Complex Aortic, Visceral and Renal Arteries Reconstruction with a Four-Branch Dacron Graft for Middle Aortic Syndrome Secondary to Takayasu's Arteritis.

The middle aortic syndrome (MAS) is an uncommon clinical expression as a result of isolated stenosis or complete occlusion of the descending thoracic and/or abdominal aorta; Takayasu's arteritis (TA) is a rare vasculitis and a recognized etiology of MAS. We herein present the case of a 52-year-old woman with refractory renovascular hypertension and progressive bilateral lower extremity claudication; she had known history of TA. A computed tomography angiography demonstrated an aortic occlusive lesion compromising the origin of the celiac trunk, superior mesenteric, and bilateral renal arteries. The patient underwent a complex aortic reconstruction with visceral and renal vessels revascularization utilizing a back-table hand-crafted 4-branch Dacron graft through a left thoracoabdominal approach. The patient recovered uneventfully and was discharged on postoperative day 5, and at 36 months from her surgery, she remains symptoms-free and without antihypertensive agents.

Explantation of infected aortic aneurysm and endograft with ascending aorta to mesenteric bypass for mesenteric ischemia.

A 65-year-old man presented with an infected perivisceral aortic aneurysm after previous treatment of an abdominal aortic aneurysm with an endograft. On presentation, he was septic and had occlusion of the celiac, superior mesenteric, inferior mesenteric, and bilateral renal arteries. He underwent a three-stage procedure: first, axillobifemoral bypass; then resection of the thoracoabdominal aorta; and finally bypass from the ascending aorta to the celiac and superior mesenteric arteries with a rifampin-soaked Gelsoft graft (Vascutek, Renfrewshire, Scotland). The abdominal pain resolved, and the patient remains symptom free 10 months postoperatively. This rare surgical revascularization technique offered a nontraditional solution to a difficult surgical issue.

Hybrid Approach to Aneurysms of the Pancreaticoduodenal Artery Associated with Occlusion of the Celiac Axis.

Pancreaticoduodenal artery aneurysms are uncommon but often associated with occlusion or absence of the celiac axis. This anatomic alteration makes management decisions challenging. Presented here are 2 cases of incidentally identified aneurysms, treated with a hybrid approach.

Simultaneous coil embolization and angioplasty using a self-expanding nitinol stent to treat pancreaticoduodenal artery aneurysms associated with celiac artery stenosis.

BACKGROUND: The degeneration of pancreaticoduodenal arcade vessels due to pancreaticoduodenal artery aneurysms is associated with celiac artery stenosis or occlusion. While technical advances have made it possible to treat pancreaticoduodenal arcade aneurysms (PDAA) and celiac artery stenosis by endovascular techniques, there is no consensus regarding their optimal treatment. PURPOSE: To treat pancreaticoduodenal arcade aneurysms (PDAA) by simultaneous coil embolization and celiac artery stenting, and propose indications for treating PDAA with celiac artery stenosis by this method. MATERIAL AND METHODS: We reviewed 11 patients who underwent transcatheter coil embolization (TCE) to treat PDAA. When the aneurysmal neck size was less than half of the short axis of the aneurysm we used packing only, when it was more than half of the short axis we undertook isolation. In the latter situation, when there was evidence of celiac artery stenosis, we performed celiac artery stenting using self-expandable stents. RESULTS: Ten of the 11 patients (91%) presented with celiac axis stenosis due to median arcuate ligament compression. Coil-packing of the aneurysmal sac only, thus preserving the native arterial circulation, was done in five patients, another five underwent isolation by embolization of vessels distal and proximal to the PDAA with simultaneous stenting of the stenotic celiac axis, and one patient was treated by isolation only. One patient developed acute pancreatitis. There were no other complications and all aneurysms were successfully excluded. In one patient the celiac stent thrombosed after stopping the antiplatelet regimen. CONCLUSION: TCE can be effective in patients with PDAA. In the presence of celiac artery stenosis, we recommend isolation of the aneurysms with simultaneous stenting of the stenotic celiac trunk using self-expandable stents.

Operative outcomes using a side-branched thoracoabdominal aortic graft (STAG) for thoraco-abdominal aortic repair.

