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Aortic remodeling after dissection is poorly understood and remains a focus of current research. In the present report, we have described the cases of two patients with acute lower extremity ischemia related to malperfusion from aortic dissection treated with extra-anatomic axillobifemoral bypass. During long-term follow-up, aortic remodeling led to reinstitution of flow through the native aorta. This resulted in competitive flow, leading to complete thrombosis of the extra-anatomic conduits. These cases highlight the occurrence of spontaneous aortic recanalization and subsequent competitive flow, two vascular phenomena that are not well understood but can significantly affect patient outcomes.

Objectives Chronic total occlusion (CTO) of the EVAR graft is a rare and serious complication. Traditionally, surgical intervention with prosthetic graft replacement or bypass graft implantation is performed. However, there are limited data in endovascular era. Methods We present a case of a 68-year-old male with a history of late EVAR graft occlusion treated with multiple surgical interventions (femorofemoral crossover, extra-anatomic bypass surgery, and thrombectomy) five years ago. Color Doppler ultrasound (CDUS) and computed tomography (CT) angiography revealed thrombosis of the entire bypass graft. Endovascular recanalization and remodeling of the abdominal stent graft CTO was performed with a combination of bare stents and stent grafts. Rupture of the stent graft occurred on the right limb. A second covered stent was placed. Results At 12-month follow-up, the patient was symptom free. Color Doppler ultrasound surveillance showed patent aortic stent graft and downstream arteries. Conclusions Endovascular recanalization of aortic stent graft CTO is a viable option in patients with failed bypass graft.

Lung autotransplantation can be a surgical alternative to gain access to the posterior mediastinum and the thoracic portion of the descending aorta through a sternotomy. We present a case of hemoptysis and bronchial obstruction due to a presumed infected aortobronchial fistula, secondary to stent graft placement in a patient with multiple previous surgeries for aortic coarctation, treated with lung autotransplantation and an extra-anatomic bypass.

Surgical correction of aortic coarctation (CoA) has been the standard treatment in infants and adolescents to prevent late consequences related to obstruction and distal hypoperfusion. Several surgical techniques for CoA repair have traditionally been applied. However, late complications, including re-CoA and pseudoaneurysm formation, are not uncommon. The incidence of complications is highly related to the type of initial surgery. Here, we are reporting two cases of late complications related to an infrequently used surgical technique, the extra-anatomical aortic bypass graft (EABG). The first case presented with pseudoaneurysm at the distal anastomosis site with the descending aorta and treated by endovascular stent graft. The second case presented with stenosis at the proximal anastomosis site with the left subclavian artery (LSCA) and treated medically upon the request of the patient.

Aortoenteric fistula is a rare complication following endovascular abdominal aortic aneurysm repair. However, there is a significant morbidity and mortality associated with this complication. Patients can present with gastrointestinal hemorrhage, fever, or nonspecific features of chronic infection. Extra anatomic bypass with complete graft explanation is the standard management.

Objective: Abdominal aortic graft and endograft infection (AGI) is primarily treated by resection of the infected graft and restoration of distal perfusion through extra-anatomic bypass (EAB) or in situ reconstruction/repair (ISR). The aim of this study was to compare these surgical strategies in a nationwide multicentre retrospective cohort study. Methods: The Swedish Vascular Registry (Swedvasc) was used to identify surgically treated abdominal AGIs in Sweden between January 1995 andMay 2017. The primary aimwas to compare short and long termsurvival, as well as complications for EAB and ISR. Results: Some 126 radically surgically treated AGI patients were identified - 102 graft infections and 24 endograft infections - treated by EAB: 71 and ISR: 55 (23 neo-aorto-iliac systems, NAISs). No differences in early 30 day (EAB 81.7% vs. ISR 76.4%, p = .46), or long term five year survival (48.2% vs. 49.9%, p = .87) were identified. There was no survival difference comparing NAIS to other ISR strategies. The frequency of recurrent graft infection during follow up was similar: EAB 20.3% vs. ISR 17.0% (p = .56). Survival and re-infection rates of the new conduit did not differ between NAIS and other ISR strategies. Age >= 75 years (odds ratio [OR] 4.0, confidence interval [CI] 1.1 - 14.8), coronary artery disease (OR 4.2, CI 1.2 - 15.1) and post-operative circulatory complications (OR 5.2, CI 1.2 - 22.5) were associated with early death. Prolonged antimicrobial therapy (> 3 months) was associated with reduced long term mortality (HR 0.3, CI 0.1 - 0.9). Conclusion: In this nationwide multicentre study comparing outcomes of radically treated AGI, no differences in survival or re-infection rate could be identified comparing EAB and ISR.

