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We present a case report of a bifurcated aorto-iliac stent graft infection two years after implantation. The initial procedure of implantation as well as the patient's recovery was uneventful. Two years later the patient presented with a growing aneurysmal sac without a detectable endoleak and consequent rupture. Instead of graft explantation, we left the graft in situ and performed thorough debridement and an omentoplasty, because of the poor condition of the patient. A Staphylococcus species grew out of the cultures of the aortic wall. The patient recovered well without persistent infection and is still doing well after 43 months. This conservative approach might be an alternative in patients who are deemed to be at high risk for classic graft explantation and an extra-anatomic bypass or in situ bypass.

Purpose To assess the safety, feasibility, and effectiveness of coil embolization of the proximal internal iliac artery (IIA) before stent-graft extension in patients previously treated by endovascular aortic repair (EVAR). Materials and Methods Over a period of 9 years, 16 ipsilateral, proximal IIA coil embolization procedures were performed before stent-graft extension in 13 patients previously treated by a modular aortic stent graft. Indication for coil embolization and concomitant stent-graft extension were secondary (ie, late) distal type I endoleak ( n = 9) and late onset of an isolated common iliac artery aneurysm ( n = 7) as a result of increasing dilation of a common iliac artery during follow-up after EVAR; mean common iliac artery diameter before coil embolization was 26.1 mm (range, 15–35 mm). Clinical and radiologic follow-up (mean, 39 months; range, 6–102 months) was done in accordance with an established registry. Results All procedures were successful except for one performed with 0.035-inch coils. Clinically, buttock claudication was noted in five of 13 patients (38%). No type II endoleak occurred through the coil-embolized internal iliac arteries. The mean common iliac artery diameter at 6-month follow-up was 23.0 mm (range, 14–30 mm; P = .0005). Conclusions Ipsilateral coil or microcoil embolization of the proximal IIA before stent-graft extension in patients previously treated by an aortic stent graft seems to be safe and feasible, with favorable outcomes after a mean follow-up of 39 months.

Objective Many patients with peripheral arterial occlusive disease who require a lower-limb bypass have no available autologous saphenous vein (ASV) for the procedure and thus require a prosthetic graft. Expanded polytetrafluoroethylene (ePTFE) grafts are commonly used, but results with these prostheses have varied, especially when the distal anastomosis is below the knee. However, there is increasing evidence that ePTFE grafts to which heparin has been bound with use of covalent endpoint linkage provide better results. This nonrandomized study compared the performance of these grafts with that of ASV conduits in the largest clinical series of heparin-bonded ePTFE graft implantations reported so far. Methods The records of 350 patients who underwent a lower-limb bypass procedure that used either a heparin-bonded ePTFE graft (n = 240) or an ASV graft (n = 110) were reviewed, and preoperative, operative, and follow-up data were recorded. Kaplan-Meier analyses were used to calculate primary patency and limb salvage rates in the two graft groups; results were compared by using log-rank testing. Results The primary patency rates at 1 year for the heparin-bonded ePTFE grafts were 92% for above-knee femoropopliteal (AK FP) bypasses, 92% for below-knee femoropopliteal (BK FP) bypasses, and 79% for femorocrural (FC) applications. The corresponding 2-year rates were 83%, 83%, and 69%, respectively. In the ASV group, the 1-year primary patency rates for AK FP, BK FP, and FC bypasses were 91%, 72%, and 69%, respectively; the 2-year rates were 80%, 72%, and 64%, respectively. There were no significant differences in patency when AK FP, BK FP, or FC procedures were considered separately. Two-year limb salvage rates in the heparin-bonded ePTFE graft group were 92%, 98%, and 87%, respectively, for AK FP, BK FP, and FC bypasses; in the ASV group, the rates were 100%, 91%, and 96%, respectively. Two infections occurred in patients given a heparin-bonded ePTFE graft. Conclusion In this large retrospective study, heparin-bonded ePTFE grafts had 1- and 2-year primary patency results that were not significantly different from those for ASV grafts. Results in BK FP and FC applications were especially promising. Randomized studies comparing the use of heparin-bonded ePTFE and ASV grafts in the treatment of peripheral arterial disease are needed to substantiate our results.

