Ipsilateral Common Iliac Artery Research Articles

Iliac Artery Tortuosity Index in Chinese Patients with or without Aortic Artery Aneurysms and Related Influencing Factors

Iliac artery tortuosity is an important anatomical factor that influences the endovascular repair of aortic artery aneurysms. The influencing factors of the iliac artery tortuosity index (TI) have not been well studied. TI of iliac arteries and related factors in Chinese patients with and without abdominal aortic aneurysm (AAA) were studied in this study. One hundred and ten consecutive patients with AAA and 59 patients without AAA were included. For patients with AAA, the diameter of the AAA was 51.9±13.3mm (24.7-92.9mm). Those without AAA had no history of definite arterial diseases and came from a cohort of patients diagnosed with urinary calculi. The central lines of the common iliac artery (CIA) and external iliac artery were depicted. The actual length and the straight distance were measured and used to calculate the TI (actual length/straight distance). Common demographic factors and anatomical parameters were analyzed to identify any related influencing factors. For patients without AAA, the total TI of the left and right side was 1.16±0.14 and 1.16±0.13, respectively (P=0.48). For patients with AAAs, the total TI in the left and right side was 1.36±0.21 and 1.36±0.19, respectively (P=0.87). The TI in external iliac artery was more severe than that in CIA both in patients with and without AAAs (P<0.01). Age was the only demographic factor found to be associated with TI in patients with AAA (Pearson's correlation coefficient r≈0.3, P<0.01) and without AAA (r≈0.6, P<0.01). For anatomical parameters, the diameter was positively associated with the total TI (left side: r=0.41, P<0.01; right side: r=0.34, P<0.01). The ipsilateral CIA diameter was also associated with the TI (left side: r=0.37, P<0.01; right side: r=0.31, P<0.01). The length of the iliac arteries was not associated with age or AAA diameter. Reduction of the vertical distance of the iliac arteries may be a common underlying reason for age and AAA. Tortuosity of the iliac arteries was probably an age-related problem in normal individuals. It was also positively correlated with the diameter of the AAA and the ipsilateral CIA in patients with AAA. Attention should be paid to the evolution of iliac artery tortuosity and its influence when treating AAAs.

Identification of the Risk Factors for the Failure of Ureteral Access Sheath Placement.

Purpose Insertion of a ureteral access sheath (UAS) may fail in some patients in retrograde intrarenal surgery (RIRS), and this study aimed to seek preoperative risk factors for the failure of 12/14F UAS placement. Methods We retrospectively analyzed 260 consecutive patients who underwent RIRS between May 2020 and March 2022 at our institution. Data on patient and stone characteristics and several computed tomography (CT)-based measurements were collected and compared between the success and failure UAS placement groups. Results Twenty-nine (11.2%) patients failed to insert the UAS. Age, gender, height, weight, stone side, stone location, length of history, and computed tomography (CT)-based parameters were not significant differences between the two groups. Univariate logistic regression analyses showed sex (female/male) (odds ratio: 0.287 and 95% CI [0.107, 0.722], p=0.013), length of history 15–31 days (odds ratio: 0.315 and 95% CI [0.102, 0.974], p=0.045), length of history >31 days (odds ratio: 0.202 and 95% CI [0.051, 0.805], p=0.023), and diameter of the ipsilateral common iliac artery (odds ratio: 1.285 and 95% CI [1.018, 1.623], p=0.035) were associated with UAS placement. Conclusion Our study indicated that males, the short length of history, and the short diameter of the ipsilateral common iliac artery were the risk factors for the failure of UAS placement.

Ipsilateral common iliac artery plus femoral artery clamping for inducing sciatic nerve ischemia/reperfusion injury in rats: a reliable and simple method

The aim of this study was to develop a practical model of sciatic ischemia reperfusion (I/R) injury producing serious neurologic deficits and being technically feasible compared with the current time consuming or ineffective models. Thirty rats were divided into 6 groups (n = 5). Animal were anesthetized by using ketamine (50 mg/kg) and xylazine (4 mg/kg). Experimental groups included a sham-operated group and five I/R groups with different reperfusion time intervals (0 h, 3 h, 1 d, 4 d, 7 d). In I/R groups, the right common iliac artery and the right femoral artery were clamped for 3 hrs. Sham-operated animals underwent only laparotomy without induction of ischemia. Just before euthanasia, behavioral scores (based on gait, grasp, paw position, and pinch sensitivity) were obtained and then sciatic nerves were removed for light-microscopy studies (for ischemic fiber degeneration (IFD) and edema). Behavioral score deteriorated among the ischemic groups compared with the control group (p < 0.01), with maximal behavioral deficit occurring at 4 days of reperfusion. Axonal swelling and IFD were found to happen only after 4 and 7 days, respectively. Our observations led to an easy-to-use but strong enough method for inducing and studying I/R injury in peripheral nerves.