Acute aortic dissection type A with subtotal or total occlusion of one carotid artery is a complex situation. An additional extra-anatomic carotid artery bypass can restore carotid artery perfusion after standard emergency surgery with aortic replacement.

Objectives Aortobronchial fistula (ABF) is rare but lethal condition if left untreated, and the treatment still remains challenging. We retrospectively reviewed data at our Institution and report our experience in the management of ABF. Methods From September 2010 to May 2019, 14 patients (13 men, average age 52 ± 11 years) with ABF were treated in our hospital. Three types of management were applied according to the patients' different clinical presentation, including conservative treatment, that is, antibiotic treatment (n = 3), endovascular repair (n = 7), and open surgery (n = 4). In the open surgery group, Dacron grafts were used, two cases received in situ descending thoracic aortic replacement through left thoracotomy and two cases received extra-anatomic bypass through median thoracoabdominal incision. Results In the conservative treatment group (n = 3), two patients died during follow-up, the third was alive in good condition. In the endovascular repair group (n = 7), one patient died 22 days after the endovascular repair because of massive hemoptysis and another patient died 4 days after the procedure because of cerebral infarction. In the medium term, two patients died of massive hemoptysis, and one was lost at follow-up. In the open surgery group (n = 4), one patient died because of massive hemoptysis 2 days after his extra-anatomic bypass procedure, the remaining patients were alive in good condition at follow-up. Conclusions ABF is catastrophic if left untreated. Endovascular repair might be a reasonable temporary bridge solution in emergency cases, but is less durable in the long run. Open surgery, despite more challenging, provides a more definitive treatment for ABF.

Destructive infections of the aortic arch and great vessels are challenging to manage. We describe a novel technique for debranching the right cerebral and upper extremity arteries via composite extra-anatomic bypasses from the femoral artery, with subsequent homograft in-line reconstruction of the arch, in a patient with Staphylococcus sepsis and necrosis of the arch and great vessels.

Background Extra-anatomic bypass (EAB) remains a viable alternative for lower limb revascularization if aorto-bifemoral bypass and endovascular therapy are contraindicated. Among EAB, perigraft seroma (PS) occurs in about 4% of cases. Diagnostic and therapeutic management, as well as standardized treatment paradigm, are still not well defined. The aim of this study is to report 5 PS cases in EAB and to review the literature about similar cases. Methods We retrospectively reviewed EAB performed during the period 2002–2015. Among these, PS cases were analyzed. A similar description for all cases found in the literature through research on the major international databases (PubMed, Scopus, EMBASE) was conducted. Results During the study period, 797 bypasses—528 (66.3%) anatomical and 269 (33.7%) extra-anatomical—were performed. Among the latter, 169 femoro-femoral (FF), 20 axillo-femoral (AXF), 22 axillo-bifemoral (AxBF), and 58 aortouni-iliac endoprosthesis (AUI) + FF bypasses were performed. Five cases (1.86%) of PS in EAB population were detected: 3 after AxBF and 2 after AUI + FF. Although we initially preferred percutaneous drainage, a surgical choice with graft explant and replacement were imposed by the high recurrence rate. Literature analysis identified 20 additional cases (11 after AxBF, 7 after AXF and one after AUI + FF). Conclusions Our case series and the literature confirm that the most widely used therapy is the surgical drainage with primary or secondary replacement of the graft of a different material. Percutaneous drainage has proved to be ineffective because not conclusive and potential to increase risk of graft infection. Careful follow-up, even years after surgery, remains necessary for PS diagnosis and management, to prevent complications and potential infection.

Background and Objectives Coarctation of the aorta in adulthood is generally associated with other cardiovascular disorders requiring surgical management. An extra anatomic bypass grafting from the ascending to descending aorta by posterior pericardial approach via median sternotomy could be a reasonable single stage surgical strategy for these patients. Subjects and Methods Seven male patients aged between 14-41 years underwent an extra anatomic bypass grafting for coarctation repair concomitantly with the surgical management of the associated cardiovascular disorders via median sternotomy. Preoperative mean systolic arterial blood pressure was 161.8±24.5 mmHg, although the patients were under treatment of different combinations of antihypertensive agents. Additional surgical procedures were: aortic valve replacement (n=4), ventricular septal defect (VSD) closure (n=2), ascending aortic replacement (n=3) and Bentall procedure (n=1). None of our patients have been previously diagnosed or operated on for coarctation. Data were evaluated during their hospital stay and in post-operative follow-up. Results The post-operative course was uneventful in all but one patient was re-operated on due to bleeding. There was neither mortality nor significant morbidity during the in-hospital period and all patients were discharged within 5-9 (mean: 6.3±1.5) days. The mean follow up period was 71.83±23 months (range: 23-95 months). Unfortunately one of our patients could not be contacted for a follow up period because of invalid personal data. Conclusion Coarctation of the aorta in adulthood associated with other cardiovascular disorders can be operated on simultaneously via an extra anatomic bypass grafting technique with low morbidity and mortality.