Le traitement actuel de l'occlusion aigue des pontages sous-inguinaux consiste an une revascularisation chirurgicale ou une thrombolyse intra-arterielle guidee par catheter avec correction de la lesion sous-jacente. Pour maintenir la permeabilite a long terme, l'amelioration du nombre d'arteres d'aval peut etre tres importante. Pour comparer l'efficacite de la thrombolyse et de la revascularisation chirurgicale primaire et etudier l'effet de la thrombolyse sur le nombre d'arteres d'aval permeables, une etude non randomisee prospective a ete realisee. Entre fevrier 2002 et aout 2003, 54 patients presentant 56 occlusions de pontages etaient inclus. Trente pontages ont ete traites par thrombolyse, 26 par chirurgie. La thrombolyse etait reussie dans 80% des cas, avec une restauration de la permeabilite du pontage mais egalement avec un doublement de la quantite d'arteres d'aval permeables ; la chirurgie etait reussie dans 85,71% des cas. Cependant, dans seulement 60% des pontages lyses avec succes aucune chirurgie principale additionnelle n'etait necessaire. La survie sans amputation etait de 87,5% 1 ans apres la chirurgie et de 82,6% 1 ans apres thrombolyse. Un an apres la thrombolyse sans chirurgie principale associee, la survie sans amputation n'etait que de 39,7%. Par consequent, une strategie pourrait etre de commencer par la thrombolyse pour ameliorer le lit d'aval, suivie d'un nouveau pontage, quelle que soit la lesion causale.

El tratamiento actual de las oclusiones agudas de las derivaciones infrainguinales consiste en la revascularizacion quirurgica o en la trombolisis intraarterial guiada con cateter mas la correccion adyuvante de la lesion subyacente limitante de flujo. Aumentar el numero de vasos eferentes puede ser de importancia primordial para mantener la permeabilidad a largo plazo. Se realizo un estudio prospectivo, con asignacion no aleatoria, para comparar la eficiencia tanto de la trombolisis como de la revascularizacion quirurgica primaria, y estudiar el efecto de la primera sobre el numero de vasos eferentes permeables. Se incluyeron 54 pacientes con 56 derivaciones ocluidas entre febrero de 2002 y agosto de 2003. Se trataron con trombolisis 30 derivaciones y 26 con cirugia primaria. La trombolisis presento un resultado satisfactorio en el 80% de los casos, con el restablecimiento de la permeabilidad del injerto pero tambien con la duplicacion del numero de vasos eferentes permeables; el tratamiento quirurgico resulto satisfactorio en el 85,71% de los casos. Sin embargo, tan solo en el 60% de los injertos de derivacion repermeabilizados mediante la trombolisis se pudo evitar la necesidad de cirugia mayor adyuvante. La supervivencia libre de amputacion a un ano despues de la cirugia fue del 87,5% y del 82,6% en el caso de la trombolisis. Despues de un ano de la practica de la trombolisis sin cirugia mayor adyuvante, la supervivencia libre de amputacion fue tan solo del 39,7%. Por consiguiente, una estrategia podria ser iniciar el tratamiento con trombolisis para mejorar el flujo eferente seguido de una nueva derivacion, con independencia de las lesiones causales subyacentes.

Purpose To assess the incidence and clinical significance of thrombotic, nonocclusive mural deposits in abdominal aortic stent-grafts incidentally found on follow-up computed tomography scans after endovascular aneurysm repair (EVAR). Materials and Methods Between 1998 and 2007, 288 patients underwent EVAR of an infrarenal aortic aneurysm. In the majority of cases, a Zenith stent-graft ( n = 187) or Excluder stent-graft ( n = 71) was implanted. Clinical and radiologic follow-up was performed prospectively according to the EUROSTAR registry, with mean follow-up periods of 4.69 and 5.05 years, respectively, for the Excluder and Zenith groups. Results Thrombotic deposits were found in 17% and 33% of patients in the Excluder and Zenith groups, respectively, which represents a significant difference ( P = .038). Clinically, no distal atheroembolic events were noted during follow-up, and there was no significant difference in survival between patients with and without thrombotic deposits ( P = .80). Conclusions Incidentally found thrombotic deposits in abdominal aortic endografts are common and device-specific, with a lower incidence in the Excluder group versus the Zenith group. These thrombotic deposits are clinically silent, do not require additional treatment at short-term and midterm follow-up, and do not affect the overall survival of the treated patients.

