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Challenging Arterial Reconstructions: 100 Clinical Cases [1st ed.]
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Sachinder Singh Hans

Table of contents :
Front Matter ....Pages i-xxviii
Front Matter ....Pages 1-1
Symptomatic Proximal Anastomotic Pseudoaneurysm of Suprarenal Aorta (Sachinder Singh Hans)....Pages 3-8
Repair of Juxtarenal Abdominal Aortic Aneurysm with Aortorenal Bypass (Sachinder Singh Hans)....Pages 9-13
Abdominal Aortic Aneurysm Repair in a Patient with Celiac Artery Occlusion and a Large Inferior Mesenteric Artery (Sachinder Singh Hans)....Pages 15-17
Abdominal Aortic Aneurysm Repair in a Patient with a Pelvic Kidney (Sachinder Singh Hans)....Pages 19-21
Open Repair of Abdominal Aortic Aneurysm in a Patient with Double Inferior Vena Cava (Sachinder Singh Hans)....Pages 23-26
Mycotic Aneurysm of the Abdominal Aorta (Sachinder Singh Hans)....Pages 27-30
Open Abdominal Aortic and Iliac Aneurysm Repair in a Patient with Cirrhosis of the Liver (Sachinder Singh Hans)....Pages 31-32
Major Venous Injury During Repair of Abdominal Aortic and Iliac Aneurysm (Sachinder Singh Hans)....Pages 33-34
Secondary Aortoduodenal Fistula Following Abdominal Aortic Aneurysm Repair (Sachinder Singh Hans)....Pages 35-38
Open Repair of an Inflammatory Abdominal Aortic Aneurysm (Sachinder Singh Hans)....Pages 39-41
Right Subhepatic Approach for Inflammatory Aortic Aneurysm in a Patient with Scoliosis (Sachinder Singh Hans)....Pages 43-45
Large Symptomatic Abdominal Aortic Aneurysm (Sachinder Singh Hans)....Pages 47-48
Abdominal Aortic Aneurysm in a Patient with Chronic Lymphocytic Leukemia (Sachinder Singh Hans)....Pages 49-52
Inflammatory Abdominal Aortic Aneurysm Presenting with Testicular Pain (Sachinder Singh Hans)....Pages 53-54
Abdominal Aortic Aneurysm Repair in a Patient with Factor VII Deficiency (Sachinder Singh Hans)....Pages 55-56
Front Matter ....Pages 57-57
Open Repair of Ruptured Abdominal Aortic Aneurysm Complicated by Pancreatitis and Duodenal Obstruction (Sachinder Singh Hans)....Pages 59-60
Rupture of Abdominal Aortic Aneurysm in a Patient with a Horseshoe Kidney (Sachinder Singh Hans)....Pages 61-62
Rupture of Pararenal Aortic Aneurysm (Sachinder Singh Hans)....Pages 63-68
Rupture of Abdominal Aortic Aneurysm with Tear of Inferior Vena Cava in a Patient with Prior Endograft (Sachinder Singh Hans)....Pages 69-72
Prosthetic Graft Infection Following Open Repair of Ruptured Abdominal Aortic Aneurysm (Sachinder Singh Hans)....Pages 73-78
Front Matter ....Pages 79-79
Open Repair of Common Iliac Artery Aneurysm (Sachinder Singh Hans)....Pages 81-83
Open Repair of Ruptured Common Iliac Artery Aneurysm (Sachinder Singh Hans)....Pages 85-87
Open Repair of Ruptured Mycotic Aneurysm of the Common Iliac Artery (Sachinder Singh Hans)....Pages 89-92
Rupture of Hypogastric Artery Aneurysm (Sachinder Singh Hans)....Pages 93-96
Front Matter ....Pages 97-97
Contained Rupture of Femoral Anastomotic Aneurysm (Sachinder Singh Hans)....Pages 99-101
Open Repair of Right Common Femoral Artery Aneurysm (Sachinder Singh Hans)....Pages 103-104
Front Matter ....Pages 105-105
Open Repair of Contained Rupture of Right Popliteal Aneurysm (Sachinder Singh Hans)....Pages 107-110
Open Repair of Giant Recurrent Popliteal Aneurysm (Sachinder Singh Hans)....Pages 111-114
Front Matter ....Pages 115-115
Open Repair of Large Symptomatic Subclavian/Axillary Artery Aneurysm with Partial Claviculectomy (Sachinder Singh Hans)....Pages 117-119
Front Matter ....Pages 121-121
Repair of Extracranial Carotid Artery Aneurysm with Mandibular Subluxation (Sachinder Singh Hans)....Pages 123-127
Front Matter ....Pages 129-129
Open Repair of the Superior Mesenteric Artery Aneurysm (Sachinder Singh Hans)....Pages 131-132
Front Matter ....Pages 133-133
Resection of a Malignant Carotid Body Tumor with Carotid Artery Resection (Sachinder Singh Hans)....Pages 135-138
Resection of a Large Carotid Body Tumor with Mandibular Subluxation (Sachinder Singh Hans)....Pages 139-142
Front Matter ....Pages 143-143
Infected Dacron Patch Following Carotid Endarterectomy (Sachinder Singh Hans)....Pages 145-148
Carotid Endarterectomy for a Recent Minor Stroke (Sachinder Singh Hans)....Pages 149-150
Carotid Endarterectomy with Mandibular Subluxation (Sachinder Singh Hans)....Pages 151-153
Carotid Endarterectomy with Intraoperative Stroke Due to Plaque Embolization During Shunt Insertion (Sachinder Singh Hans)....Pages 155-157
Intracerebral Hemorrhage Following Carotid Endarterectomy (Sachinder Singh Hans)....Pages 159-162
Carotid Endarterectomy for Symptomatic Radiation Induced Carotid Stenosis (Sachinder Singh Hans)....Pages 163-166
Nonconvulsive Status Epilepticus Following Carotid Endarterectomy (Sachinder Singh Hans)....Pages 167-170
Carotid Endarterectomy Followed by Retrieval of Plaque Embolus from M-1 Segment of the Middle Cerebral Artery (Sachinder Singh Hans)....Pages 171-175
Redo Carotid Endarterectomy for Recurrent Atherosclerotic Carotid Stenosis (Sachinder Singh Hans)....Pages 177-179
Carotid Interposition Graft in a Patient with Prior Carotid Stenting for Acute Stroke (Sachinder Singh Hans)....Pages 181-183
Carotid Endarterectomy in a Patient with Recent Minor Stroke Due to Unstable High Plaque (Sachinder Singh Hans)....Pages 185-187
Front Matter ....Pages 189-189
Redo Aorto-bifemoral Graft (Sachinder Singh Hans)....Pages 191-194
Aorto-bifemoral Graft in a Patient with Horseshoe Kidney (Sachinder Singh Hans)....Pages 195-197
Spiral Vein Graft for Radiation-Induced Right Common and External Iliac Artery Occlusion (Sachinder Singh Hans)....Pages 199-201
Infected Aorto-bifemoral Graft (Sachinder Singh Hans)....Pages 203-206
Aorto-femoral Graft: A 30-Year Follow-Up (Sachinder Singh Hans)....Pages 207-209
Aorto-Bifemoral Grafting for Infrarenal Aortic Occlusion (Sachinder Singh Hans)....Pages 211-213
Exposed Femoral Graft Following Multiple Arterial Reconstruction (Sachinder Singh Hans)....Pages 215-220
Complications (Early and Late) of Aortofemoral Grafting (Sachinder Singh Hans)....Pages 221-225
Front Matter ....Pages 227-227
Mesenteric Revascularization in Patients with Acute on Chronic Bowel Ischemia (Sachinder Singh Hans)....Pages 229-233
Front Matter ....Pages 235-235
Femoral-Peroneal Bypass for Critical Limb Ischemia in a Patient with Unstable Angina (Sachinder Singh Hans)....Pages 237-239
Femoral-Peroneal Bypass for Severe Calcific Disease Using Tourniquet Occlusion (Sachinder Singh Hans)....Pages 241-243
Femoral Distal Posterior Tibial Bypass for Established Gangrene (Sachinder Singh Hans)....Pages 245-247
Autogenous Composite Vein Bypass for Redo Infrainguinal Arterial Reconstruction (Sachinder Singh Hans)....Pages 249-252
Repeat Femoral Posterior Tibial Bypass Using Spliced Cephalic Vein (Sachinder Singh Hans)....Pages 253-255
Front Matter ....Pages 257-257
Management of a Patient with Complicated Adventitial Cystic Disease of the Popliteal Artery (Sachinder Singh Hans)....Pages 259-262
Front Matter ....Pages 263-263
Popliteal Venous Pseudoaneurysm and Associated Arteriovenous Fistula Following Knee Arthroscopy (Sachinder Singh Hans)....Pages 265-267
Front Matter ....Pages 269-269
Endovascular Aneurysm Repair in a Patient with Severe Aortic Neck Angulation Using Aorfix™ Device (Sachinder Singh Hans)....Pages 271-274
Endovascular Aneurysm Repair in a Patient with Short Aortic Neck with Use of EndoAnchors (Sachinder Singh Hans)....Pages 275-277
Endovascular Aneurysm Repair Followed by Multiple Interventions for Endoleaks (Sachinder Singh Hans)....Pages 279-282
Aortic Neck Rupture During Endovascular Aneurysm Repair in a Patient with a Horseshoe Kidney (Sachinder Singh Hans)....Pages 283-286
Exposed Graft in the Groin Following Crossover Femoral-Femoral Graft and Aorto-Uniiliac Stent Graft (Sachinder Singh Hans)....Pages 287-290
Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm, Bilateral Common Iliac Artery Aneurysm, and Left Hypogastric Aneurysm with Right Iliac Branch EXCLUDER® Device (Sachinder Singh Hans)....Pages 291-294
Endovascular Aneurysm Repair with Late Graft Limb Occlusion (Sachinder Singh Hans)....Pages 295-297
Front Matter ....Pages 299-299
Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysm (Sachinder Singh Hans)....Pages 301-304
Ruptured Abdominal Aortic Aneurysms in Patient with Type III Endoleak Following Endovascular Aneurysm Repair with Endologix Graft (Sachinder Singh Hans)....Pages 305-310
Ruptured Abdominal Aortic Aneurysm due to Type IB Endoleak (Sachinder Singh Hans)....Pages 311-313
Ruptured Abdominal Aortic Aneurysm Secondary to Delayed Type 1A Endoleak (Sachinder Singh Hans)....Pages 315-318
Endovascular Repair for Ruptured Abdominal Aortic Aneurysm in a Patient with Antecedent Endograft (Sachinder Singh Hans)....Pages 319-322
Front Matter ....Pages 323-323
Endovascular Repair of Large Left Iliac Anastomotic Aneurysm Following Open Abdominal Aortic Aneurysm Repair (Sachinder Singh Hans)....Pages 325-326
Endovascular Repair of a Large Hypogastric Aneurysm Following Open Repair of Abdominal Aortic Aneurysm (Sachinder Singh Hans)....Pages 327-328
Front Matter ....Pages 329-329
Endovascular Repair of Hypogastric Artery Aneurysm in a Patient with Prior Endovascular Aneurysm Repair (Sachinder Singh Hans)....Pages 331-333
Front Matter ....Pages 335-335
Endovascular Aneurysm Repair for Symptomatic Abdominal Aortic Aneurysm Followed by Thoracic Endovascular Aneurysm Repair Complicated by Type IB Endoleak (Sachinder Singh Hans)....Pages 337-339
Thoracic Endovascular Repair for Ruptured Aberrant Right Subclavian Artery Aneurysm Without Subclavian Artery Revascularization (Sachinder Singh Hans)....Pages 341-345
Front Matter ....Pages 347-347
Management of Stent Graft Thrombosis for Popliteal Aneurysm Following Partial Knee Arthroplasty (Sachinder Singh Hans)....Pages 349-353
Endovascular Repair of a Large Ruptured Popliteal Aneurysm (Sachinder Singh Hans)....Pages 355-357
Front Matter ....Pages 359-359
Endovascular Repair of Splenic Artery Aneurysm (Sachinder Singh Hans)....Pages 361-363
Front Matter ....Pages 365-365
Carotid Stenting for Symptomatic Carotid Restenosis Secondary to Myointimal Hyperplasia (Sachinder Singh Hans)....Pages 367-369
Carotid Artery Stenting for Symptomatic Radiation-Induced Carotid Stenosis (Sachinder Singh Hans)....Pages 371-374
Carotid Stenting for Carotid Interposition Vein Graft Stenosis (Sachinder Singh Hans)....Pages 375-377
Carotid Artery Stenting for Recurrent Internal Carotid Artery Stenosis with Contralateral Internal Carotid Artery Occlusion (Sachinder Singh Hans)....Pages 379-380
Carotid Stenting and Redo Carotid Endarterectomy in Patient with Bilateral Recurrent Carotid Stenosis with Type III Aortic Arch (Sachinder Singh Hans)....Pages 381-383
Front Matter ....Pages 385-385
Iliac Stenting for Chronic Total Occlusion Using Brachial Artery Access (Sachinder Singh Hans)....Pages 387-389
Covered Stent Placement for Flush Occlusion of Common Iliac Artery: A 12-Year Follow-Up (Sachinder Singh Hans)....Pages 391-393
Covered Iliac Stenting for Acute on Chronic Ischemia Following Thoracotomy (Sachinder Singh Hans)....Pages 395-398
Management of Iliac Stent Thrombosis (Sachinder Singh Hans)....Pages 399-402
Iliac Stenting Complicated by Iliac Artery Rupture (Sachinder Singh Hans)....Pages 403-405
Front Matter ....Pages 407-407
Aortic Stenting for Isolated Aortic Stenosis at the Level of the Inferior Mesenteric Artery (Sachinder Singh Hans)....Pages 409-411
Covered Bilateral Iliac Artery Stenting with Extension into Common Iliac Arteries for Near Occlusion of Distal Aorta (Sachinder Singh Hans)....Pages 413-415
Front Matter ....Pages 417-417
Percutaneous Intervention for Infrainguinal Arterial Occlusive Disease with Heel Ulcer (Sachinder Singh Hans)....Pages 419-424
Angioplasty for Femoral-Tibial in Situ Vein Bypass Stenosis (Sachinder Singh Hans)....Pages 425-430
Front Matter ....Pages 431-431
Management of Radiation-Induced Superior Mesenteric Artery Stenosis with Small Bowel Ischemia (Sachinder Singh Hans)....Pages 433-437
Superior Mesenteric Artery In-stent Restenosis (Sachinder Singh Hans)....Pages 439-441
Endovascular Treatment of Symptomatic Celiac and Superior Mesenteric Artery Occlusive Disease (Sachinder Singh Hans)....Pages 443-446
Front Matter ....Pages 447-447
Renal Artery Stenting for Renal Vascular Hypertension in a Patient with Solitary Kidney (Sachinder Singh Hans)....Pages 449-452
Front Matter ....Pages 453-453
Subclavian Artery Stenting for Ischemic Left Index Finger (Sachinder Singh Hans)....Pages 455-457
Front Matter ....Pages 459-459
Acquired Arteriovenous Fistula of the Axillary Artery (Sachinder Singh Hans)....Pages 461-463
Front Matter ....Pages 465-465
100 Multiple Choice Questions (Sachinder Singh Hans)....Pages 467-478
Back Matter ....Pages 479-490

Citation preview

Challenging Arterial Reconstructions 100 Clinical Cases Sachinder Singh Hans

123

Challenging Arterial Reconstructions

Sachinder Singh Hans

Challenging Arterial Reconstructions 100 Clinical Cases

Sachinder Singh Hans Medical Director of Vascular and Endovascular Services Henry Ford Macomb Hospital Clinical Assistant Professor at Wayne State University School of Medicine Clinton Township MI, USA

ISBN 978-3-030-44134-0 ISBN 978-3-030-44135-7 (eBook) https://doi.org/10.1007/978-3-030-44135-7 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Foreword

The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy. —Martin Luther King, Jr.