A rare case of May-Thurner-like syndrome in an elderly lady

An elderly lady presented with decreased mobility, sputum production and intermittent confusion. She was treated for chest sepsis, fast atrial fibrillation, and acute kidney injury, and also noted to have a swollen left leg. Venous duplex imaging showed extensive thrombus within the left common iliac, left external iliac and left common femoral veins. A CT Venogram showed compression of the left common iliac vein between an osteophyte at L5 and a calcified ipsilateral common iliac artery. It also showed a pelvic kidney with an extra renal pelvis and large renal cyst which was indirectly contributing to venous compression by splinting the left iliac artery. A decision was made after discussion at the Vascular MDT that the patient was not fit enough for surgery and to manage her medically with anticoagulation. Discussion: Proximal DVT’s are rarer than distal thrombosis, but have similar causes. One of the rarer causes of proximal DVT is May-Thurner syndrome and its variants known collectively as non-thrombotic iliac vein lesions. May-Thurner originally described DVT formation caused by extrinsic compression of the left common iliac vein between the overriding contralateral (right) common iliac artery and adjacent lumbar vertebrae. The best imaging modality is a CT Venogram. Duplex ultrasonography can be used, although it can be difficult to visualize the iliac veins. The mainstay of management is surgical thrombectomy, or thrombolysis, followed by stenting of the affected vessel. However, if intervention is not appropriate, then it can be managed medically with anticoagulation.

Single-center experience in the endovascular management of isolated iliac artery aneurysm

Isolated iliac artery aneurysms (IAA) are relatively uncommon and represent 2-7% of all intra-abdominal aneurysms. Surgery is the gold standard treatment for IAA. However, endovascular stent-graft placement is gaining acceptance as an alternative to surgery especially in patients with high surgical risk. To evaluate the effectiveness and safety of endovascular management of isolated IAA having various anatomic and pathologic bases. Between 2008 and 2011, 31 patients who underwent endovascular treatment for isolated IAA were retrospectively analyzed. The mean aneurysm size was 43 mm (range, 30-71 mm). The age ranged from 37 to 87 years (mean, 70.0 years). Isolated IAAs were treated in one of three different ways: (i) infrarenal aortic stent-graft placement with limb extension; (ii) stent-graft placement for isolated iliac artery coverage; and (iii) embolization with a coil and a vascular plug combined with femoral-femoral bypass grafting. All patients were assessed by contrast-enhanced computed tomography (CT). The mean follow-up period was 25.1 months (range, 1-60 months). Common iliac artery involvement was seen in 28 patients. Ten (35.7%) of those patients also had an internal IAA. Three patients had an isolated internal IAA. Infrarenal stent-graft placement was performed in 25 patients. Stent-graft placement for coverage of the only iliac artery was performed in five patients. One patient, who had a mycotic aneurysm of the right common iliac artery underwent coil embolization of the ipsilateral common iliac artery with concurrent femoral-femoral bypass graft. Five of the 31 patients (16.1%) with stent grafts had type II endoleaks at the time of the last imaging study, one of those patients underwent percutaneous embolization with glue. None of the patients showed major procedure-related complications. Percutaneous management of IAA is effective and safe with various techniques depending on the anatomical and pathologic features of the isolated IAA.

PMMA embolization to the left dorsal foot artery during percutaneous vertebroplasty for spinal metastases

