Femorofemoral Crossover Bypass Research Articles

Perioperative Evaluation of Iliac ZBIS Branch Devices: A French Multicenter Study

The purpose of this study was to evaluate short-term results of endovascular treatment of common iliac artery (CIA) aneurysms without a distal neck by using iliac branch devices (IBDs), which enable maintenance of antegrade perfusion to the internal iliac artery(IIA). Our investigation was done in a prospective, multicenter, nonrandomized manner. IBD were implanted to exclude CIA aneurysms with a diameter >25 mm in patients unfit for open repair. The stent grafts were designed based on preoperative angio-CT findings. A covered stent implantation between the IBD and the target IIA was performed during the same surgical procedure. Angio-CT was performed within the 30 days after the procedure. From January 2009 to April 2010, 39 patients were included in our study (38 men and 1 woman, mean age 73 years). The CIA aneurysm (mean diameter 32.3 mm) was isolated in 15 patients and associated with an abdominal aorta aneurysm (mean diameter 66 mm) in 24 patients. The IBD was systematically connected to a bifurcated aortobiiliac stent graft. The bifurcated stent graft was implanted during the same procedure in all patients, except for two who had a bifurcated stent graft history. Median surgery time, fluoroscopy time, and volume of contrast product were 192 (range 90-360) minutes, 32 (10-120) minutes, and 150 (60-352) mL, respectively. In 37 patients (95%), the internal iliac branch was patent at the end of the surgery. In two patients (5%), it was occluded, entailing a subischemic colic episode and buttock claudication in one of them. To treat a type I endoleak, a proximal extension partially covering a renal artery was implanted during the same surgery. A type III endoleak was diagnosed on the postoperative angio-CT. In three patients, a cross-over femorofemoral bypass was performed for an external iliac leg thrombosis (and for an internal iliac branch thrombosis in one case). In all, at 30 days, no death was reported and the success rate was 90% (three leg stenoses and a type III endoleak). IBD implantation to maintain an antegrade internal iliac perfusion is possible and has shown promising early success. Our results can be compared with those in the published literature. A learning curve will be needed to improve the technical success rate.

Collective Therapy and Therapeutic Strategy for Critical Limb Ischemia

To determine a treatment strategy based on the outcomes of various previous interventions for critical limb ischemia in arteriosclerosis obliterans (ASO). We examined outcomes of 292 ASO patients who had had critical limb ischemia between May 1995 and July 2009. Patients underwent the following procedures in 167 cases: aortofemoral bypass (n = 14), femorofemoral crossover bypass (n = 29), femoropopliteal bypass (n = 104) and femorotibial bypass (n = 40). Other procedures included bypass only (n = 147), bypass combined with thromboendarterectomy (n = 10), bypass combined with endovascular therapy (n = 6), bypass combined with lumbar sympathectomy (n = 2), endovascular therapy combined with thromboendarterectomy (n = 4), endovascular therapy (n = 19), lumbar sympathectomy (n = 6), conservative therapy (n = 65), and major amputation (n = 31). We also calculated P3 risk scores and measured transcutaneous oxygen pressure (tcPO2) and skin perfusion pressure (SPP) before and after therapy. The limb salvage rate was 87% at 2 years in the arterial reconstruction group. In the low-risk group (a P 3 risk score of 3), the 1-year amputation-free survival rate was 96%. In the medium-risk group (a P 3 risk score of 4-7), the 1-year amputation-free survival rate was 88%. In the high-risk group (a P 3 risk score of 8), the 1-year amputation-free survival rate was 66%. The hospital death rate in the arterial reconstruction group was 3.2%, all of whom were patients who underwent bypass. The survival rate at 5 years was 65% and 36% in the conservative therapy only group. Ulcers healed in 140 out of 144 patients. The 4 patients with unhealed infections had tcPO2 or SPP values of more than 30 mmHg after treatment. Major amputations were performed in 4 of 5 patients who had tcPO2 or SPP values from 20 to 30 mmHg after treatment. Major amputations were performed in all 6 patients who had tcPO2 or SPP values of less than 20 mmHg after treatment. In cases with tcPO2 or SPP values of more than 30 mmHg, an ulcer will probably heal, except in infected cases. We suggest that, if these values are less than 30 mmHg, complete revascularization should be performed. The P3 risk score was useful in predicting limb salvage in the current series. Hybrid therapy in bypass and endovascular therapy must be performed in cases where patients are in a generally poor condition. It is important to attempt amelioration in limb salvage and to control the operative mortality rate with sufficient perioperative control. (English Translation of Jpn J Vasc Surg 2011;20:905-911).