Purpose To assess the time period of onset, etiology, and outcomes of limb occlusion after endovascular repair of abdominal aortic aneurysms with supported endografts. Materials and Methods From 1998 to 2007, 288 patients underwent endovascular aneurysm repair (EVAR) to exclude an infrarenal aortic aneurysm. In the majority of patients, a Zenith stent-graft ( n = 187) or Excluder stent-graft ( n = 71) was implanted. Nine patients presented with limb occlusion during follow-up. All occluded stent-grafts were modular ( n = 8) or aortomonoiliac ( n = 1) Zenith endoprostheses. One additional patient who was previously treated with a Zenith aortomonoiliac stent-graft was referred to our institution for further treatment of stent-graft thrombosis. Results The initial clinical presentations were acute ischemia ( n = 5), buttock claudication ( n = 3), and incidental findings on follow-up imaging ( n = 2). Occlusion occurred within the first month after EVAR ( n = 5), between the first and second month after EVAR ( n = 2), 10 months after EVAR ( n = 1), and 4–5 years after EVAR ( n = 2). Underlying causes of occlusion were kinking of the stent-graft ( n = 5), small-diameter endograft limb with extension to the external iliac artery ( n = 3), and migration and dislocation of an endograft limb ( n = 2). Treatment consisted of catheter-directed thrombolysis and stent placement ( n = 3), surgical thrombectomy or bypass operation ( n = 5), and expectant management ( n = 2). Outcome of all revascularization procedures showed immediate clinical success in all patients and no late recurrent limb ischemia at a mean follow-up of 38.9 months. Conclusions Limb occlusion of aortic stent-grafts mostly occurs shortly after EVAR and can be related to underlying kinking of the metallic skeleton, extension of the stent-graft into the external iliac artery, or migration and dislocation of an endograft limb. Satisfactory and durable clinical outcomes can be obtained after appropriate revascularization.

Objectives Totally laparoscopic aortic surgery is appealing. However, the adoption of this technique in the broad vascular world is hampered by the steep learning curve and the fear of exposing patients to excessive morbidity and mortality. We assessed how many patients should be treated to overcome this learning curve. Materials and methods The first 50 patients treated with totally laparoscopic aortobifemoral bypass for severe aorto-iliac occlusive disease were followed prospectively. Operative variables such as operative time, aortic clamping time, amount of blood loss, conversion to laparotomy etc were recorded (as well as 30-day mortality and morbidity). To discover a turning point we used the technique of sliding averages. These data were compared with the mortality and morbidity as predicted by POSSUM and P-POSSUM. Results A clear turning point, with improved operative variables, was seen after 20–30 patients. Mortality and morbidity were not higher than predicted by POSSUM and P-POSSUM. Conclusions These data confirm the intuition of most people involved in laparoscopic aortic surgery that the learning curve could be set at 25–30 cases. However, patients are not exposed to excessive morbidity and mortality during this learning curve.

Endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA) involving the entire common iliac arteries requires proximal coil embolisation of both internal iliac arteries and extension of the stent graft into the external iliac arteries (type E according to the Eurostar classification). A potential complication of this treatment is pelvic ischemia. Therefore, this type of aneurysm is a relative contra-indication for EVAR. In this case-report we describe a hybrid procedure preserving antegrade circulation in one of the internal iliac arteries in a patient with a type E aneurysm who was unfit for open surgery.

We report a case of an unusual and late presentation of an asymptomatic contained rupture after modular stent-graft implantation to treat an aortobiiliac aneurysm. Follow-up computed tomography (CT) scans 4 and 5 years after endovascular aneurysm repair showed a homogeneous, nonenhancing, but clearly growing, pelvic collection. CT-guided drainage of the collection was performed, and cultures of the evacuated brown fluid were negative for any infection. Control CT scan after drainage showed a complete collapse of both the collection and the previously excluded iliac aneurysms. A direct communication between the sterile pelvic collection and the excluded iliac aneurysm was suggested on this CT imaging and confirmed afterwards by surgery. From these imaging and surgical findings, this pelvic collection can be considered as an atypical presentation of an asymptomatic contained rupture of the excluded aneurysm.

We report a case of translumbar embolization of an aortic pseudoaneurysm complicating lumbar disk surgery. The iatrogenic pseudoaneurysm was initially treated by open repair, but due to failure of this treatment, we opted for direct translumbar thrombin injection under computed tomography (CT) guidance. The patient recovered completely, and follow-up CT scans showed progressive shrinkage of the residual retroperitoneal hematoma. This minimally invasive treatment should be considered in selected cases as a valuable treatment option for pseudoaneurysms that arise from the aorta.

