Extra-anatomic bypass grafting in patients with lower extremity malperfusion due to type A acute aortic dissection / 中华胸心血管外科杂志

Objective:To summarize the efficacy of artificial blood vessel bypass grafting in patients with acute type A aortic dissection (ATAAD) complicated with lower extremity malperfusion.Methods:From January 2004 to January 2021, a total of 896 patients with ATAAD underwent surgical operations in Nanjing First Hospital, Among which 75 patients with lower extremity malperfusion was retrospectively analyzed.Results:There were 61 males and 14 females with mean age (50.9±11.3) years old. The cardiopulmonary bypass time (CPB) was (181.9±27.0) min, the cross-clamp time was (125.7±25.0)min, and the lower body circulatory arrest time was (20.4±3.1) min. Fifty-five patients had total aortic arch replacement and 20 cases had hemi-arch replacement surgery. Lower extremity arterial perfusion was restored in 48 patients after dissection surgery. Twenty-six patients underwent dissection surgery concurrently with extra-anatomic bypass grafting. The main postoperative complications were: acute kidney injury in 9 cases, delayed extubation (≥72 h) in 10, pulmonary infection in 13, tracheotomy in 6, paralysis in 1, stroke in 2 and lower limb amputation in 3. ICU stay time was (5.8±4.5) days, in-hospital time was (21.4±13.8) days. Nine patients (12%) died in the whole group: pulmonary infection, respiratory failure in 2 cases, multiple organ failure in 3 cases, iliac artery rupture in 1 case, intestinal necrosis in 1 case, severe cerebral infarction in 1 case, and giving-up in 1 case. A total of 66 patients (88%) were successfully discharged. The follow-up time was (55.8±33.4) months. The results of survival analysis showed that the 5-year survival rate was (96.7±4.2)%, and the 10-year survival rate was (56.4±16.3)%.Conclusion:Extra-anatomic bypass grafting is a feasible method to solve ATAAD complicated with lower extremity malperfusion. It is simple and easy to operate, and the long-term effect is satisfactory.

Extra-anatomic bypass for complex aorta coarctation / 中华胸心血管外科杂志

Objective To evaluate the safety and feasibility of extra-anatomic bypass in the treatment of complex aorta coarctation concomitant with cardiac lesions,multiple stenosis of aorta or severe stenosis.Methods Complex aorta coarctation include a combination of heart disease (valve disease,coronary artery disease,ect.),or multiple constrictive lesions of the thoracic abdominal aorta or an aneurysm due to constriction of the arch,which are all difficult by interventional surgery or open thoracotomy surgery.From October 2016 to October 2017,6 patients with complex aorta coarctation have received surgical therapy in our department,including 3 males and 3 females,with the average age(50.0-± 17.9) years old.One-staged extra-anatomic bypass was used to establish an ascending aorta to the distal aorta bypass,4 patients underwent median thoracotomy and bypass surgery with thoracic aorta from the posterior inferior pericardium,1 patient underwent bypass surgery with abdominal aorta through thoracoabdominal incision,and 1 patient underwent bypass surgery with bilateral femoral artery from bilateral inguinal incision and guiding with laparoscopic through peritoneal cavity.Among them,3 patients underwent valve surgery in the same period,and 1 patient underwent coronary artery bypass surgery.Results No patient died.The mean cardiopulmonary bypass time was 273.8 minutes and the average aorta blocking time was 216.0 minutes.Pulse pressure of extremities blood pressure was significantly reduced compared with preoperative,and the clinical symptoms were significantly alleviation.During follow-up,6 patients presented with patent artificial blood vessels and alleviated symptoms.Conclusion Extra-anatomic bypass is a safe and effective method for the treatment of complex vasoconstriction without increasing the risk of surgery.

