb occlusions, with no occlusions seen among the Gore and Teramed devices. No significant increased risk of graft limb thrombosis was observed in unsupported grafts (1/16; 6.3%) versus supported grafts (25/686; 3.6%; P = not significant). Thromboses occurred between 1 day and 23 months after surgery. Thirteen of the 26 thromboses (50%) occurred within 30 days of surgery. Presenting symptoms were mild to moderate claudication in eight patients (30.8%), severe claudication in 16 patient (61.5%), and paresthesia and rest pain in two patients (7.7%). Eighteen of 26 patients (69.2%) eventually needed intervention to reestablish flow to the occluded limb, including thrombolysis and stenting in two patients (7.7%), axillary femoral bypass in one patient (3.8%), femoral-femoral bypass in 13 patients (50.0%), and axillary-bifemoral bypass in two patients (7.7%). All patients with mild to moderate symptoms under observation had improvement in symptoms with no further interventions necessary. All revascularizations were successful in relieving symptoms. Graft limb occlusion is a recognized complication of endovascular treatment of abdominal aortic aneurysms that may be associated with smaller graft limb diameter and extension to the external iliac artery. Occlusions usually necessitate additional intervention for resolution of ischemic symptoms. The use of small diameter grafts should be avoided when possible to reduce the risk of graft limb occlusions.

Isolated Iliac Artery Aneurysmocolonic Fistula with Pericolic Abscess

We report the successful management of a 66-year-old man who had common iliac aneurysmosigmoid colon fistula. The initial presentation was abdominal pain, fever, and melena. Digital subtraction angiography showed no evidence of rupture. However, computed tomography scanning revealed fine gas formations in the common iliac artery aneurysm. To reduce the risk of graft infection and prolonged ischemia, we created an extraabdominal femoral-femoral bypass graft, closed the wounds, removed the aneurysm, and closed the colon primarily. The postoperative course and recovery were uneventful.

Limb interventions in patients undergoing treatment with an unsupported bifurcated aortic endograft system: A review of the Phase II EVT Trial

Introduction: Both supported and unsupported bifurcated endograft limbs develop flow-restricting lesions, including kinks, stenoses, and occlusions, which can be identified during or after surgery. Recognition and intervention are essential to achieve long-term graft patency and a satisfactory functional result. This report represents a comprehensive retrospective review of graft limb interventions from the Phase II EVT Trial with the Endovascular Grafting System unsupported bifurcated endograft (Guidant/EVT, Menlo Park, Calif). Methods: The study population consists of 242 patients who underwent treatment with bifurcated endografts implanted during the EVT Phase II Trial. Graft limb interventions have been divided into two groups: those in whom the intervention occurred during surgery versus those in whom the intervention occurred after surgery. Parameters studied included type, incidence, and timing of graft limb intervention, indications for intervention, procedures performed, and overall patient outcome. Results: The mean follow-up period was 31 months. Primary, primary assisted, and secondary limb patency rates were 61.6%, 93.7%, and 97.1%, respectively. Technical success rate at case completion was 97.5%. In 68 of the 242 cases, limb interventions were performed during surgery to assure patency (28.1%). In 28 cases, interventions were performed after surgery (11.6%). Of these postoperative limb problems, 82% occurred during the first 6 months. Repeat limb interventions were necessitated in three patients (1.2%). Within the intraoperative intervention group, perceived indications included kinks (15%), stenosis (57%), dissection (6%), graft redundancy (12%), and instances of twists, thrombosis, and pressure gradients (10%). These findings were successfully managed with percutaneous transluminal angioplasty only (41%), percutaneous transluminal angioplasty and stent (50%), and various combined interventions. Within the postoperative intervention group, symptomatic indications included stenosis (46%) and thrombosis/occlusion (54%). These postoperative limb events were successfully managed with stent (64%), thrombolysis (32%), and femoral-femoral bypass (21%). When limb dysfunction developed in the postoperative setting, it most often occurred within the first 6 months of implantation. Only one patient in this Phase II cohort had a lower extremity amputation unrelated to a graft limb abnormality. Conclusion: The unsupported bifurcated limbs of this endograft necessitated primary adjunctive intervention in 40% of cases. Primary intervention was two times more likely to be performed at the time of the implant rather than after surgery. Repeat limb interventions were not common. Endograft limb flow problems were successfully treated with standard endovascular or surgical interventions or both. These data may support prophylactic stenting of unsupported Ancure graft limbs. A strategy that includes both intraoperative and early postoperative graft limb surveillance is essential to detect reduced limb flow. (J Vasc Surg 2002;36:118-26.)

