The Results of Femorofemoral Bypass Using a Saphenous Vein Graft as an Alternative to PTFE Grafts

Purpose@#This study aimed to report the results of femorofemoral bypass (FFB) using a great saphenous vein (GSV) graft as an alternative to polytetrafluoroethylene (PTFE) grafts. @*Materials and Methods@#From January 2012 to December 2021, 168 patients who underwent FFB (PTFE, 143; GSV, 25) were included. The patients’ demographic features and surgical intervention results were retrospectively reviewed. @*Results@#There were no intergroup differences in patients’ demographic features.In GSV vs. PTFE grafts, the superficial femoral artery provided statistically significant inflow and outflow (P<0.001 for both), and redo bypass was more common (P=0.021). The mean follow-up duration was 24.7±2.3 months. The primary patency rates at 3 and 5 years were 84% and 74% for PTFE grafts and 82% and 70% for GSV grafts, respectively. There was no significant intergroup difference in primary patency (P=0.661) or clinically driven target lesion revascularization (CD-TLR)-free survival (P=0.758). Clinical characteristics, disease details, and procedures were analyzed as risk factors for graft occlusion. Multivariate analysis revealed that none of the factors was associated with an increased risk of FFB graft occlusion. @*Conclusion@#FFB using PTFE or GSV grafts is a useful method with an approximately 70% 5-year primary patency rate. The GSV and PTFE grafts showed no difference in primary patency or CD-TLR–free survival during follow-up; however, FFB using GSV may be an option in selective situations.

Characteristics and Effect of Rivaroxaban on Venous Thromboembolism in Korean Patients Compared to Western Population: A Subgroup Analysis from XALIA(-LEA) Study

Purpose@#This study aimed to compare the characteristics of venous thromboembolic disease (VTE) in Korean to Caucasian population. @*Materials and Methods@#XALIA-LEA and XALIA were phase IV non-interventional prospective studies with identical designs that investigated the effect of rivaroxaban versus standard anticoagulation for VTE. Koreans accounted for the largest proportion of the overall enrolled population of XALIA-LEA. However, in the XALIA study, most patients were Caucasian. Therefore, Korean data from XALIA-LEA and Caucasian data from XALIA were used in this study. This study compared the clinical characteristics and primary outcomes of the XALIA program, including major bleeding, recurrent VTE, and all-cause mortality. @*Results@#The Korean population was older, was less obese, and had more active cancer at baseline than the Caucasian population. Provoked VTE was more common in the Korean population. Interestingly, Koreans showed less accompanying thrombophilia than Caucasians, and factor V Leiden mutations were not detected. Korean analyses comparing the effects of rivaroxaban and standard anticoagulation with primary outcomes showed a lower incidence of major bleeding, recurrent VTE, and all-cause mortality with rivaroxaban. Similar results were obtained in the propensity score matching analysis. @*Conclusion@#Characteristic differences were found between Korean and Caucasian VTE patients. Despite these ethnic differences, the effectiveness and safety of rivaroxaban therapy in these patients were consistent.

Changes in Neck Angle, Neck Length, Maximum Diameter, Maximum Area and Thrombus after Endovascular Aneurysm Repair

Purpose@#The correlation of initial anatomy of the aneurysm, aneurysmal remodeling and endoleaks is controversial. We performed a retrospective study to measure aneurysmal remodeling with time, and to assess the structural changes in the aneurysm neck after endovascular aneurysm repair (EVAR). @*Materials and Methods@#From January 2013 to February 2018, 108 patients with abdominal aortic aneurysms (AAA) underwent EVAR. Follow-up computed tomography images were available for 90 patients. Anatomic variables, including the neck angle, neck length, maximal diameter, maximal area, and thrombus volume were measured. Temporal changes were measured preoperatively, immediate postoperatively (within 1 week after EVAR), and at 6 months, 1 year, and 2 years post-EVAR. Correlation between the variables according to the temporal changes and presence of type Ia endoleaks (T1aE) was analyzed. @*Results@#The mean follow-up period was 10.63±20.34 months. Significant decreases in neck angle and length occurred immediately postoperative (P<0.001 and 0.036). Maximum diameter decreased at 6 months post-EVAR (P=0.003), but no significant changes in the maximal area occurred over time (P=0.142). Thrombus volume in the aneurysm sac increased immediately post-EVAR (P=0.008). There was no significant relationship between T1aE and neck changes in the group and time comparison (P=0.815 and 0.970). @*Conclusion@#Changes in neck angle, length and thrombus volume occurred immediately after EVAR, whereas a change in the maximum diameter of the AAA was noted 6 months after EVAR. Preoperative anatomic variables related with T1aE were not found.