Surgical management for 40 adult patients with aortic coarctation / 中国胸心血管外科临床杂志

@#Objective    To summarize the experiences of the surgical management for adult patients with aortic coarctation. Methods     Clinical data of 40 adult patients diagnosed with aortic coarctation undergoing surgical repair in our center between July 2004 and March 2015 were retrospectively analyzed. There were 28 males and 15 females with a mean age of 26.3±11.0 years (ranging 16-57 years). We evaluated the effect of surgery by the change of pressure gradient between upper limb and lower limb, mechanical ventilation time, and length of ICU stay and hospital stay. Results    Forty surgeries were finished successfully. One patient died after surgery. The follow-up ranged from 12 to 36 months. The mean pressure gradient reduced significantly after surgery. There were 6 patients suffering blood hypertension at their discharge, and all of them still need antihypertensive drugs. Conclusion    Surgical repair is an effective treatment for adult with aortic coarctation. Extra-anatomic ascending-to-descending aortic bypass and concomitant repair of intracardiac anomalies is safe and effective.

Application of extra-anatomic prosthesis bypass in the retroperitoneum for the treatment of infected abdominal aortic aneurysms / 中华普通外科杂志

Objective To assess the effectiveness of extra-anatomic prosthesis bypass in the retroperitoneum as a treatment for infected abdominal aortic aneurysms (iAAAs).Methods We retrospectively reviewed the records of 10 consecutive patients diagnosed with iAAAs and treated by an extraanatomic prosthesis bypass in the retroperitoneum over the past 7 years.All 10 patients were regularly followed up by outpatient observation after their discharge.Results Ten patients with iAAAs underwent an extra-anatomic prosthesis bypass in the retroperitoneum and debridement of the infected aneurysm.An emergency operation was performed for one patient who underwent concomitant gastrointestinal procedures for aortoduodenal fistula,the other 9 cases underwent an elective operation after an intravenous antibiotic therapy for 2-4 weeks.All 10 patients were definitely diagnosed by one or more sequential CT scans combining with other methods.All patients had at least a positive preoperative blood culture or intraoperative tissue culture during the perioperative period,including Salmonella in 5 cases,Burkholderia pseudomallei in 3 cases,Escherichia coli in 1 case,Klebsiella pneumoniae in 1 case.All patients were discharged in 4-6 weeks after their operations.Except 1 case who died 16 months after surgery,all other patients were alive and were free from graft infection during the follow-up period.Conclusions The extra-anatomic prosthesis bypass in the retroperitoneum for treating iAAAs are safe and effective.

Extra-Anatomic Ascending Aorta to Abdominal Aorta Bypass in Takayasu Arteritis Patients with Mid-Aortic Syndrome

BACKGROUND: We evaluated the operative outcomes of an extra-anatomic bypass from the ascending aorta to the abdominal aorta in patients with type II or III Takayasu arteritis (TA) with mid-aortic syndrome. METHODS: From 1988 to 2014, 8 patients with type II (n=2) or III (n=6) TA underwent an ascending aorta to abdominal aorta bypass. The mean patient age was 43.5±12.2 years and the mean peak pressure gradient between the upper and lower extremities was 54.8±39.0 mm Hg. The median follow-up duration was 54.4 months (range, 17.8 to 177.4 months). RESULTS: There were no cases of operative mortality. The mean peak pressure gradient significantly decreased to −2.4±32.3 mm Hg (p=0.017 compared to the preoperative value). Late death occurred in 2 patients. The symptoms of upper extremity hypertension and claudication improved in all patients. The bypass grafts were patent at 47.1±58.9 months in 7 patients who underwent follow-up imaging studies. CONCLUSION: An extra-anatomic ascending aorta to abdominal aorta bypass could be an effective treatment option for severe aortic steno-occlusive disease in patients with type II or III TA, with favorable early and long-term outcomes.