Challenging surgical cases test skills and judgment of the surgeon and put limbs, organs, or the life of the patient in great danger. The true challenge for the surgeon is to establish correct diagnosis, recognize potential problems in advance, plan with care, and perform a successful operation with the least risk and maximum benefit to the patient, using hospital resources prudently to achieve durable result. No matter how complex the situation looks, the surgeon must stay calm, think with a clear mind, and find the safest, simplest, most effective way to solve the problem and proceed as planned. Challenging Arterial Reconstructions: 100 Clinical Cases written by Sachinder Hans reflects the lifetime experience of a master surgeon. All 100 cases, just 6 with participation of colleagues, were performed by the author, an exceptionally well-trained vascular and endovascular surgeon of a solo vascular practice. A graduate of the renowned fellowship program of the Beaumont Hospital in Royal Oak, MI, Dr. Hans currently works as the Medical Director of Vascular and Endovascular Services, Henry Ford Macomb Hospital, Clinton Township MI, formerly Chief of Vascular Surgery at Ascension Macomb, Oakland Hospital (Macomb Campus), Warren, MI. This book is a gold mine of interesting cases of a rich and exciting vascular surgery practice and reflects expertise in almost the full spectrum of vascular and endovascular surgery. The chapters include difficult surgical problems of patients with aortic, visceral, and peripheral arterial aneurysms, with expert management of mycotic, inflammatory, and ruptured aneurysms and major complications like aortoduodenal fistula, graft infection, or inferior vena cava injury. Open aortoiliac and extra anatomic reconstructions are amply covered. The volume presents difficult cases of carotid artery surgery, discusses management of carotid body tumors, and describes the rarely used but helpful maneuver of mandibular subluxation. There is ample evidence of an excellent surgical practice in this volume, with 30-year follow-up of aortofemoral grafts, with description of tips and techniques for lower extremity distal revascularization using spliced vein grafts or tourniquet occlusions. The reader will find information on how to manage rare cases of popliteal adventitial cystic disease, popliteal arteriovenous fistula, or venous aneurysm. More than a third of the chapters are v

vi

d edicated to endovascular interventions, including stent-graft repair of elective, symptomatic, and ruptured aortic and iliac aneurysms, thoracic endovascular repairs, and stent grafting for popliteal artery aneurysms. Interventionists will enjoy reading about carotid artery stenting in challenging patients, like in those after radiation, with contralateral occlusion or following previous open surgery. This book concludes with cases of infrainguinal endovascular reconstructions and visceral and renal stenting and the expert management of a patient with arteriovenous fistula of the axillary artery. Some of the chapters are followed by insightful expert commentaries of Dr. Charles W. Acher, Professor of Surgery at the University of Wisconsin School of Medicine and Public Health. This book is nicely illustrated with black and white and colored photographs of the procedures, with imaging studies and drawings. The text is easy to read and is especially suitable for short review, before embarking in a surgical or endovascular intervention of a similar challenging case. It is easy for me to recommend this book to all who just learn or regularly perform open surgical or endovascular interventions. Keep in mind, however, that your patient with a challenging problem relies on your judgment and competence. If you feel you can treat your patient, proceed. If you need consultation of your colleagues or of other specialties, do not delay. If you feel this challenge is beyond your expertise, refer the patient for appropriate care. Remember what you signed up for as a physician: you are committed to take care of your patient like you would want someone treat a member of your family. This collection of cases is testimony that there are many situations when competent vascular specialists can appropriately handle even rare and challenging patients. In some cases, referral is not even an option because of intraoperative problems requiring instant care, local issues, or long-distance travel. For appropriate management of all these cases, this book will be invaluable. Peter Gloviczki, MD, FACS Roberts Professor and Chair (Emeritus) Division of Vascular and Endovascular Surgery Mayo Clinic, Rochester, MN, USA Editor in Chief, Journal of Vascular Surgery

Foreword

Preface

essons Learned from 100 Challenging Arterial L Reconstructions The unpredictability of vascular reconstructions is such that a very small error in judgment in patient selection, or a technical error during execution of open or an endovascular reconstruction, can lead to poor outcome. With that in mind, 100 challenging cases encountered by the author since January 1980 through December 2019 are presented in this book. These cases have been selected from the author’s vascular registry of 7000 vascular reconstructions (endovascular and open). These reconstructions were primarily performed at 2 mid-sized (approximately 350 beds each) suburban teaching hospitals, which are representative of the “real-world” experience of vascular surgery in the United States. The selection of cases in this book was based on either difficulty with case selection or complex operative or an endovascular technique. The natural history of vascular reconstructions often leads to secondary reconstructions, which are far more complex and therefore are included in significant numbers in this text. I am keenly aware that certain cases in this book may not appear to be of a sufficient complexity to an experienced vascular surgeon, but to many recent vascular surgery trainees, these challenging arterial reconstructions will hopefully be valuable in their clinical practices. In this book, both and good and unsatisfactory results have been included, and the lessons learned from the poor outcomes are emphasized. Certain advanced vascular reconstructions (branched aortic endografts, open repair of Type II and Type III thoracoabdominal aneurysm repair) were not within the purview of my practice. In order to keep uniformity in patient selection, technique, and post- intervention care, the cases presented in this book were selected only from my own vascular registry. Other treatment options selected by an experienced vascular surgeon may have worked equally as well, and I do not profess that my methods are the only way to have provided care for these patients. I am thankful to many physicians who also participated in some aspects of the patient’s care (Chaps. 1, 20, 41, 72, 80, 100). Invited commentaries from leading experts in the field have been added to a few chapters offering an alternate viewpoint in the management of patients with complex pathology. I am grateful to the contributors of the invited vii

Preface

viii

c ommentary for submitting their comments in a timely manner and being objective in their evaluation of the case management. Dr. Mary Lee, our Chief Surgery Resident (starting vascular fellowship in 2020), was involved in helping with multiple-choice questions (n100), and her contributions are appreciated. I am extremely grateful to my patients and their families for their patience and understanding during some of the most trying times in their lives. I also owe a sense of gratitude to the house staff, nursing personnel, and our vascular intervention lab for their immense contributions in care of our patients. My special thanks to Connie Walsh, Lillie Gaurano, and Richard Hruska (Springer) for their tireless help and support. My special thanks to Shagufta Din for her strong work in getting the chapters transcribed timely and efficiently. My wife, Dr. Bijaya Hans, an interventional radiologist, has been of great help and inspiration during the completion of this book as it was taking time away from the family. I sincerely hope that this book will help vascular surgeons to learn from my successes as well as my failures. Clinton Township, MI, USA

Sachinder Singh Hans

Contents

Part I Open Repair of Intact Abdominal Aortic Aneurysm

1 Symptomatic Proximal Anastomotic Pseudoaneurysm of Suprarenal Aorta �� 3 History�� 3 Physical Examination�� 3 Procedure �� 5 Discussion�� 6 Invited Commentary from Charles W. Acher, MD�� 6 References�� 8

2 Repair of Juxtarenal Abdominal Aortic Aneurysm with Aortorenal Bypass �� 9 Physical Examination�� 9 Procedure �� 9 Discussion�� 11 Invited Commentary from Timothy J. Nypaver, MD�� 12 References�� 12 3 Abdominal Aortic Aneurysm Repair in a Patient with Celiac Artery Occlusion and a Large Inferior Mesenteric Artery�� 15 Physical Examination�� 15 Procedure �� 15 Discussion�� 16 Invited Commentary from Mitchell Ross Weaver, MD �� 17 References�� 17 4 Abdominal Aortic Aneurysm Repair in a Patient with a Pelvic Kidney�� 19 Physical Examination�� 19 Procedure �� 19 Discussion�� 20 Invited Commentary from Mitchell Ross Weaver, MD �� 21 References�� 21 5 Open Repair of Abdominal Aortic Aneurysm in a Patient with Double Inferior Vena Cava �� 23 Physical Examination�� 23 Procedure �� 23 ix

Contents

x

Discussion�� 24 Invited Commentary from Graham W. Long, MD�� 25 References�� 26 6 Mycotic Aneurysm of the Abdominal Aorta�� 27 Physical Examination�� 27 Procedure �� 27 Discussion�� 29 References�� 29 7 Open Abdominal Aortic and Iliac Aneurysm Repair in a Patient with Cirrhosis of the Liver�� 31 Physical Examination�� 31 Procedure �� 31 Discussion�� 32 References�� 32

8 Major Venous Injury During Repair of Abdominal Aortic and Iliac Aneurysm�� 33 History and Procedure�� 33 Discussion�� 33 Reference �� 34 9 Secondary Aortoduodenal Fistula Following Abdominal Aortic Aneurysm Repair �� 35 History and Physical Examination�� 35 Procedure �� 35 Discussion�� 36 References�� 38 10 Open Repair of an Inflammatory Abdominal Aortic Aneurysm�� 39 History and Physical Examination�� 39 Procedure �� 39 Discussion�� 40 References�� 41 11 Right Subhepatic Approach for Inflammatory Aortic Aneurysm in a Patient with Scoliosis �� 43 History and Physical Examination�� 43 Procedure �� 43 Discussion�� 44 References�� 45 12 Large Symptomatic Abdominal Aortic Aneurysm�� 47 Physical Examination�� 47 Procedure �� 47 Discussion�� 47 References�� 48

Contents

xi

13 Abdominal Aortic Aneurysm in a Patient with Chronic Lymphocytic Leukemia �� 49 History and Physical Examination�� 49 Procedure �� 50 Discussion�� 50 Invited Commentary from Dipankar Mukherjee, MD �� 52 References�� 52 14 Inflammatory Abdominal Aortic Aneurysm Presenting with Testicular Pain �� 53 Physical Examination�� 53 Procedure �� 54 Discussion�� 54 15 Abdominal Aortic Aneurysm Repair in a Patient with Factor VII Deficiency�� 55 Physical Examination�� 55 Procedure �� 55 Discussion�� 55 References�� 56 Part II Open Repair of Ruptured Abdominal Aortic Aneurysm 16 Open Repair of Ruptured Abdominal Aortic Aneurysm Complicated by Pancreatitis and Duodenal Obstruction�� 59 History�� 59 Procedure �� 59 Discussion�� 60 References�� 60 17 Rupture of Abdominal Aortic Aneurysm in a Patient with a Horseshoe Kidney�� 61 Physical Examination�� 61 Procedure �� 61 Discussion�� 61 References�� 62 18 Rupture of Pararenal Aortic Aneurysm�� 63 History and Physical Examination�� 63 Procedure �� 63 Discussion�� 64 Invited Commentary from Audra A. Duncan MD, FACS, FRCSC �� 66 References�� 67 19 Rupture of Abdominal Aortic Aneurysm with Tear of Inferior Vena Cava in a Patient with Prior Endograft�� 69 Physical Examination�� 69 History�� 69 Procedure �� 70 Discussion�� 71 Invited Commentary from Audra A. Duncan MD, FACS, FRCSC�� 71 References�� 72

xii

20 Prosthetic Graft Infection Following Open Repair of Ruptured Abdominal Aortic Aneurysm�� 73 History�� 73 Procedure �� 73 Discussion�� 76 Invited Commentary from Audra A. Duncan MD, FACS, FRCSC�� 77 References�� 77 Part III Open Repair of Intact and Ruptured Iliac Artery Aneurysms 21 Open Repair of Common Iliac Artery Aneurysm�� 81 History and Physical Examination�� 81 Procedure �� 81 Discussion�� 82 Invited Commentary from Jonathan R. Thompson, MD, and Iraklis I. Pipinos, MD�� 82 References�� 83 22 Open Repair of Ruptured Common Iliac Artery Aneurysm�� 85 Physical Examination�� 85 Procedure �� 85 Discussion�� 86 Invited Commentary from Jonathan R. Thompson, MD, and Iraklis I. Pipinos, MD�� 87 References�� 87 23 Open Repair of Ruptured Mycotic Aneurysm of the Common Iliac Artery�� 89 Physical Examination�� 89 Procedure �� 89 Discussion�� 92 References�� 92 24 Rupture of Hypogastric Artery Aneurysm�� 93 Physical Examination�� 93 Procedure �� 93 Discussion�� 94 Invited Commentary from Jonathan R. Thompson, MD, and Iraklis I. Pipinos, MD�� 95 References�� 96 Part IV Open Repair of Femoral Artery and Femoral Anastomotic Aneurysms 25 Contained Rupture of Femoral Anastomotic Aneurysm�� 99 Physical Examination and History�� 99 Procedure �� 100 Discussion�� 100 References�� 101