Influence of atheromatous lesions in the ilio-femoral segment on the occurrence of stentgraft thrombosis after endovascular treatment of an abdominal aortic aneurysm.

Limb graft thrombosis (LGT) is one of the most frequent severe complications after endovascular repair of abdominal aortic aneurysms. The aim of the study was to assess the influence of atherosclerosis in ileo-femoral segment on the incidence of LGT as well as to analyze the methods of treatment of LGT. The medical records of 564 consecutive patients operated endovascularly for abdominal aortic aneurysm by means of bifurcated stentgrafts in the Department of General, Vascular and Transplantat Surgery of Medical University of Warsaw were analyzed. The minimal observation time after surgery was one year. Patients with inflammatory, ruptured and falls aneurysms as well as those with the observation period below 12 months were excluded from the study. Patients were divided into two groups: test (B) and control (K) depending on the progression of atherosclerosis in the iliac arteries. Group B included 184 patients (13 women and 171 men), with advanced atherosclerotic lesions of ilio-femoral segment, corresponding to the A - C class in the TASC classification. The remaining 380 patients (25 women and 355 men) without significant blood flow disorders in the iliac arteries, constituted the group K. The computed tomography was done in all patients with acute limb ischemia. During the observation time up to 114 month, the LGT occurred in 43 (7.6%) cases: [group B - 34/184 (18.5%), group K - 9/380 (2.4%)]. The treatment of LGT included an attempt of patency restoring of the prosthesis by means of thrombolysis or thrombectomy combined with stenting. In case of failure the cross-over femoro-femoral bypass was implanted. Thrombectomy was successful in 21 of 40 cases (52.5%), the local thrombolysis was done in 5 patients and it was successful in three cases and in the remaining two patients the thrombectomy was done. In 16 of 24 patients after patency restoring of the prosthesis the angioplastics and stenting was done. In 17 cases the femoro-femoral bypass was implanted. The atherosclerosis in ileo-femoral segment significantly increases the risk of LGT. An attempt of patency restoring (thrombectomia or thrombolysis) combined with stenting and cross-over femoro- femoral bypass implantation in case of failure seems to be the successful method of LGT treatment.

Crossover ilio-iliac bypass and removal of femoro-femoral graft as first treatment for the infection of crossover bypass in aortouniiliac endovascular aneurysm repair

The crossover femoro-femoral bypass, classically used for the treatment of unilateral iliac arterial obstruction, has recently become an integral part of aorto-uni-iliac endovascular aneurysm repair. We therefore, reconsider the therapeutic problems related to thrombosis and in particular to infection of the femoro-femoral prosthesis, when many attempts have been made to preserve the bypass and treat the infection. Showing a case treated and well eight months later, we put forward the old technique of crossover ilio-iliac bypass, followed by the removal of the infected femoro-femoral graft. In our opinion, this technique circumvents the need for autologous tissue and allows for the use of prosthetics in a new, sterile, uncontaminated field. As this approach for these cases has so far not been reported in the literature, further cases and long-term follow-up are needed.

Arterial Thrombosis After Surgery of Pelvic Side Wall Recurrence of a Villoglandular Adenocarcinoma of the Cervix

Abstract Background: Villoglandular adenocarcinoma of the cervix is a rare condition that appears in young women and is characterized by its low aggressiveness. The most common treatment is surgery, consisting of either a conization or hysterectomy. Ovaries may be preserved depending upon the patient's reproductive desires. Case: The case reported here involves the recurrence of a stage IB1 villoglandular adenocarcinoma of the cervix. This may be the first case report of the recurrence of a villoglandular adenocarcinoma of the cervix with no lymph node metastasis following a radical hysterectomy, and the first case of a laterally extended endopelvic resection being complicated by an arterial thrombosis. Results: Resection was performed, leaving part of the residual tumor. The patient experienced a postoperative thrombosis of the left common iliac artery. A fasciotomy of the tibia and calf was performed, followed by a femoro-femoral crossover bypass. The patient is still undergoing rehabilitation, as well ...

