A Hybrid Approach in the Management of a Large Pancreaticoduodenal Artery Aneurysm.

Pancreaticoduodenal artery aneurysms (PDAA) are rare and represent a small fraction of known visceral aneurysms. We describe a case of a 79-year-old male with an 82 mm PDAA in the setting of chronic celiac artery occlusion. The patient was treated with an open repair. Due to the large size of the aneurysm and the dense adhesions to the surrounding tissues, vascular control of the superior mesenteric artery (SMA) was achieved by endovascular balloon occlusion and the aneurysm repaired with resection and primary aneurysmorrhaphy. The patient had an uneventful postoperative course.

The Superficial Femoral Artery: An Alternative Access for Percutaneous Endovascular Aneurysm Repair.

BACKGROUND: The aim of this study was to report the results of percutaneous endovascular aortic aneurysm repair (PEVAR) using the superficial femoral artery (SFA) for large bore vessel access. METHODS: We reviewed all PEVAR procedures at our institution over an 18-month period, identifying all patients who underwent PEVAR with the use of one or both SFAs for endograft delivery with dual ProGlide large bore access closure. Indications for use of the SFA instead of the common femoral artery (CFA) included morbid obesity, CFA vessel wall disease, and scarring from previous CFA surgery. RESULTS: In total, 158 percutaneous access closures were performed in 79 patients. Ten patients had one or both SFAs used. We accessed a total of 13 SFAs: 6 for the endograft main body (size range 18- to 20-French) and 7 for the limb (14- to 16-French). The freedom from open conversion was 84.6%. In comparison, of 145 CFA accesses (in 76 patients) there were 9 conversions (93.7% success). Of the 13 SFAs accessed, there were no major access site complications (pseudoaneurysm, access site bleed, limb ischemia, or need to return to the operating room). All SFAs accessed remained patent at the latest follow-up (range 1-13 months, median 8 months). CONCLUSIONS: Our preliminary case series suggests that, in the absence of a healthy or percutaneously accessible CFA, a healthy SFA may be considered for PEVAR access. While likely carrying a higher risk of open conversion, this technique, when combined with intraoperative duplex ultrasound (both before and after the procedure) and with meticulous ultrasound-guided vascular access, appears safe for up to 20-French device diameters.

Outcomes of open and endovascular repair for ruptured and nonruptured internal iliac artery aneurysms.

OBJECTIVE: To evaluate outcomes of open (OR) and endovascular repair (II-EVAR) of internal iliac artery aneurysms (IIAAs) with or without preservation of internal iliac artery (IIA) flow. METHODS: We reviewed the clinical data of consecutive patients treated for IIAAs between 2001 and 2012. End-points were morbidity, mortality, graft patency, and freedom from pelvic ischemic symptoms (buttock claudication, ischemic colitis, and spinal cord injury). RESULTS: There were 97 patients, 87 male and 10 female, with mean age of 74 ± 8 years. A total of 125 IIAAs (71 unilateral and 27 bilateral) with mean diameter of 3.6 ± 2 cm were treated. Eighty-two patients (86%) had elective repair and 15 (14%) required emergent repair (mean size, 6.7 ± 2.4 cm; range, 3.6-10 cm). OR in 60 patients (62%; 49 elective, 11 emergent) included IIA bypass in 36 (60%) patients and endoaneurysmorrhaphy in 24 (40%). II-EVAR in 37 patients (38%; 30 elective, 4 emergent) required IIA embolization in 29, iliac branch device in five or open IIA bypass in three, combined with bifurcated aortic stent grafts in 17. Early mortality was 1% for elective (1/49 open, 0/33 endovascular) and 7% for emergent repair (1/11 open, 0/4 endovascular). Early morbidity (43% vs 8%; P < .001) and length of stay (9 vs 1 day; P < .001) were significantly higher for OR as compared with II-EVAR. Pelvic ischemic complications occurred in 25 patients (26%), including hip claudication in 23, ischemic colitis in two, and paraplegia in one. Freedom from buttock claudication at 2 years was 25% in patients with no IIA preserved, 68% with preservation of one, and 95% with preservation of both IIAs (P = .002). Freedom from buttock claudication was higher after OR than after II-EVAR (79% vs 59%; P = .05). Primary and secondary patency rates of IIAA bypasses were 95%, and 80% at 1 and 3 years, respectively. CONCLUSIONS: II-EVAR of IIAAs is associated with fewer complications and shorter hospital stay compared with OR. Open and endovascular IIA reconstructions have very good long-term patency, and preservation of IIA flow is associated with higher freedom from buttock claudication.

Treatment strategies and outcomes in patients with infected aortic endografts.

OBJECTIVE: Endovascular abdominal (EVAR) and thoracic (TEVAR) endografts allow aneurysm repair in high-risk patients, but infectious complications may be devastating. We reviewed treatment and outcomes in patients with infected aortic endografts. METHODS: Twenty-four patients were treated between January 1997 and July 2012. End points were mortality, morbidity, graft-related complications, or reinfection. RESULTS: Twenty males and four females with median age of 70 years (range, 35-80 years) had 21 infected EVARs and 3 TEVARs. Index repairs performed at our institution included eight EVARs and two TEVARs (10/1300; 0.77%). There were 19 primary endograft infections, 4 graft-enteric fistulae, and 1 aortobronchial fistula. Median time from repair to presentation was 11 months (range, 1-102 months); symptoms were fever in 17, abdominal pain in 11, and psoas abscess in 3. An organism was identified in 19 patients (8 mono- and 11 polymicrobial); most commonly Staphylococcus in 12 and Streptococcus in 6. All but one patient had successful endograft explantation. Abdominal aortic reconstruction was in situ repair in 21 (15 rifampin-soaked, 2 femoral vein, and 4 cryopreserved) and axillobifemoral bypass in three critically ill patients. Infected TEVARs were treated with rifampin-soaked grafts using hypothermic circulatory arrest. Early mortality (30 days or in-hospital) was 4% (n = 1). Morbidity occurred in 16 (67%) patients (10 renal, 5 wound-related, 3 pulmonary, and 1 had a cardiac event). Median hospital stay was 14 days (range, 6-78 days). One patient treated with in situ rifampin-soaked graft had a reinfection with fatal anastomotic blowout on day 44. At 14 months median follow-up (range, 1-82 months), patient survival, graft-related complications, and reinfection rates were 79%, 13%, and 4%, respectively. CONCLUSIONS: Endograft explantation and in situ reconstruction to treat infections can be performed safely. Extra-anatomic bypass may be used in high-risk patients. Resection of all infected aortic wall is recommended to prevent anastomotic breakdown. Despite high early morbidity, the risk of long-term graft-related complications and reinfections is low.

May-Thurner syndrome associated with Klippel-Trenaunay syndrome.

We present an unusual case of a 23-year-old man who had symptomatic lower extremity varicosities that have been present since birth. He was complaining of pain and swelling of several years duration. Evaluation revealed Klippel-Trenaunay syndrome with associated compression of the left common iliac vein by the overriding left common iliac artery (May-Thurner syndrome). The patient was treated with left common iliac vein stenting followed by high ligation and inversion stripping of his grossly incompetent left small saphenous vein, stripping of his aberrant left lateral embryonic veins, and also by multiple stab phlebectomies, with excellent early result.