Endovascular Aneurysm Repair by Combining Different Endografts: the Zenith Body and Endurant Limbs

PURPOSE: There are several commercially approved stent grafts in Korea for the treatment of abdominal aortic aneurysms (AAAs). Each device has its advantages and disadvantages based on the patient’s anatomy and the clinical situation. The Zenith device allows accurate and precise endograft placement, whereas the Endurant device has improved flexibility and trackability. We reviewed 5 cases in which a combination of the Zenith main body and the Endurant iliac limb was used. MATERIALS AND METHODS: From January 2010 to February 2015, 90 patients with AAA underwent endovascular aneurysm repair (EVAR) using the Zenith body at Daegu Catholic University Hospital. Among them, 5 patients who underwent EVAR with the Zenith body and Endurant iliac limb were included in this study. RESULTS: The mean age of the patients was 74.20±3.35 years. All patients were men. The main reason for use of the Endurant iliac limb was aortoiliac angulation. Type III endoleak, stent migration, and stent kinking were not noted. Comparing 85 patients who received a Zenith endograft with 5 patients who received the hybrid endograft, there were no statistical differences in clinical characteristics, intraoperative details and post procedural complications. The mean admission duration was 19.00±13.60 days, and the mean follow-up duration was 1,018.11±925.34 days. In the hybrid endograft group, there was no mortality during the follow-up duration. CONCLUSION: Although the material, radial force, diameter, and length of the overlap zone differ between the two devices, EVAR with the hybrid endograft is safe and effective.

Endovascular Aneurysm Repair in Patients with Conical Neck Anatomy

PURPOSE: Cone shape neck is regarded as non-instruction for use (IFU) in most commercial stent graft. However, in real practice, liberal application of endovascular aneurysm repair (EVAR) for outside of IFU happens. We investigate non-adherence to conical neck anatomy in terms of early aneurysmal exclusion results. MATERIALS AND METHODS: From January 2010 to December 2013, 105 patients with abdominal aortic aneurysm (AAA) underwent EVAR in Daegu Catholic University Medical Center. Among them, 38 patients (36.2%) had AAA with conical neck. We investigated the clinical characteristics of patients and the details of conical neck. We also analyzed the clinical results, such as endoleak, migration, procedure failure, perioperative mortality, and admission duration between conical neck and non-conical neck. RESULTS: The maximum diameter of AAA was larger (60.95 mm vs. 52.68 mm, P=0.016) and the infrarenal neck length was shorter (25.07 mm vs. 38.13 mm, P=0.000) in conical neck group. During the procedure, type Ia endoleak occurred more in conical neck group (23.7% vs. 6.0%, P=0.013) and it could be successfully solved with additional adjunctive treatments, such as balloon or Palmaz stent. Although there was no statistical significance, mortality was higher and admission duration was longer in the conical neck (15.8% vs. 6.0%, 16.62±13.12 days vs. 13.03±13.13 days). Mean follow-up duration was 319.2±366.45 days. Successful aneurysmal exclusion was achieved. CONCLUSION: The presence of conical neck may not be a contraindication for EVAR. However, conical neck requires careful observation for additional adjunctive treatments because it increases the risk of type Ia endoleak.