The treatment of choice for aortic coarctation in adults remains open surgical repair. Aortobronchial fistula is a rare but potentially fatal late sequela of surgical correction of isthmic aortic coarctation via the interposition of a graft.The endovascular treatment of aortobronchial fistula is still under discussion because of its high risk for infection, especially if the patient has a history of cardiovascular prosthetic implantation. Patients need close monitoring, most notably those with secondary aortobronchial fistula. We discuss the case of a 65-year-old man who presented with the combined conditions, and we briefly review the relevant medical literature.

Background: Aortic occlusion is rare catastophic pathology with high rates of mortality and severe morbidity. In this study, we aimed to share our experience in the management of aortic occlusion and to assess the outcomes of extra-anatomic bypass procedures. Methods: Eighteen patients who had undergone extra-anatomic bypass interventions in the cardiovascular surgery department of our tertiary care center between July 2009 and May 2013 were retrospectively evaluated. All patients were preoperatively assessed with angiograms (conventional, computed tomography, or magnetic resonance angiography) and Doppler ultrasonography. Operations consisted of bilateral femoral thromboembolectomy, axillo-bifemoral extra-anatomic bypass and femoropopliteal bypass and were performed on an emergency basis. Results: In all patients during early postoperative period successful revascularization outcomes were obtained; however, one of these operated patients died on the 10th postoperative due to multiorgan failure. The patients were followed up for a mean duration of 21.2±9.4 months (range, 6 to 36 months). Amputation was not warranted for any patient during postoperative follow-up.. Conclusion: To conclude, acute aortic occlusion is a rare but devastating event and is linked with substantial morbidity and mortality in spite of the recent advances in critical care and vascular surgery. Our results have shown that these hazardous outcomes may be minimized and better rates of graft patency may be achieved with extra-anatomic bypass techniques tailored according to the patient.

Extra-anatomic revascularizations of intra-abdominal or lower limbs arteries, or both, are indicated (1) when the aorta is unsuitable for anatomic bypasses, (2) in patients unfit for aortic surgery, (3) for graft infections, and (4) for visceral debranching during hybrid treatment of a thoracoabdominal aneurysm. We describe a new extra-anatomic bypass from the brachiocephalic artery with video-guided retrosternal tunneling. We discuss the advantages and drawbacks of this technique.

We encountered an informative case of infected aortic arch aneurysm. The proximal descending aorta, left common carotid artery, and left subclavian artery were severely involved in an abscess; thus, typical in situ reconstruction of the arch was considered impossible. Therefore, to secure more distal branches appropriate for anastomosis, a modified extra-anatomic arch repair was performed through additional incisions. The patient developed renal and respiratory failure and died of septicemia five and a half months after the operation. However, postoperative computed tomograms demonstrated that the abscess had disappeared.

Interrupted aortic arch is a very rare but well-described congenital anomaly. Concomitant presentation of interrupted aortic arch and giant subclavian artery aneurysm is an unusual event in adulthood. To the best of our knowledge, hybrid intervention for type A aortic arch interruption with a giant aneurysm of the subclavian artery is an alternative approach for the management of these concomitant pathologies in adults.

A 40-year-old man was transferred from a rural hospital with symptoms of multiorgan failure. Before admission, his antihypertensive medication had been intensified because of arterial blood pressures up to 240/120 mm Hg, which resulted in an apparently normotensive situation, measured at the right arm. At our hospital, we performed computed tomography angiography to exclude an aortic dissection (Figure 1A). We found an impressive aortic coarctation (Figure 1A, red arrow), obviously responsible for the multiorgan malperfusion, accompanied by a 5.3-cm aneurysm …

Mycotic aneurysm is a disease requiring immediate treatment because of the high risk of rupture. A difficult surgical approach, especially in the case of occurrence on the iliac artery, involving endovascular embolization and extra-anatomic bypass grafting, is known to be a suitable treatment. We performed extra-anatomic bypass grafting after endovascular embolization successfully in two patients. The postoperative computed tomography of both patients showed complete exclusion of the mycotic aneurysm.