Distal arterial embolization to the foot with PMMA during vertebral augmentation has not been previously reported. We report a rare case of distal PMMA embolization to the dorsal foot artery during ipsilateral percutaneous lumbar vertebral augmentation in a patient with spinal osteolytic metastases. A 68-year-old woman was admitted because of severe disabling low back pain. Plain roentgenograms, MRI and CT-scan revealed osteolysis in the L4 and L5 vertebral bodies with prevertebral soft tissue involvement. Percutaneous vertebroplasty with PMMA was performed in L2 to L5 vertebrae under general anesthesia. Intraoperatively, leakage into the segmental vessels L3 and L5 was observed. Four hours after the procedure the clinical diagnosis of acute ischemia and drop foot on the left was made. CT-angiography justified linear cement leakage in the course of the left third lumbar vein and fifth lumbar artery, and to the ipsilateral common iliac artery. The patient was treated with low molecular heparin and the ischemia resolved without further sequelae 1 week postoperatively. PMMA leakage is a complication associated with vertebroplasty and kyphoplasty. Although the outcome of the PMMA embolization to the vessels resolved without sequelae, in our case spine surgeons and interventional radiologists should be aware on this rare complication in patients with osteolytic vertebral metastases even when contemporary cement containment techniques are used.

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).

Comparing patient outcomes between multiple ipsilateral iliac artery stents and isolated iliac artery stents

Endovascular stents are accepted therapy for iliac artery stenoses and occlusions. Surgery is the recommended therapy for patients with severe iliac artery disease, including those with the combination of ipsilateral common iliac artery (CIA) and external iliac artery (EIA) stenoses/occlusions. This study compared patient outcomes, including late open conversion rates, for combined ipsilateral CIA and EIA stenting vs CIA or EIA stents alone. Between 1998 and 2010, 588 patients underwent iliac artery stenting at two institutions. Patient comorbidities and outcomes were retrospectively reviewed, and analyses were performed using multivariate regression and Kaplan-Meier methods. There were 436 extremities with CIA stents, 195 with EIA stents, and 157 with CIA and EIA stents. The groups did not differ significantly in demographics, comorbidities, or treatment indications. During follow-up, 183 patients died, 95 underwent an endovascular reintervention, and 48 required late open conversion. For patients in the CIA or EIA stent group, the mean ± standard error survival was 5.3 ± 0.3 years, secondary endovascular intervention-free survival was 7.4 ± 0.6 years, late open conversion-free survival was 9.8 ± 0.4 years, and amputation-free survival was 7.6 ± 0.4 years. In the CIA and EIA stent group, survival was 6.1 ± 0.6 years, secondary endovascular intervention-free survival was 7.2 ± 0.6 years, late open conversion-free survival was 9.0 ± 1.1 years, and amputation-free survival was 8.4 ± 0.5 years. Survival, reintervention-free survival, late open conversion-free survival, and amputation-free survival were all similar between patient groups (all P > .05). CIA and EIA stenting in combination was not a predictor of death, reintervention, late open conversion, or amputation. Outcomes are similar for patients with CIA or EIA stents and for those with combined ipsilateral CIA and EIA stents. Late open conversions for iliac artery stent failure are uncommon and not influenced by the location or extent of prior iliac artery stent placement. Endovascular therapy for aortoiliac disease should be extended to consider selected patients with ipsilateral CIA and EIA stenoses/occlusions.

