Femoral anastomotic aneurysms in the modern era: a reappraisal of a continuing challenge.

AIM: Despite improvement in the operative technique and graft and suture material, femoral anastomotic aneurysms (FAAs) represent a continuing problem for patients undergoing lower extremity revascularization. The present retrospective study investigates the clinical presentation, the infection as a cause of FAAs, the interval between the original operation and the development of FAAs. It also evaluates the mortality and amputation rate of patients with FAAs. METHODS: We reviewed the records of 124 patients (thrombendarterectomy in 9, femoro-femoral bypass in 3 and axillofemoral bypass in 1). RESULTS: There were 13 infected and 14 recurrent FAAs. The overall mean time elapsing between the initial operation and the development of FAAs was 56.9 months (range 1-219). This interval was 62 months for the noninfected FAAs, while it was only 8 months for the infected FAAs. The mean time interval in which a recurrence of FAAs occurred was 39 months. The most common type of repair was an interposition prosthetic graft from the proximal prosthesis to the profunda femoral artery (100 cases). In the postoperative period local complications occurred in 21 (15.4%) cases and systemic in 7 (5.1%). The postoperative mortality was 3.7%. The overall survival at 1 year was 91.3% (standard error: +/-2.5%) and at 2 years 85.4% (standard error: +/-3.3%). Kaplan-Meier analysis showed a cumulative limb salvage of 94.2%, 93.3 % and 89.2% after 6 months, 1 and 2 years, respectively. A significant relationship was demonstrated between amputation and the following parameters: infected FAAs (Log rank test: 26.1, P-value <0.001), diabetes (Log-rank test: 12.9, P-value <0.01), peripheral arterial occlusive disease (Log-rank test: 3.1, P-value =0.08), and prior limb amputation (Log-rank test: 9.9, P-value <0.01). The mean time to amputation for the infected FAAs was 49.6 months (95% CI: 24.3-74.8), while for the noninfected it was 98.8 months (95% CI: 93.4-104.2). CONCLUSIONS: Complicated FAAs are still responsible for significant morbidity and mortality. Elective treatment produce the maximum benefit.

[Infra-inguinal suture aneurysm]. / Infrainguinale Nahtaneurysmen.

Anastomotic aneurysms represent late complications of reconstructive surgery. They are preferably localized in the inguinal area. From 1975 to 1989 forty patients were operated for 50 infrainguinal anastomotic aneurysms (46 inguinal, 4 popliteal). They developed after a mean time interval of 60.6 months. In nine cases bilateral inguinal aneurysms occurred. Three of the inguinal aneurysms were infected. The inguinal aneurysms were usually treated by total excision followed by prosthetic graft interposition with distal anastomosis to the deep femoral artery. If the superficial femoral artery was patent, it was inserted into the interposed graft. The infected aneurysms were treated with aseptic extra-anatomic bypass procedures. Five patients died after the operation. In one case a transmetatarsal amputation had to be performed and in one case a relapsing aneurysm occurred after three years. In general surgical repair of anastomotic aneurysms following vascular reconstructions should be performed before complications occur. In the inguinal area this can be performed with low local and general risk and with good longterm results.

[Autogenous reconstruction in mycotic inguinal aneurysm--long-term result]. / Autogene Rekonstruktion bei mykotischem inguinalem Aneurysma--Langzeitergebnis.

A ruptured mycotic aneurysm of the left femoral artery in the groin area in a 44-year-old man had to be surgically treated in 1990 by an autogenous in-situ-repair consisting of aneurysmectomy including the femoral bifurcation, autologous vein interposition using medium-term absorbable suture material, and local application of an antibiotic bonded collagen. The infection could be checked in a short time. Three years after the operation the check-up gave evidence of an excellent local result with good arterial circulation in both legs. Autogenous in-situ-repair appears to be the most efficient procedure for treatment of an arterial infection or an infected graft. Especially in the area of bifurcations (i.e. inguinal and popliteal as well) this management is preferable to the aseptic extra-anatomic bypass procedure, since only this method can preserve the orthograde perfusion of the bifurcation branches.