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

Purpose: Embolic events during carotid angioplasty are a challenging problem. This experimental study was undertaken to determine the embolic risk after each stage of carotid angioplasty procedure. Methods: Five ex vivo carotid artery balloon angioplasties were performed on fresh carotid specimens. The carotid specimens were obtained from five patients who underwent an internal carotid artery bypass for stenosis >75%. Before the endovascular maneuvers and after each stage of the procedures, the specimens were flushed with 20 mL of saline solution. Small particulate emboli (diameter

Purpose : The purposes of this study were to prove the efficacy of cryopreserved aortic allografts to treat an established vascular graft infection by in situ replacement in an animal model and to evaluate the role of the antibiotics normally used to decontaminate the allografts. Methods : Twenty-three dogs underwent infrarenal aortic replacement with a gelatin-sealed knitted polyester graft contaminated in vitro by staphylococcus epidermidis RP-62. One week later, the 18 surviving animals underwent reoperation for graft removal and were randomized into three groups for in situ replacement: group I (control, n = 6) received a new gelatin-sealed graft; group II ( n = 6) received a non–antibiotic-treated cryopreserved allograft; and group III ( n = 6) received an antibiotic-treated cryopreserved allograft. Control grafts and allografts were removed 4 weeks after the initial intervention for quantitative bacteriologic analysis and histologic analysis. Bacteriologic results were expressed as colony-forming units per square centimeter of graft material. Qualitative bacteriologic analysis was also obtained from perigraft fluid and tissue. Results : All of the initially implanted grafts and all of the control grafts (group I) were infected at the time of removal. In group II, three out of six allografts were not totally incorporated, whereas in group III incorporation was always complete, with a significantly decreased inflammatory reaction. All of the antibiotic-treated allografts were sterile, whereas three untreated allografts grew bacteria. Conclusions : In this model, cryopreserved aortic allografts were more resistant to reinfection than synthetic grafts after in situ replacement of an infected prosthetic graft. However, the antibiotic loading of the cryopreserved aortic allograft appears to be essential to obtain optimal therapeutic effects. (J Vasc Surg 1998;27:689-98.)

We report two cases in which concurrent abdominal aortic aneurysm and colon carcinoma were treated in the same surgical procedure. In the first case both lesions were detected preoperatively but were uncomplicated. Single-stage treatment was undertaken electively. In the second case the colonic lesion was found during treatment of the aneurysm and both lesions were complicated. The decision to undertake single-stage treatment was made intraoperatively. Recovery was uneventful in both cases. Based on previous case reports and our experience in these two patients, we discuss the advantages and disadvantages of single-stage management. The principal risk is prosthetic infection. The advantages include avoidance of complications of the unoperated lesion and the ability to manage both lesions with only one operation. With a two-staged approach, complications following the first procedure and/or progression of the unoperated lesion may prohibit the second procedure. Despite the successful outcome in our patients, we recommend using single-stage management only in selected cases.

In this report we describe the use of an indwelling stent for end-to-end anastomosis of an arterial prosthesis. Designed as an alternative to conventional suturing in patients with heavily calcified arteries, this stent-anastomosis technique was developed by preliminary experimental study using arteries harvested from human cadavers. After the prosthesis is introduced into the artery, an angioplasty balloon catheter is inflated to expand the Palmaz stent and press the prosthesis against the calcified wall of the popliteal artery. From January 1993 to February 1994 we used this technique for end-to-end anastomosis of a polytetrafluoroethylene graft on the popliteal artery in six patients with extensive circumferential calcification of the popliteal artery. In all patients surgery was indicated to avoid amputation and no other method was suitable (no available vein graft, poor runoff). Stent anastomosis was successful in all six patients with no postoperative complications. lntraoperative controls using arteriography and angioscopy and postoperative Doppler ultrasound studies were normal in all patients. During follow-up, graft occlusion occurred in two patients at 10 and 14 months, respectively. Three patients died after control studies at 2, 6, and 8 months had shown the grafts to be patent. No false aneurysms were detected by clinical examination or ultrasound imaging. Although our data do not allow assessment of long-term outcome, this study demonstrates the feasibility of stent anastomosis in patients with extensive, circumferential calcification of the popliteal artery.

Adrenal hemorrhagic necrosis is one of several possible complications of heparin-related thrombocytopenia. We report a case in which adrenal hemorrhagic necrosis developed after aortofemoral bypass. This serious complication remains difficult to diagnose in the absence of a high index of suspicion. A routine search for this condition in the setting of heparin-related thrombocytopenia is essential since a favorable outcome is dependent on early diagnosis.

Purpose This report presents our experience with open repair of post-traumatic aneurysms of the aortic isthmus using recent surgical techniques, including distal aortic perfusion and the preferential use of direct aortoaortic anastomosis without interposition of prosthetic material. Methods From 1990 to 2004, the senior author (EK) patients (21 men; mean age, 40.3 years) who presented with post-traumatic aneurysms of the aortic isthmus were treated operatively, either with (20 patients) or without (3 patients) distal aortic perfusion, or endovascularly with a stent graft (3 patients). In 15 (75 %) of the 20 patients treated with distal aortic perfusion, the technique consisted of resection followed by direct aortoaortic anastomosis. Eight patients, including the three patients treated with simple clamping, had prosthetic replacement. Results No postoperative deaths or permanent spinal cord complications occurred. One patient required reoperation to control hemorrhage. Aortography or computed tomography angiography was performed on 12 of the 15 patients treated by direct aortoaortic anastomosis, with a mean follow-up of 58.7 ± 8.9 months. No morphologic abnormality was found. Conclusion This study shows that low-risk patients with a chronic post-traumatic aneurysm of the aortic isthmus can be successfully treated with excellent long-term results by resection and direct aortoaortic anastomosis without prosthetic interposition. In our opinion, endovascular repair should only be used in patients who present with absolute contraindications for open surgical repair.