Infected Abdominal Aortic Aneurysm with a Previous History of Coronary Artery Bypass Grafting with the Right Gastroepiploic Artery / 日本心臓血管外科学会雑誌

We report a case of successful anatomical reconstruction with omentopexy of an infected abdominal aortic aneurysm (AAA) in a patient with a previous history of coronary artery bypass grafting with the right gastroepiploic artery. A 60-year-old man was referred to our institute because of fever and abdominal pain during hemodialysis for chronic renal failure. Antibiotic therapy was started after computed tomography revealed an infected abdominal aortic aneurysm. After infection control, surgical treatment was scheduled. At surgery, left axillo-bifemoral bypass was performed first, because it was unclear whether the omentum was large enough for omentopexy. At laparotomy, adequate omentum and infective AAA were confirmed. AAA repair using a rifampicin-soaked graft, and omentopexy were performed. <i>Enterobacter aerogenes </i>was detected from the resected aortic wall. After the operation, intravenous antibiotic was used for 25 days until CRP was normalized. One year follow-up showed no sign of re-infection.

The Role of Extra-Anatomic Bypass in the Surgical Treatment of Acute Abdominal Aortic Occlusion

BACKGROUND: Aortic occlusion is rare catastophic pathology with high rates of mortality and severe morbidity. In this study, we aimed to share our experience in the management of aortic occlusion and to assess the outcomes of extra-anatomic bypass procedures. METHODS: Eighteen patients who had undergone extra-anatomic bypass interventions in the cardiovascular surgery department of our tertiary care center between July 2009 and May 2013 were retrospectively evaluated. All patients were preoperatively assessed with angiograms (conventional, computed tomography, or magnetic resonance angiography) and Doppler ultrasonography. Operations consisted of bilateral femoral thromboembolectomy, axillobifemoral extra-anatomic bypass and femoropopliteal bypass and were performed on an emergency basis. RESULTS: In all patients during early postoperative period successful revascularization outcomes were obtained; however, one of these operated patients died on the 10th postoperative due to multiorgan failure. The patients were followed up for a mean duration of 21.2+/-9.4 months (range, 6 to 36 months). Amputation was not warranted for any patient during postoperative follow-up. CONCLUSION: To conclude, acute aortic occlusion is a rare but devastating event and is linked with substantial morbidity and mortality in spite of the recent advances in critical care and vascular surgery. Our results have shown that these hazardous outcomes may be minimized and better rates of graft patency may be achieved with extra-anatomic bypass techniques tailored according to the patient.

One Stage Surgery in an Elderly Patient with Aortic Coarctation and Heart Disease / 日本心臓血管外科学会雑誌

A 78-year-old woman had been undergoing medical treatment for hypertension since she delivered a son in her early twenties. Three months previously, she was admitted with heart failure. She had felt leg fatigue for a long time, and the pressure gradient between the upper and lower limbs was about 60 mmHg. On further examinations, she was found to have an atrial septal defect (ASD), tricuspid valve regurgitation, atrial fibrillation, and severe coarctation of the aorta (CoA) with well-developed collateral arteries. We performed ASD closure, tricuspid annuloplasty with a flexible ring, left atrial maze operation and extra-anatomic bypass from the ascending to the abdominal aorta through a median sternotomy and upper median laparotomy. She had no postoperative complications and the pressure gradient between the upper and lower limbs improved remarkably postoperatively. It is rare for a patient over 70 years old who for the first time was given a diagnosis of CoA and ASD with other heart disease and who underwent surgical correction. We think one stage surgery with extra-anatomic bypass from the ascending to the abdominal aorta is a safe and effective technique for patients suffering CoA with heart disease.