Type IB and type III endoleak 8 years after endovascular aneurysm repair

An 86-year-old man was admitted to our hospital for abdominal pain and underwent an AneurRx bifurcated endograft (Medtronic AVE, Sunnyvale, Calif) implantation 8 years earlier for a 7-cm-diameter abdominal aortic aneurysm (AAA). His comorbidities were chronic atrial fibrillation, diabetes, dyslipidemia, chronic renal failure, hypertension, severe chronic obstructive pulmonary disease, and coronary artery disease. This patient also underwent an appendicectomy, inguinal hernioplasty, and cholecystectomy. An expandible abdominal mass was found during a clinical examination. Doppler ultrasound imaging and a computed tomography scan showed a severe increase of AAA diameter to 11 cm, associated with a type IB endoleak from the right leg displaced into the aneurysmal sac itself and to a type III endoleak due to detachment of the contralateral leg (A-C). Similar patients reported in the literature underwent open or endovascular treatment. Our patient was assessed by the anesthesiologist and cardiologist as being in American Society of Anesthesiologist class IV and therefore unfit for surgical repair, so an endovascular approach was planned. Through a left transaxillary access, a hydrophilic guidewire was introduced first into the endograft main body and its right leg and, thereafter, was captured by means of an Amplatz GooseNeck (EV3, Plymouth, Minn) introduced through the right common femoral artery. This was exchanged with a stiff guidewire, and a right aorto-uni-iliac Zenith Cook endograft (Cook Inc, Bloomington, Ind) was deployed. After surgical exposure of the left common femoral artery, an endovascular plug (Iliac Plug Cook Zip-20) was inserted in the ipsilateral common iliac artery. A femoro-femoral crossover bypass was completed with a 7-mm external-supported polytetrafluoroethylene graft (Vascutek Ltd, Inchinnan, Scotland). The procedure was performed with spinal anesthesia, the operating time was 135 minutes, and the contrast medium amount was 250 mL. The patient’s postoperative period was uneventful and he was discharged after 8 days, with no worsening of renal condition. A computed tomography scan at 6 months showed a good result of the procedure, with no endoleak and reduction of the AAA diameter (D).

Crossover Femoropopliteal Bypass: Single Graft or Double Grafts

Both single-graft crossover femoropopliteal (COFP) bypass and crossover femorofemoral plus femoropopliteal bypasses using double grafts may be performed for patients with a medical history of abdominal vascular operations or comorbidity, thereby ineligible for retroperitoneal or transperitoneal approaches. In this study, these two methods were compared. A total of 15 patients who were operated on between February 2002 and March 2010 were included and studied retrospectively. Eight of them underwent crossover femorofemoral bypass plus femoropopliteal bypass with double grafts (group 1), whereas the rest seven underwent single-graft COFP bypass (group 2). All the patients were included either in class 3 or class 4 according to Fontaine classification. Preoperative arterial Doppler ultrasound and arteriography were obtained from every patient. Pre- and postoperative ankle-brachial indices were measured. Postoperative clinical parameters were obtained from medical records. Median primary and secondary patency rates were 40.5 (7-105) months and 58 (7-105) months in group 1, respectively. In group 2, these rates were 42 (2-84) months and 44 (11-84) months, respectively. Two patients in group 1 and one patient in group 2 were amputated. There were no significant differences between both groups in terms of duration of hospital stay, duration of intensive care unit stay, and units of packed red blood cells transfused (P > 0.05). In addition, postoperative ankle-brachial indices were significantly improved in both groups (P < 0.05). COFP bypass can be performed for limb salvage in cases with critical limb ischemia with a medical history of previous vascular surgery or comorbidity, thereby ineligible for aortic reconstruction. This procedure may also be performed as continuous COFP bypass using a single graft.

Stent-Graft Limb Deployment in the External Iliac Artery Increases the Risk of Limb Occlusion Following Endovascular AAA Repair

