Sabrina Houthoofd

Heparin-bonded ePTFE grafts compared with vein grafts in femoropopliteal and femorocrural bypasses: 1- and 2-year results.

OBJECTIVE Many patients with peripheral arterial occlusive disease who require a lower-limb bypass have no available autologous saphenous vein (ASV) for the procedure and thus require a prosthetic graft. Expanded polytetrafluoroethylene (ePTFE) grafts are commonly used, but results with these prostheses have varied, especially when the distal anastomosis is below the knee. However, there is increasing evidence that ePTFE grafts to which heparin has been bound with use of covalent endpoint linkage provide better results. This nonrandomized study compared the performance of these grafts with that of ASV conduits in the largest clinical series of heparin-bonded ePTFE graft implantations reported so far. METHODS The records of 350 patients who underwent a lower-limb bypass procedure that used either a heparin-bonded ePTFE graft (n = 240) or an ASV graft (n = 110) were reviewed, and preoperative, operative, and follow-up data were recorded. Kaplan-Meier analyses were used to calculate primary patency and limb salvage rates in the two graft groups; results were compared by using log-rank testing. RESULTS The primary patency rates at 1 year for the heparin-bonded ePTFE grafts were 92% for above-knee femoropopliteal (AK FP) bypasses, 92% for below-knee femoropopliteal (BK FP) bypasses, and 79% for femorocrural (FC) applications. The corresponding 2-year rates were 83%, 83%, and 69%, respectively. In the ASV group, the 1-year primary patency rates for AK FP, BK FP, and FC bypasses were 91%, 72%, and 69%, respectively; the 2-year rates were 80%, 72%, and 64%, respectively. There were no significant differences in patency when AK FP, BK FP, or FC procedures were considered separately. Two-year limb salvage rates in the heparin-bonded ePTFE graft group were 92%, 98%, and 87%, respectively, for AK FP, BK FP, and FC bypasses; in the ASV group, the rates were 100%, 91%, and 96%, respectively. Two infections occurred in patients given a heparin-bonded ePTFE graft. CONCLUSION In this large retrospective study, heparin-bonded ePTFE grafts had 1- and 2-year primary patency results that were not significantly different from those for ASV grafts. Results in BK FP and FC applications were especially promising. Randomized studies comparing the use of heparin-bonded ePTFE and ASV grafts in the treatment of peripheral arterial disease are needed to substantiate our results.

Treatment of mycotic aneurysms with involvement of the abdominal aorta: single-centre experience in 44 consecutive cases

OBJECTIVE To review our management of mycotic aneurysms involving the abdominal aorta over the past 2 decades to assess the safety and efficacy of in-situ and extra-anatomic repair combined with antibiotic treatment. MATERIALS AND METHODS From March 1990 to August 2008, 44 patients with a mycotic aneurysm involving the abdominal aorta were treated at our University Hospital. For all patients, we recorded the aetiology, clinical findings and anatomic location of the aneurysm, as well as bacteriology results, surgical and antibiotic therapy and morbidity and mortality. RESULTS Twenty-one (47.7%) of the mycotic aneurysms had already ruptured at the time of surgery. Free rupture was present in nine patients (20.5%). Contained rupture was observed in 12 patients (27.3%). Urgent surgery was performed in 18 cases (40.9%). Revascularisation was achieved by in-situ reconstruction in 37 patients (84.1%), while extra-anatomic reconstruction was performed in six patients (13.6%). One patient (2.3%) was treated with a combined in-situ and extra-anatomic reconstruction. In one case (2.3%), endovascular aneurysm repair (EVAR) was performed. In-hospital mortality was 22.7%, 50% in the extra-anatomic reconstruction group and 18.9% in the in-situ repair group. One-third (33.3%) of our patients, who presented with a ruptured mycotic aneurysm died in the peri-operative period. This mortality was 13% in the patient-group presenting with an intact aneurysm. Of the 34 surviving patients, 12 patients (27.3% of surviving patients died after discharge from our hospital. In half of these patients, an acute cardiac event was to blame. Three patients (8%) showed re-infection after in-situ reconstruction. CONCLUSION Management of mycotic aortic aneurysms remains a challenging problem. The results of surgery depend on many factors. In our experience, in-situ repair remains a feasible and safe treatment option for patients who are in good general condition at the time of surgery.