Femoral-deep femoral crossover bypass for unilateral iliofemoral arteriosclerosis obliterans / 中华普通外科杂志

Objective To evaluate the clinical results of femoral-deep femoral crossover bypass in the treatment of long-segment unilateral iliac artery occlusive disease.Methods From July 1995 to December 2010,40 patients (28 males,12 females,aged from 66 to 90,with mean age of 73) with comprehensive unilateral iliac-superficial femoral arteriosclerosis obliterans were enrolled in this procedure.All patients suffered from unilateral common iliac,external iliac,common femoral,and superficial femoral arteriosclerosis obliterans.These patients were treated with femoral-deep femoral crossover bypass.Postoperative ankle-brachial index,blood flow velocity and patency rates in 5,7 and 10 years and limb salvage rates in 5,7 and 10 years were evaluated.Results There was no perioperative mortality nor extremity amputation.35 (87.5％ ) patients were followed-up from 1 to 13 years (mean 5.7 y).Anklebrachial index rose from preoperative 0.23 ± 0.10 to postoperative 0.55 ± 0.11 (t =15.91,P =0.000 ).Popliteal arterial velocity rose from preoperative ( 14 ±6) cm/s to postoperative (34 ± 10) cm/s (t =15.63,P =0.000) ; Tibial arterial velocity rose from ( 10 ±4) cm/s to (22 ±7) cm/s (t =15.71,P =0.000).The primary and secondary patency rates were 60.1％,44.3％,25.3％,and 93.5％,86.8％,57.9％ at 5,7 and 10 years,respectively.Limb salvage rates were 97.5％,95％,and 90％,at 5,7 and 10 years,respectively.Conclusions Femoral-deep femoral crossover bypass is safe and reliable in treating certain unilateral iliofemoral occlusive disease,especially for high-risk old patients or those who are not indicated for endovascular therapies or direct aortic approaches.

Extra-anatomic Bypass Grafting after Endovascular Embolization for the Treatment of Mycotic Aneurysm: 2 case reports

Mycotic aneurysm is a disease requiring immediate treatment because of the high risk of rupture. A difficult surgical approach, especially in the case of occurrence on the iliac artery, involving endovascular embolization and extra-anatomic bypass grafting, is known to be a suitable treatment. We performed extra-anatomic bypass grafting after endovascular embolization successfully in two patients. The postoperative computed tomography of both patients showed complete exclusion of the mycotic aneurysm.

A Case of Successful Treatment of Prosthetic Graft Infection Caused by Bacteroides fragilis / 日本心臓血管外科学会雑誌

A 73-year-old man who had undergone Y-grafting suffered from septicemia. A culture of arterial blood yielded <i>Bacteroides fragilis</i>. Computed tomography showed abscess and gas around the prosthetic graft. Under a diagnosis of a prosthetic graft infection caused by <i>Bacteroides fragilis</i>, removal of the infected graft, extra-anatomic bypass and omental grafting were performed 13 days after the first operation. After intensive treatment, he recovered and was discharged on the 45th day postoperatively.

Surgical Treatment of Arterial Aneurysm due to Salmonella Infection / 日本心臓血管外科学会雑誌

Infectious arterial aneurysm in a rare condition with a high mortality because of rapid aneurysmal growth and subsequent rupture. We encountered 3 cases of arterial aneurysm due to <i>Salmonella</i> infection. We evaluated there 3 cases and an additional 14 cases reported in the Japanese literature. Eleven patients with <i>Salmonella</i> infection had bacteremia. The incidence of bacteremia in patients with <i>Salmonella</i> infection was more frequent than that in patients with other bacillary infections. The location of the aneurysm was the abdominal aorta in 14. Rupture or impending rupture of the aneurysm was identified in 12. Fifteen patients underwent operation including <i>in situ</i> reconstruction in 9 and extra-anatomic bypass in 6. Among 15 patients who underwent an operation, 14 survived. These data suggest that accurate preoperative diagnosis, long-term antibiotic therapy, and immediate surgical intervention are essential for effective treatment of arterial aneurysm due to <i>Salmonella</i> infection.