To assess whether deployment of an endograft limb in the external iliac artery (EIA) increases the rate of limb occlusion following endovascular aneurysm repair (EVAR). Interrogation of a prospectively maintained database identified 661 patients (596 men; median age 73 years, range 37-93) with infrarenal abdominal aortic aneurysm who underwent EVAR between 1996 and 2010 using Zenith stent-grafts predominately. Of these, 567 patients [56 (9.9%) women] had both endograft limbs deployed in the CIA (1203 limbs at risk), while 94 patients [9 (9.6%) women] had at least 1 limb in the EIA (22 bilateral; 116 limbs at risk). An adjunctive bare metal stent was used in 8 (9%) limbs deployed in the EIA. There were 31 limb occlusions, all unilateral: 17 (3%) patients in the CIA group had an occluded limb (1% of limbs at risk) vs. 14 (15%) patients in the EIA group (12% of limbs at risk; p<0.0001). The median time to occlusion was 3 months (0-60) in the CIA group and 1 month (0-36) in the EIA group. The majority of occlusions were treated by extra-anatomical revascularization, most often a femorofemoral crossover bypass. No legs were amputated following occlusion of a limb placed in the CIA, but there were 3 amputations in the EIA group (p=0.003). Deployment of endograft limbs into the EIA led to a higher rate of occlusion and leg amputation. Increased tortuosity of the EIA and a smaller caliber vessel are likely to account for the increased risk.

Use of the Reversed Zenith Iliac Limb Extension in the Treatment of Iliac Artery Aneurysms and Various Aortoiliac Pathologies: Outcome in Midterm Follow-up

To report the midterm follow-up after treatment of various aortoiliac pathologies in an acute setting using reversed Zenith iliac limb extensions when appropriately sized stent-grafts were not available. From 2005 to 2007, 12 patients (10 men; mean age 71.5 ± 7.3 years) were treated with reversed Zenith iliac limb extensions for solitary iliac artery aneurysms (n = 8), an abdominal aortic aneurysm (AAA) in a small caliber aorta (n = 1), an anastomotic pseudoaneurysm in an aortobi-iliac graft (n = 1), a hypogastric artery aneurysm (n = 1), and a ruptured AAA secondary to a late type Ib endoleak after Talent stent-graft implantation (n = 1). The Zenith iliac limb extensions were deployed on the back table and reloaded in a reversed manner to treat aneurysms and other lesions with a broad range of different diameter necks and landing zones. The technical success rate was 100%, and no endoleaks were present at the end of the procedures. The endoleak patient with the ruptured AAA died owing to respiratory insufficiency. The other 11 patients have a mean follow-up of 29±9 months. In this period, 2 patients received a femorofemoral crossover bypass because of an occluded iliac limb extension. One patient had a type II endoleak without growth of the iliac aneurysm. Two patients died of a ruptured 4.4-cm AAA at 16 months and of respiratory insufficiency due to metastases at 47 months, respectively. When necessary, it is feasible to use a revered Zenith limb extension to treat solitary iliac aneurysms and other aortoiliac pathologies, achieving satisfactory midterm outcomes.

Secondary Procedures After Infrarenal Abdominal Aortic Aneurysms Endovascular Repair With Second-Generation Endografts

To study the incidence, the types, and the results of secondary procedures performed after endovascular treatment of infrarenal abdominal aortic aneurysm (AAA). To compare the population of patients who underwent secondary procedure (P2) with the population of those who did not require it. Between 1998 and 2008, this study included all the patients electively treated for AAA with stentgrafts that were still available on the market on January 1, 2009. Data were prospectively collected and retrospectively analyzed. The postoperative follow-up included at least a systematic computed tomography scan at 6, 12, 18, and 24 months and then every year. P2 were defined as any additionnal procedures performed to treat aneurysm related complications after initial stentgraft implantation. We studied 162 patients with a mean 40 ± 31 months' follow-up. In 32 patients (19.7%), there were 46 P2, 3 of them were surgical conversion and 1 with endovascular conversion. Thirty-nine P2 were scheduled, and seven were performed in emergency. Nine patients underwent more than one P2. P2 was indicated for type II endoleak in 17 cases, 13 of them with a diameter increase; for type I endoleak in 10 cases; for AAA rupture in 3 cases; for occlusion or stentgraft stenosis in 13 cases; and for 1 type III endoleak, 1 endotension, and 1 femoro-femoral crossover bypass infection. Two ruptures occurred in patients who had undergone P2. The immediate technical success was 89.1%. At 30 days, morbidity was 10.9%, and there was no mortality. Survival rates at 3 and 5 years were respectively 85.2% and 71.9% in patients with secondary procedure and 70.6% and 47.5% in the others (p = 0.046). In patients treated for AAA with second generation stentgrafts, in the long term, secondary procedure rate was 19.7%. Survival rate for patients who underwent a secondary procedure was better, which was probably related to the fact that they were younger at the time of stentgraft implantation. Large AAA diameter was a secondary-procedure risk factor.