A Modified Model for Rat Sciatic Nerve Ischemia/Reperfusion Injury

Sir: A number of different models of unilateral ischemia/reperfusion injury in rat sciatic nerve have been developed. In one method described by Mitsui et al.,1 the abdominal aorta, the right iliac and femoral arteries, and all identifiable collateral vessels supplying the right sciatic-tibial nerve are ligated for 3 hours and then reperfused for different time intervals. In another model introduced by Saray and his colleagues,2 only the femoral artery and vein–-just distal to the inguinal ligament–-are clamped for 3 hours, followed by reperfusion. The first method is time-consuming and requires advanced surgical techniques and instruments, and the second one, albeit easy to perform, does not produce severe injury.3 The aim of this study was to develop a practical model producing serious neurologic deficits that was still technically feasible. For this purpose, clamping of the femoral artery as well as the ipsilateral common iliac artery was used to induce sciatic nerve ischemia/reperfusion. For this pilot study, 12 Sprague–Dawley male rats weighting 150 to 200 g were randomly divided into two groups: the sham-operated group and the ischemia/reperfusion group. All animals were anesthetized with ketamine (50 mg/kg) and xylazine (4 mg/kg) and subjected to laparotomy. In the ischemia/reperfusion group, the right common iliac artery and the femoral artery–-just distal to the inguinal ligament–-were clamped for 3 hours using two Yasargil aneurysm clips providing 125 g (1.24 N) of force. By using a thermal pad, the deep rectal temperature was monitored by a rectal probe inserted 5 cm into the rectum and maintained at 36.5°C ± 1°C. All procedures were carried out for the sham-operated group, but arterial clamping was excluded. After 1 week of reperfusion, each animal's behavioral score was assessed based on gait, grasp, paw position, and pinch sensitivity; the score for each index was based on a scale of 0 (no function) to 3.0 (normal function), except for pinch sensitivity, the score for which ranged from 0 to 2.1 Then, the sciatic nerve was fixed in situ for 30 minutes using 4% formaldehyde in phosphate buffer (pH adjusted to 7.4), and then trifurcation of the sciatic nerve was removed, the nerve was embedded in paraffin, and sections were stained with hematoxylin and eosin and trichrome Gomori for light microscopy studies. The median behavioral scores were 5 and 11 in the ischemia/reperfusion and sham groups, respectively, and were significantly different (p < 0.05, Mann-Whitney U test). The pathologic markers for ischemia/reperfusion, including epineurial and endoneurial edema and demyelination in trichrome Gomori staining, were observed in the ischemia/reperfusion group but were absent in the sham-operated group (Figs. 1 and 2).Fig. 1.: Transverse section of the rat sciatic nerve after 7 days of reperfusion shows epineurial and endoneurial edema (hematoxylin and eosin stain).Fig. 2.: Transverse section of the rat sciatic nerve after 7 days of reperfusion shows epineurial and endoneurial edema and demyelination (trichrome Gomori stain).Our results show that common iliac artery and femoral artery clamping induces ischemia/reperfusion injury in the rat sciatic nerve. This method offers the obvious advantage of producing an easily inducible, moderate to severe neurologic deficit compared with current methods. However, a more comprehensive study containing several groups of different reperfusion intervals and quantification of pathological changes is needed to make the method practical for use in experimental studies. Mohammad R. Rasouli, M.D. School of Medicine Mohsen Nouri, M.D. School of Medicine Reza Rahimian, Ph.D. Department of Pharmacology Fahimeh Asadi Amoli, M.D. Trauma and Surgery Research Center Vafa Rahimi-Movaghar, M.D. Trauma and Surgery Research Center Ahmad R. Dehpour, Ph.D. Department of Pharmacology School of Medicine Medical Sciences/Tehran University Tehran, Iran

Fate Of Culture-Expanded Mesenchymal Stem Cells in The Microvasculature

Vascular delivery of mesenchymal stem cells (MSCs) following myocardial infarction is under clinical investigation. Little is known about the microvascular fate of MSCs. We used intravital microscopy of rat cremaster muscle microcirculation to track intraarterially delivered MSCs. Rat MSCs (average diameter, 23 microm) were bolused into the ipsilateral common iliac artery. Interrogation of an arteriole-venule pair revealed that 92+/-7% (n=6) of MSCs arrest and interrupt flow during first pass at the precapillary level, resulting in decreased flow in the feeding arteriole (velocity decreased from 6.3+/-1.0 to 4.6+/-1.3 mm/sec; P<0.001). MSC deformability evaluated using filtration through polycarbonate membranes revealed that the cortical tension of MSCs (0.49+/-0.07 dyne/cm, n=9) was not different from that of circulating mononuclear cells (0.50+/-0.05 dyne/cm, n=7). When intravital microscopy was performed 3 days following injection, the number of MSCs in the cremaster further decreased to 14% of the initial number, because of cell death in situ. In vivo labeling of the basement membrane revealed that at 1 day, the surviving cells were spread out on the luminal side of the microvessel, whereas at 3 days, they integrated in the microvascular wall. Despite their deformability, intraarterially delivered MSCs entrap at the precapillary level because of their large size, with a small proportion of surviving MSCs integrating in a perivascular niche.

Endovascular Repair of a Ruptured Internal Iliac Arterial Aneurysm With a Novel Application of the Aorto-uni-iliac Converter Device

Internal iliac artery aneurysms are rarely discovered by examination and may consequently present with rupture in a patient without an established diagnosis. Ruptured internal iliac aneurysms harbor a high risk of morbidity and mortality. Although open repair is possible, endovascular repair may be an option in some patients. We present a case of a ruptured internal iliac artery aneurysm with an adjoining ipsilateral common iliac artery aneurysm repaired with a novel use of an aorto-uni-iliac device.