Extra-Anatomic Bypass

Extra-anatomic bypass(EAB) is defined as bypass grafts that pass through a significantly different anatomic pathway than the natural blood vessles they replace. The two categorical reasons for doing this in aortoiliac occlusive disease are to avoid "hostile" intra-abdominal pathologic features and to avoid the high risk of transabdominal reconstruction in patients with serious visceral and systemic disease. To determine the application of this procedure, we reviewed retrospectively the characteristics and outcomes of 30 patients who underwent extra-anatomic bypasses during April, 1986 to April, 1997. Three EABs in brachiocephalic reconstruction were done including 2 carotid-subclavian bypass, 1 femoral-biaxillary bypass. 27 EABs in aortoiliac reconstruction were done including 22 femorofemoral bypass(FFB), 4 axillobifemoral bypass(AxBF). In the latter, EABs were used in older patients with medical comorbidities and contraindication to direct reconstructive procedures involving the abdominal aorta including aneurysms, graft infection, and trauma. One and five-year primary patency rates for entire EABs and FFB were 76.9%, 63.8% and 83.1%, 63.5%, respectively. In FFB, patients with limb- threatening ischemia proved to be inferior to those with claudication as measured by primary patency(p=0.013). Age(>65yr.), sex, smoking, medical comorbidities, duration of symtoms, preoperative angioplasty, use of externally supported graft did not influence primary patency in FFB. The 5-year patient survival rates for entire EABs and FFB were 70.4%, 67.9%. Limb salvage rates for entire EABs and FFB were 65.1%, 66.7% at 3 years. Our results suggest that strict selection of patients with limb-threatening ischemia and medical comorbidities may contribute inferior patency rate of EABs. To determine the application of EABs in aortoiliac reconstruction, the nature of intraabdominal pathology and operative risk with vascular surgeon's experience and judgement should be considered.

A Successfully Treated Case of Aortoenteric Fistula after Operation for the "Inflammatory" Abdominal Aortic Aneurysm / 日本心臓血管外科学会雑誌

A 59-year-old man, who had received graft replacement for the “inflammatory” abdominal aortic aneurysm two years previously was admitted to our hospital because of preshock caused by intermittent intestinal hemorrhage. Gastrointestinal endoscopy revealed an ulcer at the 3rd portion of the duodenum. As aortoenteric fistula was diagnosed and he underwent an emergency operation. After initial axillo-bifemoral bypass grafting, the aortic graft was removed and the aortic stump was closed directly. The duodenal rent was closed by Albert-Lembert suture, He survived the operation and was discharged. We suggest that extra-anatomic bypass is safer than <i>in situ</i> graft replacement in patients with secondary aortoenteric fistula after operation for “inflammatory” abdominal aortic aneurysm, because adjacent organs adhere firmly to the proximal suture line in such cases.

The Late Results of Extra Anatomic Bypasses in Aortoiliac Occlusive Disease / 日本心臓血管外科学会雑誌

From November 1976 to December 1991, we performed extra anatomic bypass procedures (EAB) in 100 cases with aortoiliac occlusive disease. The operative procedures included 26 axillo-femoral bypasses (Ax-F), 27 femoro-femoral bypasses (F-F) and 47 aorto-femoro-femoral bypasses (Ao-F-F). The average age was 75.8 years in Ax-F and 73.8 years in F-F. These were significantly higher than that of Ao-F-F (70.8 years). In addition, the rate of limb salvage in Ax-F was 85%, and this group had more critical cases than the other two groups. The cumulative primary patency rate and survival rate at 5 years were 64.4%, 20.8% (Ax-F), 65.9%, 51.1% (F-F) and 96.5%, 70.4% (Ao-F-F) respectively. The late results of Ao-F-F were comparable to direct aorto-femoral bypass procedures performed in our institution during the same period. On the contrary, the results of Ax-F and F-F were discouraging. We suggest that EAB should be selected for high risk, limb salvage cases and in particular, Ax-F and F-F should be limited to patients with nonphysical acting. We are opposed to appealing for an extended indications of EAB and it should not be regarded simply as a low-risk substitute for aorto-femoral bypass.