Open repair for infrarenal AAA: technical aspects.

The aim of this study was to describe the technique and report our single center experience of abdominal aortic aneurysm (AAA) open surgical repair over the last 17 years. From 1993 to 2010, a total of 4347 open surgical procedures for repair of AAA were performed in our center. The details of 3857 (88.7%) patients undergoing infrarenal AAA open repair were analyzed; mean age at the time of surgery was 71.8 years ranging from 58 to 89 years. Among all repairs, 23.7% (914) were performed in women and 24.3% (937) in octogenarians; 3587 (93.0%) procedures were performed for degenerative aneurysms, 146 (3.8%) for inflammatory aneurysms, 100 (2.6%) for dissecting aneurysms, and 19 (0.5%) for other pattern of disease. In 162 cases (4.2%) surgery was performed for ruptured aneurysm. In most cases (N.=2596; 67.3%) infrarenal AAA open repair was performed by means of aorto-aortic bypass using a tube graft. A total of 1261 patients were treated using a bifurcated graft: 417 (33.1%) aorto-iliac bypasses, 530 (42.0%) aorto-femoral bypasses and 314 (24.9%) aorto-iliac-femoral bypasses were performed. In elective aorto-aortic bypass, mean aortic clamping time was 21.3+6.7 minutes. The average duration of the procedure was 126+84 minutes (range, 42-410 minutes). Mean intraoperative bleeding was 803.4+422.7 mL (range 250-3,100). Overall intraoperative mortality was 0.2%. Intraoperative mesenteric ischemia was observed in 3% of cases, all treated with inferior mesenteric artery reimplantation. The rate of intraoperative lower limbs ischemia was 2.2%. One intraoperative acute type A aortic dissection occurred. The overall 30-day mortality was 0.6%. Permanent renal function impairment occurred in 4.3% of cases. The rate of pulmonary complications was 9.8%. Other complications were myocardial infarction, congestive heart failure, late ischemic colitis, late leg ischemia, wound infection, urinary tract infection, and sepsis. Although endovascular techniques have emerged as a less invasive alternative to open repair, short- and long-term outcomes associated to the surgery of infrarenal AAAs remain satisfactory for a large range of patients.

Management of thoracic endograft infection.

Thoracic endovascular aortic repair (TEVAR) has emerged as a promising, less invasive alternative to conventional open surgery for the treatment of thoracic aortic pathology. Most surveillance after TEVAR concentrates on the technical aspects of the procedure, including endoleak, device migration and endograft rupture; so far, the knowledge on endograft infectious complications is limited to anecdotal reports. Several etiopathogenetic factors may play a role in thoracic endograft infections (TEIs), including perioperative contamination, hematogenous seeding, and local bacterial translocation. Moreover, fistulization with the esophagus or the bronchial tree is a common mechanism of secondary TEI, and it represents a dramatic event requiring a multidisciplinary management. Risk factors assessment and prevention have a key role in avoiding the development of new TEIs. When a TEI is established, treatment is demanding, and includes several medical therapies associated with various surgical options. Patients are usually severely compromised by sepsis, and in most cases they are considered unfit for surgery for general clinical conditions or local concerns. Thus, results of different therapeutic strategies for TEI are still burdened with very high morbidity and mortality. In this paper, we reviewed the English literature regarding the main strategies proposed for operative management of TEI, we reported and analyzed our personal series of 7 patients treated at our institution for TEI from 1999 to 2009, and we summarized results from the data collected during a recent Italian multicenter national survey, performed to investigate aortoesophageal and aortobronchial fistulae treated with TEVAR or developed following TEVAR.