To report our experience with a combined endovascular and surgical approach for arterial thoracic outlet syndrome (TOS) complicated by an aneurysm of the subclavian artery.We treated three consecutive patients suffering from arterial thoracic outlet syndrome complicated by an aneurysm of the subclavian artery by the use of a stent-graft and a first rib resection. These patients were reviewed retrospectively.At a mean follow-up of 37.3 months all patients were free of symptoms without late complications.Endovascular stent-grafting followed by decompression of the costoclavicular space is an attractive alternative to the conventional surgical approach of complicated arterial TOS.

Fibromuscular dysplasia is a multifactorial arteriopathy most commonly affecting the renal and carotid arteries. In this report we present a case of visceral artery involvement, causing occlusion of the superior mesenteric artery and celiac trunk and resulting in visceral ischemia. Treatment consisted of superior mesenteric artery reimplantation. Visceral artery FMD can present as occlusive or aneurysmal disease and treatment depends on patient characteristics and symptoms.

In analogy with the good results of laparoscopic abdominal procedures minimal-access aortic surgery looks very promising. However, in spite of the many technical improvements that have already been made, totally laparoscopic and even laparoscopically assisted aortic surgery remains technically demanding. This explains the rather slow introduction of minimal-access aortic surgery in the vascular society. In anticipation of increasing surgical experience and better instrumentation that will make the technique feasible for each vascular surgeon, hand-assisted laparoscopy (HALS) can be a valuable intermediate approach. HALS offers an easy to perform and still clearly less invasive approach for all aorto-iliac reconstructions.

The purpose of this study was to evaluate the feasibility, safety and midterm outcome of elective implantation of the Carotid Wallstent in patients considered to be at high surgical risk. In a prospective study, 54 carotid artery stenoses in 51 patients were stented over a 24-month period. Three patients underwent bilateral carotid artery stenting. Institutional inclusion criteria for invasive treatment of carotid occlusive disease (carotid endarterectomy or carotid artery stenting) are patients presenting with a 70% or more symptomatic stenosis and those with an 80% or more asymptomatic stenosis having a life-expectancy of more than 1 year. All patients treated by carotid artery stenting were considered at high risk for carotid endarterectomy because of a hostile neck (17 patients--31.5%) or because of severe comorbidities (37 patients--68.5%). No cerebral protection device was used. Of the 54 lesions, 33 (61.1%) were symptomatic and 21 (38.8%) were asymptomatic. Follow-up was performed by physical examination and by duplex ultrasonography at 1 month, 6 months, 1 year and 2 years after the procedure. All 54 lesions could be stented successfully without periprocedural stroke. Advert events during follow-up (mean 13.9 +/- 5.7 months) were non-stroke-related death in 6 patients (11.1%), minor stroke in 4 stented hemispheres (7.4%), transient ipsilateral facial pain in 1 patient (1.8%), infection of the stented surgical patch in 1 patient (1.8%) and asymptomatic instent restenosis in 4 patients (7.4%). The percutaneous implantation of the Carotid Wallstent, even without cerebral protection device, appears to be a safe procedure with acceptable clinical and ultrasonographic follow-up results in patients at high surgical risk. But some late adverse events such as ipsilateral recurrence of non-disabling (minor) stroke or instent restenosis still remain real challenging problems.

Replacement of aortic aneurysms by a prosthetic graft is a common procedure in vascular surgery. Although success is generally achieved, infection or fistula may occur. Prosthetic graft infection has been reported in between one and six percent in most large series and is one of the most dreaded complications of abdominal aorta surgery. Dissatisfaction with extraanatomic procedures has led to the development of techniques of in situ replacement by allogenic material. However, adequate debridement and coverage of the aortic graft is necessary. To our knowledge, this is the first report of the use of a rectus abdominis muscle flap to cover an aortic allograft when other reconstructive options were impossible.

Our objective was to determine the efficacy of ultrasound-guided direct injection of human thrombin to close postcatheterization pseudoaneurysms and to evaluate the midterm results of this new percutaneous technique by ultrasound follow-up. One hundred one postcatheterization pseudoaneurysms in 100 patients were treated by direct injection of human thrombin (mean dose 200 IU, range 50-750 IU) under ultrasound guidance. Patient demographics, clinical data and ultrasonographic morphology of the pseudoaneurysms were analyzed. Midterm (mean 99 days, range 25-210 days) ultrasonographic follow-up was performed in 57 of 82 called patients (69.5%). Ninety-six of 101 pseudoaneurysms thrombosed completely after the first procedure. Of the remaining 5 pseudoaneurysms, 3 were treated successfully after the second attempt, and 2 patients underwent surgical repair; thus, the primary success rate was 95% (96 of 101), and the overall success rate was 98% (99 of 101). No changes in distal pulses or other adverse events were noted immediately or 1 day after the procedure. Ultrasound follow-up revealed complete disappearance of the pseudoaneurysm in 70% (40 of 57), presence of small, residual groin hematoma in 26% (15 of 57), and partial reperfusion of the pseudoaneurysm in 3.5% (2 of 57). Human thrombin injection under ultrasound guidance is a very effective and safe method of therapy. Failure (immediate and late) of the technique as well as procedure-related complications are very rare. In our institution, sonographically guided human thrombin injection has become the treatment of choice for postcatheterization pseudoaneurysms.

