Aorto-iliac stent graft infection complicated by endotension and consequent rupture of the aneurysmal sac: a case report.

We present a case report of a bifurcated aorto-iliac stent graft infection two years after implantation. The initial procedure of implantation as well as the patient's recovery was uneventful. Two years later the patient presented with a growing aneurysmal sac without a detectable endoleak and consequent rupture. Instead of graft explantation, we left the graft in situ and performed thorough debridement and an omentoplasty, because of the poor condition of the patient. A Staphylococcus species grew out of the cultures of the aortic wall. The patient recovered well without persistent infection and is still doing well after 43 months. This conservative approach might be an alternative in patients who are deemed to be at high risk for classic graft explantation and an extra-anatomic bypass or in situ bypass.

Does medical specialty influence the treatment of asymptomatic carotid stenosis? a Belgian multidisciplinary survey.

AIM: The aim of this study was to supplement the few data that exist regarding the potential effect of the referring medical specialty on the proposed treatment for asymptomatic carotid stenosis. METHODS: In a web survey, we presented Belgian cardiologists, neurologists and vascular surgeons with two fairly uncomplicated case vignettes on asymptomatic carotid stenosis differing only in the degree of stenosis (70-80% in case 1 and >80% in case 2). RESULTS: In both cases the suggested therapies were different per medical specialty (P<0.000002 and P<0.00002, respectively). Cardiologists were more conservative and vascular surgeons were more aggressive. Preferred therapies for both cases differed statistically significantly (odds ratio 8.63; 95% confidence interval 5.11-14.58). Suggesting a different therapy or not for case 1 and case 2 was also different per medical specialty (P<0.035). Cardiologists were most inclined to suggest a different therapy and vascular surgeons the least. Nobody switched to a more conservative treatment. Younger physicians suggested a more conservative approach (P<0.014). CONCLUSION: Different medical specialties prefer different treatments for asymptomatic carotid stenosis. Also, younger physicians seem more conservative. We elaborate on the different reasons that could explain these findings.

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.

Aortoduodenal fistula six weeks after EVAR for abdominal aortic aneurysm: a case report.

The technique of endovascular repair of abdominal aortic aneurysm has markedly improved over the years, showing a lower 30-day mortality rate compared to the open technique. Despite improvements, the percentage of reinterventions remains high due to late failure. A rare but severe complication of EVAR is the development of an aortoduodenal fistula, which has a very high mortality rate. The pathogenesis still remains unclear.

PEPE II--a multicenter study with an end-point heparin-bonded expanded polytetrafluoroethylene vascular graft for above and below knee bypass surgery: determinants of patency.

AIM: The Propaten European Product Evaluation (PEPE II) study was a product evaluation intended to characterize the performance of the GORE PROPATEN vascular graft in above-knee (AK) and below-knee bypass (BK) surgery. METHODS: This prospective multicenter trial enrolled 142 patients with peripheral arterial disease. In 87 patients AK and in 52 patients BK bypasses (including 15 femorocrural) were implanted (67.6% males, 32.4% females). RESULTS: The one-year overall primary and secondary patency rates were 80% and 84.7%, respectively. Overall limb salvage rate at 12-months was 96.2%. The primary patency rate for AK bypasses was 82.7%, for BK femoro-popliteal bypasses 74.2% and for BK tibial-peroneal bypasses 79.4%. Secondary patency rates were 87.3%, 78.8% and 85.1%, respectively. Primary patency rates decreased depending on the number of patent run-off vessels (three 84.3%, two 80.8%, one 73.3%). Subgroup analysis showed that female patients had a significantly higher primary patency rate for BK bypasses (95.5% vs. 67.8%, P=0.037 ) compared to male patients. Subgroup analysis comparing patients younger and older than 70 years did not show a statistically significant difference in patency rates. Twenty-one patients underwent 42 reinterventions after bypass surgery. CONCLUSIONS: Present data show that the end-point heparin-bonded polytetrafluoroethylene graft yields patency rates comparable to those obtained with other graft material in above-knee locations. The encouraging results for BK bypasses suggests that this graft is an excellent option for small diameter vascular reconstructions when autologous vein is unavailable.

Endovascular aneurysm repair or open surgery for treatment of abdominal aortic aneurysm with involvement of both common iliac arteries?

Endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA) involving the entire common iliac arteries requires proximal coil embolisation of both internal iliac arteries and extension of the stent graft into the external iliac arteries (type E according to the Eurostar classification). A potential complication of this treatment is pelvic ischemia. Therefore, this type of aneurysm is a relative contra-indication for EVAR. In this case-report we describe a hybrid procedure preserving antegrade circulation in one of the internal iliac arteries in a patient with a type E aneurysm who was unfit for open surgery.

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.

Long-term surveillance is paramount after implantation of the Vanguard stent-graft for abdominal aortic aneurysms.

AIM: The aim of this study was to describe the results and long-term follow-up of the Vanguard endovascular graft for infrarenal abdominal aortic aneurysm (AAA) repair. METHODS: Between February 1997 and October 1999, 76 patients were treated with a median aneurysm diameter of 52 mm (39-90 mm). All were followed up according to the Eurostar criteria. RESULTS: The primary technical success rate was 100%. Perioperative mortality was 1.3%. During follow-up (median 75 months, 6-112 months) 9 aneurysm related deaths occurred. A total of 79 late complications occurred in 45 patients (64%). Complications were noticed more frequently in the group of aneurysms larger than 5.5 cm (P=0.014). Patients who ultimately developed aneurysm rupture after endovascular repair had more postoperative complications compared to the majority who did not rupture their aneurysm. (P=0.001) Secondary interventions were mandatory in 23 patients, surgical conversion in 9. At 72 months this has resulted in an overall survival rate of 57%, an aneurysm rupture free survival of 88%, a conversion free survival of 95%, an endoleak free survival of 83% and a secondary intervention free survival of 82% (Kaplan Maier). CONCLUSION: The importance of life-long strict surveillance of patients treated with a Vanguard endograft was confirmed. Patients with graft-related complications should be treated accordingly.

Chronic contained rupture of an abdominal aortic aneurysm presenting as a Grynfeltt lumbar hernia. A case report.

We report a unique case of chronic contained thoraco-abdominal aneurysm rupture presenting as a Grynfeltt lumbar hernia. A 79-year-old man presented with backpain and a bluish swelling in the left lumbar region in the presence of a non tender aortic aneurysm. CT scan confirmed contained rupture of a type IV thoraco-abdominal aortic aneurysm. The peri-aortic haematoma protruded through the lumbar wall causing a Grynfeltt lumbar hernia. The aneurysm was replaced through a thoraco-phreno-lumbotomy. The patient survived and is doing well six months postoperatively.

Cerebral ischemia after filter-protected carotid artery stenting is common and cannot be predicted by the presence of substantial amount of debris captured by the filter device.

PURPOSE: Protected carotid artery stent placement is currently under clinical evaluation as a potential alternative to carotid endarterectomy. The current study was undertaken to determine the incidence of new ischemic lesions found on diffusion-weighted MR imaging (DWI) in nonselected patients after protected carotid artery stent placement using a filter device and to determine the potential relationship between these new ischemic lesions and the presence or absence of a clear amount of debris captured by the neuroprotection filter device. MATERIALS AND METHODS: A nonrandomized cohort of 52 patients (40 men, 12 women) presenting with carotid occlusive disease underwent protected carotid artery stent placement using a filter device. DWI obtained 1 day before stent placement was compared with that obtained 1 day after stent placement. In addition, the macroscopic and microscopic analysis of debris captured by the filter device during the carotid stent placement procedure was assessed. RESULTS: Neuroprotected carotid stent placement was technically successful in all 53 procedures but was complicated by a transient ischemic attack in 3 patients (5.6%). In 22 patients (41.5%), new ischemic lesions were found on DWI, and in 21 filter devices (39.6%), a substantial amount of atheromatous plaque and/or fibrin was found. No clear relationship between the presence of debris captured by the filter device and new lesions detected by DWI was found (P = .087; odds ratio 3.067). CONCLUSION: Neuroprotected carotid artery stent placement will not avoid silent cerebral ischemia. Systematic microscopic analysis of debris captured by the filter device has no predictive value for potential cerebral ischemia after carotid artery stent placement.

Hand-assisted laparoscopy versus conventional median laparotomy for aortobifemoral bypass for severe aorto-iliac occlusive disease: a prospective randomised study.