Contents

Contents

xiii

26 Open Repair of Right Common Femoral Artery Aneurysm �� 103 Physical Examination�� 103 Procedure �� 103 Discussion�� 104 Reference �� 104 Part V Open Repair of Popliteal Artery Aneurysms 27 Open Repair of Contained Rupture of Right Popliteal Aneurysm�� 107 History and Physical Examination�� 107 Procedure �� 107 Discussion�� 109 References�� 110 28 Open Repair of Giant Recurrent Popliteal Aneurysm �� 111 History and Physical Examination�� 111 Procedure �� 111 Discussion�� 113 Invited Commentary from Daniel J. Reddy, MD�� 114 References�� 114 Part VI Open Repair of Subclavian-Axillary Aneurysm 29 Open Repair of Large Symptomatic Subclavian/Axillary Artery Aneurysm with Partial Claviculectomy�� 117 Physical Examination and History�� 117 Procedure �� 117 Discussion�� 119 References�� 119 Part VII Open Repair of Carotid Aneurysm 30 Repair of Extracranial Carotid Artery Aneurysm with Mandibular Subluxation �� 123 Physical Examination and History�� 123 Procedure �� 123 Discussion�� 124 Invited Commentary from Karen J. Ho, MD �� 126 References�� 127 Part VIII Open Repair of SMA Aneurysm 31 Open Repair of the Superior Mesenteric Artery Aneurysm�� 131 History and Physical Examination�� 131 Procedure �� 131 Discussion�� 132 References�� 132 Part IX Resection of Carotid Body Tumor 32 Resection of a Malignant Carotid Body Tumor with Carotid Artery Resection�� 135 Physical Examination�� 135 Procedure �� 135

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Discussion�� 136 References�� 138 33 Resection of a Large Carotid Body Tumor with Mandibular Subluxation�� 139 History and Physical Examination�� 139 Procedure �� 139 Discussion�� 141 Reference �� 141 Part X Carotid Endarterectomy 34 Infected Dacron Patch Following Carotid Endarterectomy�� 145 History and Physical Examination�� 145 Procedure �� 145 Discussion�� 146 References�� 148 35 Carotid Endarterectomy for a Recent Minor Stroke �� 149 History and Physical Examination�� 149 Procedure �� 149 Discussion�� 150 References�� 150 36 Carotid Endarterectomy with Mandibular Subluxation�� 151 History and Physical Examination�� 151 Procedure �� 151 Discussion�� 152 References�� 153 37 Carotid Endarterectomy with Intraoperative Stroke Due to Plaque Embolization During Shunt Insertion�� 155 Physical Examination and History�� 155 Procedure �� 155 Discussion�� 156 References�� 157 38 Intracerebral Hemorrhage Following Carotid Endarterectomy�� 159 Physical Examination�� 159 Procedure �� 159 Discussion�� 159 References�� 162 39 Carotid Endarterectomy for Symptomatic Radiation Induced Carotid Stenosis�� 163 History and Physical Examination�� 163 Procedure �� 164 Discussion�� 165 Invited Commentary from Benjamin D. Colvard, MD, and Vikram S. Kashyap, MD �� 166 References�� 166

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xv

40 Nonconvulsive Status Epilepticus Following Carotid Endarterectomy�� 167 History and Procedures�� 167 Discussion�� 168 References�� 170 41 Carotid Endarterectomy Followed by Retrieval of Plaque Embolus from M-1 Segment of the Middle Cerebral Artery�� 171 History and Physical Examination�� 171 Procedure �� 171 Discussion�� 173 References�� 175 42 Redo Carotid Endarterectomy for Recurrent Atherosclerotic Carotid Stenosis�� 177 History and Physical Examination�� 177 Procedure �� 177 Discussion�� 177 References�� 179 43 Carotid Interposition Graft in a Patient with Prior Carotid Stenting for Acute Stroke�� 181 History and Physical Examination�� 181 Procedure �� 181 Discussion�� 182 References�� 183 44 Carotid Endarterectomy in a Patient with Recent Minor Stroke Due to Unstable High Plaque�� 185 Physical Examination and History�� 185 Procedure �� 185 Discussion�� 185 References�� 187 Part XI Aorto-Femoral Grafting 45 Redo Aorto-bifemoral Graft �� 191 History and Physical Examination�� 191 Procedure �� 191 Discussion�� 192 References�� 194 46 Aorto-bifemoral Graft in a Patient with Horseshoe Kidney �� 195 Physical Examination and History�� 195 Procedure �� 195 Discussion�� 195 References�� 197 47 Spiral Vein Graft for Radiation-Induced Right Common and External Iliac Artery Occlusion�� 199 History and Physical Examination�� 199 Procedure �� 199

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Discussion�� 200 References�� 201 48 Infected Aorto-bifemoral Graft�� 203 History and Physical Examination�� 203 Procedure �� 203 Discussion�� 204 References�� 206 49 Aorto-femoral Graft: A 30-Year Follow-Up�� 207 History and Physical Examination�� 207 Procedure �� 207 Discussion�� 208 References�� 209 50 Aorto-Bifemoral Grafting for Infrarenal Aortic Occlusion �� 211 Physical Examination and History�� 211 Procedure �� 211 Discussion�� 211 Reference �� 213 51 Exposed Femoral Graft Following Multiple Arterial Reconstruction�� 215 History and Procedures�� 215 Discussion�� 217 Invited Commentary from Mark D. Morasch, MD, FACS, RPVI�� 219 References�� 219 52 Complications (Early and Late) of Aortofemoral Grafting�� 221 History and Physical Examination�� 221 Procedure �� 221 Discussion�� 222 Invited Commentary from Peter K. Henke, MD�� 224 References�� 225 Part XII Aorto-Mesenteric Bypass 53 Mesenteric Revascularization in Patients with Acute on Chronic Bowel Ischemia�� 229 Patient A: History and Physical Examination�� 229 Patient A: Procedure�� 229 Patient B: History and Procedure�� 230 Discussion�� 231 Invited Commentary from Frank M. Davis, MD, and Peter K. Henke, MD�� 232 References�� 233 Part XIII Infrainguinal Arterial Bypass Graft 54 Femoral-Peroneal Bypass for Critical Limb Ischemia in a Patient with Unstable Angina�� 237 History and Physical Examination�� 237 Procedure �� 237

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Discussion�� 237 References�� 239 55 Femoral-Peroneal Bypass for Severe Calcific Disease Using Tourniquet Occlusion�� 241 Physical Examination and History�� 241 Discussion�� 241 References�� 243 56 Femoral Distal Posterior Tibial Bypass for Established Gangrene�� 245 Physical Examination�� 245 Procedure �� 245 Discussion�� 246 References�� 247 57 Autogenous Composite Vein Bypass for Redo Infrainguinal Arterial Reconstruction�� 249 History and Physical Examination�� 249 Procedure �� 250 Discussion�� 250 Invited Commentary from Nicolas J. Mouawad, MD MPH MBA FSVS FACS FRCS RPVI �� 251 References�� 252 58 Repeat Femoral Posterior Tibial Bypass Using Spliced Cephalic Vein�� 253 History and Physical Examination�� 253 Procedure �� 253 Discussion�� 255 References�� 255 Part XIV Adventitial Cystic Disease of the Popliteal Artery 59 Management of a Patient with Complicated Adventitial Cystic Disease of the Popliteal Artery�� 259 Physical Examination�� 259 Procedure �� 260 Discussion�� 261 Invited Commentary from S. Keisin Wang, MD, and Raghu L. Motaganahalli, MD �� 261 References�� 262 Part XV Popliteal Venous Pseudoaneurysm and Arteriovenous Fistula 60 Popliteal Venous Pseudoaneurysm and Associated Arteriovenous Fistula Following Knee Arthroscopy�� 265 History and Physical Examination�� 265 Procedure �� 266 Discussion�� 267 References�� 267

xviii

Part XVI Endovascular Aneurysm Repair for Intact Abdominal Aortic Aneurysm 61 Endovascular Aneurysm Repair in a Patient with Severe Aortic Neck Angulation Using Aorfix™ Device�� 271 Physical Examination�� 271 Procedure �� 271 Discussion�� 272 Invited Commentary from M. Ashraf Mansour, MD, MBA, FACS�� 273 References�� 274 62 Endovascular Aneurysm Repair in a Patient with Short Aortic Neck with Use of EndoAnchors �� 275 Physical Examination and History�� 275 Procedure �� 275 Discussion�� 275 References�� 277 63 Endovascular Aneurysm Repair Followed by Multiple Interventions for Endoleaks�� 279 History and Procedures�� 279 Discussion�� 280 References�� 282 64 Aortic Neck Rupture During Endovascular Aneurysm Repair in a Patient with a Horseshoe Kidney �� 283 History and Procedures�� 283 Discussion�� 286 References�� 286 65 Exposed Graft in the Groin Following Crossover Femoral- Femoral Graft and Aorto-Uniiliac Stent Graft �� 287 Physical Examination and History�� 287 Procedure �� 287 Discussion�� 288 References�� 290 66 Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm, Bilateral Common Iliac Artery Aneurysm, and Left Hypogastric Aneurysm with Right Iliac Branch EXCLUDER® Device �� 291 History and Physical Examination�� 291 Procedure �� 291 Discussion�� 293 References�� 294 67 Endovascular Aneurysm Repair with Late Graft Limb Occlusion�� 295 History and Physical Examination�� 295 Procedure �� 296

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Discussion�� 296 References�� 297 Part XVII Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysm 68 Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysm�� 301 Physical Examination�� 301 Procedure �� 301 Discussion�� 303 References�� 304 69 Ruptured Abdominal Aortic Aneurysms in Patient with | Type III Endoleak Following Endovascular Aneurysm Repair with Endologix Graft�� 305 Physical Examination and History�� 305 Procedure �� 306 Discussion�� 307 Invited Commentary from Paul G. Bove, MD, FACS, FSVM�� 308 References�� 310 70 Ruptured Abdominal Aortic Aneurysm due to Type IB Endoleak�� 311 Physical Examination and History�� 311 Procedure �� 312 Discussion�� 313 References�� 313 71 Ruptured Abdominal Aortic Aneurysm Secondary to Delayed Type 1A Endoleak �� 315 History and Procedures�� 315 Discussion�� 316 Invited Commentary from Faisal Aziz, MD, DFSVS, FACS, and Marvin Chau, BS�� 317 References�� 318 72 Endovascular Repair for Ruptured Abdominal Aortic Aneurysm in a Patient with Antecedent Endograft�� 319 Physical Examination�� 319 Procedure �� 319 Discussion�� 322 References�� 322 Part XVIII Endovascular Repair for Large Iliac and Hypogastric Aneurysms Following Open Abdominal Aortic Aneurysm Repair 73 Endovascular Repair of Large Left Iliac Anastomotic Aneurysm Following Open Abdominal Aortic Aneurysm Repair �� 325 Physical Examination and History�� 325

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Procedure �� 325 Discussion�� 326 References�� 326 74 Endovascular Repair of a Large Hypogastric Aneurysm Following Open Repair of Abdominal Aortic Aneurysm �� 327 Physical Examination and History�� 327 Procedure �� 327 Discussion�� 328 Reference �� 328 Part XIX Endovascular Repair for Hypogastric Aneurysm Following EVAR 75 Endovascular Repair of Hypogastric Artery Aneurysm in a Patient with Prior Endovascular Aneurysm Repair�� 331 Physical Examination�� 331 Procedure �� 331 Discussion�� 333 References�� 333 Part XX Thoracic Endovascular Aneurysm Repair 76 Endovascular Aneurysm Repair for Symptomatic Abdominal Aortic Aneurysm Followed by Thoracic Endovascular Aneurysm Repair Complicated by Type IB Endoleak�� 337 Physical Examination�� 337 Procedure �� 337 Discussion�� 339 References�� 339 77 Thoracic Endovascular Repair for Ruptured Aberrant Right Subclavian Artery Aneurysm Without Subclavian Artery Revascularization �� 341 Physical Examination and History�� 341 Procedure �� 341 Discussion�� 343 Invited Commentary from Himanshu J. Patel, MD �� 344 The Ruptured Kommerell’s Diverticulum�� 344 References�� 344 Part XXI Endovascular Repair for Popliteal Artery Aneurysm 78 Management of Stent Graft Thrombosis for Popliteal Aneurysm Following Partial Knee Arthroplasty�� 349 Physical Examination and History�� 349 Procedure �� 349 Discussion�� 352 References�� 353

