A Comprehensive Review of In Situ Fenestration of Aortic Endografts.

OBJECTIVE: Despite technical advances of fenestrated and branched endografts, endovascular exclusion of aneurysms involving renal, visceral, and/or supra-aortic branches remains a challenge. In situ fenestration (ISF) of standard endografts represents another endovascular means to maintain perfusion to such branches. This study aimed to review current indications, technical descriptions, and results of ISF. METHOD: A review of the English language literature was performed in Medline databases, Cochrane Database, Web of Science, and Scopus using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Sixty-seven relevant papers were selected. Thirty-three papers were excluded, leaving 34 articles as the basis of the present review. RESULTS: Most experimental papers evaluated ISF feasibility and assessed the consequences of ISF on graft fabric. Regarding clinical papers, 73 ISF procedures have been attempted in 58 patients, including 26 (45%) emergent and three (5%) bailout cases. Sixty-five (89%) ISF were located at the level of the arch, and eight (11%) in the abdominal aorta. Graft perforation was performed by physical, mechanical, or unspecified means in 33 (45%), 38 (52%), and two vessels (3%), respectively. ISF was technically successful in 68/73 (93%) arteries. At 30 days, two (3.4%) patients died in the setting of an aorto-bronchial fistula and an aorto-oesophageal fistula, respectively. No post-operative death, major complication, or endoleak was described as secondary to the ISF procedure. With follow-up between 0 and 72 months, four (6.9%) late deaths were noted, unrelated to the aorta. One (1.7%) LSA stent was stenosed without symptoms. CONCLUSIONS: Although there may be publication bias, multiple techniques were described to perform ISF with satisfactory short-term results. Long-term data remain scarce. Aortic endograft ISF is an off-label procedure that should not be used outside emergent bailout techniques or investigational studies. A comparison with alternative techniques of preserving aortic side branches is needed.

Totally laparoscopic tube graft bypass for infrarenal aortic aneurysm: a well-established surgical technique.

Abdominal aortic aneurysm (AAA) repair enters the field of laparoscopic surgery. Main advantage of laparoscopic AAA repair is to perform the gold standard endoaneurysmorraphy with a reduced surgical trauma. Since 2001, the technique has evolved and is now well-established. We describe the standard technique of totally laparoscopic endoaneurysmorraphy with tube graft interposition through a transperitoneal left retrorenal approach. Main technical points are discussed.

Experimental development of an endovascular graft for thoraco-abdominal aortic aneurysm repair.

AIM: Current treatment of thoraco-abdominal aortic aneurysms is surgical. Despite significant advances in surgical technique and anesthetic management, significant morbidity and mortality remain associated with their repair. In compliance with principles of reducing postoperative morbidity, we developed a thoraco-abdominal endovascular graft in experimental models of type III and type IV thoraco-abdominal aortic aneurysm. This device had to preserve the vascularization of the visceral arteries while ensuring full aneurysmal exclusion. METHODS: Six implantations of the endovascular graft were performed. This graft was a modular system, made of: 1) a custom made main body containing 4 prosthetic visceral branches, 2) 4 self-expandable stent-grafts connecting prosthetic visceral branches with visceral arteries, 3) a custom made tubular endovascular graft connecting the main body with one of the iliac arteries. RESULTS: On angiographic controls, full aneurysmal exclusion was achieved while maintaining visceral artery perfusion. At the end of each procedure, the experimental model was opened. Macroscopic examination showed harmonious thoraco-abdominal endovascular graft deployments, without abnormal component constraint or kinking. There was no discordance between macroscopic and angiographic CONCLUSIONS: Our experimental work led to the development of a thoraco-abdominal endovascular graft, demonstrating feasibility of thoraco-abdominal aneurysm endoluminal treatment on an in vitro model close to the anatomical conditions observed in human pathology.

Undiagnosed aorto-caval fistula during total laparoscopic abdominal aortic aneurysm repair: a cause of conversion.

Total laparoscopic aortic repair is evolving and is now the technique of choice for the treatment of infrarenal abdominal aortic aneurysms (AAA) in our department. With growing experience, surgeons will be confronted with the same peroperative situations than open surgery. We report a case of total laparoscopic AAA repair with peroperative diagnosis of aorto-caval fistula (ACF).

Total laparoscopic abdominal aortic aneurysms repair.