The authors describe the operative technique approach and its post-operative course used in an adult patient with coarctation of aorta, in which it was not possible to perform the traditional correction with an end-to-end anastomosis with graft interposition. During the surgery it was necessary to make an extra-anatomic bypass: ascending-descending aorta with an enlarged left posterior-lateral thoracotomy approach. The authors also make a short review of several possible approaches used for extra-anatomic bypass as well as its advantages and drawbacks.

Key Clinical Message Explantation of an infected patent vascular graft does not necessarily require concomitant revascularization procedures. The need for revascularization can be determined by a trial cross‐clamping of the graft and clinical assessment of limb perfusion. We report a case of an infected axillofemoral graft transgressing the chest wall in a surgically high risk patient.

感染性大動脈瘤は比較的稀な疾患ではあるが致死率が高く,適切な術式選択が必要であることに加え,その血行再建法の選択には未だ議論の多いところである.今回われわれは,既存の腹部大動脈瘤へ化膿性脊椎炎が波及し,瘤径の急速な拡大をきたした症例に対し,非解剖学的バイパス術 (extra-anatomic bypass: EAB) を施行,良好な結果を得たので報告する.症例は69歳男性,腹部大動脈瘤のフォローアップ中腰痛,熱発を主訴に近医受診.施行されたCTにて腹部大動脈瘤後面の化膿性脊椎炎と,瘤径の急速な拡大を呈し,腰痛症状も持続していた為,血液検査上の炎症所見の鎮静化を待たずして手術を施行.手術はaxillo-bifemoral bypassを施行した後,腹部大動脈瘤切除術に加え,後腹膜に大網を充填した.術後経過は良好で炎症所見は順調に低下,神経学的異常は認められなかった.

Primary infection of aorta, in absence of atherosclerosis, leading to aneurysm formation occurs in

A previously described but rarely used surgical technique for the repair of complex or recurrent coarctation of the aorta through a right thoracotomy approach is presented in detail. It has the advantages of being simple and avoiding left chest re-entry, median sternotomy and cardiopulmonary bypass altogether.

Axillofemoral bypass operation is an alternative approach for patients at high risk for aortofemoral reconstruction and for patients with comorbid factors. Proximal anastomotic disruption, upper extremity thromboembolism, graft infection and seroma formation are known postoperative complications after axillofemoral bypass. Proximal anastomotic disruption is a severe complication in the early postoperative period and is usually secondary to technical errors in anastomosis, mechanical distress and infections. We performed a left axillofemoral bypass and left femoropopliteal bypass operation under general anesthesia by using an 8 mm full ringed polytetrafluoroethylene graft. On the seventh postoperative day, patient complained a sudden pain and swelling on left subclavian incision after a hyperabduction of the left arm. Patient was taken into operation theatre just after this complaint for suspicion of disruption of the proximal anastomosis. We report a case with proximal anastomotic disruption after axillofemoral bypass operation in accordance with literature data.

Extra-anatomic bypass grafts have been used to treat complex and recurrent forms of coarctation of the aorta. Here we describe the use of an extra-anatomic bypass graft from the ascending to supraceliac aorta to treat an unusual complication of compression of mediastinal structures caused by a bucket handle graft.

腋窩松葉杖による慢性的圧迫が上腕動脈の損傷・閉塞の原因となることがある.症例は63歳,男性で,乳児期のポリオ後遺症により両下肢の麻痺・脱力を伴い,生来腋窩松葉杖を使用.右上肢の脱力・冷感・しびれをきたし来院.松葉杖による圧迫のため腋窩動脈の慢性閉塞をきたし,末梢側に二次血栓を伴ったものと診断された.松葉杖による圧迫を避けるため非解剖学的経路による鎖骨下動脈-上腕動脈バイパス術を施行した.

Recently the extra-anatomic bypass operation has been increasingly performed for high risk cases having a chronic aortoiliac occlusive disease. In this study twenty-eight consecutive patients undergoing extra-anatomic bypass for chronic aortoiliac occlusive disease were reviewed. Of the twenty-eight patients twelve underwent femorofemoral (F-F) bypass and sixteen underwent axillo-femoral (Ax-F) bypass. There were no perioperative deaths in either group. Overall, graft patency at 5th year after F-F bypass or Ax-F bypass was 71.1±18% and 85.9±9.3%, respectively. Five-year survival rate after F-F bypass or Ax-F bypass was 91.0±8.7% or 57.8±13.3%, respectively. Analysis of the early and late results of extra-anatomic bypass confirms the safety and effectiveness of this procedure, but further studies would be mandatory for its operative indication.