Reprinted Article “Endovascular Repair with Bifurcated Stent-Grafts under Local Anaesthesia to Improve Outcome of Ruptured Aortoiliac Aneurysms”

Introduction Acute haemodynamic changes and/or loss of abdominal muscle tone can occur during induction of general anaesthesia and may be the Achilles’ tendon in endovascular aneurysm repair (EVAR) of ruptured aortoiliac aneurysms (rAIA). The purpose of this study was to evaluate the use of local anaesthesia (LA) for EVAR to overcome these limitations. Methods Twenty-one consecutive patients with rAIA are included in this study. Twenty patients underwent EVAR under LA, and 1 patient was treated under general anaesthesia. Haemodynamics were stabilised during assessment of EVAR feasibility by CT-scan and during the procedure itself by controlled hypotension (MAP 50-60 mmHg) and moderate fluid resuscitation. Results Median procedure time was 120 min. Haemodynamics remained stable in all but 3 patients who required transfemoral balloon occlusion of the supra-renal aorta. Perioperative intubation was necessary in 5 patients because of respiratory distress (n = 3), or retroperitoneal access (n = 2). Temporary deterioration of renal function occurred in 6 patients, with 2 requiring hemofiltration. CT-scan confirmed sealing of the rAIA in all patients at discharge. 30-day mortality was 9.5% (2 deaths). In the median follow-up of 19 months, there were no deaths, but 3 endovascular re-interventions, 1 crossover femoro-femoral bypass, and 1 open surgical graft repair. Discussion Our series is the first to show that EVAR for rAIA can be safely performed under LA. This approach allows implantation of commercially available bifurcated SG and improves patient outcome.

Cross Pubic Femoro-femoral Artery Bypass with Great Saphenous Vein

Purpose: The purpose of this study was to evaluate the great saphenous vein (GSV) as a conduit for crossover femoro-femoral bypass. Generally the conduit for crossover femoro-femoral bypass is a synthetic material because of the acceptable long-term patency and low complication rates. But, as the average life expectancy becomes extended, a better patency rate becomes more important. In this study, we compared the patency rates and hemodynamic results between crossover femoro-femoral bypass operations with GSVs and those with synthetic grafts. Methods: From 1998 to 2008, 119 femoro-femoral bypass operations were done. Among them, 38 femoro-femoral bypass used GSV as a conduit (group I) and 79 operations used expanded polytetrafluoroethylene (group II). Two cases used arm veins and we excluded those cases. Results: The 3 year primary patency rate of total cases was 75.1%, 93.7% in group I and 66.1% in group II. There were no statistical differences in hemodynamic results such as peak systolic velocity, volume flow and ankle/brachial systolic pressure index between the two groups. Conclusion: The 3 year primary patency rate of group I was better than that of group II. However there were no differences in hemodynamic changes. So GSV is recommended as a conduit for crossover femoro-femoral bypass especially in young patients who are eager to have longer patency rates after surgery instead of less invasive endovascular therapy.

Factors influencing early results of femoro-femoral crossover bypass

Femoro-femoral crossover bypass is an extraanatomic reconstruction used for revascularization of lower limb with contralatateral femoral artery as an inflow vessel, and the graft placed in the suprapubic region. We perform this procedure when anatomic reconstruction is not possible or is contraindicated. To analyze the influence of different risk factors on early patency of femoro-femoral crossover bypass. This retrospective study analyzed the results of 88 femoro-femoral bypass grafting during an 11-year period. There were 66 (75%) males and 22 (25%) females of average age 64.93 years (42-79 years). In 76 patients the operations were performed due to critical limb ischemia. Revascularization was urgent in 12 patients, while 76 patients were elective. Dacron prosthesis was used in 81 patients, while PTFE was used in 7 patients. Statistical analysis was made by logistic regression. During hospitalisation the graft remained patent in 82 patients, and graft thrombosis occurred in 6 patients. Limb salvage rate was 90.91%. Early morbidity rate (within the first postoperative month) was 13.64%, while early mortality rate was 4.55%. Using logistic regression we established that early graft patency was statistically more significant in males (p < 0.05). Age (p = 0.07) and hypertension (p = 0.08) appeared to be predicting influence of the graft patency on the border of the accepted statistical significance level. Femoro-femoral crossover bypass is a good alternative for revascularization in high risk patients for standard anatomic reconstructions due to comorbid conditions or local problems.