Role of Intraoperative Completion Duplex Scan for Diagnosis of Iatrogenic Injuries of the Common Femoral Artery (CFA) and External Iliac Artery (EIA) during Endograft Placement

Objective To assess whether the femoral artery entry site could cause early endograft limb occlusion complication, we prospectively evaluated the ipsilateral common femoral artery (CFA) with intraoperative duplex scans (IDS). Methods Forty-seven patients underwent 41 abdominal aortic and 8 common iliac artery (CIA) aneurysms repair with endografts. All procedures were performed via open exposure of the CFA. All patients underwent IDS of the CFA and distal external iliac artery after repair of the arteriotomies. Results Overall, there were 91 arteries assessed with IDS. Overall incidence of significant lesions requiring repair was 11 of 91 (12%). In 10 arteries (11%) we documented intimal flaps causing severe (&gt;80%) stenoses that required repair. One more patient (1%) had no defects at the repair site, but low CFA peak systolic velocity with ratio 2:1 as compared with the contralateral CFA. Intraoperative abdominal duplex scan revealed a severe stenosis in the ipsilateral CIA that was not observed on the completion arteriogram. In addition, 13 (14%) nonsignificant flaps were visualized. No limb thromboses were noted in this group of patients on follow-up examinations. Conclusions IDS is helpful in detecting clinically unsuspected technical defects of the CFA. Timely diagnosis and repair of these defects may improve early patency of endograft limbs.

External iliac artery–to–internal iliac artery endograft: A novel approach to preserve pelvic inflow in aortoiliac stent grafting

Purpose: To describe four patients with abdominal aortic aneurysm and bilateral common iliac artery aneurysms repaired by coil embolization of the ipsilateral internal iliac artery, aortouniiliac endograft extended to the ipsilateral external iliac artery, femorofemoral bypass grafting, and a contralateral external iliac to internal iliac stent graft to preserve pelvic perfusion. Methods: Four patients with multiple risk factors, abdominal aortic aneurysm (mean diameter, 6.6 cm), and bilateral common iliac artery aneurysms were evaluated with contrast-enhanced computed tomography scanning, arteriography, and intravascular ultrasonography. Aortobiiliac endovascular abdominal aortic aneurysm repair was not feasible because of extension of the common iliac artery aneurysms to the iliac bifurcation bilaterally. Results: The abdominal aortic aneurysms were repaired with an aortouniiliac endograft. The ipsilateral common iliac artery aneurysms were treated by coil embolization of the internal iliac artery and extension of the endograft to the external iliac artery. The contralateral common iliac artery aneurysms were excluded by a custom-made stent graft (n = 2) or a commercial stent graft (n = 2) from the external iliac artery to the internal iliac artery, which preserved pelvic inflow via retrograde perfusion from the femorofemoral bypass. Mean length of stay was 3.5 days. One patient had hip claudication. Follow-up (mean 10 months, range 6 to 17) demonstrated exclusion of the abdominal aortic aneurysm and common iliac artery aneurysms with no endoleak and patent external iliac artery–to–internal iliac artery endografts in all patients. Conclusion: Patients with bilateral common iliac artery aneurysms that extend to the iliac bifurcation may be excluded from endovascular abdominal aortic aneurysm repair because of concerns regarding pelvic ischemia after occlusion of both internal iliac arteries. External iliac artery–to–internal iliac artery endografting is a feasible alternative to maintain pelvic perfusion and still allow endograft repair of the abdominal aortic aneurysm in these patients. (J Vasc Surg 2002;35:120-4.)

Improving microcirculation of muscle flaps by tissue plasminogen activator in the rat cremaster muscle flap model

Currently, tissue-plasminogen activator (t-PA) is the most potent and nevertheless safe fibrinolytic in clinical use. Its indications are fibrinolysis in acute myocardial infarction, ischemic stroke, deep vein thrombosis, pulmonary thromboembolism, as well as different kinds of peripheral arterial embolism. However, controlled studies on the effect of t-PA in microsurgery and free tissue transplantation are lacking. This study was designed to evaluate the effect of tissue-plasminogen activator on skeletal muscle flap perfusion after a thrombogenic stimulus. 24 male Sprague-Dawley rats were divided into four experimental groups of six animals each. In group 1, the cremaster was isolated as an end organ flap, in group 2 after cremaster isolation a semicircular inverted suture as a thrombogenic insult was performed at the ipsilateral common iliac artery. In group 3, local t-PA infusion followed the inverted suture and in group 4, vehicle was infused. After 24 hours, we measured cremaster muscle flap hemodynamics using intravital microscopy. Capillary perfusion significantly decreased after the inverted suture from 6.23 (group 1) to 1.50 (group 2) functional capillaries per visual field (medians). t-PA significantly increased capillary perfusion after the thrombogenic insult from 1.50 (group 2) and 2.50 (group 4) to 6.00 (group 3) (medians). Restoring capillary perfusion after a thrombogenic insult t-PA may increase flap survival rates.

