Faculty Bibliography

Bypass surgery in aortoiliac or aortofemoral occlusive disease can be technically demanding and hazardous due to huge calcifications and/or patient co-morbidities. We report about mid-term results of a telescoping sutureless aortic anastomosis technique using endografts as connectors to address such challenging situations. This is a single-center experience (2004-2011) in seven patients (63 +/- 6 years) requiring aortoiliac (three) or aortofemoral (four) bypass surgery. In six cases, an aortic stent graft was telescoped into the infrarenal aorta and partly deployed within the aorta and partly outside the aorta. In the first case, a bifurcated stent graft was deployed and the iliac legs were prolonged extra-anatomically with surgical grafts to reach the femoral bifurcation. In the following five cases, a tapered tubular stent graft was deployed through the aortic wall, landing inside a bifurcated surgical graft that was extra-anatomically connected to the iliac or femoral arteries. In the last case, which presented a hostile abdomen and high-risk for extensive surgery, a similar technique was used, but on the iliac artery level. In that case, an iliac stent graft re-loaded 'upside down' was deployed through the left common iliac wall, landing distally inside a hand-made 10 x 10 mm bifurcated surgical graft that was extra-anatomically connected to the left external iliac artery and to the right femoral artery. The distal anastomoses on the seven cases were performed either with running sutures (ten) or with VORTEC (four). Telescoping aortic and/or iliac anastomosis was successful in all patients. There was no perioperative mortality. One patient developed postoperative hyperperfusion of the left leg and necessitated fasciotomy. During a mean follow-up of 1.8 +/- 2 years (minimum: 270 days, maximum: 7.1 years), all of the grafts remained patent and there was neither stent-graft migration nor stenosis on the level of the aortic or iliofemoral connection. One patient showed disease progression and required percutaneous transluminal angioplasty on the external iliac artery during follow-up. The uneventful perioperative course in these seven patients, with a follow-up of up to six years, underscores that this new technique can be considered in patients with aortoiliac or aortofemoral occlusive disease and in whom clamping and/or anastomosis is expected to be cumbersome or impossible.

Endovascular repair of ruptured abdominal aortic aneurysms seems to have better outcomes than open repair if certain strategies, techniques, and adjuncts are employed. These include a standard approach or protocol; use of fluid restriction (hypotensive hemostasis), performance of the procedure in a site equipped for excellent fluoroscopic imaging and open surgery, use of percutaneous approaches and local anesthesia for initial guide wire and catheter placement, placement of a large supraceliac aortic sheath, and obtaining balloon control only when absolutely necessary. Details of obtaining this control are critical, and aortic control must not be lost until the rupture site is excluded. Multiple balloons might be required, including ones placed within the endograft. Sheath placement and fixation until the balloon is removed are also critically important. Bifurcated and unilateral endografts can be used successfully. Abdominal compartment syndrome must be looked for and treated aggressively; endovascular repair must be used in the highest-risk patients, including those in profound hemorrhagic shock, to gain the greatest advantages of this approach.

OBJECTIVE: This study reviews a single-center experience of endovascular popliteal aneurysm (PAA) repair. METHODS: A retrospective review was performed to identify all endovascular PAA repairs performed between September 2004 and January 2011. RESULTS: We identified 21 patients (mean age, 74 +/- 9 years, 91% men) with PAAs (mean size, 2.89 +/- 1.0 cm) in 26 limbs, of which 38% were symptomatic. All patients underwent endovascular repair with a Viabahn covered stent graft (W. L. Gore & Assoc, Inc, Flagstaff, Ariz). Postoperatively, all patients were maintained on antiplatelet therapy with clopidogrel or aspirin, or both. Mean follow-up was 22 +/- 17 months (range, 1-57 months). One patient with one aneurysm was lost to follow-up. Primary and secondary patencies were both 91.2% at 1 year and were 85.5% and 91.2%, respectively, at 2 years. The limb salvage rate was 100%. Four stent graft failures occurred at a mean of 12.3 +/- 11 months. One technical failure due to stent graft infolding required conversion to an open femoral-popliteal bypass. Three additional graft failures occurred in patients with poor (single-vessel) runoff. Compared with patients with two- or three-vessel runoff, the graft failure rate in patients with single-vessel runoff was statistically significant (P = .02). Two of the graft failures were successfully treated with open thrombectomy, and one required a tibial artery bypass for limb salvage. CONCLUSIONS: Endovascular repair of PAAs is feasible and has acceptable midterm patency rates. Poor distal runoff predicted graft failure.

In 2011, five independent, international guideline committees reported their recommendations for the management of symptomatic and asymptomatic carotid artery stenosis. These included the American College of Cardiology/American Heart Association, the Society for Vascular Surgery, the European Society of Cardiology, the Australasian, and the UK National Institute of Health and Clinical Excellence. As the recommendations of these five guideline committees were based on the same published literature, it would be expected that they are similar, at least to a large extent. Surprisingly, there were considerable differences between the five guidelines regarding the management of both symptomatic and asymptomatic carotid patients. The differences in the recommendations between the five Guideline Committees are analyzed and discussed.