Risk Factor Analysis for Buttock Claudication after Internal Iliac Artery Embolization with Endovascular Aortic Aneurysm Repair

PURPOSE: Endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) involving the common iliac artery requires extension of the stent-graft limb into the external iliac artery. For this procedure, internal iliac artery (IIA) embolization is performed to prevent type II endoleak. In this study, we investigated the frequency and risk factor of buttock claudication (BC) in patients having interventional embolization of the IIA. MATERIALS AND METHODS: From January 2010 to December 2013, a total of 110 patients with AAA were treated with EVAR in our institution. This study included 27 patients (24.5%) who had undergone unilateral IIA coil embolization with EVAR. We examined hospital charts retrospectively and interviewed by telephone for the occurrence of BC. RESULTS: Mean age of total patients was 71.9±7.0 years and 88.9% were males. During a mean follow-up of 8.65±9.04 months, the incidence of BC was 40.7% (11 of 27 patients). In 8 patients with claudication, the symptoms had resolved within 1 month of IIA embolization, but the symptoms persisted for more than 6 months in the remaining 3 patients. In univariate and multivariate analysis, risk factors such as age, sex, comorbidity, patency of collateral arteries, and anatomical characteristics of AAA were not significantly related with BC. CONCLUSION: In this study, BC was a frequent complication of IIA embolization during EVAR and there was no associated risk factor. Certain principles such as checking preoperative angiogram, proximal and unilateral IIA embolization may have contributed to reducing the incidence of BC.

Diagnosis and Treatment of Lower Extremity Deep Vein Thrombosis: Korean Practice Guidelines

Lower extremity deep vein thrombosis is a serious medical condition that can result in death or major disability due to pulmonary embolism or post-thrombotic syndrome. Appropriate diagnosis and treatment are required to improve symptoms and salvage the affected limb. Early thrombus clearance rapidly resolves symptoms related to venous obstruction, restores valve function and reduces the incidence of post-thrombotic syndrome. Recently, endovascular treatment has been established as a standard method for early thrombus removal. However, there are a variety of views regarding the indications and procedures among medical institutions and operators. Therefore, we intend to provide evidence-based guidelines for diagnosis and treatment of lower extremity deep vein thrombosis by multidisciplinary consensus. These guidelines are the result of a close collaboration between interventional radiologists and vascular surgeons. The goals of these guidelines are to improve treatment, to serve as a guide to the clinician, and consequently to contribute to public health care.

Self expandable stent application to prevent limb occlusion in external iliac artery during endovascular aneurysm repair

PURPOSE: Iliac extension of stent-graft during endovascular aneurysm repair (EVAR) increases the incidence of limb occlusion (LO). Hypothetically, adjunctive iliac stent (AIS) could offer some additional protection to overcome this anatomic hostility. But still there is no consensus in terms of effective stent characteristics or configuration. We retrospectively reviewed our center's experience to offer a possible answer to this question. METHODS: Our study included 30 patients (38 limbs) with AIS placed in the external iliac artery (EIA) from January 2010 to December 2013. We classified iliac tortuosity based on anatomic characteristics. AIS's were deployed in EIA with a minimum 5-mm stick-out configuration from the distal edge of the stent-graft. RESULTS: According to the iliac artery tortuosity index, grade 0, grade 1, and grade 2 were 5 (13.2%), 30 (78.9%), and 3 (7.9%), respectively. The diameter of all AIS was 12 mm, which was as large as or larger than the diameter of the stent-graft distal limb. SMART stents were preferred in 34 limbs (89.5%) and stents with 60-mm length were usually used (89.5%). During a mean follow-up of 9.13 ± 10.78 months, ischemic limb pain, which could be the sign of LO, was not noticed in any patients. There was no fracture, kinking, migration, in-stent restenosis, or occlusion of AIS. CONCLUSION: The installation of AIS after extension of stent-graft to EIA reduced the risk of LO without any complications. AIS should be considered as a preventive procedure of LO if stent-graft needs to be extended to EIA during EVAR.