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xxi

79 Endovascular Repair of a Large Ruptured Popliteal Aneurysm�� 355 Physical Examination and History�� 355 Procedure �� 355 Discussion�� 356 References�� 357 Part XXII Endovascular Repair of Splenic Artery Aneurysm 80 Endovascular Repair of Splenic Artery Aneurysm�� 361 Physical Examination�� 361 Procedure �� 361 Discussion�� 363 Invited Commentary from Timur P. Sarac, MD�� 363 References�� 363 Part XXIII Carotid Stenting 81 Carotid Stenting for Symptomatic Carotid Restenosis Secondary to Myointimal Hyperplasia�� 367 History and Physical Examination�� 367 Procedure �� 367 Discussion�� 368 References�� 369 82 Carotid Artery Stenting for Symptomatic Radiation-Induced Carotid Stenosis�� 371 Physical Examination and History�� 371 Procedure �� 371 Discussion�� 373 Invited Commentary from Hitinder S. Gurm, MBBS�� 374 References�� 374 83 Carotid Stenting for Carotid Interposition Vein Graft Stenosis�� 375 History and Procedures�� 375 Discussion�� 376 References�� 377 84 Carotid Artery Stenting for Recurrent Internal Carotid Artery Stenosis with Contralateral Internal Carotid Artery Occlusion�� 379 History and Procedures�� 379 Discussion�� 380 References�� 380 85 Carotid Stenting and Redo Carotid Endarterectomy in Patient with Bilateral Recurrent Carotid Stenosis with Type III Aortic Arch�� 381 History and Procedures�� 381 Discussion�� 382 References�� 383

xxii

Part XXIV Iliac Stenting 86 Iliac Stenting for Chronic Total Occlusion Using Brachial Artery Access�� 387 History�� 387 Procedure �� 387 Discussion�� 389 References�� 389 87 Covered Stent Placement for Flush Occlusion of Common Iliac Artery: A 12-Year Follow-Up�� 391 Physical Examination and History�� 391 Procedure �� 391 Discussion�� 392 References�� 393 88 Covered Iliac Stenting for Acute on Chronic Ischemia Following Thoracotomy�� 395 History and Physical Examination�� 395 Procedure �� 395 Discussion�� 397 References�� 398 89 Management of Iliac Stent Thrombosis �� 399 History and Physical Examination�� 399 Procedure �� 400 Discussion�� 402 References�� 402 90 Iliac Stenting Complicated by Iliac Artery Rupture�� 403 Physical Examination and History�� 403 Procedure �� 403 Discussion�� 404 References�� 405 Part XXV Aorto-Iliac Stenting 91 Aortic Stenting for Isolated Aortic Stenosis at the Level of the Inferior Mesenteric Artery�� 409 Physical Examination and History�� 409 Procedure �� 409 Discussion�� 410 References�� 411 92 Covered Bilateral Iliac Artery Stenting with Extension into Common Iliac Arteries for Near Occlusion of Distal Aorta �� 413 Physical Examination and History�� 413 Procedure �� 414 Discussion�� 414 References�� 415

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Part XXVI Percutaneous Intervention for Infrainguinal Arterial Disease 93 Percutaneous Intervention for Infrainguinal Arterial Occlusive Disease with Heel Ulcer�� 419 Physical Examination and History�� 419 Procedure �� 419 Discussion�� 422 References�� 424 94 Angioplasty for Femoral-Tibial in Situ Vein Bypass Stenosis�� 425 Patient A: History and Procedure�� 425 Patient B: History and Procedure�� 425 Discussion�� 429 References�� 430 Part XXVII Endovascular Therapy for Mesenteric Ischemia 95 Management of Radiation-Induced Superior Mesenteric Artery Stenosis with Small Bowel Ischemia�� 433 Physical Examination and History�� 433 Procedure �� 433 Discussion�� 436 References�� 437 96 Superior Mesenteric Artery In-stent Restenosis �� 439 Physical Examination�� 439 Procedure �� 439 Discussion�� 440 References�� 441 97 Endovascular Treatment of Symptomatic Celiac and Superior Mesenteric Artery Occlusive Disease�� 443 Physical Examination and History�� 443 Procedure �� 444 Discussion�� 445 References�� 446 Part XXVIII Renal Artery Stenting 98 Renal Artery Stenting for Renal Vascular Hypertension in a Patient with Solitary Kidney �� 449 History and Physical Examination�� 449 Procedure �� 449 Discussion�� 451 References�� 452 Part XXIX Subclavian Artery Stenting 99 Subclavian Artery Stenting for Ischemic Left Index Finger�� 455 Physical Examination and History�� 455 Procedure �� 455

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Discussion�� 456 Reference �� 457 Part XXX Acquired Arteriovenous Fistula 100 Acquired Arteriovenous Fistula of the Axillary Artery�� 461 Physical Examination and History�� 461 Procedure �� 461 Discussion�� 462 Invited Commentary from Nitin Jain, MD, MS (Master of Surgery)�� 463 References�� 463 Part XXXI Question Set 101 100 Multiple Choice Questions �� 467 Part I Open Repair of Intact Abdominal Aortic Aneurysm�� 467 Part II Open Repair of Ruptured Abdominal Aortic Aneurysm�� 469 Part III Open Repair of Intact and Ruptured Iliac Artery Aneurysms�� 469 Part IV Open Repair of Femoral Artery and Femoral Anastomotic Aneurysms�� 470 Part V Open Repair of Popliteal Artery Aneurysms�� 470 Part VI Open Repair of Subclavian-Axillary Aneurysm�� 470 Part VII Open Repair of Carotid Aneurysm�� 470 Part VIII Open Repair of SMA Aneurysm�� 471 Part IX Resection of Carotid Body Tumor�� 471 Part X Carotid Endarterectomy�� 471 Part XI Aortofemoral Grafting�� 472 Part XII Aortomesenteric Bypass�� 473 Part XIII Infrainguinal Arterial Bypass Graft�� 473 Part XIV Adventitial Cystic Disease of the Popliteal Artery �� 473 Part XV Popliteal Venous Pseudoaneurysm and Arteriovenous Fistula�� 474 Part XVI Endovascular Aneurysm Repair for Intact Abdominal Aortic Aneurysm �� 474 Part XVII Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysm �� 474 Part XVIII Endovascular Repair for Large Iliac and Hypogastric Aneurysms Following Open Abdominal Aortic Aneurysm Repair �� 475 Part XIX Endovascular Repair for Hypogastric Aneurysm Following EVAR�� 475 Part XX Thoracic Endovascular Aneurysm Repair�� 475 Part XXI Endovascular Repair for Popliteal Artery Aneurysm �� 476 Part XXII Endovascular Repair of Splenic Artery Aneurysm �� 476 Part XXIII Carotid Stenting �� 476 Part XXIV Iliac Stenting�� 476 Part XXV Aortoiliac Stenting�� 477 Part XXVI Percutaneous Intervention for Infrainguinal Arterial Disease�� 477

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xxv

Part XXVII Endovascular Therapy for Mesenteric Ischemia�� 477 Part XXVIII Renal Artery Stenting�� 478 Part XXIX Subclavian Artery Stenting�� 478 Part XXX Acquired Arteriovenous Fistula�� 478 Index �� 479

List of Invited Discussants

Charles W. Acher, MD Vascular Surgery, Department of Surgery, University of Wisconsin Madison, Madison, WI, USA Faisal Aziz, MD, DFSVS, FACS Division of Vascular Surgery, Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Hershey, PA, USA Paul G. Bove, MD, FACS, FSVM Department of Surgery, Oakland University William Beaumont School of Medicine, Rochester, MI, USA Sections of Vascular Surgery and Surgical Critical Care, William Beaumont Hospital, Troy, MI, USA Marvin Chau, BS Department of Medical Education, Pennsylvania State University College of Medicine, Hershey, PA, USA Benjamin D. Colvard, MD Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA Frank M. Davis, MD Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA Audra A. Duncan, MD, FACS, FRCSC Division of Vascular Surgery, Department of Surgery, University of Western Ontario, London, ON, Canada Peter Gloviczki, MD Division of Vascular and Endovascular Surgery, Mayo Clinic; Journal of Vascular Surgery, Rochester, MN, USA Hitinder S. Gurm, MBBS Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA Peter K. Henke, MD Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA Karen J. Ho, MD Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA Nitin Jain, MD, MS (Master of Surgery) Department of Interventional Radiology, Ascension St. John Macomb and Oakland Hospitals, Michigan, Warren, MI, USA

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xxviii

Vikram S. Kashyap, MD Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA Graham W. Long, MD Department of Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA M. Ashraf Mansour, MD, MBA, FACS Department of Surgery, Spectrum Health, Michigan State University, Grand Rapids, MI, USA Mark D. Morasch, MD, FACS Department of Vascular Surgery, St. Mark’s Hospital, Salt Lake City, UT, USA Raghu L. Motaganahalli, MD Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN, USA Nicolas J. Mouawad, MD, MPH, MBA,FSVS,FACS,FRCS,RPVI Vascular & Endovascular Surgery, McLaren Bay Heart & Vascular, Department of Surgery, McLaren Bay Region, Bay City, MI, USA Dipankar Mukherjee, MD Vascular Surgery, Department of Surgery, Inova Fairfax Hospital, Falls Church, VA, USA Timothy J. Nypaver, MD Department of Surgery, Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA Himanshu J. Patel, MD Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA Iraklis I. Pipinos, MD Department of Surgery, Division of Vascular Surgery, University of Nebraska Medical Center, Omaha, NE, USA Daniel J. Reddy, MD, FACS, DFSVS Department of Surgery, Wayne State University, Detroit, MI, USA Timur P. Sarac, MD Department of Vascular Surgery, Aortic Center, The Ohio State University School of Medicine, Columbus, OH, USA Jonathan R. Thompson, MD Department of Surgery, Division of Vascular Surgery, University of Nebraska Medical Center, Omaha, NE, USA S. Keisin Wang, MD Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN, USA Mitchell Ross Weaver, MD Department of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA

List of Invited Discussants

Part I Open Repair of Intact Abdominal Aortic Aneurysm

1

Symptomatic Proximal Anastomotic Pseudoaneurysm of Suprarenal Aorta

History

Physical Examination

A 37-year-old white male was admitted to the hospital on February 13, 1981, with the history of low back pain and abdominal pain of 3-week duration. This patient was first seen January 1972 by an ophthalmologist with a 2-week history of blurred vision. At that time his blood pressure was found to be 240/140 mm Hg, with grade IV retinopathy. A comprehensive evaluation for hypertension in 1972 was compatible with idiopathic malignant hypertension. Twenty-four-hour urinary VMA was 9.2 (normal). Renal vein renin assay was 4000 ngE/hr in the right and 5900 ngE/ hr. in the left (normal up to 275 ngE/hr). An intravenous pyelogram revealed mild hydronephrosis due to left ureteropelvic junction obstruction. From 1972 until 1980, the patient’s blood pressure was well controlled. In May 1973, the patient suffered right monoparesis involving the right upper extremity and speech difficulty, from which he recovered in 3–6 months. He has been on propranolol 30 mgm q.i.d., hydrochlorothiazide 50 mgm b.i.d., spironolactone 25 mgm q.d., and guanethidine 10 mgm q.d. In September 1980, during the stress of his father’s severe illness, the patient decided to discontinue his medication and later developed confusion and hallucinations. He was admitted to the psychiatric service with probable diagnosis of acute psychotic reaction.

The patient’s height was 5′7″, with body weight of 90 pounds. Examination of the heart showed apex beat was outside the midclavicular line. The lungs were unremarkable. Examination of the abdomen revealed a large, pulsatile abdominal aortic aneurysm, upper limit of which could be reached with great difficulty. He had excellent femoral, popliteal, and pedal pulses. Laboratory studies revealed hemoglobin 12.5 gm and a hematocrit of 37.8%, BUN 23 mgm/dl, and creatinine 1.4 mgm/dl. Chest X-ray revealed cardiomegaly; EKG showed evidence of left ventricular hypertrophy. Ultrasound of the aorta revealed a large, abdominal aortic aneurysm with a transverse diameter of 10–12 cm. A retrograde aortogram performed through the right femoral artery revealed large abdominal aortic aneurysm, arising very close to the origin of the renal arteries and abruptly assuming its largest transverse diameter in its proximal portion (Fig. 1.1). The patient was taken to the operating room on February 22, 1981. A very large aortic aneurysm with focal, thinned-walled protrusions was noted on the anterior wall (Fig. 1.2). The left renal vein was mobilized, and left testicular vein was ligated, and silastic vessel loop was passed around the left renal vein. The proximal aortic clamp was applied above the left renal vein but

© Springer Nature Switzerland AG 2020 S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_1

3

4

1 Symptomatic Proximal Anastomotic Pseudoaneurysm of Suprarenal Aorta

Fig. 1.3 Operative specimen showing thrombus

Fig. 1.1 Aortography showing large abdominal aortic aneurysm

Fig. 1.2 Intraoperative picture of aneurysm

just distal to the renal artery obliquely. Distal control of the aneurysm was obtained at the common iliac artery level. The aneurysm was large, 10 cm in diameter, and contained a large amount of thrombus (Fig. 1.3). The aneurysm was resected and reconstructed with an aorto-bi-iliac graft (18 × 9 mm) woven Dacron. The patient was discharged on postoperative day 7 in satisfactory condition. The patient was seen 13 years later with back pain that had been present for several weeks and was admitted to the hospital where he underwent a CTA. CTA showed normal-sized aorta from the diaphragm down to the celiac and superior mesenteric arteries. The aorta then dilated up to a lumen of around 10 cm with a large anastomotic false aneurysm. There was contrast in the right renal artery but no contrast seen into the left renal artery going into the left kidney. The aorto-bi- iliac graft that had previously been placed was patent from below the aneurysm down to both iliacs. There was a slight iliac enlargement distal to the right limb of the aortoiliac graft. The arterial runoffs were normal. Angiography showed a large juxtarenal abdominal aortic aneurysm measuring 10 cm × 10 cm in AP/transverse diameter. Right renal artery begins adjacent to cephalad border of aneurysm. The left renal artery likely originates from the aneurysm, and there is a probably occlusion of the left renal artery. The aorto-bi-iliac graft is patent.