BACKGROUND: Pre-manufactured branched grafts now allow an endovascular approach to the repair of thoraco-abdominal aortic aneurysm (TAAA) with visceral vessels' involvement. Similar grafts have been employed in open surgery, generally as a second choice for TAAAs, which are not amenable to patch/inclusion technique for visceral vessel attachment. Results with branched grafts have not been reported in series of open TAAA repairs. The purpose of this report is to describe perioperative risks and outcomes in a consecutive series of patients with pre-manufactured side-branched thoracoabdominal aortic grafts (STAGs) for surgical TAAA repair. METHODS: Between 1996 and 2009, pre-manufactured STAGs were used in 50 patients with TAAA that required reattachment of the visceral and renal arteries. Operative details, perioperative mortality and ischaemic complications were examined. RESULTS: Mean age was 53 years; 18 patients were females. The cases included redo (n = 24), patients affected by genetic disorder (Marfan) (n = 20) and patients with aortic dissection (n = 27). The mean clamp time was 84.1 min. Perioperative mortality was 12.0% (6/50). Neurologic deficits occurred in 2% (1/50). Postoperative renal dysfunction was detected in 19 patients (38%). CONCLUSION: The use of a STAG produced acceptable mortality, bowel and neurological ischaemic risks. Improved strategies to prevent renal ischaemia before and during repair of TAAA with visceral involvement are needed.

Percutaneous occlusion of the left subclavian and celiac arteries before or during endograft repair of thoracic and thoracoabdominal aortic aneurysms with detachable nitinol vascular plugs.

PURPOSE: To review an experience with the Amplatzer vascular plug (AVP) for prevention of type II endoleaks during endovascular aneurysm repair (EVAR) of thoracic and thoracoabdominal aneurysms. MATERIALS AND METHODS: Retrospective review was undertaken of 14 patients undergoing transcatheter occlusion of the left subclavian (n = 12) or celiac artery (n = 2) with the AVP as part of EVAR of thoracic and thoracoabdominal aneurysms at a single institution. Procedural criteria evaluated were success at target vessel occlusion, the number of AVPs used, use of adjunctive embolization devices, and embolization-related ischemic end-organ events. Follow-up imaging criteria included evaluation of persistent target vessel occlusion, evidence of device migration, and the presence and characterization of endoleak secondary to AVP failure. RESULTS: Complete target vessel occlusion was documented for all cases. In six cases, more than one AVP was placed, with an average of 1.5 devices per patient. In two cases, adjunctive coils were placed. Computed tomographic or magnetic resonance angiography follow-up was available for all patients (mean follow-up, 419 days; range 28-930 d). No case showed evidence of device migration or type II endoleak resulting from AVP failure. There was a single instance of left subclavian artery recanalization without type II endoleak. There were no embolization-related ischemic end-organ events. CONCLUSIONS: Transcatheter arterial occlusion of the subclavian and celiac arteries with the AVP is a valuable adjunct to endografting in cases in which side branch embolization is necessary to extend the landing zone.

[Celiac artery aneurysm: a case report]. / Aneurisma del tronco celaco: presentazione di un caso clinico.

The aneurysms of the celiac trunk are extremely rare. The authors describe a case of aneurysm of the celiac trunk dealt with aneu-rysmectomy and reconstruction by means of protesic graft made in Dacron. The patient was asymptomatic, and the aneurysm was discovered accidentally during abdominal computerized tomography (CT) for the stadiation of hepatic cirrhosis. The aneurysmectomy and the reconstruction have been executed by means of a prosthetic graft finish-terminal in Dacron, succeeding in preserving the three arteries originating from the celiac trunk (left gastric, hepatic, splenic). The histologic examination documented the degeneration of the medium trunk with loss of elastic fibers and atherosclerotic lesions. The postoperative course was complicated by hepatic ascites, and severe renal insufficiency. As a result of paracentesis and diuretic dose titration, the blood parameters and the conditions of the patient improved progressively until allowing the discharge on XL postoperative day in good conditions. Six months after, abdomen CT documented the integrity of the prosthetic graft and the absence of perianastomotic leak.

Combined endovascular stent-graft repair and adjunctive visceral vessel reconstruction for complex thoracoabdominal aortic aneurysms.

