Giovanni Colacchio

Infrapopliteal polytetrafluoroethylene and composite bypass: Factors influencing patency

Between January 1, 1979, and December 31, 1988, 149 infrapopliteal polytetrafluoroethylene (PTFE) bypasses were performed in 145 patients with chronic, critical, limb-threatening ischemia. These operations represented 27.9% of 534 infrapopliteal bypasses performed during the same period. There were 92 males and 53 females. Mean age was 71.8±12.3 years. Signs and symptoms of critical ischemia were gangrene, ulceration, and isolated rest pain in 101 (69%), 23 (15.3%), and 25 (16.7%) cases, respectively. A composite (PTFE-saphenous vein) graft was used in 53 (35%) cases. In 96 prosthetic bypasses the distal anastomosis was performed using vein patch angioplasty in 65 (44%) cases and directly in 31 (21%). The in-hospital mortality rate was 3.3%. Patency, limb salvage, and patient survival rates were plotted according to the actuarial method and the curves obtained were compared using the log-rank test. Actuarial survival rates were 68%±5% and 57%±7% at 3 and 5 years, respectively. Primary patency and lower limb salvage rates were 41%±5% and 68%±6% at 3 years and 35%±9% and 65%±10% at 5 years, respectively. There was no statistically significant difference noted in primary patency rates at 3 years according to the type of bypass (composite or all-prosthetic: 36% vs. 44%), the type of distal anastomosis (direct or vein patch angioplasty: 43% vs. 45%), the site of distal anastomosis (upper or lower half of the leg: 38% vs. 46%), lateral or medial placement of the bypass (39% vs. 43%), or according to whether or not it was a repeat operation (40% vs. 44%). In conclusion, patency rates using infrapopliteal PTFE bypasses are low. Certain technical approaches, although they do not seem to improve patency, definitely increase the feasibility of bypass and in our opinion decrease the risk of early failure in unfavorable anatomic settings. The limb salvage rates following infrapopliteal PTFE and composite bypass are encouraging and justify the use of routine distal revascularization, even in the absence of autogenous vein graft.

Total laparoscopic juxtarenal abdominal aortic aneurysm repair

OBJECTIVES This study describes our experience of total laparoscopic juxtarenal abdominal aortic aneurysm (JAAA) repair. METHODS Between February 2002 and October 2007, we performed 148 total laparoscopic AAA repairs, including a subset of 13 patients who underwent a laparoscopic JAAA repair. Median age was 70 years (range, 50-81years). Median aneurysm size was 55 mm (range, 50-80 mm). Eight patients were in American Society of Anesthesiologist class II, and five were in class III. We used laparoscopic transperitoneal left retrorenal approaches and suprarenal clamping in all patients. RESULTS We implanted tube grafts in nine patients and bifurcated grafts in four. No conversions to open repair were required. Median operative time was 260 minutes (range, 180-355 minutes). Total median aortic clamping time was 77 minutes (range, 36-105 minutes). Median suprarenal clamping time was 24 minutes (range, 9-37 minutes). Median blood loss was 855 mL (range, 215-2100 mL). No patients died. One patient had a postoperative coagulopathy with hemorrhagic syndrome. Five patients had moderate systemic complications, including four renal insufficiencies without dialysis and one grade I ischemic colitis. Liquid diet was reintroduced after 1 day (range, 1-7 days). Most patients were ambulatory by day 3 (range, 2-17 days). Median lengths of stay were 48 hours (range, 12-336 hours) in the intensive care unit and 10 days (range, 4-30 days) in the hospital. With a median follow-up of 19 months (range, 1-36 months), patients had complete recovery without graft anomalies. CONCLUSION Total laparoscopic JAAA repair is feasible and worthwhile for patients. Prior experience in laparoscopic aortic surgery is essential to perform these challenging procedures. Despite these encouraging results, a greater experience is required to ensure the benefit of this technique compared with open repair.

Renal Revascularization in High-Risk Patients: The Role of Iliac Renal Bypass

Between 1984 and 1989, 29 iliac renal artery bypasses were performed in 29 patients (mean age 67.8 years) with severe renovascular disease due to atheroma. The indication for renal artery reconstruction was hypertension in all patients, which was associated with kidney failure in 16 cases. In six cases, reconstruction was performed after failure or complications of percutaneous transluminal angioplasty. The bypass was constructed with polytetrafluoroethylene in 24 cases (83%) and vein graft in five cases (17%). There was no postoperative mortality. All bypasses were found to be patent on duplex scanning or digital subtraction arteriograms. One patient was lost to follow-up. Mean follow-up was 23.2 months. One patient died of acute kidney failure, probably related to occlusion of the bypass. Hypertension improved in 22 cases (79%), was cured in two cases (7%), and remained unchanged in four (14%). Renal function remained unchanged in six cases (40%) and improved in nine (60%). Iliac-to-renal artery bypass seems to be the surgical renal revascularization modality best adapted to high-risk patients or those who have severe atheroma. Additionally, this technique enables rapid treatment of failures or complications of percutaneous transluminal angioplasty of the renal artery.