Procedure

Procedure

5

The right renal, left renal, and SMA orifices were identified. Irrigating Fogarty catheters were The patient was taken to the operating room and placed in these orifices and helped control bleedwas placed in the lateral retroperitoneal position ing. Iced Lactated Ringer’s solution was then with the left side up. Arterial line, Swan-Ganz infused into all these, both renal arteries and catheter, and Foley catheter were placed. A spinal SMA, to help preserve the renal and the intesdrain was placed. tines. The proximal aorta was debrided, and it A retroperitoneal incision was made from the was felt that a graft could be sutured to the orifice previous paramedian incision below the umbili- of the SMA and right renal. A 20 millimeter cus laterally over the tenth rib onto the chest. The Gortex graft was then brought onto the field, and chest was opened. The diaphragm was opened in this was sutured in placed with 3-0 cardiovascua circumferential fashion approximately 2 cm lat- lar Prolene suture. The beveled anastomosis was eral to its insertion on the chest wall. The retro- performed proximally including the SMA inferiperitoneal dissection was continued medially orly and the right renal artery. toward the aorta. The kidney and ureter were After the proximal anastomosis was comelevated on the medial portion of the incision, pleted, a silver clip was placed at the proximal and dissection was carried posterior to that down anastomosis. Clamps were placed distally and to the aorta. flow was restored to the celiac, SMA, and right The subdiaphragmatic aorta was identified. renal. After flow was restored, it was noted the The inferior pulmonary ligament was dissected clamp time was 33 minutes. The Dacron graft free to allow exposure of this segment of the was sized at the appropriate length and sutured in aorta. Proximal control was obtained by dissec- an end to end fashion to the remotely placed tion posterior and anterior to the aorta above the Dacron graft using 3-0 cardiovascular Prolene in diaphragm. a simple running fashion. Next, the large pulsatile mass beneath the kidPrior to completion of the anastomosis, ney was dissected free. The aortic hiatus was dis- anterograde and retrograde bleeding was persected free, and the crus of the diaphragm was formed. The anastomosis was tied. The flow dissected. The dissection was carried down, and was restored to the legs. the origin of the celiac artery was identified. A 6 millimeter PTFE (W.L. Gore, Newark, Next, the left renal artery was identified and DE) side graft, which had previously been sutured was dissected back to its origin off the aorta. The onto the graft prior to being placed in the patient, kidney was dissected off this large pseudoaneu- was cut to the appropriate length and bypass graft rysm. The entire lateral aspect of the aneurysm and then sutured end to the end of the left renal was exposed. artery. The kidney was small, approximately The spinal fluid was drained (approximately 8 cm, but renal artery was patent. A 1 millimeter 50 cc’s), and papaverine was placed into the spi- probe was easily passed through the first branch nal canal. Next, the supradiaphragmatic aortic of the renal artery. The renal artery was then clamp was placed. After the aorta was cross- sutured in an end-to-end fashion with a 6-0 clamped, the false aneurysm was opened up Prolene simple running suture. After this was using electrocautery and scissors. Upon opening sutured into place, the anastomosis was tied, and the large anastomotic aneurysm in the lower por- flow was restored to the kidney. There was a good tion of the aneurysm, the old woven graft was Doppler signal in both branches of the renal identified. There was a broken suture sitting artery. inside the aneurysm. The aortic graft had comThe patient developed some evidence of coagpletely become unincorporated with the aorta, ulopathy, and coagulation factors were replaced, and the large aneurysm was surrounding the free and the patient was warmed. After hemostasis end of the graft inside the lumen. was obtained, the aneurysm sac was closed over

6

1 Symptomatic Proximal Anastomotic Pseudoaneurysm of Suprarenal Aorta

the aortic graft with interrupted 3-0 Vicryl sutures. The pleura was closed over the thoracic aorta with interrupted 3-0 Vicryl sutures. Next, the diaphragm was closed with interrupted 2-0 Prolene interrupted horizontal mattress sutures. After the diaphragm was closed, the intercostal stitches were placed with a #2 doubled PDS suture. The chest tube was placed through an anterior incision above the operative incision. A #32 French chest tube was placed posteriorly and was tied in place with a 2-0 silk. After the chest tube was in adequate place, the intercostal stitches were tied, and the diaphragm was approximated. There was palpable pulse in renal arteries, celiac artery, and superior mesenteric artery. Dressings were applied. Chest tube was connected to water seal. The patient was then transferred to the intensive care unit in satisfactory condition. Patient was subsequently discharged in satisfactory condition and lost to follow-up 4 years later.

Discussion Proximal anastomotic pseudoaneurysms after AAA repair are uncommon as compared to distal iliac and femoral anastomotic aneurysms. Hallet et al. reported nine para-anastomotic aneurysms at a median follow-up of 6.1 years and three at the proximal aortic anastomosis [1]. Conrad et al. reported six visceral segment aneurysms, three of which underwent open repair among 152 patients who underwent surveillance with imaging studies following open AAA repair [2]. A proximal aortic para-anastomotic pseudoaneurysm developed in six patients (2.9%) in a retrospective study of 208 patients who survived elective open repair of infrarenal aortic aneurysm [3]. Crawford et al. reported a long-term outcome of open repair of AAA. During a 15-year followup, late complications occurred in 26 (3.2%) patients with anastomotic pseudoaneurysms in 23 patients and secondary aortoenteric fistula in the remaining 3 patients [4]. Following an open AAA repair, an anastomotic aneurysm or aneurysmal dilatation of adjacent visceral segment and/or iliac arteries may occur in 1%, 5%, and

20% at 5, 10, and 15 years, respectively. Therefore CTA abdomen and pelvis should be obtained every 5 years after open repair. All patients with proximal para-anastomotic pseudoaneurysms do not need repair. Repair of such aneurysms is dictated by their size (>5.5 cm) and coexisting medical comorbidities. When indicated, retroperitoneal flank approach is preferred. The role of endovascular repair with branched endografts is not clearly defined in the management of para-anastomotic pseudoaneurysms. In patients undergoing repair of type IV thoracoabdominal aneurysm, continuous cold perfusion of the left kidney can be carried out during performing of distal anastomosis [5, 6]. Postischemic renal dieresis occurs commonly when suprarenal clamp time exceeds 30 minutes. Patients should have adequate volume replacement. Postoperatively, a spinal cord protection protocol is maintained for at least 24 hours in all patients treated with a lumbar drain [5, 6]. This case illustrates the importance of careful followup with imaging studies, as well as adequate treatment of hypertension. It is possible that uncontrolled blood pressure in this case led to rapid enlargement of juxtarenal AAA before the first operation and probably played a role in the development of proximal para-anastomotic pseudoaneurysm.

I nvited Commentary from Charles W. Acher, MD What is striking about this patient is his age of 37 at the time of his first aneurysm repair. Even with such severe malignant hypertension, which was diagnosed and treated 10 years previously, it is unusual to develop an aneurysm at this age without some underlying genetic molecular disorder which we can now test for but was unavailable at the time of either aneurysm repair. A smoking history was not mentioned but would be present in most of these patients. His mental decompensation in 1980 after stopping his medications might very well have been hypertensive encephalopathy, or encephalopathy may have contributed, but it also raised the question of how consistent he was in controlling his blood pressures in the

Invited Commentary from Charles W. Acher, MD

decade preceding and after his initial aneurysm surgery with what was undoubtedly a hypertensive stroke in 1973, a year after diagnosing his hypertension. Also, in 1981 he already had hypertensive nephropathy with diminished renal function, and he may have been malnourished from aneurysm-related anorexia with a BMI of 14.1. All of these factors may have contributed to his subsequent aneurysm/pseudoaneurysm 13 years later. The actual repair of his aneurysm/pseudoaneurysm in 1994 appears to have gone flawlessly and demonstrates several points which are important in planning and executing such a complicated repair even today and were ahead of their time in 1994. The use of a spinal drain was not done in most centers in 1994. We reported the largest clinical series up to that time of 40 TAAA patients in 1989 with experience since 1986 showing an 80% reduction in spinal cord injury, but general acceptance of spinal drains did not really take hold until Coselli’s randomized trial in 1999 [7]. In 1994 we would have drained CSF, but in a surgery like this today, we might avoid the spinal drain but use the rest of our spinal cord protection protocol which is hypothermia (32–33 °C), proximal hypertension, steroids and naloxone, plus aggressive volume resuscitation with blood (cell saver and bank) and FFP. We would use spinal drainage for a true Crawford type 4 TAAA in most cases. Renal cooling with iced saline was also not standard in 1994 but is the best strategy for renal protection. We always advocated rapid renal cooling (over 2–4 minutes) with 300–400 infusion of LR with 12.5 gm and 1000 units of heparin/liter at 4C into each kidney [6]. This is very protective with permanent dialysis-dependent renal failure in 0.8% of our patients and was confirmed by a randomized trial by Lamaire and Coselli [8]. Also I think it was important to investigate the left kidney and revascularize for maximum renal preservation if the renal artery was not occluded as suggested by the pre-op imaging. The cold renal perfusion is important in attaining moderate hypothermia (32– 33 °C) which is end-organ (kidney, bowel, liver) protection during aortic reconstruction [9]. We do not reverse hypothermia with active warming (no bare huggers) and allow patients to rewarm on their own over several hours in the ICU. This

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intentional hypothermia has not resulted in increased bleeding or postoperative bleeding because we are very aggressive with volume and factor replacement during the surgery and patients are on an FFP drip at 75 cc per hour until the next day. We feel this hypothermia is protective of the spinal cord in more extensive replacements until the axial collateral network defined so elegantly by Etz and Griepp improves blood flow to the cord [10]. In this case that is not as important because of the limited aortic replacement but is important for the bowel and liver which we do not perfuse directly. There are a few other technical points that have changed since 1994 when we exposed and closed in much the same way as described. We do extraperitoneal exposure now and have for the last 20 years if the incision is in the 7th intercostal space or lower, and we close the diaphragm with a running double-stranded 0 PDS suture and not interrupted Ethibond. In 5th and 6th interspace incisions, we still may need interrupted Ethibond for the last third of the diaphragm which are tied after the chest wall is approximated. In addition to a chest tube, we also drain the retroperitoneum with a 10 flat JP drain with a ReliaVac reservoir which maintains a constant -80 mmhg suction to minimize fluid and blood from accumulating in the retroperitoneum and has a one-way valve so reservoir contents don’t reflux back into the drain. Just as important as the surgical repair are the anesthetic protocols which are standardized in our unit. All of these cases are done by cardiovascular anesthesiologists who follow the protocols that have been developed from basic science and experience and modified by consensus as new information comes to light that has strong scientific foundation. Postoperative ICU protocols are also important to optimize cardiac function, hemodynamics, oxygen delivery, and tissue perfusion. These protocols have been agreed upon by the anesthesiologists, surgeons, and intensivists who we co-manage with daily while in the ICU with face-to-face interactions. Reading about this case brought back memories of those patients we treat successfully who disappear into the ether of time and we wonder what happened to them. Did all that work result in a longer and better life? It also brings home the

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1 Symptomatic Proximal Anastomotic Pseudoaneurysm of Suprarenal Aorta

reason we try so hard to maintain contact with these patients so we can better understand the long-term success or failure of our efforts.

References 1. Hallett JW, Marshall DM, Petterson TM, Gray DT, et al. Graft-related complications after abdominal aortic aneurysm repair: reassurance from a 36-year population-based experience. J Vasc Surg. 1997;25(2):277–84; discussion 285–286. 2. Conrad MF, Crawford RS, Pedraza JD, Brewster DC, et al. Long-term durability of open abdominal aortic aneurysm repair. J Vasc Surg. 2007;46(4):669–75. 3. Crawford ES, Saleh SA, Babb JW, Glaeser DH, Vaccaro PS, Silvers A. Infrarenal abdominal aortic aneurysm: factors influencing survival after operation performed over a 25-year period. Ann Surg. 1981;193(6):699–709. 4. Biancari F, Ylönen K, Anttila V, Juvonen J, Romsi P, Satta J, Juvonen T. Durability of open repair of infrarenal abdominal aortic aneurysm: a 15-year follow-up study. J Vasc Surg. 2002;35(1):87–93. 5. Shepard AD. Proximal abdominal aortic aneurysm repair in endovascular reconstruction. In: Hans SS,

Shephard AD, Weaver MR, Bove PG, Long GW, editors. Endovascular and open vascular reconstruction: a practical approach. Boca Raton: CRC Press; 2018. p. 213–20. 6. Wynn MM, Acher C, Marks E, Engelbert T, Acher CW. Post operative renal failure in thoracoabdominal aortic aneurysm repair with simple cross-clamp technique and 4°C renal perfusion. J Vasc Surg. 2015;61(3):611–22. 7. Acher CW, Wynn MM, Archibald J. Naloxone and spinal fluid drainage as adjuncts in the surgical treatment of thoracoabdominal and thoracic aneurysms. Surgery. 1990;108(4):755–61; discussion 61–2. 8. Coselli JS, LeMaire SA, Koksoy C, Schmittling ZC, Curling PE. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial. J Vasc Surg. 2002;35(4):631–9. 9. Koksoy C, LeMaire SA, Curling PE, et al. Renal perfusion during thoracoabdominal aortic operations: cold crystalloid is superior to normothermic blood. Ann Thorac Surg. 2002;73(3):730–8. 10. Etz CD, Kari FA, Mueller CS, Brenner RM, Lin HM, Griepp RB. The collateral network concept: remodeling of the arterial collateral network after experimental segmental artery sacrifice. J Thorac Cardiovasc Surg. 2011;141(4):1029–36.

2

Repair of Juxtarenal Abdominal Aortic Aneurysm with Aortorenal Bypass

Physical Examination A 68-year-old male was scheduled for open repair of a 5.0 cm abdominal aortic aneurysm (AP/transverse diameter) in February 2005. The aneurysm was juxtarenal with associated 2.8 cm bilateral common iliac artery aneurysms and a 2.0 cm left hypogastric artery aneurysm (Fig. 2.1a). Preoperative aortography showed accessory left lower pole renal artery (Fig. 2.1b). Medical comorbidities included history a

Fig. 2.1 (a, b) Aortography showing abdominal aortic aneurysm and bilateral iliac aneurysm with accessory left lower pole renal artery. Because of large amount of throm-

of atrial flutter, hypertension, and post-thrombotic syndrome involving both lower extremities.