Intermittent Claudication.

Intermittent claudication is the most common symptom in patients with peripheral arterial disease (PAD). As such, it is mandatory for clinicians to treat both the PAD-specific symptoms (to decrease functional impairment and thereby improve quality- of-life, as well as to decrease rates of amputation) and the underlying systemic atherosclerosis (and thereby reduce cardiovascular ischemic events, especially myocardial infarction and stroke). Most patients with claudication can successfully decrease their exertional limb symptoms via a combination of exercise (preferably supervised) and pharmacotherapeutic interventions (eg, cilostazol). Endovascular revascularization currently serves as an effective therapy for patients with high-grade stenoses of the proximal limb arterial segments, (eg, the distal aorta, common iliac artery, or external iliac artery, and occasionally the proximal common femoral artery). Surgical revascularization usually is reserved for patients who present with severe aortoiliac disease in whom long-term patency is likely to be achieved (eg, aortobifemoral or femoral-femoral bypass) and who have a low cardiovascular perioperative ischemic risk. Patients who undergo successful revascularization also are likely to benefit from exercise rehabilitation programs. All patients with PAD, of any severity, must successfully normalize atherosclerosis risk factors and use antiplatelet therapies. Such interventions include complete smoking cessation, glycemic control, normalization of blood pressure (less than 130/90 mm Hg), and lowering of low-density lipoprotein (LDL) cholesterol to less than 100 mg/dL. Antiplatelet agents (eg, clopidogrel, aspirin) should be prescribed to decrease rates of cardiovascular ischemic events in all patients with PAD, unless otherwise contraindicated.

Cecal erosion by an aortobifemoral bypass graft

A 71-year-old man underwent an uneventful aorta bifemoral graft bypass surgery for an inflammatory aortic aneurysm. He was well for 3 years after which he was hospitalized on multiple occasions with episodes of bacteremia, caused by organisms compatible with an intra-abdominal source (Clostridium ramosum, Bacteroides, and Escherichia coli). He was treated with appropriate antibiotics with temporary relief. During the last admission the patient also had marked left lower abdominal pain and rectal bleeding associated with E coli and Staphylococcus aureus septicemia. It was therefore unclear whether the source of this septicemia was his aortic graft, diverticular disease, or other large bowel pathosis. An urgent colonoscopy revealed that the right limb of his aortobifemoral graft had eroded into his cecum (Figure, arrow). He underwent an urgent limited right hemicolectomy and femoral-femoral bypass graft, after which he made an uneventful recovery.

Matrix Metalloproteinase Inhibitor: Differential Effects on Pulmonary Neutrophil and Monocyte Sequestration Following Cardiopulmonary Bypass

Acute respiratory distress syndrome (ARDS) following cardiopulmonary bypass (CPB), also known as “post-pump” or “post-perfusion syndrome” (PPS), results from sequential priming and activation of neutrophils. We hypothesized that chemically modified tetracycline (CMT-3) an inhibitor of neutrophil matrix metalloproteinase (MMP) and elastase, would prevent PPS. We performed histometric analysis of lung tissue from our porcine PPS model to correlate cellular sequestration and histologic injury with CMT-3 treatment. Methods: Yorkshire pigs were randomized into five groups: Control (n=3); CPB (n=5); femoral-femoral bypass 1 hour; LPS (n=7), Escherichia coli lipopolysaccharide (1μg/kg); CPB+LPS (n=6); and CPB+LPS+CMT (n=5), sequential insults and CMT-3. Protocol histometric analysis defined cellular and tissue components of lung injury. Results: CMT-3 decreased neutrophil sequestration in the CPB+LPS+CMT-3 group (p&lt;0.0001 vs. CPB+LPS). There were no differences in monocytes between CPB+LPS and CPB+LPS+CMT treatment groups. Conclusions: CMT-3 attenuates neutrophil sequestration but has no effect on mononuclear sequestration in our PPS model. This finding supports current research on leukocyte chemokines and has important implications regarding mechanisms of CMT-3. Despite lack of monocyte response to CMT-3, PPS was prevented by inhibiting neutrophils alone; confirming the primary role of neutrophils in PPS.

Repair of right ventricular rupture complicating mediastinitis

A treatment strategy for rupture of right ventricle complicating mediastinitis is presented. We used two strips of anterior rectus sheath to buttress the ventricular closure during femoral-femoral bypass.