Self expandable stent application to prevent limb occlusion in external iliac artery during endovascular aneurysm repair

PURPOSE: Iliac extension of stent-graft during endovascular aneurysm repair (EVAR) increases the incidence of limb occlusion (LO). Hypothetically, adjunctive iliac stent (AIS) could offer some additional protection to overcome this anatomic hostility. But still there is no consensus in terms of effective stent characteristics or configuration. We retrospectively reviewed our center's experience to offer a possible answer to this question. METHODS: Our study included 30 patients (38 limbs) with AIS placed in the external iliac artery (EIA) from January 2010 to December 2013. We classified iliac tortuosity based on anatomic characteristics. AIS's were deployed in EIA with a minimum 5-mm stick-out configuration from the distal edge of the stent-graft. RESULTS: According to the iliac artery tortuosity index, grade 0, grade 1, and grade 2 were 5 (13.2%), 30 (78.9%), and 3 (7.9%), respectively. The diameter of all AIS was 12 mm, which was as large as or larger than the diameter of the stent-graft distal limb. SMART stents were preferred in 34 limbs (89.5%) and stents with 60-mm length were usually used (89.5%). During a mean follow-up of 9.13 ± 10.78 months, ischemic limb pain, which could be the sign of LO, was not noticed in any patients. There was no fracture, kinking, migration, in-stent restenosis, or occlusion of AIS. CONCLUSION: The installation of AIS after extension of stent-graft to EIA reduced the risk of LO without any complications. AIS should be considered as a preventive procedure of LO if stent-graft needs to be extended to EIA during EVAR.

Anatomical Features and Early Outcomes of Endovascular Repair of Abdominal Aortic Aneurysm from a Korean Multicenter Registry

PURPOSE: To introduce a nation-based endovascular aneurysm repair (EVAR) registry in South Korea and to analyze the anatomical features and early clinical outcomes of abdominal aortic aneurysms (AAA) in patients who underwent EVAR. MATERIALS AND METHODS: The Korean EVAR registry (KER) was a template-based online registry developed and established in 2009. The KER recruited 389 patients who underwent EVAR from 13 medical centers in South Korea from January 2010 to June 2010. We retrospectively reviewed the anatomic features and 30-day clinical outcomes. RESULTS: Initial deployment without open conversion was achieved in all cases and procedure-related 30-day mortality rate was 1.9%. Anatomic features showed the following variables: proximal aortic neck angle 48.8+/-25.7degrees (mean+/-standard deviation), vertical neck length 35.0+/-17.2 mm, aneurysmal sac diameter 57.2+/-14.2 mm, common iliac artery (CIA) involvement in 218 (56.3%) patients, and median right CIA length 34.9 mm. Two hundred and nineteen (56.3%) patients showed neck calcification, 98 patients (25.2%) had neck thrombus, and the inferior mesenteric arteries of 91 patients (23.4%) were occluded. CONCLUSION: Anatomical features of AAA in patients from the KER were characterized as having angulated proximal neck, tortuous iliac artery, and a higher rate of CIA involvement. Long-term follow-up and ongoing studies are required.

Use of Reversed Iliac Leg Stent-Graft for the Treatment of Isolated Aneurysm of Internal Iliac Artery

This is to report the technique of reversed iliac leg stent-graft in endovascular treatment for isolated internal iliac artery (IIA) aneurysm, which had significant size discrepancy between the common iliac artery (CIA) and external iliac artery (EIA) in 3 patients from different hospitals. Three patients were a 85- and two 82-year-old men. Treated were right IIA aneurysms, sized 6.5x6.2 cm, 5.0x4.0 cm, and 4.1 cm in longest diameter, respectively. The diameters of the right CIA and right EIA measured 21 mm/11 mm, 15 mm/11 mm, and 20 mm/10 mm, respectively. In all cases, reversed iliac leg stent-grafts were prepared on-site; unsheathed and mounted upside-down manually, and deployed in each right CIA. Post-stent-graft angiograms showed complete exclusion of the aneurysms, except for minimal type 1 endoleak in one case. This technique is a useful treatment option in patients with isolated IIA aneurysm.