Long-term results after endovascular abdominal aortic aneurysm repair using the Cook Zenith endograft

OBJECTIVE This study assessed the long-term outcome of patients with abdominal aortic and aortoiliac aneurysms treated with the Cook Zenith endovascular graft (Cook Inc, Bloomington, Ind). METHODS Between September 1998 and October 2003, 143 patients underwent elective endovascular aneurysm repair (EVAR) using the Cook Zenith endograft. Data from these patients were reviewed from a prospective database in October 2008. Primary outcome measures were overall survival, intervention-free survival, and freedom from aneurysm rupture. Secondary outcome measures were early and late postoperative complications, including endoleaks. RESULTS Mean follow-up was 66.4 months (range, 1.9-121.0 months). Overall survival was 72.1% at the 5-year follow-up and 50.9% at the 8-year follow-up. Intervention-free survival was 77.1% at 5 years and 63.8% at 8 years. There were no reintervention-related deaths. Six patients had a late aneurysm rupture, which was fatal in three. Freedom from aneurysm rupture was 98.1% at 5 years and 91.0% at 8 years. Late complications occurred throughout the follow-up period, with a tendency for aneurysm rupture and surgical conversion to occur at a later stage in the follow-up period. Aneurysm sac enlargement during follow-up was associated with late aneurysm rupture and with the need for reintervention. CONCLUSION Elective EVAR using the Cook Zenith endograft provides excellent results through a mean follow-up of >5 years. There is a low aneurysm-related mortality and an acceptable rate of postoperative complications and reinterventions. The occurrence of late complications throughout the follow-up period stresses the need for continued postoperative surveillance in EVAR patients.

The learning curve of totally laparoscopic aortobifemoral bypass for occlusive disease. How many cases and how safe

OBJECTIVES Totally laparoscopic aortic surgery is appealing. However, the adoption of this technique in the broad vascular world is hampered by the steep learning curve and the fear of exposing patients to excessive morbidity and mortality. We assessed how many patients should be treated to overcome this learning curve. MATERIALS AND METHODS The first 50 patients treated with totally laparoscopic aortobifemoral bypass for severe aorto-iliac occlusive disease were followed prospectively. Operative variables such as operative time, aortic clamping time, amount of blood loss, conversion to laparotomy etc were recorded (as well as 30-day mortality and morbidity). To discover a turning point we used the technique of sliding averages. These data were compared with the mortality and morbidity as predicted by POSSUM and P-POSSUM. RESULTS A clear turning point, with improved operative variables, was seen after 20-30 patients. Mortality and morbidity were not higher than predicted by POSSUM and P-POSSUM. CONCLUSIONS These data confirm the intuition of most people involved in laparoscopic aortic surgery that the learning curve could be set at 25-30 cases. However, patients are not exposed to excessive morbidity and mortality during this learning curve.

Esophageal Necrosis After Endoprosthesis for Ruptured Thoracoabdominal Aneurysm Type I: Can Long-Segment Stent Grafting of the Thoracoabdominal Aorta Induce Transmural Necrosis?

BACKGROUND To study the pathophysiology of esophageal necrosis after endoprosthesis was performed for a ruptured aneurysm and to define preventive measures and possible treatment options. METHOD A 72-year-old man with thoracoabdominal aneurysm type I and dysphagia underwent an emergent carotico-carotid bypass in combination with thoracic endovascular aortic aneurysm repair starting at a point distal to the brachiocephalic trunk and ending proximal to the superior mesenteric artery. On day 12, a decortication was performed for treating an infection in the remaining hematoma. However, further deterioration occurred as a result of mediastinitis secondary to the transmural necrosis of the middle third of the esophagus combined with accompanying mediastinitis. The patients family refused to give consent for further treatment by esophagectomy. He died 24 days after the initial operation. CONCLUSION Dysphagia aortica, mucosal abnormalities on esophagogastroscopy, and mediastinal compression by hematoma at the time of rupture draws our attention toward ischemia of the esophagus after thoracic endovascular aortic aneurysm repair. Repeated esophagoscopy can provide us with the opportunity to act before full thickness necrosis and mediastinitis occur.

Embolization of an Internal Iliac Artery Aneurysm after Image-Guided Direct Puncture

ObjectiveTo evaluate the feasibility, safety, and efficacy of embolization of internal iliac artery aneurysm (IIAA) after percutaneous direct puncture under (cone-beam) computed tomography (CT) guidance.MethodsA retrospective case series of three patients, in whom IIAA not accessible by way of the transarterial route, was reviewed. CT-guided puncture of the IIAA sac was performed in one patient. Two patients underwent puncture of the IIAA under cone-beam CT guidance.ResultsAccess to the IIAA sac was successful in all three patients. In two of the three patients, the posterior and/or anterior division was first embolized using platinum microcoils. The aneurysm sac was embolized with thrombin in one patient and with a mixture of glue and Lipiodol in two patients. No complications were seen. On follow-up CT, no opacification of the aneurysm sac was seen. The volume of one IIAA remained stable at follow-up, and the remaining two IIAAs decreased in size.ConclusionEmbolization of IIAA after direct percutaneous puncture under cone-beam CT/CT-guidance is feasible and safe and results in good short-term outcome.