Procedure Through midline transperitoneal incision, AAA was exposed to mobilize. Following application of the Bookwalter retractor, and mobilization of the ligament of Treitz, the left renal vein was b

bus in the abdominal aortic aneurysm, aortogram only shows the contrast-filled lumen

© Springer Nature Switzerland AG 2020 S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_2

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2 Repair of Juxtarenal Abdominal Aortic Aneurysm with Aortorenal Bypass

ligated close to the inferior vena cava. The aneurysm arose at the level of the left renal artery and was saccular with a bulge to the left. Left crus of the diaphragm was divided by electrocautery. Both common iliac artery aneurysms were mobilized along with mobilization of the origin of the hypogastric and external iliac artery. Aorta was clamped above the left renal artery and below the right renal artery following systemic heparinization. Proximal anastomosis was performed using 22 × 11 mm knitted Dacron graft (Meadox, Boston Scientific, Marlborough, MA) in two layers, with the first layer of interrupted horizontal mattress suture on pledgets with 3-0 cardiovascular polypropylene (Ethicon, Somerville, NJ) and a second layer of continuous suture. As the proximal clamp was released, there was excessive bleeding at the 7 o’clock position of the suture line. Reapplication of the clamp a few cm proximally resulted in a tear of the aorta. A #24 Foley balloon catheter was introduced through the left limb of the Dacron graft and inflated at the supraceliac level. Left renal artery was transected at its origin from the aorta. Proximal stump of the renal artery was suture ligated, and deep bites into the left lateral wall of the aorta were taken using horizontal mattress sutures of 3-0 cardiovascular Prolene on pledgets. Bio-glue (Cryolife, Kennesaw, GA) was applied to achieve hemostasis. A 6 mm PTFE graft (W.L. Gore, Newark,

a

DE) was anastomosed to the main body of the Dacron graft on the left side just above the bifurcation of the graft taking out a small disc of Dacron graft using 5-0 cardiovascular polypropylene and distally was anastomosed end to end to the divided left renal artery. The left lower pole renal artery was reimplanted into the left limb of the Dacron graft using 5-0 CV polypropylene as well. The left hypogastric aneurysm was excised, and back bleeding was controlled with 4-0 CV polypropylene suture. Because of severe calcific disease in the left external iliac artery, left limb of the graft was anastomosed to the left common femoral artery in an end-to-side fashion. Left common iliac aneurysm was opened, and its wall was partially removed, and proximal left external iliac artery was ligated. On the right side, anastomosis of the right limb of the Dacron graft was performed end to end to the common iliac artery at the bifurcation after removal of the aneurysm. The patient received 600 cc of blood from the cell saver, and 1 unit of PRBCs was given to the patient. Patient’s post-op course was complicated by respiratory failure which improved with ventilatory support. The patient was extubated on the third postoperative day. The patient had transient renal dysfunction. Postoperative aortography showed patent aortoiliac and femoral graft and patent left aortorenal bypass (Figs. 2.2 and 2.3). Patient did

b

Fig. 2.2 (a, b) Aortography showing aortic bifurcation graft and left aortorenal bypass

Discussion

Fig. 2.3 Left femoral anastomotic aneurysm

well and underwent repair of 3.5 cm left femoral anastomotic aneurysm 8 years after the original procedure. The patient later expired from complications of Alzheimer’s dementia in 2017.

Discussion Operative repair of juxtarenal AAA is a technically challenging operation. In absence of the need to visualize distal right common iliac artery (as was the case for this patient due to 2.5 cm right iliac aneurysm), a left flank retroperitoneal approach is increasingly used for open repair of proximal complex AAA in patients with need to explore the aorta proximal to the renal arteries, redo aortic surgery, AAAs in the presence of a horseshoe kidney, hostile abdomen with prior osteotomies, or inflammatory AAA. A concomitant renal artery bypass became necessary as proximal aortic clamp resulted in tear of the aorta above the renal arteries [1]. Because of the improvement in medical management of renovascular hypertension, concomitant renal artery bypass with open AAA is rarely indicated. In order to perform suprarenal dissection via transperitoneal approach, mobilization of left renal vein or ligation of left renal vein close to the inferior

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vena cava preserving gonadal and adrenal vein as venous outflow from the kidneys is necessary. Mobilization of the left renal vein without division often requires ligation of adrenal vein and gonadal vein. In addition, the left crus of the diaphragm needs to be divided to gain proximal aortic exposure. Follow-up aortography showed satisfactory proximal anastomosis, patent left aortorenal bypass, occluded lower pole renal artery reimplantation (Fig. 2.2), and an anastomotic aneurysm involving the graft and left femoral artery. Though not always possible, either tube graft (aorto-aortic) or aortoiliac anastomosis should be preferred as femoral anastomosis may result in increased incidence of surgical site infection, lymphoceles, and late development of anastomotic aneurysms [1]. Repair of left femoral anastomotic aneurysm was performed by interposition of an 8 mm knitted Dacron graft. A left flank approach through 9th or 10th ICS, 9th ICS for paravisceral extent IV thoracoabdominal aneurysms, and 10th ICS for pararenal aortic aneurysms is preferable [1]. Renal, visceral, and occasionally spinal cord ischemia may occur with prolonged proximal clamping [1]. Renal artery reconstruction at the time of open repair of paravisceral aneurysm is associated with increased incidence of acute renal failure and mortality [2, 3]. Minimizing renal ischemia time to less than 40 minutes is important in reducing the risk of acute kidney injury. Before aortic cross clamping above the suprarenal or supraceliac level, hemodynamics need to be optimized. Mannitol 25 g is administered 30 minutes prior to aortic cross clamping, though its benefit in preventing renal dysfunction has not been proven. Deery et al. reported from vascular surgery group of New England registry for the repair of complex AAA (defined by need of suprarenal or supraceliac clamping) had higher perioperative mortality (3.2% compared to 1.2% standard infrarenal AAA repair) [4]. Renal or visceral ischemia independently predicted cardiac, respiratory, and renal complications according to results of their study [4].

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2 Repair of Juxtarenal Abdominal Aortic Aneurysm with Aortorenal Bypass

I nvited Commentary from Timothy J. Nypaver, MD This operative management of a juxtarenal aneurysm highlights many of the intraoperative and postoperative challenges and complications that can and do occur with standard open repair. In addition, juxtarenal aneurysms are now frequently managed via endovascular means with use of fenestrated grafts and alternate techniques, including extension of the landing zone more proximally with renal preservation via chimney or snorkel grafts into the renal arteries [5]. This has resulted in less operative exposure for both vascular surgeons and trainees, and the intraoperative rescue maneuvers, clearly demonstrated in this case, are becoming less familiar to practicing vascular surgeon. The author should be congratulated with this difficult case, managing a proximal clamp site tear and avulsion of a renal artery with the following critical maneuvers: proximal balloon control (inserted through a limb of the vascular graft), reimplantation of the avulsed renal artery, implantation of an accessory renal artery, and successful management of a bleeding proximal anastomosis. This was accomplished with minimal blood transfusions and complete operative management and correction of existing aneurysms (the common iliac and the hypogastric aneurysm). In doing so, the patient has been rewarded with a durable operative repair, one that lasted up to his death 12 years later from non-aortic causes. This case also indirectly highlights the potential benefits of endovascular repair with its less invasive nature and its reduced operative risk and morbidity. While this patient recovered from this challenging operative management with transient respiratory failure (3 days) and reversible renal dysfunction, other patients, frailer or those with more significant comorbidities, may not have been able to do so. Thus, careful consideration should always be given to each approach, endovascular or open, so that the vascular surgeon hopefully can select the right operation for the right patient. While each approach is complementary, it is recognized, as with standard

infrarenal abdominal aortic aneurysm operations, that endovascular repair will become the more commonly performed and the probable favored approach for repair of juxtarenal aneurysms [6]. The author has appropriately pointed out the significant benefits of the left flank retroperitoneal approach. If an open repair is to be undertaken for a juxtarenal or suprarenal aneurysm, for a paravisceral extent IV thoracoabdominal aneurysms, or for a proximal type I endoleak or other complications related to infrarenal endografting, a left flank retroperitoneal approach is preferred. If necessary, the first 1–2 cm of the right renal artery can be dissected and exposed, and in addition, the right common iliac artery can be exposed distally allowing either an anastomosis to the mid to distal common iliac or alternately allowing for ligation of the common iliac with the bypass limb then routed to the femoral level. Retroperitoneal abdominal aortic aneurysm has been associated with lower estimated blood loss and less fluid requirement within the first 24 hours following operation than transperitoneal repair [7]. In addition, the left flank retroperitoneal approach allows more facile access to the suprarenal, supramesenteric, and supraceliac levels, all performed thru the same visual plane. Once open repair is selected for a juxtarenal aneurysm, the decision for transperitoneal versus retroperitoneal is often based upon the surgeon’s preference and experience and, as illustrated in this example, whether the right iliac artery is extensively involved with the disease process.

References 1. Shepard AD. Proximal abdominal aortic aneurysm repair. In: Hans SS, Shepard AD, Weaver MR, Bove PG, Long GW, editors. Endovascular and open vascular reconstruction: a practical approach. Boca Raton: CRC Press; 2018. p. 213–20. 2. Ultee KHJ, Soden PA, Zettervall SL, McCallum JC, Siracuse JJ, Alef MJ, Vascular Study Group of New England. Perioperative effect of concomitant procedures during open infrarenal abdominal aortic aneurysm repair. J Vasc Surg. 2016;64(4):934–940.e1.

References 3. Wooster M, Back M, Patel S, Tanious A, Armstrong P, Shames M. Outcomes of concomitant renal reconstruction during open paravisceral aortic aneurysm repair. J Vasc Surg. 2017;66(4):1149–56. 4. Deery SE, Lancaster RT, Baril DT, Indes JE, et al. Contemporary outcomes of open complex abdominal aortic aneurysm repair. J Vasc Surg. 2016;63(5):1195–200. 5. Lee JT, Greenberg JI, Dalman RL. Early experience with the snorkel technique for juxtarenal aneurysms. J Vasc Surg. 2012;55:935–46.

13 6. Soler R, Bartoli MA, Faries C, et al. Fenestrated endovascular aneurysm repair and open surgical repair for the treatment of juxtarenal aortic aneurysms. J Vasc Surg. 2019;70(3):683–90. 7. Nypaver TJ, Shepard AD, Reddy DJ, et al. Repair of pararenal abdominal aortic aneurysms: an analysis of operative management. Arch Surg. 1993;128:803–13.

3

Abdominal Aortic Aneurysm Repair in a Patient with Celiac Artery Occlusion and a Large Inferior Mesenteric Artery

Physical Examination

Procedure

A 75-year-old male with history of hypertension, nicotine abuse, and now chronic back pain underwent CTA evaluation of the abdomen for a large pulsatile mass in his abdomen. A 7.4 cm infrarenal AAA with 80% stenosis of the celiac artery, 40% stenosis of the superior mesenteric artery, and an enlarged inferior mesenteric artery with a collateral vessel between the celiac and IMA (Fig. 3.1) was demonstrated. Patient had not had any symptoms of intestinal angina.

Patient was taken to the hybrid room for possible endovascular or open repair. An aortogram performed via the left femoral artery sheath revealed a large collateral artery in the upper abdomen communicating with the IMA (Fig. 3.2). Because of the risk of development of bowel infarction due to the coverage of the IMA with EVAR, it was decided to perform open repair. Through a midline laparotomy incision, AAA was explored, and a large collateral artery joining the IMA was identified.

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b

Fig. 3.1 (a, b) CTA showing iliac artery stenosis. Mild stenosis of SMA and large AAA

© Springer Nature Switzerland AG 2020 S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_3

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3 Abdominal Aortic Aneurysm Repair in a Patient with Celiac Artery Occlusion and a Large Inferior…

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c

Fig. 3.2 (a–c) Aortogram showing AAA with a large mesenteric collateral joining the IMA

Patient was seen in 6 months later in the clinic and in a satisfactory condition.

Discussion

Fig. 3.3 Intraoperative picture showing reimplanted IMA as Carrel patch

Open repair of the AAA with 20 mm tube graft was performed. Origin of the IMA and its first few centimeters were mobilized and reimplanted into the Dacron graft as a carrel patch (Fig. 3.3). Postoperative course was uneventful except for the development of transient atrial fibrillation and encephalopathy which improved gradually. Postoperative CTA showed satisfactory graft placement and patent IMA with mild to moderate stenosis (Fig. 3.4).

Complications of colon ischemia following open or endovascular aneurysm repair are rare. Patients undergoing open AAA repair with prior colon resection or a large IMA with arc of Riolan with associated celiac and SMA occlusive disease are more likely to develop the dreaded complication of ischemic colitis due to ligation of the IMA. Coverage of the IMA during endovascular repair of AAA in such patients may also result in ischemic colitis. In a recent retrospective analysis by Lee et al, IMA reimplantation during open AAA repair was associated with higher incidence of ischemic colitis [1]. However, the patient population under study did not demonstrate enlarged mesenteric collaterals suggesting need for IMA reimplantation. In the case described above, patient had a large collateral between the celiac with inferior mesenteric artery. The IMA reimplantation was thought to be a good option for prevention of bowel ischemia. The large collateral in this patient was not the arc of Riolan, which connects the middle colic (branch of SMA) to the IMA. This large collateral was a novel collateral from the celiac artery to the left upper colic artery of the IMA. An endovascular option with preservation of the IMA using a single fenestration in the back-table modification of the stent can be used occasionally in high-risk patients [2].

References

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b

c

Fig. 3.4 (a–c) Postoperative CTA images showing patent aortic graft with mild stenosis of the origin of the reimplanted IMA

I nvited Commentary from Mitchell Ross Weaver, MD This case illustrates the importance of fully evaluating a patient’s anatomy beyond only determining if there are adequate proximal and distal landing zones for an endograft to seal and adequate access for delivering the device. Coverage of the inferior mesenteric artery is a mandatory step in the endovascular treatment of abdominal aortic aneurysms for all commercially available abdominal aortic endograft systems, and even with this the incidence of clinically relevant postoperative mesenteric ischemia is very low. As well as in open surgical repair of abdominal aortic aneurysms, the inferior mesenteric artery is routinely ligated except in circumstances where it was patent preoperatively and has poor back bleeding following the aortic reconstruction. In this case however, given the large size of the inferior mesenteric artery and the mesenteric occlusive disease noted in the celiac and superior mesenteric arteries, one must assume that if flow is not preserved in the inferior mesenteric artery, mesenteric ischemia and bowel infarction will follow.

For this patient the inferior mesenteric artery patency was preserved by an open aortic aneurysm repair and reimplantation of the inferior mesenteric artery. While each patient’s anatomy is unique to them, in some patients other options may be to intervene either with endoluminal or open interventions on the celiac or superior mesenteric arteries to preserve adequate mesenteric blood flow. Nevertheless, this case does stress the importance of case planning and being mindful of the physiological effects caused by the anatomic changes of surgical intervention, whether open or endovascular.