AIM: The aim of the study was to describe our experience of total laparoscopic abdominal aortic aneurysm (AAA) repair. METHODS: Between February 2002 and September 2004, we performed 49 total laparoscopic AAA repair in 45 men and 4 women. Median age was 73 years (range, 46-85 years). Median aneurysm size was 52 mm (range, 30-95 mm). ASA class of patients was II, III and IV in 16, 32 and 1 cases, respectively. We used the laparoscopic transperitoneal left retrocolic approach in 47 patients. Seven patients were operated via a tranperitoneal left retrorenal approach and one patient via a retroperitoneoscopic approach. RESULTS: We implanted tube grafts and bifurcated grafts in 19 and 30 patients, respectively. Median operative time was 290 min (range, 160-420 min). Median clamping time was 81.5 min (range, 35-230 min). Median blood loss was 1800 cc (range, 300-6900 cc). Mortality was 6.1% (3 patients). In our early experience, two patients died of myocardial infarction. The 3rd death was due to a multiple organ failure. Thirteen major non lethal postoperative complications were observed in 9 patients (18%). Four patients had local/vascular complications, which required reintervention (8%). Nasogastric tube is now removed at the end of procedure. Median duration of ileus, return to general diet, ambulation and hospital stay were 2, 3, 3 and 10 days. With a median follow-up of 19 months (range, 8-39 months), complete recovery with patent graft was observed in 44 patients. Two patients needed a crossover femoral graft for one iliac dissection and one graft limb occlusion. CONCLUSIONS: These results show that total laparoscopic AAA repair is feasible and worthwhile for patients once the learning curve is overcome. It remains technically demanding and a previous training in videoscopic sutures is essential. Initial learning curve in laparoscopic aortic surgery with aortoiliac occlusive lesions is preferable before to begin laparoscopic AAA repair.

Total laparoscopic aortic surgery: transperitoneal direct approach.

OBJECTIVE: We describe the laparoscopic transperitoneal direct approach to the abdominal aorta. OPERATIVE TECHNIQUE: The patient is placed in the right lateral decubitus position, which allows dropping of the small bowel into right side of the abdomen. Anatomical exposure of the abdominal aorta follows the same steps as in open surgery. DISCUSSION: Laparoscopic transperitoneal direct approach allows a reproducible exposure of the abdominal aorta. This technique was useful when retrocolic and/or retrorenal approaches were not possible because of previous left nephrectomy.

Laparoscopic resection of a retroperitoneal schwannoma.

We report a case of a successfully resected retroperitoneal benign schwannoma using laparoscopic surgery. A 62-year-old woman presented with an asymptomatic retroperitoneal mass. Computed tomography (CT) scan revealed a solid tumor compressing the inferior vena cava (IVC). First, we performed an intraoperative biopsy analysis, which revealed a benign neurologic tumor. We then proceeded with the complete laparoscopic resection of the tumor. Pathology revealed a benign schwannoma 8 x 5 cm in size. To our knowledge, only three other cases of the laparoscopic resection of retroperitoneal schwannoma have been reported. In our case, despite the large size of the tumor and the high level of compression of the IVC, a totally laparoscopic resection was feasible.

Experimental treatment of vascular graft infection due to Staphylococcus epidermidis by in situ replacement with a rifampin-bonded polyester graft.

In situ prosthetic graft replacement (ISPGR) of an infected prosthesis raises the risk of recurrent infection in the new graft, especially in cases involving drug-resistant microorganisms. The purpose of this animal study was to evaluate in situ replacement of a vascular graft infected by a highly rifampin-resistant strain of Staphylococcus epidermidis with the use of a rifampin-bonded polyester graft. Antibiotic bonding was obtained by soaking grafts in a high dose of rifampin solution (60 mg/mL). The infrarenal abdominal aorta of 20 dogs was replaced using a polyester prosthesis infected with a highly rifampin-resistant strain of Staphylococcus epidermidis. One week later, the 18 surviving animals were randomized into three groups. Group I (n = 6) did not undergo reoperation. Group II (n = 6) underwent ISPGR using a rifampin-bonded prosthesis. Group III (n = 6) underwent ISPGR using an untreated prosthesis. All surviving animals were killed 28 days after the first procedure. Infectious signs were noted and bacteriological study was carried out on explanted prostheses and various tissue samples. The findings of this experimental study show that soaking a polyester prosthesis in a high-dose rifampin solution can prevent reinfection after in situ replacement of a prosthesis infected by a highly rifampin-resistant Staphylococcus epidermidis.

Retrograde aortomesenteric bypass with tunneling behind the left renal pedicle.

This report describes a new technique for revascularization of the superior mesenteric artery (SMA) which creates a retrograde bypass tunneled behind the left renal pedicle. The procedure can be performed by the left retroperitoneal or transperitoneal route, alone or in association with reconstruction of the infrarenal aorta. Proximal anastomosis is retrograde on the left side of the infrarenal aorta or aortic prosthesis. The course of the bypass runs first in the back and top of the retrorenal dissection plane, then loops behind and over the left renal pedicle, and finally turns downward and forward to the SMA. Distal anastomosis can be made either end-to-end or end-to-side. This large, loop-shaped course not only reduces the risk of kinking but also gives the bypass enough length to adapt to movements of the SMA. This technique has been performed in association with reconstruction of the infrarenal aorta in three patients. Postoperative control using Doppler ultrasound, arteriography, and helical CT scan showed no kinking or other abnormality. One patient died a month after the procedure from myocardial infarction. Follow-up Doppler ultrasound in the two surviving patients showed bypass patency with no stenosis at 19 and 30 months.