Crossover iliofemoral bypass grafting for treatment of unilateral iliac atherosclerotic disease

Purpose: In patients with unilateral iliac disease, a less invasive procedure than aortobifemoral bypass grafting may be desirable, especially in poor-risk patients or when sexual dysfunction is feared. In these cases, femorofemoral (FF) bypass grafting is often proposed. Compared with FF bypass grafting, iliofemoral (IF) bypass grafting avoids bilateral exposure of the groins, which may reduce the risk of infection. When the primitive iliac artery is occluded from its origin or heavily calcified, one may use the contralateral artery as inflow, after a small retroperitoneal exposure, to perform a crossover iliofemoral (CIF) bypass grafting procedure, through the Retzius space. Our 10-year experience with CIF bypass grafting in a select group of patients was studied. Methods: Between 1986 and 1996, 36 patients underwent CIF bypass grafting for symptomatic unilateral iliac occlusion or stenosis. All patients were examined by means of Doppler ultrasound scanning and underwent bilateral multiplane angiography. Patients were considered for this procedure when the ipsilateral common iliac artery was occluded from its origin or was diffusely and heavily calcified. The decision to perform a CIF bypass grafting procedure was made when no significant disease of the contralateral common iliac artery was seen, and patients who had features of contralateral iliac disease were excluded. The main outcomes were perioperative mortality and morbidity, long-term primary and secondary patency rates, and limb salvage rate. Results: The study included 31 men and five women, with a mean age of 58.8 years. Indications for bypass grafting were disabling claudication (26 of 36 patients, 72%) and limb-threatening ischemia (10 of 26 patients, 28%). Twelve procedures were performed simultaneously: endarterectomy of the recipient common femoral artery (n = 3), femoropopliteal bypass grafting (n = 4, 11.1%), profundoplasty (n = 4, 11%), and right internal carotid endarterectomy (n = 1). New postoperative erectile dysfunction did not develop in any of the patients. The survival rate was 97.3% at 1 year and 68.5% at 5 years. The primary and secondary patency rates were 94% and 100%, respectively, at 1 year and 76.7% and 95%, respectively, at 5 years. The limb salvage rate was 100% at 1 year and 87% at 3 years. Conclusion: The operative mortality associated with CIF is low. The long-term primary and secondary patency rates are satisfactory, and they are lower than those reported for aortobifemoral bypass grafting. This procedure does not preclude a later performance of an aortobifemoral bypass grafting procedure. CIF bypass grafting is not only suitable for poor-risk patients with a limited life expectancy who have the appropriate arterial anatomy, but also may be warranted for young patients in whom erectile dysfunction is feared. (J Vasc Surg 1999;30:693-700.)

Tissue-plasminogen activator restores muscle flap perfusion in the rat.

This study was designed to evaluate the effect of tissue-plasminogen activator on skeletal muscle flap perfusion after a thrombogenic insult. Twenty-four male Sprague-Dawley rats were divided into 4 experimental groups of 6 animals each. In group 1 (sham), the cremaster muscle was isolated as an end-organ flap. In group 2, after cremaster muscle isolation, a semicircular inverted suture as a thrombogenic insult was performed at the ipsilateral common iliac artery. In group 3, local tissue-plasminogen activator infusion followed the inverted suture. In group 4, vehicle was infused. After 24 hours, the cremaster muscle flap hemodynamics and leukocyte-endothelial interactions were measured using intravital microscopy. Capillary perfusion significantly decreased after the inverted suture from a median of 6.23 (group 1) to 1.50 (group 2) functional capillaries per visual field. Tissue-plasminogen activator significantly increased capillary perfusion after the thrombogenic insult from a median of 1.50 (group 2) and 2.50 (group 4) to 6.00 (group 3). Tissue-plasminogen activator restored capillary perfusion after a thrombogenic insult to the main feeding artery.

Thrombogenic stimulus causes long-term decrease of muscle flap perfusion.