A technical tip for total laparoscopic type II endoleak repair

Laparoscopy is a minimally invasive alternative for type II endoleak repair after endovascular aneurysm repair. However, control of lumbar and median sacral arteries is considered technically difficult due to the dense inflammatory tissue surrounding the aorta. We describe a technical tip that avoids close dissection of the aneurysm sac. After the transperitoneal approaches we commonly use during laparoscopic aortic surgery, the aneurysm is drawn rightward to access the plane of the anterior longitudinal ligament. This technique allows a direct exposure of the lumbar and median sacral arteries, which are all methodically dissected and ligated along the anterior wall of the spine without close dissection of the aneurysm sac. In our experience, this technical tip was always feasible and simplified laparoscopic type II endoleak repair.

Single anterior retroperitoneal approach for bilateral exposure of iliac arteries

Elective bilateral exposure of iliac arteries during endovascular or laparoscopic aneurysm repair is commonly performed through two retroperitoneal incisions in the iliac fossa. Larger incisions are necessary when simultaneous external and common iliac exposures are needed. We describe a new technique using a single incision for bilateral approach of the iliac arteries. Exposure of iliac arteries through this bilateral anterior paramedian retroperitoneal approach allows the introduction of endografts, crossover ilioiliac bypass, implantation of graft limbs for bifurcated bypass grafting, reconstruction of internal iliac arteries, and ligature of iliac arteries.

Hybrid Repair of Type II Dissecting Thoracoabdominal Aneurysm Using Amplatzer Vascular Plugs for Entry Tear Closure

Endovascular repair of chronic aortic dissections (CAD) intend to promote false lumen thrombosis (FLT). This article describes a technique using Amplatzer vascular plugs (AVPs) for entry tear closure of CAD. A 70-year-old man presented with a type II dissecting thoracoabdominal aneurysm. Computed tomography scan showed a very tight true lumen, partial FLT, and 2 entry tears at the level of the left subclavian artery and the visceral aorta, respectively. During a first procedure, aortic debranching was performed using the ascending aorta as bypass inflow. In a second intervention entry tears were closed using AVPs protected by short stent grafts. Technical success was achieved. No paraplegia occurred. Eighteen months later, FLT was complete and aortic diameter decreased. Entry tear closure using AVPs is feasible and allows FLT. Further reports are needed to determine if stent-graft protection of AVPs is mandatory, which may simplify technical aspects of the procedure.

Cirugía videoscópica de los aneurismas de la aorta abdominal

En todas las disciplinas, la cirugia videoscopica implica: una vision del campo quirurgico en dos dimensiones, la ausencia de sensacion tactil y una instrumentacion especifica Los cirujanos integran enseguida la vision bidimensional a medida que adquieren experiencia. Las principales dificultades surgen durante las suturas arteriales. La ausencia de sensacion tactil dificulta en gran medida la realizacion de los distintos tiempos quirurgicos. En las vias de acceso a la aorta abdominal, el cirujano debe orientarse solo en funcion de los planos y de las referencias anatomicas. Ya no es posible dirigir la diseccion hacia los troncos arteriales ayudandose de la palpacion de las estructuras y, sobre todo, de la palpacion de los latidos arteriales. Al contactar con los troncos arteriales, el cirujano no tiene el mismo control de las zonas de calcificacion o de fragilidad de la pared arterial antes de realizar los pinzamientos y las anastomosis. Otra especificidad del acceso aortico mediante videoscopia es la utilizacion de una tecnica para mantener la exposicion porque, al contrario de la cirugia tradicional, no se dispone de separadores o de valvas para mantener la masa visceral. En noviembre de 2000, los autores de este articulo desarrollaron una tecnica nueva totalmente videoscopica para el tratamiento de las lesiones oclusivas aortoiliacas (LOAI) graves. A partir de esta experiencia, se ha desarrollado el tratamiento totalmente videoscopico de los aneurismas de la aorta abdominal (AAA). La cirugia videoscopica de los AAA consta de dos etapas tecnicas esenciales: la exposicion de la aorta abdominal seguida del desbridamiento-injerto.