Thoracic endovascular aortic repair for treatment of late complications after aortic coarctation repair.

BACKGROUND To report our experience with thoracic endovascular aortic repair (TEVAR) for treatment of postcoarctation repair aortic aneurysms. METHODS Between November 2000 and December 2008, 13 patients were treated with TEVAR and rerouting of the supra-aortic vessels for aortic aneurysm (n = 10) and pseudoaneurysm (n = 3). RESULTS One patient (7.7%) died due to peroperative perforation of the aorta. For the other patients, the median hospital stay was 9 days. One patient needed an additional stent because of a type I endoleak. Two patients (15.4%) developed a small type II endoleak for which no additional intervention was needed. One patient developed hemothorax, four patients (30.8%) had a Horner syndrome, one patient had a phrenic nerve paresis, and another patient developed hemiplegia. The mean follow-up of the survivors was 35 months (range, 2-72) with a median of 30 months. Most patients (84.6%) showed a decrease or stabilization of the size of the aneurysm sac. One patient had recurrent pneumonia with increase of the size aneurysm after 3 years. CONCLUSIONS TEVAR is appealing for patients with late complications after aortic coarctation repair, but necessitates long-term follow-up.

Conversion During Laparoscopic Aortobifemoral Bypass: A Failure?

OBJECTIVES To study the impact of conversion on postoperative recovery, morbidity and mortality in laparoscopic aortobifemoral bypass surgery for aorto-iliac occlusive disease (AIOD). DESIGN Retrospective analysis of a prospectively maintained database. METHODS Between November 2002 and December 2006, 139 patients were treated for severe AIOD with a laparoscopic aortobifemoral bypass at one community and one university hospital. Demographic data, operative data, postoperative recovery data, morbidity and mortality were recorded and analysed according to a conversion and a non-conversion group. RESULTS Conversion was needed in 13.7% of the patients. Morbidity was 16.5%-14.2% in the non-conversion group and 31.8% in the conversion group. Systemic morbidity was significantly higher in the conversion group (31.6% vs.10%; p=0.002), but only one patient had incomplete recovery; local morbidity was comparable in both groups (10.5% vs. 5.8%; p=0.337). Mortality rate was 2.2%. CONCLUSION Laparoscopic aortobifemoral bypass surgery is a safe procedure for the treatment of AIOD. The outcome of patients after conversion is not affected in the way that it could be an impediment to start a laparoscopic procedure. Conversion in time is a safe way to overcome the learning curve.

Endovascular treatment of an iliocaval arteriovenous fistula presenting with multiple organ failure.

Iliocaval arteriovenous fistula is an uncommon, but challenging condition. The most common cause is spontaneous rupture of the iliac artery into the venous system due to aneurismal dilatation. We report a case of iliocaval fistula after previous aortic surgery presenting as acute liver failure as most prominent part of multiple organ failure and successful endovascular repair.

A Case of Primary Aortoenteric Fistula: Review of Therapeutic Challenges.

BACKGROUNDS Primary aortoenteric fistula (PAEF) is a lethal cause of gastrointestinal bleeding. They mainly originate from eroding abdominal aortic aneurysms into the intestinal wall. Other known causes involve malignancies, infection, corpora aliena, or radiation therapy. Traditional treatment consists of resection of the fistula and extra-anatomic reconstruction. In situ repair and endovascular stenting have offered new therapeutic options in managing this complex entity. CASE REPORT A 79-year-old woman presented with a PAEF. She was known with a 3.9-cm abdominal aortic aneurysm and polymyalgia rheumatica. The initial treatment consisted of endovascular stenting. Several months later, she presented with persistent inflammation of the aortic endoprosthesis. The prosthesis and inflammatory tissue were resected, and in situ reconstruction with autologous superficial femoral vein and omentoplasty was performed. Two years later, she remains well with no evidence for infection or bleeding. CONCLUSIONS Polymyalgia rheumatica might induce an AEF as in this patient no other provoking factors were retained. The different therapeutic options all have their advantages and disadvantages. In line with this case, we suggest an individualized approach for AEFs. In case of precarious hemodynamical state or life expectancy, endovascular treatment is indicated. Afterward, the possibility and/or necessity of open repair should be discussed. For stable patients with respectable life expectancy in situ repair with autologuous vein or rifampicin-soaked prosthesis (adjusted to comorbidities) might be most appropriate. Extra-anatomic reconstruction still remains a valuable alternative in older patients and in the presence of any other local factors hampering in situ reconstruction.