OBJECTIVES: To demonstrate that hand-assisted laparoscopy for aortofemoral bypass for severe aorto-iliac occlusive disease reduces morbidity with earlier recovery of bowel function and shorter in-hospital stay. DESIGN: Randomised controlled trial. MATERIALS AND METHODS: Thirty-six consecutive patients with severe aorto-iliac occlusive disease (TASK C/D) without history of major abdominal surgery necessitating an aortobifemoral bypass were randomised between a hand-assisted laparoscopic (HALS) approach and a conventional medial laparotomy. Operative data, early recovery data, quality of life and vascular outcome were analysed. RESULTS: No significant differences in operative data were found. Fluid and solid diet were resumed earlier (28.8 hrs vs. 76.9 hrs; p = 0.016) (45.6 hrs vs. 105.6 hrs; p = 0.02) and in-hospital stay was shorter (7.5 vs. 8.9 days; p = 0.005) in the HALS group. Six weeks post-operatively social functioning measured by the SF-36 survey score was better in patients randomised to HALS (p=0.023). CONCLUSIONS: HALS is a less invasive approach for aortofemoral bypass.

Multicenter evaluation of a self-expanding carotid stent system with distal protection in the treatment of carotid stenosis.

PURPOSE: Carotid artery stent placement may be limited by the embolization of atheromatous material. We evaluated the safety and feasibility of the Medtronic Self-Expanding Carotid Stent (Exponent) in combination with the Medtronic Interceptor Carotid Filter System for the treatment of carotid stenosis among patients at high risk for carotid endarterectomy. METHODS: Patients at high risk for carotid endarterectomy but amenable to percutaneous treatment with stent placement were enrolled. Clinical follow-up was performed at 30 days and 6 and 12 months postprocedure. The National Institutes of Health Stroke Scale was assessed before and within 3 days postprocedure and at 30 days and 6 months postprocedure. Angiography was performed pre- and postprocedure, and carotid duplex scans were performed at baseline and at 30 days and 6 months. RESULTS: Fifty-two carotid procedures were performed in 51 patients (mean age, 69 years; 84% of patients were men). The major adverse event (MAE) rate (death, stroke, and myocardial infarction [MI]) at 30 days was 5.9%: 2 strokes and a single death from periprocedural MI. MAE rates after 6 and 12 months were 5.9% and 11.8%, respectively. The delivery success rate was 94.2% (49/52) for the Interceptor Filter System and 95.9% (47/49) for the Exponent Stent. The mean diameter stenosis of the target lesion was reduced from 62.4% preprocedure to 21.2% postprocedure. CONCLUSION: High delivery success rates were achieved with a low rate of MAE (death, stroke, or MI) in a high-risk population. Treatment of carotid artery disease with the Exponent Carotid Stent combined with distal protection from the Interceptor Filter System is effective and safe.

Endovascular repair for aorto-enteric fistula: a bridge too far or a bridge to surgery?

PURPOSE: To review our experience of endovascular treatment of aorto-enteric fistula (AEF). METHODS: Between March 1999 and March 2005, 15 patients in five university and teaching hospitals in Belgium and The Netherlands were treated for AEF by endovascular repair. Twelve (80%) were male. The mean age was 67 years. Thirteen (87%) had had previous aortic or iliac surgery, 1.7-307 months before. All patients showed clinical or biochemical signs of bleeding. Eight (53%) were in shock, five (33%) had systemic signs of infection. Eight (53%) patients were treated in an emergency setting. Ten (67%) were treated with an aortouniiliac device, three (20%) with an aortobiiliac device, one with a tube graft and one with occluders only. All patients received antibiotics postoperatively for a prolonged period of time. RESULTS: All AEF were successfully sealed, the 30-days mortality was nil. Mean hospital stay was 20 (2-81) days. One patient died 2.7 months later of postoperative complications, one died of lung cancer. Until now, there are no signs of reinfection in four (27%) patients (mean follow-up 15.7 (1-44) months). However, reinfection or recurrent AEF occurred in nine (60%) patients after 9.5 (0.61-31) months. Seven patients were reoperated successfully, two patients died after reintervention. CONCLUSION: Endovascular sealing of AEF is a promising technique, which provides time to treat shock, local and systemic infection, and co-morbidity. This creates a better situation to perform open repair in the future with possibly better outcome. Danger of reinfection remains high. Endovascular sealing of AEF should, therefore, be seen as a bridge to open surgery when possible.

Fibromuscular dysplasia of the superior mesenteric artery--case report and review of the literature.

Fibromuscular dysplasia is a multifactorial arteriopathy most commonly affecting the renal and carotid arteries. In this report we present a case of visceral artery involvement, causing occlusion of the superior mesenteric artery and celiac trunk and resulting in visceral ischemia. Treatment consisted of superior mesenteric artery reimplantation. Visceral artery FMD can present as occlusive or aneurysmal disease and treatment depends on patient characteristics and symptoms.