Consensus for the Treatment of Varicose Vein with Radiofrequency Ablation

The objective of this paper is to introduce the schematic protocol of radiofrequency (RF) ablation for the treatment of varicose veins. Indication: anatomic or pathophysiologic indication includes venous diameter within 2-20 mm, reflux time > or =0.5 seconds and distance from the skin > or =5 mm or subfascial location. Access: it is recommended to access at or above the knee joint for great saphenous vein and above the mid-calf for small saphenous vein. Catheter placement: the catheter tip should be placed 2.0 cm inferior to the saphenofemoral or saphenopopliteal junction. Endovenous heat-induced thrombosis > or =class III should be treated with low-molecular weight heparin. Tumescent solution: the composition of solution can be variable (e.g., 2% lidocaine 20 mL+500 mL normal saline+bicarbonate 2.5 mL with/without epinephrine). Infiltration can be done from each direction. Ablation: two cycles' ablation for the first proximal segment of saphenous vein and the segment with the incompetent perforators is recommended. The other segments should be ablated one time. During RF energy delivery, it is recommended to apply external compression. Concomitant procedure: It is recommended to do simultaneously ambulatory phlebectomy. For sclerotherapy, it is recommended to defer at least 2 weeks. Post-procedural management: post-procedural ambulation is encouraged to reduce the thrombotic complications. Compression stocking should be applied for at least 7 days. Minor daily activity is not limited, but strenuous activities should be avoided for 2 weeks. It is suggested to take showers after 24 hours and tub baths, swimming, or soaking in water after 2 weeks.

Surgeon Custom-Made Iliac Branch Device to Salvage Hypogastric Artery during Endovascular Aneurysm Repair

Endovascular salvage of the hypogastric artery using iliac branch device (IBD) during endovascular aortic aneurysm repair (EVAR), offers less invasive alternative solution to surgery to prevent pelvic ischemia. We have performed the first Korean surgeon custom-made IBD for this purpose to overcome the limitation of unavailability of the devices in Korea. Four patients with abdominal aortic aneurysm with bilateral common iliac artery aneurysm (CIAA) were treated using custom-made IBDs from October 2013 to December 2013. IBD was created in back table before EVAR operation using TFLE Zenith iliac limb stent graft (Cook Inc.). Three V12 (Atrium, Inc.) one Viabahn (Gore, Inc.) were used for bridging between IBD and target hypogastric artery. With this modification of IBD procedure, exteriorize the guide wire without snare device is possible which offers another benefit in terms of reducing medical costs comparing to commercial IBD. All operations were successful without any device related complications or postoperative endoleaks. During the mean follow up of 3 months, all IBD were patent without clinical complications. Surgeon custom made IBD is feasible and useful to preserve pelvic perfusion especially in the situation of limited commercial IBD availability in many countries. Long-term follow-up is needed to evaluate stent graft patency and IBD-related complications.

Preoperative Endovascular Abdominal Aortic Aneurysm Repair Planning with Centerline Measurement / 대한혈관외과학회지

PURPOSE: Sometimes, there are endograft shortenings during endovascular aneurysm repair (EVAR). They are associated with various changes of endograft position in a 3-dimensional (3D) space. The purpose of this study is to evaluate the accuracy of central luminal line (CLL) measurements and understand the degree of endograft shortenings. METHODS: Preoperative 3D computed tomographic (CT) scans were evaluated for every EVAR case. Preoperative working lengths were measured with computerized software that allowed for centerline measurements on 3D reconstructions based on CT data. We compared preoperative CLL measurements and used the endograft length. In this study, the ipsilateral limb length comparisons were excluded, because the overlapped stent-graft length can influence the total ipsilateral limb length. Hence, only the contralateral limb lengths were compared with each other. RESULTS: Preoperative contralateral lengths in the 9 limbs were studied. There was no large difference (below 10 mm) in almost all cases except for one (15 mm shortening), which was very tortuous aortoiliac anatomy. The mean difference between preoperative CLL measurements and the used stent-graft length was 4.48 mm. CONCLUSION: Although these shortenings can be overcome with the deployment technique, the operator should prepare various length extensions in tortuous anatomy.

