Shemuel B. Psalms

Aortoiliac aneurysm repair in kidney transplant recipients.

A potential problem during endovascular aortic aneurysm repair (EVAR) or open repair in renal allograft patients is ischemia of the transplanted kidney. In this study, kidney transplant patients who underwent aortic aneurysm repair in our institution were added to similar cases extracted from the literature to represent the basis of this work. Comparisons between patients treated with open surgery versus EVAR were performed in terms of renal function. In the EVAR group, most aneurysms were infrarenal, and 84% were treated with modular bifurcated devices. Protective kidney allograft perfusion measures were not used. The pre- and postoperative Cr was 1.69 and 1.73 mg/dL, respectively (P = .412). All EVAR patients had good outcomes. Complications included 8 endoleaks and 1 limb ischemia case. Three patients died from aortic repair-unrelated reasons. In the open group, the pre-and postoperative Cr was 1.45 and 1.37 mg/dL, respectively (P = .055). Most cases were infrarenal and mostly treated by aortobiiliac bypasses. In 16%, no adjuvant allograft perfusion was provided. In the rest, temporary axillofemoral bypasses were used most often. Most outcomes were favorable (57%). Reported procedural-related complications included arterial embolism, wound infection, and pneumonia. Deaths were reported in 5 occasions (none allograft failure dependent). No differences in Cr between EVAR and open techniques (P = .13) were seen. Aneurysm repair in kidney transplant recipients is associated with excellent renal preservation. Adverse outcomes were all allograft failure independent in both groups. EVAR without special allograft protection measures seems to be equally effective as open surgery with or without adjuvant kidney transplant perfusion.

Portomesenteric reconstruction during Whipple procedures: Review and report of a case

A 60-year-old man undergoing a Whipple procedure to treat a pancreatic cancer was found to have tumor adherence to the portal vein. An en block pancreaticoduodenectomy with segmental portal vein resection (PVR) was performed. A primary portal vein anastomosis was initially attempted but failed. Hemodynamic deterioration led the authors to perform a temporary prosthetic portal vein interposition graft and abdominal closure. The following morning, once stable, the patient was brought back to the operating room for autologous reconstruction with femoral vein and completion of the pancreaticoduodenectomy. The role of PVR for vein invasion or tumor adherence during a Whipple procedure is still under debate. However, there is growing evidence that the perioperative morbidity and long-term survival in patients who undergo a pancreaticoduodenectomy with PVR are similar to those of patients without vein resection. Therefore a combined resection of the pancreatic head and the portal vein has been suggested in the absence of other contraindications for resection to be able to offer a curative surgical intervention to a larger number of patients. The authors herein report the details of a patients case and also review the currently available methods for PVR and reconstruction.

Aortofemoral graft limb–to–colon paraprosthetic fistula

A 58-year-old man presented with fever. During several hospitalizations in the preceding 3 months, bacteremia had been documented on seven occasions. Escherichia coli, Clostridium, and Candida spp were repeatedly recovered in blood cultures. The patient’s history was pertinent for tobacco abuse and severe claudication, which was initially treated with femorofemoral bypass graft. This failed, however, which prompted conversion to an aortobifemoral bypass (performed elsewhere), with resultant complete relief of claudication. The patient denied abdominal pain and had no evidence of overt or occult gastrointestinal (GI) bleeding. Fever and malaise persisted for 3 months. Abdominal computed tomography (CT) scans were performed on two occasions, and the results interpreted as negative. The Vascular Surgery Service was ultimately consulted and determined the patient’s clinical history and CT were highly suggestive of a secondary aortoenteric fistula (SAEF) involving the left aortobifemoral graft limb and the colon (A, arrow). The graft body, right limb, and both femoral regions appeared to be free of infection. An indium-111 white blood cell scan suggested isolated left midprosthetic limb involvement (B, arrow), and colonoscopy unequivocally established the diagnosis (Cover). Single-stage redo femorofemoral bypass and left aortofemoral graft limb excision was performed. At laparotomy, the left graft limb was densely incorporated to adjacent tissues, without gross contamination. The limb was transected and oversewn proximally. When followed distally, it was noted to traverse the sigmoid colon (C). Partial sigmoid resection with primary anastomosis was performed. The patient has since done well, without evidence of recurrent infection and with patent vascular reconstructions. SAEF is a direct communication between a vascular prosthesis and the GI tract. Most aortoenteric fistulas involve the graft-aortic suture line, with fistulization into the bowel lumen and resultant GI hemorrhage. A less common type of fistula, termed a paraprosthetic fistula, is defined as a communication between the surface of the graft body and the bowel lumen without suture line involvement or actual fistulization into the vascular lumen. The duodenum is the most frequently involved bowel segment for both types of SAEFs. Graft-colonic fistulae are much less common, comprising only 4.8% to 6.6% of cases in reported SAEF series. Because they do not involve the anastomosis, paraprosthetic fistulas do not result in GI hemorrhage, but rather sepsis, malaise, and other less specific symptoms. In patients who do not require emergency intervention, CT is the recommended initial diagnostic study of choice whenever SAEF is considered. A positive indium-111 white blood cell scan supports the diagnosis of SAEF. Endoscopy can be a definitive diagnostic tool, but may also serve to exclude other pathology in patients with GI bleeding. Traditional therapy for SAEF, especially for aortoduodenal fistula, is GI tract restoration, complete prosthetic graft excision, aortic stump closure, and extra-anatomic bypass. More conservative approaches such as partial graft preservation, excision of the involved limb, and extra-anatomic bypass, as used in this patient, are simpler, effective, and have potentially less morbidity in carefully selected, high-risk patients.