References 1. Lee KB, Lu J, Macsata RA, Patel D, Yang A, Ricotta JJ, Amdur RL, Sidawy AN, Nguyen BN. Inferior mesenteric artery reimplantation does not decrease the risk of ischemic colitis after open infrarenal abdominal aortic aneurysm repair. J Vasc Surg. 2019;69(6):1825–30. 2. Correa JC, Mantese V, Jacobs DL. Stent graft treatment of abdominal aortic aneurysm with preservation of the inferior mesenteric artery. J Vasc Surg. 2014;60(4):118–9.

4

Abdominal Aortic Aneurysm Repair in a Patient with a Pelvic Kidney

Physical Examination A 66-year-old white male with chronic obstructive pulmonary disease was found to have an 8-cmwide asymptomatic abdominal aortic aneurysm by physical examination. Ultrasound of the abdominal aorta confirmed that the aneurysm was 8 cm in transverse diameter, and, in addition, there was a suggestion of a pelvic midline mass. Retrograde aortogram revealed the infrarenal location of the aneurysm with a normal left kidney and left renal artery. The right kidney was located in the pelvis with its blood supply arising from the lower

abdominal aorta either at its bifurcation or from the origin of common iliac artery (Fig. 4.1); this distinction could not be made with certainty on arteriogram. Pulmonary function tests revealed severe obstructive lung defects, and a chest X-ray showed mild obstructive lung disease.

Procedure On exploration the aneurysm had a short neck and was 8 cm in transverse diameter. The aneurysm was mobilized along with the blood supply to the

Fig. 4.1 Aortogram showing abdominal aortic aneurysm, pelvic kidney and its arterial supply from aorta or common iliac artery © Springer Nature Switzerland AG 2020 S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_4

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4 Abdominal Aortic Aneurysm Repair in a Patient with a Pelvic Kidney

Fig. 4.3 Scan showing normal glucoheptonate renal blood flow and I-hippuran uptake in pelvic kidney as well as left kidney

Discussion

Fig. 4.2 Operative photograph showing Dacron graft in place and loops around two renal arteries supplying the pelvic kidney, being anastomosed to the iliac limb of the graft as a cuff in common with iliac arteries

pelvic kidney arising 1 cm anterior and superior to the origin of the slightly dilated common iliac arteries. The right renal vein from the pelvic kidney joined the right common iliac vein. The aorta was clamped below the left renal artery, and the aneurysm was excised under systemic heparinization. A 19 × 9.5 mm USCI woven bifurcated Dacron graft was sutured in place after both renal arteries to the pelvic kidney had been mobilized and cuff preserved with each common iliac artery. Both renal arteries to the pelvic kidney were flushed with heparinized ice-cold saline after the aneurysm had been opened. Proximal anastomosis was performed with 4-0 cardiovascular Prolene. Distally, each common iliac artery and the attached renal artery proximal to it were joined in a common elliptical anastomosis to the Dacron limb on either side also using 4-0 cardiovascular Prolene (Fig. 4.2). Total clamp time was 30 minutes. Postoperative renal blood flow and scan showed normal blood flow to the left kidney as well as to the right pelvic kidney (Fig. 4.3). The patient was discharged after 8 days in good condition.

CT angiography and preoperative arteriography are essential diagnostic procedures for careful operative planning of such cases [1]. The pelvic kidney was rotated with its pelvis lying inferiorly. Careful surgical dissection enabled us to recognize two renal arteries to the pelvic kidney arising just above the origin of the common iliac arteries to supply the hilum of the pelvic kidney. Complete mobilization of the arterial supply to the pelvic kidney made it possible to reduce the ischemic time to less than 40 minutes. If, on freeing the aneurysm the artery to the pelvic kidney is found to arise from the aneurysm itself or from the bifurcation of the common iliac artery, this artery should be reimplanted into the Dacron graft [1]. A similar situation may arise in a patient with abdominal aortic aneurysm and a prior renal transplant. Campbell et al. used in situ renal perfusion and performed successful aneurysmectomy in a young renal transplant patient. Ex vivo renal perfusion is hazardous because of the risk to injury to the renal parenchyma, its blood supply, and the ureter. Aneurysmectomy with the use of a shunt from the proximal aorta to the common iliac artery as a means of providing blood flow to a transplanted kidney was described by Sterioff and Parks [2]. This approach may be technically difficult in arteriosclerotic vessels, and there is a potential for distal embolization. An axillofemoral graft is an attractive alternative provided blood supply

References

of the pelvic kidney is from the distal portion of the common iliac artery. Shons et al. used an axillofemoral bypass to preserve a functioning renal transplant after excision of a mycotic abdominal aortic aneurysm in a diabetic patient [3]. Schneider and Cronenweff described temporary perfusion of a pelvic kidney during repair of AAA and iliac aneurysms [4]. Pelvic renal ischemia was limited by a “double proximal clamping” technique and by placement of a temporary shunt from the body of the aortic graft into the pelvic renal artery during completion of two distal anastomoses [4]. A custom-made fenestrated endograft with prior prototype information has been described for the repair of a large AAA with right pelvic kidney in a patient with multiple comorbidities [5]. A hybrid technique was successfully performed in a patient with aortoiliac aneurysm and a congenital solitary pelvic kidney by performing right external iliac artery to two renal arteries (to the solitary kidney) using a bifurcated Dacron graft followed by coil embolization of the hypogastric artery and a standard endovascular aneurysm repair [6]. In our patient arterial supply to pelvic kidney arose close to the origin of the common iliac artery, and as such an axillofemoral graft would not have maintained renal perfusion. Systemic heparinization before aortic clamping, flushing of the renal arteries with heparinized ice-cold saline after opening the aneurysm, and reestablishment of arterial flow to such a kidney are important steps in preserving renal function in such cases.

I nvited Commentary from Mitchell Ross Weaver, MD The presence of renal anomalies such as a pelvic kidney or a horseshoe kidney can be a formidable challenge when it comes to the need for abdomi-

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nal aortic aneurysm repair. Several factors of the altered anatomy contribute to this. These include positioning in the pelvis with limited space, often multiple as opposed to a single renal artery that will require reconstruction, and abnormal course of the ureters which may place them at greater risk for injury. Thus, careful study of the preoperative imaging is a must to identify and then plan for reconstruction of the renal arteries, as well as plan for the most advantageous approach be that transperitoneal or retroperitoneal. Additional adjuncts to consider include the use of cold renal perfusion or temporary renal shunting to avoid the effects of likely longer renal ischemia times in these cases.

References 1. Campbell DA Jr, Lorber MI, Arneson WA, Kirsh MM, Turcotte JG, Stanley JC. Renal transplant protection during abdominal aortic aneurysmectomy with a pump-oxygenator. Surgery. 1981;90:559–62. 2. Sterioff S, Parks L. Temporary vascular bypass for perfusion of a renal transplant during abdominal aneurysmectomy. Surgery. 1977;82(5):558–60. 3. Shons AR, DeShazo CV, Rattazzi L, Najarian JS. Renal transplantation with blood supply by axillofemoral bypass graft. Am J Surg. 1976;132(1):97–9. 4. Schneider JR, Cronenwett JL. Temporary perfusion of a congenital pelvic kidney during abdominal aortic aneurysm repair. J Vasc Surg. 1993;17(3):613–7. 5. Majumder B, Perera AH, Browning N, MacGregor M, Chapman A. Fenestrated endograft as a new perspective for the treatment of infrarenal abdominal aortic aneurysm with a congenital pelvic kidney-a case report and review of literature. Ann Vasc Surg. 2017;45:266.e1–4. 6. Malinowski MJ, Al-Nouri O, Hershberger R, Halandras PM, Aulivola B, Cho JS. Abdominal aortic aneurysm associated with congenital solitary pelvic kidney treated with novel hybrid technique. Ann Vasc Surg. 2014;28(6):1566.e7–10.

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Open Repair of Abdominal Aortic Aneurysm in a Patient with Double Inferior Vena Cava

Physical Examination A 58-year-old male with congestive cardiomyopathy and diabetes mellitus was found to have a 6.5-cm-wide abdominal aortic aneurysm by clinical examination. In addition, the patient had patchy mottling of the right big and second toes and the left fifth toe. The right femoral pulse was slightly diminished, but the left femoral pulse was absent. Right popliteal, posterior tibial, and dorsalis pedis pulse were absent as well. The chest X-ray showed cardiomegaly, and an EKG showed left ventricular hypertrophy with ST segment changes. Ultrasound examination of the abdomen confirmed the presence of an AAA with transverse diameter of 6.5 cm. Retrograde aortogram revealed that the aneurysm extended to involve the proximal portion of the right common iliac artery. There was mild stenosis of the distal right common iliac artery. In addition, the left common iliac artery was occluded, with reconstitution of the external and internal iliac arteries at their origin (Fig. 5.1). The arteries below the groin, though smaller in size, did not show any occlusive disease. Because of the presence of a large abdominal aortic aneurysm and significant iliac artery occlusive disease, the patient underwent an open aortic reconstruction on November 11, 1982.

Fig. 5.1 Abdominal aortogram showing AAA and left iliac artery occlusion

Procedure Preoperatively, a Swan-Ganz catheter was inserted. The AAA was found between two channels of a duplicated inferior vena cava.

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5 Open Repair of Abdominal Aortic Aneurysm in a Patient with Double Inferior Vena Cava

Right IVC

Left IVC

A.A.A

Fig. 5.2 Operative picture showing left-sided IVC

The left-sided vena cava joined the right-sided vena cava at the neck of the aneurysm so as to form one common venous channel. Both renal veins joined at the same level. The left lateral wall of the aneurysm projected behind and beyond the left-sided vena cava. The neck of the aneurysm was mobilized very carefully (Fig. 5.2). The upper portion of the left vena cava was mobilized, and tape was passed around it. The aneurysm was resected between the two caval veins, and aortic bifurcation graft (18 × 9 mm Verisoft, Meadox) prosthesis was inserted (Figs. 5.3 and 5.4). On the right side, the right limb of the graft was anastomosed to the common iliac artery bifurcation and on the left to the common femoral artery in an end-to-side fashion. The postoperative course was uneventful, and the patient was discharged on the eighth postoperative day in a satisfactory condition.

Discussion The incidence of a double inferior vena cava varies between 0.5 and 0.3 percent in the general population [1, 2]. The development of the IVC is a complicated process involving three

Fig. 5.3 Diagrammatic representation of intraoperative findings

Fig. 5.4 Postoperative inferior vena cava showing double IVC

pairs of venous channels: posterior cardinal, subcardinal, and supracardinal. Chuang et al. [3] presented a simplified classification of

Invited Commentary from Graham W. Long, MD

anomalies of postrenal segment of IVC into four types: • Type A: Persistent right posterior cardinal vein (retrocaval ureter) • Type B: Persistent right subcardinal vein (normal IVC) • Type C: Persistent left subcardinal vein (left IVC) • Type BC: Persistent right and left supracardinal and subcardinal veins (double IVC) Normally, the left renal vein is formed by the persistence of the ventral limb and regression of the dorsal limb of the renal venous collar. Persistence of the dorsal limb results in formation of a retroaortic left renal vein, while persistence of both dorsal and ventral limbs results in formation of a circumaortic venous ring. Absence of hepatic segment of the IVC with azygos or hemiazygos continuation is commonly associated with congenital heart disease, asplenia, and polysplenia [3]. Detailed knowledge of various venous anomalies in association with AAA is important for the vascular surgeon, since such anomalies may be found unexpectedly at the time of exploration. Lindblad [1] found a double IVC and AAA at the time of aortoiliac reconstruction for occlusive disease. Dupont reported an isolated left-sided vena cava in a patient with AAA [2]. He obtained proximal control of the aneurysm above the level of the right renal vein. Duplicated vena cava is ten times more common than an isolated left-sided vena cava [2]. Above the level of the renal vein, the IVC is single and is on the right side even if it is duplicated below that level, as was present in our case. The preoperative detection of congenital anomalies of the IVC by CTA decreased the incidence of venous injuries [3–5]. In most patients with double IVC, mobilization of left-sided IVC is sufficient to perform open AAA repair. Division of left-sided vena cava during AAA repair with and without reconstruction has been described but is rarely necessary [3, 4]. Exposure of the neck of the aneurysm must be done very carefully in patients with duplicated vena cava, as the left-sided channel crosses toward the right anteriorly near the upper part of

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the aneurysm. A small tear in the tributary of a double vena cava can lead to serious intraoperative hemorrhage. Inadvertent ligation of one of the paired venous channels can lead to thrombosis with subsequent edema of the extremity and other sequelae of venous hypertension. The left- sided vena cava was mobilized as the aneurysm extended behind and beyond this channel for a distance of 3.0 cm. Mobilization of the iliac arteries was straightforward. Postoperative venography via bilateral femoral venous approach revealed detailed anatomic distribution of duplicated vena cava (Fig. 5.4).

I nvited Commentary from Graham W. Long, MD The author describes elective open repair of an AAA from 1982 in which an unexpected finding of a duplicated IVC was encountered. He describes the preoperative evaluation and the measures taken for uneventful conduct of the operation. The patient in this case underwent appropriate preoperative evaluation with a combination of ultrasound and aortography. Nonetheless, a potential issue with this approach is the inability to visualize incidental pathology, such as tumor or inflammatory masses and venous anomalies. This case illustrated a duplicated IVC, but more common variations include a retroaortic renal vein or circumaortic venous ring. In the current era of endovascular aneurysm repair, nearly every AAA undergoes preoperative CTA, which makes the above considerations moot. Being familiar with anatomic variations of the IVC is important to the vascular surgeon for two reasons. First, recognizing a left-sided IVC prevents ligation and subsequent left leg venous thrombotic complications. Second, the left-sided IVC crosses the aorta obliquely and is joined by the left renal vein at the level of the aortic neck. This obscures access to the neck and requires careful mobilization of these venous structures to allow for proximal clamp placement. This often includes ligation of the draining lumbar vein off this IVC-renal venous complex to prevent avulsion and hemorrhage.

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5 Open Repair of Abdominal Aortic Aneurysm in a Patient with Double Inferior Vena Cava

Aortic surgeons must be prepared for anatomic variants which affect the conduct of the operation. Dr. Hans presents a solid example of this with a duplicated IVC.