Fibromuscular dysplasia of the aorta presenting as multiple recurrent thoracic aneurysms

A 17-year-old boy, who had undergone resection of aortic coarctation with a large saccular aneurysm 10 years previously, developed recurrent aneurysms above and below the site of a Gore-Tex interposition graft. These were resected using femoral-femoral bypass, and the upper thoracic aorta was replaced with a Hemashield Dacron tube. Histology of the aorta showed fibromuscular dysplasia. In addition to aortic dissection and aortic rupture, such patients may be at risk of forming further aneurysms.

Abdominal aortic aneurysm repair using an aortoiliac stent-graft combined with femoral-femoral bypass

The purpose of this article is to describe the technique of endovascular repair of infrarenal abdominal aortic aneurysms (AAA) combined with surgical bypass. Eleven patients (eight men, three women; mean age, 64.6 years) underwent stent-graft repair of AAA using a nonbifurcated Z-stent covered with polyester or polytetrafluoroethylene (PTFE) fabric delivered through a 14F to 20F delivery catheter under fluoroscopic control. The stent-graft was used to bridge the infrarenal aorta and common iliac artery. After embolization of the contralateral common iliac artery using a self-expanding vascular occluder (SEVO), a femoral-femoral bypass was surgically created using a reinforced PTFE graft. Immediate and complete thrombosis of the aneurysm occurred in 7 of 11 patients (74%) after stent-graft, SEVO placement, and surgical bypass. Four patients required secondary interventions to repair endoleaks at the proximal anastomosis (n = 2) or leaks at the site of SEVO deployment (n = 3). One patient required only a nontapered aortic stent-graft and did not require a femoral-femoral bypass. After all endovascular procedures, no patients had back-bleeding into the aneurysm, device migration, microembolization, limb ischemia, or neurological sequelae (mean follow-up, 140 days; range, 50 to 200). All 11 patients had complete thrombosis of the aneurysm at follow-up. A nonbifurcated stent-graft can be used successfully in treating infrarenal AAAs in combination with a surgical femoral-femoral bypass.

Editorial (CON) Re Minimally Invasive Port-Access Mitral Valve Surgery

Editorial (CON) Re Minimally Invasive Port-Access Mitral Valve Surgery

Treatment of Aortoiliac Aneurysms with Use of Single-Piece Tapered Stent-Grafts

The authors describe their experience with the use of single-piece, tapered stent-grafts for the treatment of abdominal aortic or aortoiliac aneurysms. Single-piece, tapered stent-grafts were placed in 15 patients for the treatment of abdominal aortic aneurysms with small distal necks (n = 13), and aortoiliac aneurysms (n = 2). There were 13 men and two women who ranged in age from 59 to 83 years (mean, 71 years). Usual open surgery was considered high risk in all patients because of comorbid medical conditions. The stent-grafts were made of Z stents covered with polytetrafluoroethylene (PTFE). Additional stent-grafts needed to treat perigraft leaks were made of Z stents covered with woven polyester (n = 5), Wallstents covered with PTFE (n = 2), Z stents covered with PTFE (n = 1), and a PTFE-covered Palmaz stent (n = 1). After stent-graft placement, the contralateral iliac artery was occluded by a blocking device composed of either a PTFE-covered Palmaz (n = 1) or Z stent (n = 13), and a femoral-femoral bypass was created. After placement of the stent-grafts, immediate perigraft leaks were observed in eight patients (53%). These were at the proximal (n = 5) or the distal end (n = 3). All, except one, were treated successfully with additional stent-grafts. The one failure was in a patient who developed aortic rupture after balloon dilation, requiring open surgical repair. Second procedures were required in four patients (27%), including three leaks treated successfully with coil embolization and/or a back-up stent-graft, and one stent-graft migration and thrombosis treated by thrombolysis and placement of an additional stent-graft. One patient died of respiratory failure 23 days after placement of the stent-graft. The mean follow-up was 12 months (range, 4-26 months). On the last follow-up, the aneurysms in the 13 living patients remained thrombosed. Treatment of aortoiliac aneurysms with use of single-piece, tapered stent-grafts is feasible in selected patients. The morbidity and mortality rates compare favorably with those of the open surgical procedures in a high-risk population. Further improvements in the technique and longer follow-up data are needed before this procedure can be recommended for the treatment of all aortoiliac aneurysms.