The Clinical Outcomes of Endovenous Radiofrequency Ablation of Varicose Veins: Results from the Korean Radiofrequency Ablation Registry / 대한혈관외과학회지

PURPOSE: Radiofrequency ablation (RFA) has been used as an alternative to conventional high ligation and stripping surgery for the treatment of saphenous vein insufficiency. A Korean clinical registry was established in 2012. The purpose of our study is to report the clinical outcomes of RFA from the Korean RFA Registry. METHODS: Data were collected in a multicenter, retrospective registry. All patients were treated before March 31, 2013. The indication for RFA was clinical, etiology, anatomy, and pathophysiology (CEAP) clinical class C2-C6 and patients with disease-associated symptoms, complications, or cosmetic concerns. We retrospectively reviewed the clinical outcomes, such as CEAP score, venous clinical severity score (VCSS), and quality of life (QoL) score after RFA using ClosureFAST (Covidien) catheter. The paired and independent t-test using IBM SPSS ver. 19.0 (IBM Co.) was used for the statistical analysis to evaluate the clinical improvement after treatment. RESULTS: There were 698 patients (890 limbs) treated with RFA at 5 centers in Korea. The average age was 53.7+/-12.0 years (range, 19 to 89 years) with a body mass index of 23.1+/-2.8 kg/m2, 58.2% of the patients were female. All saphenous veins with reflux > or =0.5 seconds were ablated simultaneously. The most common complication was ecchymosis, which occurred in 41 patients (5.9%). All clinical parameters were significantly improved. At the mean follow-up of 13.9 months, the occlusion rate was 94.6% in great saphenous vein and 94.5% in small saphenous vein. CONCLUSION: RFA is an effective modality in the treatment of saphenous vein insufficiency. The clinical parameters including CEAP class, VCSS and QoL score showed significant improvement after RFA.

Cross Pubic Femoro-femoral Artery Bypass with Great Saphenous Vein / 대한혈관외과학회지

PURPOSE: The purpose of this study was to evaluate the great saphenous vein (GSV) as a conduit for crossover femoro-femoral bypass. Generally the conduit for crossover femoro-femoral bypass is a synthetic material because of the acceptable long-term patency and low complication rates. But, as the average life expectancy becomes extended, a better patency rate becomes more important. In this study, we compared the patency rates and hemodynamic results between crossover femoro-femoral bypass operations with GSVs and those with synthetic grafts. METHODS: From 1998 to 2008, 119 femoro-femoral bypass operations were done. Among them, 38 femoro-femoral bypass used GSV as a conduit (group I) and 79 operations used expanded polytetrafluoroethylene (group II). Two cases used arm veins and we excluded those cases. RESULTS: The 3 year primary patency rate of total cases was 75.1%, 93.7% in group I and 66.1% in group II. There were no statistical differences in hemodynamic results such as peak systolic velocity, volume flow and ankle/brachial systolic pressure index between the two groups. CONCLUSION: The 3 year primary patency rate of group I was better than that of group II. However there were no differences in hemodynamic changes. So GSV is recommended as a conduit for crossover femoro-femoral bypass especially in young patients who are eager to have longer patency rates after surgery instead of less invasive endovascular therapy.

Current Role of Endovascular Therapy in Leg Arteries

Lower extremity peripheral arterial occlusive disease poses a unique challenge to traditional angioplasty based endovascular therapies. The diffuse nature of lower extremity atherosclerotic disease, the presence of chronic total occlusions, poor distal runoff, and the presence of critical limb ischemia have all contributed to the disappointing results of balloon angioplasty of complex infrainguinal arterial disease. These challenges have spawned the development of new technologies in an attempt to improve the safety and effectiveness of percutaneous revascularization for lower extremity peripheral arterial occlusive disease. This review summarizes the advances in available technologies including conventional angioplasty balloons, nitinol stents, stent graft, drug-eluting stents, excisional atherectomy devices, devices for crossing total occlusions, and true lumen reentry devices.