References 1. Lindblad L. Duplicated inferior vena cava in a patient with an abdominal aortic aneurysm. Ann Chir Gynecol. 1978;67:30–2. 2. Chuang VP, Mena CE, Hoskins PA. Congenital anomalies of the inferior vena cava. Review of

embryogenesis and presentation of a simplified classification. Br J Radiol. 1974;47:206–13. 3. Dimic A, Markovic M, Cvetkovic S, Cinara I, Koncar I, Davidovic L. Abdominal aortic surgery in the presence of inferior vena cava anomalies: a case series. Ann Vasc Surg. 2017;39:137–42. 4. Radermecker MA, Van Damme H, Kerzmann A, Creemers E, Limet R. Association of abdominal aortic aneurysm, horseshoe kidneys, and left-sided inferior vena cava: report of two cases. J Vasc Surg. 2008;47(3):645–8. 5. Truty MJ, Bower TC. Congenital anomalies of the inferior vena cava and left renal vein: implications during open abdominal aortic aneurysm reconstruction. Ann Vasc Surg. 2007;21(2):186–97.

6

Mycotic Aneurysm of the Abdominal Aorta

Physical Examination A 53-year-old male was admitted to South Macomb Hospital on October 8, 1981, with chills and high fever of 2 week’s duration (102–103 °F). This fever was accompanied with pain in the lower back and left lower quadrant of the abdomen aggravated by walking. He had a history of 60 pack years of nicotine abuse. At the time of admission, he had a fever of 102.6 °F with a heart rate of 120 beats per minute and blood pressure 130/80 mm Hg. Examination of the chest revealed diffuse rhonchi with rales. A pulsatile non-tender mass was palpable in the abdomen lateral to the umbilicus. Laboratory data revealed a hemoglobin of 12.9 gm/dl, hematocrit 36%, and a WBC count 17,300/cm with shift to the left. Sedimentation rate was 54 mm/hg. The chest X-ray was normal. Ultrasound and CT scan of the abdomen revealed a 5.0 cm transverse diameter infrarenal aortic aneurysm. Two blood cultures were positive for E. coli, and the patient was started on antibiotics (Kefzol and Tobramycin). A retrograde aortogram revealed a saccular aneurysm of the infrarenal abdominal aorta (Fig. 6.1).

Procedure Patient underwent open repair of the aneurysm on December 16, 1981. Infrarenal abdominal aortic aneurysm was associated with an

enlarged preaortic lymph node with induration and edema of the left lateral wall of the aneurysm. Cultures of the preaortic lymph nodes were positive for E. coli. After proximal and distal control was obtained, the aneurysm was opened. There was evidence of dissection with a smaller true lumen and a larger false lumen (Fig. 6.2). The proximal extent of dissection was 2.0 cm below the origin of the renal arteries, and distally the dissection stopped at aortic bifurcation. The aneurysm was resected completely and replaced by a 16.0 × 8.0 mm Verisoft (Meadox) Dacron graft. Culture of aneurysm wall was positive for E. coli. Histopathological examination of the aneurysm revealed an atherosclerotic aneurysm with acute and chronic inflammatory changes in its wall. Patient was discharged on January 4, 1982, on oral Keflex, followed by 6 weeks of intravenous antibiotics (Kefzol and Tobramycin). The patient was readmitted on February 26, 1982, with aspirin overdose secondary to severe back pain that was an associated low-grade fever (99–100 °F). Follow-up aortogram revealed a normally functioning graft (Fig. 6.3) without any anastomotic disruption. X-ray of the lumbosacral spine revealed osteomyelitis of the 2nd, 3rd, and 4th lumbar vertebrae with positive bone scan (Fig. 6.4). Simultaneous left femoral arterial blood and a left femoral venous culture did not grow any microorganisms, but the patient continued to receive intravenous antibiotics. A

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6 Mycotic Aneurysm of the Abdominal Aorta

Fig. 6.1 Infrarenal saccular aneurysm of the aorta

Fig. 6.2 Operative specimen with aortic dissection in the aneurysm

Fig. 6.3 Showing osteomyelitis of 2nd, 3rd, and 4th lumbar vertebrae

References

Fig. 6.4 Postoperative aortogram following prosthetic graft (Dacron)

biopsy of the 3rd lumbar vertebra was negative for any microorganisms. His general condition improved, and patient became afebrile following 4 weeks on intravenous antibiotics with slight deterioration in his renal function. Patient’s back pain diminished, and he was discharged on May 15, 1982, after 12 weeks of parenteral antibiotics.

Discussion Hsu et al. reported infected aortic aneurysms in 19 patients with salmonella species being the most common responsible microorganisms [1]. They reported excellent results with wide debridement of infected aorta, in situ replacement with a Dacron graft or patch repair, and prolonged course of intravenous antibiotics. Mycotic aneurysms of the abdominal aorta are rare. Such aneurysms should be suspected in patients with high fever, non-calcified aor-

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tic wall, and characteristic finding of a saccular nature of the aneurysm on imaging studies. Isolation of E. coli from the aneurysm wall and its contents and preaortic lymph nodes and isolation of same organisms from blood showed that the patient had generalized bacteremia, but a source of the original infection could not be identified. There was no history of substance abuse or bacterial endocarditis. The cause of osteomyelitis of the spine was not obvious. The patient remained well for subsequent 5 years and was then lost to follow-up. Infected aneurysms of abdominal aorta are potentially life-threatening if not detected adequately. Aortic resection and extra-anatomic bypass were recommended by Scher et al. [2]. This patient was relatively young, without any evidence of primary source of bacteremia, and under antibiotic coverage, it was decided to resect the aneurysm and replace it with an in situ Dacron graft. At the present time, the author would have preferred rifampin-soaked prosthetic graft. In the contemporary practice, rifampin-soaked Dacron graft, cryopreserved vein graft, or use of autogenous reconstruction with deep veins (femoral-popliteal) is the preferred method of reconstruction [2–4]. Recently in a nationwide study in Sweden, Sorelius et al. demonstrated that endovascular aneurysm repair (EVAR) is the preferred modality because of improved short-term survival in comparison with direct open repair without associated increased incidence of serious infection- related complications or incidence of reoperations [5].

References 1. Hsu RB, Tsay YG, Wang SS, Chu SH. Surgical treatment for primary infected aneurysm of the descending thoracic aorta, abdominal aorta, and iliac arteries. J Vasc Surg. 2002;36:746–50. 2. Scher LA, Brener DJ, Goldenkranz RJ, et al. Infected aneurysm of abdominal aorta. Arch Surg. 1980;115:1975–8.

30 3. Muller BT, Vegeuer OR, Grabitz K, Pillny M, Thomas L, Sandmann W. Mycotic aneurysms of the thoracic and abdominal aorta and iliac arteries; experience with anatomic and extraanatomical repair in 33 cases. J Vasc Surg. 2001;33(1):106–13. 4. Nypaver TJ. Primary and secondary aorto enteric fistula. In: Hans SS, Shephard AD, Weaver MR, Bove PG, Long GW, editors. Endovascular and open vascu-

6 Mycotic Aneurysm of the Abdominal Aorta lar reconstruction: a practical approach. Boca Raton: CRC Press; 2018. p. 257–62. 5. Sorelius K, Wanhainen A, Furebring M, Bjork M, et al. Nationwide study of the treatment of mycotic abdominal aortic aneurysm comparing open and endovascular repair. Circulation. 2016;134(23):1822–32.

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Open Abdominal Aortic and Iliac Aneurysm Repair in a Patient with Cirrhosis of the Liver

Physical Examination A 75-year-old male was presented with 5.5 cm infrarenal saccular abdominal aortic aneurysm, 3.0 cm diameter bilateral common iliac aneurysms, and 2.5 cm right hypogastric aneurysm in May 2005. The aortic aneurysm measured 4.0 cm in transverse diameter in 2004 by CTA abdomen and pelvis. Patient’s comorbidities include coronary artery disease, atrial fibrillation (on warfarin), and a history of deep vein thrombosis of the left lower extremity. Preoperative cardiolite testing showed ischemia in the territory of the left anterior descending artery. Coronary arteriography showed 60% mid left anterior descending artery stenosis with a negative flow wire study.

Procedure On May 4, 2005, patient underwent open repair of abdominal aortic aneurysm (AAA), bilateral common iliac aneurysm, and left hypogastric aneurysm via transperitoneal midline approach. Micronodular cirrhosis of the liver and portal venous hypertension in the retroperitoneum were encountered. Left common iliac aneurysm and its bifurcation into external iliac and hypogastric artery were exposed by mobilizing the sigmoid colon along the incision in the white line of Toldt with excessive bleeding in the pelvic area secondary to venous hypertension.

Aneurysm was juxtarenal. Proximal vascular clamp was applied above the left and below the right renal artery, and interrupted horizontal mattress sutures using 4.0 CV Prolene were used, with an outer layer of running sutures for reconstruction of proximal anastomosis. Right common iliac aneurysm extended to involve the first centimeter of the right hypogastric artery with laminated thrombus. Right hypogastric aneurysm was ligated with 3.0 CV polypropylene (Ethicon, Somerville, NJ), and an end-toend anastomosis of an 18 × 9 mm knitted Dacron graft to the divided proximal end of the right external iliac artery was performed in a continuous fashion. Left limb of the Dacron graft was anastomosed to the left common iliac bifurcation preserving left hypogastric artery flow. This anastomosis was performed in an end-to-end fashion after resecting the anterior wall of the left common iliac aneurysm. Wedge liver biopsy was performed during the aneurysm repair which showed fatty change. His postoperative course was complicated by dilutional coagulopathy, respiratory complications, and mild ascites with elevation of alkaline phosphatase, bilirubin, and SGPT. Patient had a satisfactory post operative course and was discharged to the rehabilitation unit after an 18 day stay in the hospital. There was gradual improvement in the level of liver enzymes. Patient died in 2011 following low anterior resection for carcinoma of the rectum.

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Discussion Marrocco-Trischetta et al. reported 25 patients who underwent open AAA repair in the presence of biopsy-proven cirrhosis of liver and did not observe any difference in perioperative complications between cirrhotic patients and controls [1]. However, there were higher intraoperative blood loss, operative time, and increased length of stay in patients with cirrhosis. From their study they concluded that in compensated cirrhosis, open AAA repair can be performed safely. However, the reduced life expectancy in cirrhotic patients with MELD score > 10 suggests that the repair should not be offered in that subgroup of patients. Recently, Chu et al. reported promising short-term results after EVAR and TEVAR in patients with liver cirrhosis who otherwise have a poor long-term outcome [2]. The author has performed seven open

AAA repairs in patients with cirrhosis including two patients presenting with ruptured AAA. Both patients with ruptured AAA in the presence of associated cirrhosis died in perioperative period. Patients undergoing open repair without rupture had increased intraoperative bleeding, transient liver dysfunction by liver function tests, and increased length of stay, but all survived open repair.

References 1. Marrocco-Trischetta MM, Kahlberg A, Astore D, Tshiombo G, Mascia D, Chiesa R. Outcome in cirrhotic patients after elective surgical repair of infrarenal aortic aneurysm. J Vasc Surg. 2011;53:906–11. 2. Chu A, Chen C, Lyn Y, Lin M, Wu VC, Ting P, Chen S. A population – based analysis of endovascular stent graft therapy in patients with liver cirrhosis. J Vasc Surg. 2019;69:1395–404.

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Major Venous Injury During Repair of Abdominal Aortic and Iliac Aneurysm

History and Procedure A 62-year-old male was scheduled to undergo open repair of 6.0 cm (transverse diameter) abdominal aortic aneurysm (AAA), 4.0 cm transverse diameter right common iliac artery aneurysm, and a 3.0 cm left common iliac aneurysm (Fig. 8.1) on September 3, 2009. Patient’s past medical history included stable coronary artery disease, hypertension, and hyperlipidemia. Open repair was performed via midline transperitoneal approach. Proximal aortic clamp was applied to the aorta below the level of renal arteries and to external and hypogastric arteries on both sides. An 18 × 9 mm knitted Dacron graft was anastomosed to the aortic neck. During the mobilization of the right common iliac aneurysm, its wall was found to be adherent to the right common iliac vein. There was an inadvertent injury to the right common iliac vein. With local pressure proximally and distally from the site of the tear in the iliac vein, the anterior wall of the vein was sutured with running 5.0 cardiovascular polypropylene suture (Ethicon Somerville, NJ), and an end-to-end anastomosis of the 9 mm limb of the Dacron graft to the divided common iliac artery was performed just above its bifurcation. As the right femoral pulse was not satisfactory, the graft was extended to the right common femoral artery by suturing the divided limb end to end just above the iliac anastomosis and end to side to common femoral artery. On the left side, the left limb of

the graft was anastomosed to the common iliac artery after resection of the aneurysm just above the bifurcation. During sudden and significant bleeding from right common iliac vein, two units of packed RBC were transfused. On September 6 patient developed swelling of the right leg and was found to have thrombosis of right common femoral and proximal superficial femoral vein. Patient was anticoagulated with intravenous heparin and received Coumadin therapy for 6 months with gradual improvement in the swelling of the right lower extremity. Patient was last seen in September of 2018 in satisfactory condition with postoperative CTA of the abdomen and pelvis showing no abnormalities (Fig. 8.1).

Discussion Major venous injury, though uncommon, negatively impacts patient’s outcome following aortic reconstruction. Iliac vein injury is the most common of all major venous injuries and occurs more frequently with repair of ruptured AAA. Other contributing factors for such injury include inflammatory aortic aneurysm, presence of periarterial inflammation, and large iliac aneurysms [1]. Following iliac vein injury, there is increased incidence of deep venous thrombosis, and patients should undergo duplex venous evaluation of the lower extremity. If there are no

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Fig. 8.1 Showing abdominal aortic aneurysm and large bilateral common iliac aneurysm with adherent right common iliac vein

c ontradictions, patient should be anticoagulated for 6 months. Eighteen major venous injuries (1.9%) are discovered during open aortic reconstruction consisting of inferior vena cava (