Purpose: To evaluate the midterm clinical outcome of patients treated with a balloon-expandable polytetrafluoroethylene (ePTFE) endograft for long-segment occlusive disease of the femoropopliteal segment. Methods: Eighty-nine patients (68 men; median age 69 years, range 43–81) with disabling claudication (n=73) or critical ischemia (n=16) were treated with an ePTFE endograft (mean length 29 cm) for 7 stenosis (mean length 9 cm) and 82 occlusions (mean length 19 cm) in the femoropopliteal segment. The follow-up protocol included Doppler ankle-brachial pressure measurement and duplex scanning or angiography of the endograft at 6-month intervals. Primary and secondary patency rates were analyzed. Results: At the last examination, the endograft was patent in 52 patients (median 17 months, range 7–50) and occluded in 35 (median 7 months, range 0–40);2 patients died of nonvascular causes with a patent endograft at 6.5 and 7 months. At follow-up, the primary and secondary endograft patency rates were 71% and 83% at 6 months, 57% and 69% at 1 year, 45% and 49% at 2 years, and 30% and 44% at 3 years, respectively. Conclusions: The midterm success of this new ePTFE endograft is limited; therefore, the device needs to be refined if this minimally invasive technique is to compete with conventional bypass surgery.

Objective: The purpose of this study was to assess the incidence, risk factors, and consequences of endoleaks after endovascular repair of abdominal aortic aneurysm. Methods: Data on 2463 patients were collected from 87 European centers and recorded in a central database. Preoperative data were compared for patients with collateral retrograde perfusion (type II) endoleak (group A), patients with device-related (type I and III) endoleaks (group B), and patients in whom no endoleak was detected (group C). Only endoleaks observed after the first postoperative month of follow-up were taken into consideration. Regression analysis was performed to investigate statistical relationships between the occurrence and type of endoleak and preoperative patient and morphologic characteristics, operative details, type of device, and experience of the operating team. In addition, postoperative changes in aneurysmal morphology, the need for secondary interventions, conversions to open repair, aneurysmal rupture, and mortality during follow-up were compared between these study groups. Results: Patients in group A had a higher prevalence of a patent inferior mesenteric artery compared with patients without endoleak. Patients in group B were treated more frequently than patients in group C by an operating team with experience of less than 30 procedures. The mean follow-up period was 15.4 months. Secondary interventions were needed in 13% of the patients. Rupture of the aneurysm during follow-up occurred in 0.52% (1/191) in group A, 3.37% (10/297) in group B, and 0.25% (5/1975) in group C. Life table analysis comparing the three study groups demonstrated a significantly higher rate of rupture in group B than in group C (P =.002). The incidence of conversion to open repair during follow-up was higher in group B than in the other two study groups (P

Although some early reports describe angiographic as well as clinical success for balloon angioplasty alone in the treatment of carotid occlusive disease, most interventionists prefer stent-assisted balloon angioplasty because of the purported advantages, such as avoiding plaque dislodgement, intimal dissection, elastic vessel recoil and late restenosis. Mainly because of the different characteristics of each carotid artery segment, different types of stents are preferred. A carotid artery lesion located in the intrathoracic brachiocephalic trunc or common carotid artery would need a different stent to a lesion at the carotid bifurcation or a lesion of an intracerebral branch of the internal carotid artery.