AIM: This study demonstrates the therapeutic value of the hybrid open and endovascular procedure in anatomically challenging thoracoabdominal aortic aneurysms (TAAAs) in high-risk patients. METHODS: Between January 2000 and February 2006, 8 patients were treated with open visceral vessel revascularization and endovascular repair for TAAAs. Patient data were available from medical records. Pre- and postoperative physical examination, intra-arterial angiography, and spiral computed tomography scanning was performed in prearranged examinations. RESULTS: A total of 28 visceral bypasses were performed in the 8 patients: 6 patients with complete visceral vessel revascularization and 2 with an aorto-mesenteric-celiac bypass. Aneurysm exclusion was achieved through the deployment of in total 23 stent-grafts. Seven out of the 8 procedures were conducted electively and one under urgent conditions. The mean follow-up period was 21 months. We recorded one procedure-related death due to postoperative hemorrhage resulting from diffuse retroperitoneal bleeding with consecutive multiorgan failure. Moreover, one patient developed acute renal insufficiency, but returned to normal values after temporary hemodialysis. Major adverse events included 2 cases of pneumonia and one myocardial infarction. Two reoperations were performed due to one mesenteric bypass occlusion and one groin hematoma. No neurological complications were observed. CONCLUSION: The combined hybrid endovascular and open surgical approach in the treatment of complex TAAAs remains a feasible and effective operation technique. The less invasive character of the procedure and avoidance of aortic-cross clamping are clear advantages. Nevertheless, further study is mandatory to establish this alternative therapeutic option for complex TAAAs.

Surgical treatment of chronic multivascular mesenteric ischemia in a patient with antiphospholipid syndrome, abdominal aortic aneurism, and renal cancer: when planning overwhelms complexity.

Chronic mesenteric ischemia is a clinical condition caused by obstructive or occlusive disease of the mesenteric vessels, with potentially lethal consequences. We describe a case of open multiple revascularization in a patient affected by antiphospholipid syndrome and diffuse atherosclerosis, with an abdominal aortic aneurism, a contracted kidney, a renal cancer affecting the contralateral kidney, and as a consequence, a chronic renal failure and hypertension. We revascularized the celiac trunk, the superior and inferior mesenteric arteries, and the right renal artery using saphenous grafts; the aneurism was corrected, and the renal tumor was treated by radiofrequency ablation. Despite the invasiveness and complexity, the surgical strategy adopted allowed to save the patient's life, to treat the chronic mesenteric ischemia and the renal cancer, and to improve the chronic renal insufficiency and hypertension. KEY WORDS: Graft, Mesenteric ischemia, Occlusion, Revascularization.

Celiac axis, superior mesenteric artery, and inferior mesenteric artery occlusion: surgical considerations.

Occlusion of the celiac, superior mesenteric, and inferior mesenteric artery has been studied in 46 patients treated by operation. The condition was acute and was caused by embolic obstruction of the superior mesenteric artery in four cardiac patients and detachment of the inferior mesenteric artery in two patients during removal of infrarenal abdominal aortic aneurysms. The condition was chronic and involved two or all three of the vessels in 40 patient. Embolic obstruction caused severe abdominal pain but few physical signs early in the process,, but the picture of an acute abdomen indicating bowel gangrene developed in a few hours. Ischemia from inferior mesenteric detachment was observed at operation. Patients with chronic obstruction had abdominal pain, weight loss, and diarrhea. Patients with embolic obstruction were treated successfully by embolectomy, and patients developing intraoperative sigmoid ischemia were treated by reattachment of inferior mesenteric arteries to aortic graft. Various procedures were employed in patients with chronic multiple obstruction. However, graft bypass using Dacron tubing was preferable because of its simplicity and because the frequently (48%) associated occlusive disease and aneurysm of the distal aorta were treated at the same time. Confining operation to the abdomen significantly reduced the magnitude of operation and eliminated risks in this age group. Of the 46 patients, 91% survived and were relieved of their symptoms despite associated disease. The 5-year survival rate in this group of patients was 62%.

Injuries to the visceral arteries.

Injuries of the major visceral arteries are among the more difficult to manage and rarely occur without serious associated injuries. Sixty-six patients are presented with injuries to the celiac, superior, and inferior mesenteric arteries. Fifty-three injuries resulted from gunshot wounds, nine from stab wounds, and four from blunt trauma. Operative management included vessel ligation in 11 patients, arteriorrhaphy in 43, resection and end-to-end anastomosis in six, Dacron graft interposition in four, and aortic reimplantation in two. Twenty-three patients died, 16 from failure to control hemorrhage. In two patients failure to restore adequate visceral circulation resulted in bowel ischemia and infarction. The successful management of patients with visceral arterial injuries is dependent upon rapid and adequate exposure followed by primary repair or revascularization utilizing available surgical techniques.

Chronic intestinal ischemia. The Lahey Clinic approach to management.