This study was designed to evaluate the effect of a continuous thrombogenic insult at the feeding artery on skeletal muscle flap perfusion over 24 hours. Twelve male Sprague-Dawley rats were divided into two experimental groups. In the control group (N = 6) and in the treatment group (N = 6) the right cremaster muscle was isolated on its neurovascular pedicle and the tubular muscle flap was preserved in the medial part of the hind limb over a 24-hour period for subsequent microcirculatory observation. In the treatment group, an inverting suture was applied over half of the circumference of the ipsilateral common iliac artery to create a continuous thrombogenic stimulus. Intravital microcirculatory measurements obtained were red blood cell velocities, vessel diameters, capillary perfusion, endothelial edema index, and leukocytic-endothelial interactions. There were no statistically significant differences seen in red blood cell velocities, vessel diameters, and leukocytic-endothelial interactions between the groups. However, the inverting suture caused a significant drop in capillary perfusion from 6.23 to 1.50 capillaries per visual field (median; p = 0.002). An arterial thrombogenic insult may result in a significant decrease in capillary perfusion in muscle flaps over 24 hours although the blood flow through the thrombogenic main feeding vessel is maintained.

The Perth endoluminal bifurcated graft system - development and early experience

The study aim was to develop a reliable endoluminal graft system that would enable the deployment of a bifurcated graft for infrarenal abdominal aortic aneurysms. A life-size plastic model was made of an abdominal aorta and iliac arteries, with a 50-mm infrarenal abdominal aortic aneurysm. This model was used to develop and test self-expanding graft systems, based on a barbed Gianturco stent and series of stainless-steel ‘Z’ stents within a woven Dacron graft. The bifurcated system developed involves a trouser graft with one long leg and one short. This graft system is delivered through one femoral artery with deployment of the proximal aortic end infrarenally and the longer trouser leg within the ipsilateral common iliac artery. The short trouser leg is left hanging free within the distal end of the aneurysm cavity, just above the bifurcation. It is held open by a self-expanding stent and is cannulated from the contralateral femoral artery with a guide wire. A simple straight self-expanding stented graft is then deployed to extend this short trouser leg down into the common iliac artery, effectively creating an extension to the short leg. The graft system has been deployed in 21 patients with satisfactory exclusion of the aneurysm in 17 (81%). There has been one mortality and no conversion to open repair. All 17 aneurysms remain excluded at median follow-up of 30 (range 4–60) weeks. None of the four graft stents that leaked (two proximal and two distal) sealed spontaneously. Deployment of the uncovered Gianturco stent across the renal artery origins in 18 cases (85%) has not been associated with renal artery occlusion or deterioration in renal function at a median follow-up of 30 (range 4–60) weeks. The ability to deploy a bifurcated system increases the potential for endoluminal treatment of abdominal aortic aneurysm. Copyright © 1996 The International Society for Cardiovascular Surgery.

The Perth Endoluminal Bifurcated Graft System — Development and Early Experience

The study aim was to develop a reliable endoluminal graft system that would enable the deployment of a bifurcated graft for infrarenal abdominal aortic aneurysms. A life-size plastic model was made of an abdominal aorta and iliac arteries, with a 50-mm infrarenal abdominal aortic aneurysm. This model was used to develop and test self-expanding graft systems, based on a barbed Gianturco stent and series of stainless-steel ‘Z’ stents within a woven Dacron graft. The bifurcated system developed involves a trouser graft with one long leg and one short. This graft system is delivered through one femoral artery with deployment of the proximal aortic end infrarenally and the longer trouser leg within the ipsilateral common iliac artery. The short trouser leg is left hanging free within the distal end of the aneurysm cavity, just above the bifurcation. It is held open by a self-expanding stent and is cannulated from the contralateral femoral artery with a guide wire. A simple straight self-expanding stented graft is then deployed to extend this short trouser leg down into the common iliac artery, effectively creating an extension to the short leg. The graft system has been deployed in 21 patients with satisfactory exclusion of the aneurysm in 17 (81%). There has been one mortality and no conversion to open repair. All 17 aneurysms remain excluded at median follow-up of 30 (range 4–60) weeks. None of the four graft stents that leaked (two proximal and two distal) sealed spontaneously. Deployment of the uncovered Gianturco stent across the renal artery origins in 18 cases (85%) has not been associated with renal artery occlusion or deterioration in renal function at a median follow-up of 30 (range 4–60) weeks. The ability to deploy a bifurcated system increases the potential for endoluminal treatment of abdominal aortic aneurysm.