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Introduction: Concurrent iliac occlusion and abdominal aortic aneurysm is rare. Traditionally, the endovascular approach to these patients has consisted of aortouniiliac devices combined with femoral–femoral bypass. With improved facility of endovascular techniques, standard bifurcated endografts represent an alternative option in these patients. This study examined outcomes of patients undergoing iliac recanalization and traditional bifurcated endovascular aneurysm repair in the face of access vessel occlusion. Methods: Outcomes of patients at three academic tertiary referral centers who underwent attempted iliac recanalization of chronic iliac occlusions and concurrent endovascular aneurysm repair of an infrarenal aortic aneurysm were retrospectively reviewed. Patients with acute iliac thrombosis and those with severely stenotic (but patent) iliac vessels were excluded. Results: During a 6-year period, 15 occluded iliac arteries were treated in 14 patients (13 men). Mean age was 67.8 years (range, 52-80 years). Primary indication for intervention was disabling claudication in four patients, size of abdominal aortic aneurysm in nine, and symptomatic aneurysm in one. Seven patients presented with a unilateral common iliac artery (CIA) occlusion, four with a unilateral external iliac artery (EIA) occlusion, three with a unilateral combined CIA and EIA occlusion, and one with bilateral CIA occlusions. Stents had been placed previously in two of the occluded CIAs and in one of the occluded EIAs. Average length of the occluded segment was 7.5 cm (range, 2-17 cm). The occluded CIAs and EIAs had mean diameters of 8.6 and 5.7 mm, respectively. Successful recanalization was achieved in 14 of the 15 vessels (93.3%). One EIA ruptured during recanalization but was easily controlled with a covered stent. A re-entry device was used in two cases. Overall, 13 bifurcated devices were successfully implanted. Bilateral iliac occlusions in one patient were recanalized. One Talent (Medtronic, Santa Rosa, Calif), eight Excluder (W. L. Gore and Associates, Flagstaff, Ariz), and four Zenith (Cook Medical, Bloomington, Ind) devices were used. Mean length of stay was 2.3 days (range, 1-6 days). No major perioperative complications or deaths occurred. During a mean follow-up of 28.2 months (range, 1-86 months), there was 100% primary patency of successfully recanalized iliac arteries. Aneurysm sac size decreased from a mean of 5.1 cm (range, 3.1-7.6 cm) preoperatively to 4.4 cm (range, 2.8-7.1 cm) at follow-up. No aneurysms grew or ruptured. Three type II endoleaks occurred, one of which required coiling at 15 months. Two late deaths occurred: one at 36 months secondary to complications from a coronary artery bypass graft/mitral valve replacement and one at 34 months from a myocardial infarction. Conclusions: The use of bifurcated endovascular devices after recanalization of an occluded iliac system is technically feasible and durable at midterm follow-up. This technique re-establishes aortoiliac inflow to both lower extremities, obviates the need for extra-anatomic bypass, and may preserve hypogastric perfusion in some patients. [Copyright &y& Elsevier]

Spontaneous superior mesenteric artery dissection is rare and presents with variable symptomatology. Optimal treatment depends on the presentation; asymptomatic patients can be managed expectantly. Endoluminal intervention or open reconstruction is warranted in patients with persistent symptoms or intestinal ischemia. As more of these patients are identified with increasing utilization of computed tomography (CT), our understanding of the pathophysiology and best treatment will improve. [ABSTRACT FROM PUBLISHER]

Gluteal aneurysms are rare entity, whose surgical or endovascular management is traditionally challenging. Infectious source being increasingly more common as the underlying etiology. We herein describe successful implementation of direct thrombin injection as another therapeutic option for these patients. [ABSTRACT FROM PUBLISHER]

Purpose: Prior studies have demonstrated higher in-hospital mortality in women undergoing open abdominal aortic aneurysm repair. The current study evaluates the relationship between gender and 30-day outcomes for endovascular aneurysm repair (EVAR) in a multicenter, contemporary patient population. Methods: Patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant use file that underwent EVAR of abdominal aortic aneurysm (AAA) from 2005 to 2007 were identified by CPT codes. Outcomes analyzed were 30-day mortality, morbidity (one or more of 21 complications defined by the ACS NSQIP protocol), length of hospital stay, and six complication subgroups. Preoperative risk factors, intraoperative variables, and outcomes were compared across genders using χ2 (binary and categorical variables) and t tests (continuous variables). The relationship of gender to outcomes was further evaluated using multivariate logistic regressions to adjust for pre- and intraoperative risk variables. Results: In 3662 EVAR patients, 647 (17.7%) were women and 3015 (82.3%) men with mean ages of 75.1 ± 9.0 and 73.7 ± 8.5 years (P < .001). Tube graft (360, 9.8%); bifurcated, one docking limb (1624, 44.3%); bifurcated, two docking limbs (1294, 35.3%); unibody (218, 5.9%); and aorto-uni-iliac/femoral (166, 4.4%) repairs were performed. Tube and aorto-uni-iliac/femoral grafts were more common in women (21.4% vs 12.8%, P < .001) than men, as were femoral/femoral crossovers (3.9% vs 1.8%, P = .011) and iliac or brachial exposures (2.8% vs 1.0%, P = .009). Overall morbidity and mortality were 11.9% and 2.1%, respectively. Mortality in women was significantly higher (3.4% vs 2.1%, P = .014), as was morbidity (17.8% vs 10.6%, P < .001). Of thirteen independent preoperative risk factors for mortality or morbidity, women had a higher incidence in five: emergent operation, functional dependence, recent weight loss, underweight status or morbid obesity, and severe chronic obstructive pulmonary disease (COPD). After adjustment for these variables, the odds ratio (OR) for mortality in women vs men was 1.52 (95% confidence interval [CI] 0.85-2.69, P = .157); OR for morbidity was 1.65 (95% CI 1.28-2.14, P < .001). Female gender was also found to be an independent risk factor for length of stay (Beta 0.7 days, 95% CI 0.2-1.2, P = .006), infectious complications (OR 1.49, 95% CI 1.10-2.03, P = .011), wound complications (OR 1.80, 95% CI 1.12-2.90, P = .015) and postoperative transfusion (OR 2.92, 95% CI 1.39-6.13, P = .002). Conclusions: Mortality and morbidity were higher in women than men undergoing EVAR. Multivariate analysis showed that the increased risk of mortality was related to women presenting more emergently, more debilitated (recent weight loss and functional dependence), and requiring iliac or brachial exposure. After adjustment for multiple preoperative and operative factors, women remained at significantly higher risk for the development of a broad range of complications and increased length of stay. [Copyright &y& Elsevier]