Volumetric quantification of coronary artery calcifications using dual-slice spiral CT scanner: improved reproducibility of measurements with 180 degrees linear interpolation algorithm.

PURPOSE: The purpose of this work was to determine the reproducibility of coronary total calcium score (TCS) with dual-slice helical CT and compare three acquisition protocols. METHOD: Fifty patients (59 +/- 10 years old) underwent dual-slice helical CT (collimation = 2 x 2.5 mm) and coronary angiography. Two successive scans were performed, resulting in three sets of images: pitch = 1, 360 degrees linear interpolation (LI) (A360); pitch = 1, 180 degrees LI (A180); and pitch = 1.5, 180 degrees LI (B180). TCS values, calculated using a volumetric method with a threshold of 90 HU, were compared, and the interscan variation was determined. Diagnostic performances were compared with receiver operating characteristic curves. RESULTS: Protocol A360 provided significantly lower TCS than protocols A180 and B180 (p < 0.0001). No statistical difference was seen between A180 and B180, which provided the lowest interscan variation (40 +/- 58%). However, no significant clinical impact of the observed interscan variations was found. CONCLUSION: Reproducibility of TCS with dual-slice helical CT is improved by the 180 LI algorithm. However, dual-slice helical CT is not sufficiently reproducible to allow serial quantification of TCS over time.

Embolic risk of the different stages of carotid bifurcation balloon angioplasty: an experimental study.

PURPOSE: Embolic events during carotid angioplasty are a challenging problem. This experimental study was undertaken to determine the embolic risk after each stage of carotid angioplasty procedure. METHODS: Five ex vivo carotid artery balloon angioplasties were performed on fresh carotid specimens. The carotid specimens were obtained from five patients who underwent an internal carotid artery bypass for stenosis >75%. Before the endovascular maneuvers and after each stage of the procedures, the specimens were flushed with 20 mL of saline solution. Small particulate emboli (diameter, <60 microm) were searched in all the effluents according to the Coulter technique. After this procedure, each effluent was also submitted to scanning electron microscopy. RESULTS: When the stenosis was crossed with the guidewire or the balloon catheter, the number and the mean diameter of embolic particles did not change with three plaques (CP1, CP2, and CP3) and were increased with two plaques (CP4 and CP5). The maximal size of particles was 220 microm (CP5). After balloon angioplasty, the number and the mean diameter of particles increased with CP1, CP2, and CP3. With CP4 and CP5, the number of particles decreased, but their size increased. The maximal size of particles was 1100 microm (CP4). CONCLUSION: Carotid balloon angioplasty generates embolic particles after each stage of the procedure. Techniques of prevention should then be effective from the initial step of the angioplasty procedure, and the selection of patients for carotid angioplasty remains crucial.

Can knitting structure affect dilation of polyester bifurcated prostheses? A randomized study with the use of helical computed tomography scanning.

PURPOSE: The aim of this study was to prospectively evaluate the postoperative dilation of two types of knitted polyester arterial prostheses with the use of helical computed tomographic scanning. METHODS: Thirty-four patients who underwent aortoiliac or aortofemoral bifurcation grafting were randomized to receive a collagen-sealed warp-knitted polyester graft (n = 16 patients) or a gelatin-sealed Köper-knitted polyester graft (n = 18 patients). Alterations in size of all parts of the grafts were evaluated by helical computed tomographic scanning at postoperative day 8, at 3 months, and at 6 months. RESULTS: On postoperative day 8, the mean dilation of the Köper-knitted grafts was 18% +/- 8% for the stem and 15% +/- 12% for the limbs. At the same time period, the mean dilation of warp-knitted grafts was 27% +/- 13% for the stem and 33% +/- 18% for the limbs. No increase in graft dilation was observed at 3 and 6 months. Despite the wide range of values among patients with the same graft type, at each time interval, the Köper-knitted grafts dilated significantly less than the warp-knitted grafts (P <. 05). CONCLUSION: In this randomized study, helical computed tomographic scanning was an accurate technique with which to assess graft dilation. For a 6-month follow-up interval, the Köper-knitted polyester structure dilated less than the warp-knitted structure. Longer-term serial scans should allow a better understanding of the clinical significance of graft dilation.

Abdominal aortic aneurysm: pretherapy assessment with dual-slice helical CT angiography.