Nontraumatic Aneurysms Affecting Crural Arteries: Case Report and Review of the Literature

Aneurysms involving the infrapopliteal arteries are rare, with most cases being attributed to a previous traumatic event. Mycotic aneurysms in this location are even more uncommon. Owing to their infrequency, these aneurysms represent a difficult diagnostic challenge. We present a case of a symptomatic anterior tibial artery aneurysm in a 59-year-old male with a medical history significant only for an episode of bacterial endocarditis, subsequently requiring an aortic valve replacement. Surgical repair was performed with a popliteal to anterior tibial bypass with a reversed saphenous vein graft. The patients recovery was uneventful. We also reviewed the literature on this type of aneurysm to assess the incidence, etiology, options for treatment, and outcomes.

Endovascular Common Iliac Aneurysm Exclusion with Antegrade Hypogastric Artery Flow Preservation: A Novel Approach

Open surgical repair of iliac aneurysms has been usually associated with significant morbidity and mortality. The introduction of novel endovascular techniques has expanded the currently available options to treat these aneurysms. However, the use of endoluminal stent grafts to treat common iliac artery aneurysms by landing their distal end into the hypogastric artery in patients where flow into the latter artery is crucial to avoid end-organ ischemia has only been rarely reported in the past. A case report of a common iliac aneurysm case treated with a novel therapeutic approach, not previously reported is herein presented. Three telescopically-overlapping Hemobahn/Viabahn polytetrafluoroethylene (PTFE)-covered endoprosthesis (W.L. Gore & Associates, Flagstaff, AZ) were used with success.

Aortitis and bacterial endocarditis.

Aortitis is an inflammatory condition that can be due to numerous causes. It is a diagnostic quandary because it commonly shows similar clinical, pathologic, and aortographic features independently of the etiology. A case of aortitis, possibly secondary to bacterial endocarditis, initially misdiagnosed as an atherosclerotic aortic ulcer and managed with an endoprosthesis is presented. On the fourth postoperative day, the patient presented with fever and worsening abdominal pain, which was later diagnosed as infectious aortitis. It required débridement and replacement of the infrarenal aorta with a cadaveric cryopreserved allograft. This case emphasizes the need for early diagnosis and aggressive therapy to avoid life-threatening sequelae.

Diabetic foot infections in the elderly: primary amputation versus ‘foot-sparing surgery’. A case report

Renal failure diabetic patients who present with lower extremity gangrene represent one of the most difficult problems encountered in a typical vascular practice. We report the hospital course and management of a 74‐year‐old male patient with such comorbidities, affected by a non healing ulcer that progressed into a large plantar abscess. Our case unfortunately mirrors a common method of evaluation and therapy of patients with such comorbidities and sets up the stage for a very controversial subject.

DIABETIC FOOT INFECTIONS IN OLDER PEOPLE WITH END-STAGE RENAL DISEASE: PRIMARY AMPUTATION VERSUS “FOOT-SPARING SURGERY”

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