Femorofemoral bypass感染に対するグラフト切除後の急性下肢虚血に対して，腹膜前脂肪織内での血行再建を行った1例

Femorofemoral bypass感染に対するグラフト切除後の急性下肢虚血に対して，腹膜前脂肪織内での血行再建を行った1例

Repetición de videovigilancia EEG: ¿Por qué y con qué resultados?

Anatomy has been the major challenge to overcome to increase safe and durable applicability of endografting for the treatment of abdominal aortic aneurysm. Bilateral iliac aneurysm preventing an appropriate distal landing zone for the endograft is a common condition and can be managed by (a) increasing the diameter of the endograft, with limitations in available sizes, (b) bilateral hypogastric embolization, accepting an increased morbidity, (c) the use of a branched device, increasing the cost and currently with limited availability, (d) combined surgical hypogastric revascularization by the retroperitoneal approach, or (e) retrograde revascularization from the ipsilateral external iliac artery using an endograft. We describe the use of widely available devices to obtain stable antegrade revascularization of one hypogastric artery during aortic endografting. We report the case of a 68-year-old man, at high risk for an open procedure, who presented with bilateral iliac aneurysm and minor aortic ectasia; no iliac landing zone was available. A regular bifurcated graft was deployed and extended into one of the external iliac arteries, preceded by ipsilateral hypogastric embolization. Through an upper extremity approach, an endograft was deployed from the remaining bifurcated graft branch into the other hypogastric artery, followed by ipsilateral external iliac occlusion. Finally a femorofemoral crossover bypass was performed. The patient recovered event free, and patency of the endograft and absence of endoleak were demonstrated on computed tomography. Minor unilateral buttock claudication resolved in 6 weeks and sexual function was preserved. This technique is a reasonable alternative to consider in the endovascular treatment of patients with bilateral iliac aneurysm, allowing preservation of pelvic perfusion, limiting cost, and using available devices.

Is Femorofemoral Crossover Bypass an Option in Claudication?

Since the introduction of femorofemoral crossover bypass by Freeman and Leeds in 1952 (Calif Med 1952;77:229-233), it has been used as an alternative to anatomic surgical reconstruction for unilateral iliac disease. The objective of this review was to summarize results on femorofemoral crossover bypass surgery for disabling claudication from the most recent studies. All publications describing series or registries of patients treated for claudication by femorofemoral crossover bypass were sought through computerized searches of MEDLINE database. Main outcome measures considered for comparisons were primary and secondary patency rates; mortality; complications such as infection, amputation, or loss of function; improving walking distance or ankle-brachial index; Quality of Life (QoL) variations. Six studies met the inclusion criteria. In the considered series, primary interventions were performed with Dacron, polytetrafluoroethylene (PTFE) or autologous vein graft. The number of patients treated for claudication ranged from 66 to 211 in the considered series. One-year primary patency rates ranged from 71.6 to 96%. In two series, 5-year primary patency rates reported were 71.8 and 72%, and in one series secondary patency rate at 5 years was 89%. The femorofemoral crossover bypass in patients with disabling claudication caused by unilateral iliac artery disease is still a valuable alternative to aortofemoral grafting in those who are not suitable for endovascular repair or major abdominal surgery, or have poor general (age, coronary artery disease, chronic obstructive pulmonary disease (COPD), etc.) or local (hostile abdomen, sepsis, porcelain aorta) conditions, presenting in recent series with good long-term patency and low complication rates.

Endovascular treatment of endotension with dacron stent graft reinforcement and femorofemoral crossover bypass: therapeutic challenge

A 54 year-old man with an asymptomatic 5.9 cm AAA was treated with an Excluder® 26 mm/14.5 mm/16 cm endoprosthesis (Gore, USA). Initial aortic morphology showed a proximal neck of 2.0 cm of extension by 23 mm of diameter. The common iliac arteries measured 13 mm in right diameter and 12 mm in left diameter. No endoleak was detected immediately after the procedure. One month after the procedure, computed tomography (CT) scan showed maintenance of aneurysmal diameters without evidence of endoleak (Figure 1). After one year, follow-up duplex ultrasound and CT scan showed no endoleak, but a small growth of the aneurysmal sac to 6.2 cm was observed (Figure 2). Aortography with selective visceral and hypogastric arteries showed no endoleak (Figure 3). We decided to observe the outcome of the condition with a second CT scan within six months. The patient only returned after one year, when CT scan found the aneurysmal diameter had increased to 7.5 cm, but without evidence of endoleak. The case was interpreted as endotension, and intervention was considered. Since the patient presented class II heart failure, poorly controlled cardiac arrhythmia and a previous left pneumonectomy for a neoplasm, an endovascular approach was chosen.