OBJECTIVE: The purpose of this study was to evaluate dual-slice helical CT in the pretherapy assessment of abdominal aortic aneurysms. SUBJECTS AND METHODS: Dual-slice helical CT angiography was performed in 47 consecutive patients (mean age, 59 years) with abdominal aortic aneurysm to determine whether we could then evaluate the extent of aneurysm and see associated renal, celiac, mesenteric, and iliofemoral artery disease. Results were compared with those of digital subtraction angiography (n = 47) and surgery (n = 37). RESULTS: The proximal and distal extents of abdominal aortic aneurysm correlated well with surgical findings. Dual-slice helical CT showed all main (n = 102) and accessory (n = 13) renal arteries with a sensitivity of 91% and a specificity of 100% for revealing associated renal artery stenosis exceeding 50%. Sensitivity and specificity of dual-slice helical CT for revealing stenosis exceeding 75% in celiac and superior mesenteric arteries were both 100%. Three of four iliofemoral artery stenoses and two occlusions of the common iliac artery were revealed by dual-slice helical CT. CONCLUSION: Helical CT angiography with dual-slice scanning is a useful and minimally invasive technique that can provide with high accuracy all the necessary information for treatment of abdominal aortic aneurysm.

Resistance of antibiotic-bonded gelatin-coated polymer meshes to Staphylococcus aureus in a rabbit subcutaneous pouch model.

This study examines the efficacy of the bonding of rifampicin, vancomycin or gentamicin to gelatin-coated knitted polymer meshes to prevent perioperative infection. Antibiotic bonding was obtained by soaking the meshes for 15 min in a solution containing 20 mg ml(-1) of rifampicin or 10 mg ml(-1) of vancomycin or gentamicin. A polymer mesh was implanted in a subcutaneous pouch in 16 rabbits: four received a rifampicin-soaked mesh, four received a vancomycin-soaked mesh, four received a gentamicin-soaked mesh, and four received an untreated mesh (control group). At the time of implantation, all the meshes were contaminated locally with 10(8) colony forming units of Staphylococcus aureus. Meshes were harvested one week later and submitted to bacterial counts. At the time of explantation, none of the antibiotic-soaked meshes were infected, whereas all the untreated meshes were infected. These results show that antibiotic soaking evidently prevents perioperative infection of gelatin-coated knitted polymer meshes in this model.

Treatment of vascular graft infection by in situ replacement with cryopreserved aortic allografts: an experimental study.

PURPOSE: The purposes of this study were to prove the efficacy of cryopreserved aortic allografts to treat an established vascular graft infection by in situ replacement in an animal model and to evaluate the role of the antibiotics normally used to decontaminate the allografts. METHODS: Twenty-three dogs underwent infrarenal aortic replacement with a gelatin-sealed knitted polyester graft contaminated in vitro by Staphylococcus epidermidis RP-62. One week later, the 18 surviving animals underwent reoperation for graft removal and were randomized into three groups for in situ replacement: group I (control, n = 6) received a new gelatin-sealed graft; group II (n = 6) received a non-antibiotic-treated cryopreserved allograft; and group III (n = 6) received an antibiotic-treated cryopreserved allograft. Control grafts and allografts were removed 4 weeks after the initial intervention for quantitative bacteriologic analysis and histologic analysis. Bacteriologic results were expressed as colony-forming units per square centimeter of graft material. Qualitative bacteriologic analysis was also obtained from perigraft fluid and tissue. RESULTS: All of the initially implanted grafts and all of the control grafts (group I) were infected at the time of removal. In group II, three out of six allografts were not totally incorporated, whereas in group III incorporation was always complete, with a significantly decreased inflammatory reaction. All of the antibiotic-treated allografts were sterile, whereas three untreated allografts grew bacteria. CONCLUSIONS: In this model, cryopreserved aortic allografts were more resistant to reinfection than synthetic grafts after in situ replacement of an infected prosthetic graft. However, the antibiotic loading of the cryopreserved aortic allograft appears to be essential to obtain optimal therapeutic effects.

Acute upper extremity ischemia during concomitant use of ergotamine tartrate and ampicillin.

Individual hypersensitivity to the vasoconstrictor effects of ergotamine tartrate has been observed even at doses within recommended limits. Hypersensitivity can be induced by concomitant use with other drugs. The best-documented example of drug-induced hypersensitivity to ergotamine tartrate involves antibiotics of the macrolides class. The mechanism underlying this interaction appears to be interference with metabolism of ergotamine tartrate by the liver. In the present report we describe a case of upper extremity ischemia during concomitant use of ergotamine tartrate and ampicillin. The fact that the effect was not dose-dependent, disappeared when administration of ampicillin was discontinued, and reappeared when administration of ampicillin was resumed suggests that the underlying mechanism in our patient was immunologic. Since immunologic hypersensitivity to the vasoconstrictor effects of ergotamine tartrate is unpredictable, great caution and close surveillance is advisable when ergotamine tartrate is used in association with other drugs.