出版社版, 1976年11月から1991年12月までに施行した下肢閉塞性動脈硬化症に対するEAB症例は100例165肢である。術式は腋窩-大腿動脈バイパス(Ax-F)26例,大腿-大腿動脈バイパス(F-F)27例,大動脈-大腿-大腿動脈バイパス(Ao-F-F)47例である。5年一次累積開存率および生存率は,Ax-F 64.4%・20.8%,F-F 65.9%・51.1%,Ao-F-F 96.5%・70.4%であり,Ao-F-Fでは標準術式と遜色ない良好な結果が得られているが,Ax-F,F-Fでの遠隔成績はAo-F-Fに比較し有意に不良であった。腹腔内感染症,腹部手術の既往歴などの局所的要因は別としてEABの適応は主として高齢者high riskのlimb salvage症例であるのはいうまでもないが,Ax-F,F-F術式は,自力歩行に対する意欲のない生活活動性のきわめて低い例に限定すべきである

In this retrospective study, 21 patients requiring treatment for primary infection of an aortic prosthesis between 1981 and 1991 were identified from a prospective register. Ten of the 21 patients had had additional peripheral reconstructive vascular surgery before the diagnosis of aortic graft infection. The median interval between aortic graft insertion and diagnosis of graft infection was 16 months (range 1–84). Infected grafts were removed and an extra-anatomic bypass constructed in all patients. All but three patients had axillodistal reconstruction. Six patients had simultaneous operations, whilst the other 15 patients had a staged procedure with extra-anatomic reconstruction preceding graft removal. Two patients died before discharge from the hospital (9.5%). No patient required extremity amputation in the perioperative period. By life-table analysis patient survival (including perioperative deaths) was 80% at 1 year, 55% at 3 years and 40% at 5 years. Primary graft patency was 62% at 1 year, 51% at 3 years and 40% at 5 years. Limb salvage rate was 89% at 1 year, 63% at 3 years and 63% at 5 years. The median length of follow-up was 24 months. Extra-anatomic reconstruction in patients with aortic graft infection can be performed with low perioperative mortality. Limb salvage rates following extra-anatomic reconstruction are determined not only by the mode of reconstruction, but also by the primary disease.

Aortic arch pathology requiring surgery most often affects elderly patients with multiple co-morbidities and represents a significant challenge to both patient and surgeon. This case report describes the repair of an 8.2 cm aortic arch aneurysm arising at the origin of the left subclavian artery using a combined endovascular and open surgical approach. Hybrid techniques allow for the treatment of pathology that would otherwise not be amenable to surgery.

Arterial injuries are best treated by primary repair or anatomically placed interposition grafts. Occasionally, these repairs fail due to adverse local factors, such as soft-tissue infection or enteric contamination. In these instances, limb salvage may require extra-anatomic arterial reconstruction. Between 1979 and 1989, 13 extra-anatomic bypasses were performed in ten male patients following nine failed primary repairs and one ligation of a traumatic arterial injury. The sites of arterial injury were: aorta (two), iliac (five), femoral (two), popliteal (one). Enteric contamination was present at initial operation in six patients; the remaining four had sustained massive soft-tissue injury. Reoperation was required for hemorrhage (seven), pseudoaneurysm (two), and arteriovenous fistula (one). All patients had developed local wound problems that militated against another anatomic repair. Extra-anatomic bypasses performed were: axillo-femoral (three), femoro-femoral (four), obturator (one), and two extra-anatomic femoral to popliteal saphenous vein grafts routed around an infected field. A second extra-anatomic reconstruction was performed for recurrent hemorrhage in three patients, (axillo-femoral--two, obturator--one). One patient with a neuropathic extremity and a functioning graft underwent amputation at 2 months following the initial injury. Two patients died of systemic sepsis. Seven patients (70%) have functional extremities with intact pulses at 2 to 24 months post bypass (mean, 7 months). Limb salvage after secondary disruption of secondarily infected arterial repairs can be achieved by appropriate extra-anatomic arterial reconstruction. In such cases, limb loss is due to soft-tissue sepsis or neuro-skeletal injuries and not vascular insufficiency.