Results of Simultaneous Hybrid Operation in Multi-level Arterial Occlusive Disease

PURPOSE: Hybrid procedure in lower extremity arterial disease is composed of open bypass and endovascular treatment. For proximal inflow bypass operations for distal lesions used to be performed 1 or 2 weeks after endovascular therapy. Since Aug 2005, all hybrid operations have been performed simultaneously in the operation room in our center. In this study, we compared the results of the staged hybrid operations with those of simultaneous procedures. METHODS: From Jan 1999 to Dec 2009, 115 endovascular treatments and 139 bypass operations were performed. 44 bypasses were performed 1 day to 14 days after angioplasty in inflow lesions (group I) and 95 bypasses were performed simultaneously in the operation room with mobile fluoroscopy (group II). In both groups, inflow procedures included 3 femoral balloon angioplasties, 3 femoral stents, 24 iliac balloon angioplasties and 85 iliac stents. Bypass operations were composed of 39 femorofemoral and 102 infrainguinal bypasses including 60 femoropopliteal and 42 other bypasses. RESULTS: The 3-year patency rate of bypass graft is 71.5%. There is no difference in either group. But in endovascular treatment lesion, the 3-year patency rate is 80% and that of the simultaneous group is higher than that of the staged group (P<0.05). CONCLUSION: Hybrid operation is a less invasive therapy for revascularization in multilevel peripheral arterial occlusive disease. With development of endovascular therapy, simultaneous hybrid operations become more efficient.

The Tolerance for Misalignment When Repairing Standardized Multi-Branched Thoracoabdominal Stent Grafts

PURPOSE: We wanted to assess the accuracy of thoracoabdominal stent graft deployment and the effect of the stent graft orientation on the angulation of the visceral branches. METHODS: The accuracy of thoracoabdominal stent graft deployment and the effect of the stent graft orientation on the angulation of the visceral branches were assessed. The actual cuff orientation (ACO), the actual vessel orientation (AVO) and the longitudinal branch length (LBL) were measured by 3-dimensional analysis (TeraRecon) of the postoperative CT scans. The ACO was compared with the planned orientation (PCO) to assess malorientation (ACO-PCO). The ACO was also compared with the AVO to assess the branch angulation in the trans-axial (ACO-AVO) and longitudinal branch angle (LBA) planes. RESULTS: Between Nov 2005 and Dec 2008, 38 patients underwent multi-branched endovascular aortic aneurysm repair with a total of 136 branches to the visceral arteries. Small degrees of malorientation (ACO-PCO) were common, but severe malorientation (>45 degrees) was rare. The cuff-bearing portion of the stent graft usually rotated as a single unit. Only one patient had >30 degrees of twisting between the celiac artery (CA) and SMA cuffs and only 4 had >30 degrees between the CA and the left renal artery (LRA). Ninety one percent of the visceral arteries lay within a vertical 60 degree-wide arc (LBA x2) that was centered on the outer orifice of the corresponding cuff. All 141 branches were inserted as planned. None have migrated, disconnected or kinked. CONCLUSION: The branches of a thoracoabdominal stent graft do bend to accommodate a modest degree of malorientation, but these angles do not compromise the stability of the branch implantation.

Experience with Transobturator Foramen Bypass Surgery: a Case Report

The obturator bypass operation is not a common procedure. In 1963, Shaw and Baue first described performing bypass surgery through the obturator foramen as a technique to deal with infected arterial prostheses in the groin. This operation has been used to reconstruct patients with groin infection, irradiation ulcer, mycotic aneurysm, trauma and excessive scar tissue in the femoral region. We experienced one case of transobturator foramen bypass surgery from a Dacron iliac limb to the popliteal artery.