Acute Complex Type A Dissection associated with peripheral malperfusion syndrome treated with a staged approach guided by lactate levels

Acute type A aortic dissection can be complicated by visceral malperfusion and is associated with a significant surgical morbidity and mortality. We describe a case of successful management of a complex acute type A dissection with mesenteric and lower limb ischemia treated with endovascular thoracic stenting and femoro-femoral crossover bypass grafting followed by aortic arch repair. To accomplish this, we applied a staged therapeutic approach using serial lactate measurements to assess the adequacy of peripheral perfusion and metabolic status prior to surgical repair of the proximal dissection.

Emergency endovascular aneurysm repair for ruptured abdominal aortic aneurysms: an institutional experience

Objectives: Emergency endovascular aneurysm repair (eEVAR) for ruptured abdominal aortic aneurysms (rAAA) is still under investigation. Since installation of an urgent eEVAR kit in our hospital, all patients with a rAAA or urgent thoracic aortic aneurysm are candidates for eEVAR or eTEVAR (emergency thoracic evar), respectively. For this study, we analyzed all rAAA patients treated with eEVAR.Methods: Data were recorded prospectively. Criteria for an eEVAR were an infrarenal neck > 15mm, acceptable landing zone, angles below 70° and a good femoral approach. We prefer preoperative angio CT-scan but in case of instability, an intra-aortic balloon can stabilize the patient during angiography (in the OR) to decide between open or eEVAR repair. Follow-up was performed on regular intervals by duplex or CT-scan. Thirty-day mortality and overall survival were calculated.Results: Since 2006, nine male rAAA patients with a mean age of 73 years (range: 62–82) had eEVAR repair. Aneurysm diameter was 8 cm (range: 5.8–11). The Hardman index was 1.5 (range: 0–3). In eight patients an aorto-uni-iliac device was placed succesfully followed by a femorofemoral crossover bypass. The 30-day operative mortality was 12.5% (one patient with septic shock). Three patients showed a type 2 endoleak with stable diameter during follow-up but one patient showed expansion 4 years after treatment.Conclusions: Treating rAAA with eEVAR in selected patients with acceptable anatomy and a kit permanently available in the operating room yielded good results by a surgical team trained for both open and eEVAR repair. The conversion rate was low (11%) and the survival (immediate and 30-days) was excellent (87.5%).

Antegrade Hypogastric Revascularization During Endovascular Aortoiliac Aneurysm Repair: An Alternative to Bilateral Embolization

Anatomy has been the major challenge to overcome to increase safe and durable applicability of endografting for the treatment of abdominal aortic aneurysm. Bilateral iliac aneurysm preventing an appropriate distal landing zone for the endograft is a common condition and can be managed by (a) increasing the diameter of the endograft, with limitations in available sizes, (b) bilateral hypogastric embolization, accepting an increased morbidity, (c) the use of a branched device, increasing the cost and currently with limited availability, (d) combined surgical hypogastric revascularization by the retroperitoneal approach, or (e) retrograde revascularization from the ipsilateral external iliac artery using an endograft. We describe the use of widely available devices to obtain stable antegrade revascularization of one hypogastric artery during aortic endografting. We report the case of a 68-year-old man, at high risk for an open procedure, who presented with bilateral iliac aneurysm and minor aortic ectasia; no iliac landing zone was available. A regular bifurcated graft was deployed and extended into one of the external iliac arteries, preceded by ipsilateral hypogastric embolization. Through an upper extremity approach, an endograft was deployed from the remaining bifurcated graft branch into the other hypogastric artery, followed by ipsilateral external iliac occlusion. Finally a femorofemoral crossover bypass was performed. The patient recovered event free, and patency of the endograft and absence of endoleak were demonstrated on computed tomography. Minor unilateral buttock claudication resolved in 6 weeks and sexual function was preserved. This technique is a reasonable alternative to consider in the endovascular treatment of patients with bilateral iliac aneurysm, allowing preservation of pelvic perfusion, limiting cost, and using available devices.