Recognizing decreased mesenteric arterial blood supply in symptomatic and asymptomatic patients is essential to successful treatment of the ischemic bowel. The vascular disease can be documented by using standard arteriography, including a lateral projection. We favor revascularization by bypass in the celiac and superior mesenteric systems and by reimplantation or bypass in the inferior mesenteric system. Externally supported ringed PTFE is our conduit of choice. The chances of late recurrence can be lessened by complete revascularization. For the patient with no symptoms of mesenteric insufficiency who undergoes revascularization for other abdominal arteries, it is important to avoid restricting the mesenteric flow when disease is present, and it may be necessary to revascularize the superior mesenteric artery simultaneously as a prophylactic measure. Avoidance of the major problems of bowel infarction can be achieved by these maneuvers.

Coeliac artery aneurysm: aorto-hepatic artery reconstruction.

Aneurysms of the coeliac axis are rare. Up to 1997, 137 cases had been reported. Here we present a coeliac aneurysm which involved the origin of the splenic, left gastric, and common hepatic arteries. After making a midline incision, infra-diaphragmatic control of the aorta was obtained. The aorta was clamped for 25 minutes to resect the aneurysm. The defect at the origin of the coeliac axis was closed with 1.5 cm PTFE patch. The distal segments of the splenic and left gastric arteries were ligated. A 6-mm ringed PTFE graft was interposed between the infra-renal aorta and the proper hepatic artery. The control arteriogram showed a good arterial flow. The patient recovered uneventfully after surgery with normalisation of hepatic function.

Reconstructive surgery for a fusiform common celiomesenteric trunk aneurysm and coexistent abdominal aortic aneurysm: report of a case.

A celiomesenteric trunk (CMT) accounts for fewer than 1% of all visceral artery anomalies. Aneurysms involving a CMT are exceptionally rare: our search of the literature found only eight cases reported. We treated a 73-year-old man with both a fusiform CMT aneurysm and an abdominal aortic aneurysm (AAA). The celiac artery and superior mesenteric artery were reconstructed by performing a retrograde prosthetic-graft bypass originating from the right limb of the bifurcated aortic graft used to repair the AAA. To our knowledge, this is the first report of successful surgical treatment of a CMT aneurysm and coexistent AAA.

Thoracoabdominal aortic aneurysms. A review and current status.

Surgical management of the thoracoabdominal aortic aneurysm is a formidable undertaking. Presently two fairly distinct operative methods are available. The conventional technique, pioneered by Etheredge, involves replacement of the aneurysm with a synthetic graft and then, step by step, revascularization of the abdominal organs with prosthetic side limbs taken from the primary graft. Individual organ ischemic time is limited to that time required for the performance of each distal side limb anastomosis. The second operative method, first described by Crawford, consists of proximal and distal control of the aneurysm, followed by its incision to simultaneously expose the origin of all four major intra-abdominal arteries. Replacement is then rapidly performed with a tubular Dacron graft including anastomosis of these major intra-abdominal arteries to four elliptical graft incisions, from within the aneurysm. Total operating time is reduced at the expense of prolonged organ ischemia. The conventional method allows for step-by-step intraoperative planning and action, and this technique is accordingly recommended to most surgeons, who have had little experience with this unusual lesion. Our recent successful experience with two cases of extensive thoracoabdominal aortic aneurysms is described as well as a discussion of additional measures which may become useful in certain cases to favor a successful outcome. Finally the problem of potential resultant paraplegia is discussed.

Two-stage combined endovascular and surgical approach for recurrent thoracoabdominal aortic aneurysm.

PURPOSE: To present a 2-stage combined endovascular and surgical approach for recurrent thoracoabdominal aortic aneurysm (TAAA). CASE REPORT: A 78-year-old man with previous surgical repairs of infrarenal abdominal and descending thoracic aortic aneurysms was referred for dysphagia due to an enlarging 9-cm aneurysm extending from the mid thoracic to the suprarenal aorta. Because no suitable endograft was available, an open repair was attempted, but the presence of a "frozen" chest made the redo procedure extremely difficult. A 2-stage treatment was thus decided upon. First, a retrograde bifurcated bypass graft was implanted from the abdominal aortic graft to the superior mesenteric and celiac arteries. Twenty days later, the TAAA was successfully excluded with a stent-graft, during which spinal fluid drainage was performed to prevent paraplegia. At 6 months, computed tomography showed patency of the endoprosthesis and visceral grafts. At 1 year, the patient remains asymptomatic. CONCLUSIONS: This case illustrates that a 2-stage combined endovascular and surgical approach may be a safe and effective alternative to reoperation for recurrent TAAA.