Hand-assisted laparoscopic aortobifemoral bypass for occlusive disease. Early and mid-term results.

OBJECTIVES: To evaluate the early and mid-term results of hand-assisted laparoscopic surgery (HALS) for aorto-iliac reconstruction. DESIGN: Prospective survey. MATERIALS AND METHODS: Between February 2002 and January 2004, 46 patients received an aortobifemoral bypass for advanced occlusive disease by HALS. RESULT: There was one conversion to open surgery. Mortality was 4.5%. The median return to solid oral diet took 36 h (24-182), the median hospital stay was 5 days (3-26). Primary patency rate at 1 year was 97.5%. The incidence of incisional hernia was 19.5%. CONCLUSIONS: HALS aorto-iliac reconstruction should be considered as a minimal invasive technique with good early and mid-term results.

Endovascular stent-graft and first rib resection for thoracic outlet syndrome complicated by an aneurysm of the subclavian artery.

PURPOSE: To report our experience with a combined endovascular and surgical approach for arterial thoracic outlet syndrome (TOS) complicated by an aneurysm of the subclavian artery. METHODS: We treated three consecutive patients suffering from arterial thoracic outlet syndrome complicated by an aneurysm of the subclavian artery by the use of a stent-graft and a first rib resection. These patients were reviewed retrospectively. RESULTS: At a mean follow-up of 37.3 months all patients were free of symptoms without late complications. CONCLUSIONS: Endovascular stent-grafting followed by decompression of the costoclavicular space is an attractive alternative to the conventional surgical approach of complicated arterial TOS.

Hemobahn stent-grafts in the treatment of femoropopliteal occlusive disease.

AIM: The aim of this study was to determine our results and indications for the Hemobahn stent-graft in femoropopliteal occlusive disease. METHODS: Since 1999, 38 patients with femoropopliteal occlusive disease in 40 legs have been treated by endovascular dilation or recanalisation and additional endografting. All have been followed up prospectively at 6 month intervals by clinical examination, Doppler and duplex. RESULTS: In 40 legs, 15 high grade stenoses were dilated and 25 occlusions needed first recanalization. Additional Hemobahn stent-graft deployment was successful in all cases (total grafts n=60). The median length of the stented segment was 15 cm. Immediate complications during the procedure were stent-graft thrombosis (n=1) and distal embolization (n=3), instantly treated with thrombolysis and thrombus aspiration. The median ankle-brachial index in rest increased from 0.5 preoperatively to 1 postoperatively. With a median follow-up time of 28.2 months (range from 1 to 48 months), there were 4 high grade stenoses and 13 stent-graft occlusions (1 year primary patency rate of 66%). All 4 stenoses were treated with balloon dilation (1 year assisted primary patency rate of 76%) and 4 of the occluded grafts were recovered by thrombectomy (n=1) or thrombolysis (n=3), resulting in a 1 year secondary patency rate of 87%. CONCLUSIONS: The Hemobahn stent-graft can be used in the treatment of femoropopliteal occlusive disease with a low complication rate and acceptable patency rates in the short-term. We had the best results when there was no recanalization needed before.

Minimal-access aortic surgery: the potentials of hand-assisted laparoscopy.

In analogy with the good results of laparoscopic abdominal procedures minimal-access aortic surgery looks very promising. However, in spite of the many technical improvements that have already been made, totally laparoscopic and even laparoscopically assisted aortic surgery remains technically demanding. This explains the rather slow introduction of minimal-access aortic surgery in the vascular society. In anticipation of increasing surgical experience and better instrumentation that will make the technique feasible for each vascular surgeon, hand-assisted laparoscopy (HALS) can be a valuable intermediate approach. HALS offers an easy to perform and still clearly less invasive approach for all aorto-iliac reconstructions.

Endovascular abdominal aortic aneurysm treatment: device-specific outcomes.

Endoluminal grafting, introduced now 13 years ago, has been greeted enthusiastically as an alternative treatment for infrarenal abdominal aortic aneurysms (AAAs). It is estimated that last year, over 30,000 implants were performed in Europe and the US. In this review, we want to touch on the actual results of the most commonly used devices. Comparison of device-specific outcomes remains difficult however since there are few comparative and certainly no randomized studies, which is explained by the fact that the indication to treatment and selection of the device depends largely on patient related and anatomical criteria, as well as on commitment to clinical trials.