The objective of this study was to evaluate the effectiveness of cryopreserved arterial homografts for management of prosthetic graft infection. Between October 1992 and July 1998, 90 patients (84 men) with a mean age of 64 years from six different hospitals were treated for prosthesis infection by in situ replacement using a cryopreserved arterial homograft (CAH). In 43 patients (47%), the primary procedure had been performed at a nonparticipating center. Prosthetic graft infection occurred early (i.e., within 1 month after the primary procedure) in 15 cases and late in 75 cases. In the late group, the mean interval between the primary procedure and CAH replacement was 34 months (range, 3 to 330 months). In 41 patients, infection was located in the aortic region, including 17 presenting with enteroprosthetic fistula (EPF). In 49 patients, infection was confined to the femoral, popliteal, or subclavian region. Bacteriologic cultures were positive for one or more germs in 75 patients and negative in 15. The surgical procedure consisted of complete or partial removal of the infected prosthetic graft, debridement, and in situ reconstruction using one or more CAH. Our results showed that management of prosthetic graft infection, a grave complication, using a CAH is a promising technique, especially for patients in stable condition prior to reconstruction.

SummaryWild-type or equipotent variants of recombinant staphylokinase (rSak) were given intra-arterially (as a 2 mg bolus injection followed by an infusion of 1 mg/h or 0.5 mg/h overnight, with concomitant heparin [1000 IU/h]) to 191 patients of less than 80 years (62 ± 1 years, mean ± SEM), with a peripheral arterial occlusion (PAO) of less than 120 days (mean 14 ± 1 days, median 11 days, 5 to 95 percentiles 3 to 30 days). Ninety nine patients presented with acute or subacute ischemia, 57 with severe claudication, 33 with chronic rest pain and 2 with gangrene. Occlusion occurred in 122 native arteries and in 69 grafts. Revascularization was complete in 83 percent (158/191), partial in 13 percent (24/191) and absent in 4 percent (7/191) after administration of 12 ± 0.5 mg rSak over 14 ± 0.7 h. Complete revascularization of acute occlusions of popliteal or more distal arteries was less frequent (60 percent, 15/25) than of acute occlusions of more proximal native arteries (95 percent, 37/39, p In conclusion, rSak appears to be a highly effective thrombolytic agent in patients with PAO, resulting in a low one month mortality (3.1 percent) and a high one year amputation free survival (84 percent), with an acceptable incidence of major bleedings, but with occasional fatal intracranial hemorrhages.

Iliocaval arteriovenous fistula is an uncommon, but challenging condition. The most common cause is spontaneous rupture of the iliac artery into the venous system due to aneurismal dilatation. We report a case of iliocaval fistula after previous aortic surgery presenting as acute liver failure as most prominent part of multiple organ failure and successful endovascular repair.

Objectives: to identify risk factors for complications following endovascular repair of abdominal aortic aneurysms (AAAs). Materials and methods: endovascular AAA exclusion was attempted in 64 patients. Patient characteristics, anatomic features of the aneurysm, operative technical aspects, and the experience of the teams were correlated with mortality, occurrence of endoleak, and other complications. Perioperative complications were graded following the recommendations of the Ad Hoc Committee on reporting standards. For the assessment of correlation between risk factors and outcomes a logistic regression analysis was used. Results: complications were observed in 43% of the procedures and were classified as mild (24%), moderate (55%) or severe (21%). American Society of Anaesthesiology (ASA) risk class 3 or 4, and advanced age were independent risk factors for perioperative death and complications. Adjuvant procedures or overstenting of the renal arteries with the uncovered part of the stent were not associated with increased risk of complications. Nevertheless, in four of 24 overstented renal orifices, a renal infarction or ischaemia of the kidney was observed on a postoperative CT scan. Advanced experience was associated with less complications, less endoleaks, and shorter operating time. Conclusions: high age and medical co-morbidity were associated with increased risk for perioperative complications and death. Additional perioperative procedures are usually well tolerated. With greater experience in endovascular AAA grafting the incidence of complications and endoleaks decreased.

The aim of this study was to test the hypothesis that a drop in the systolic blood flow velocity in the middle cerebral artery of 70% or more, measured by transcranial Doppler, is a better criteria in the detection of cross-clamp intolerance than electroencephalogram (EEG) and somatosensory evoked potential (SSEP) monitoring. After exclusion of patients with a recent stroke, urgent procedures and combined procedures, a transcranial Doppler with compression test was scheduled in 85 patients. In 13 patients the drop was 70% or more and in these patients a transcranial Doppler was also performed during the reconstruction of the internal carotid artery (the study group) under general anaesthesia. A shunt was used because of EEG and SSEP abnormality in one patient. No changes were observed in the remaining patients and no intraoperative strokes were seen. The transcranial Doppler monitoring was unreliable in three patients. During cross-clamp, the systolic blood flow velocity in the middle cerebral artery dropped less than 70% in four and 70% or more in six patients. It is concluded that using a drop of 70% or more of the systolic blood flow velocity in the middle cerebral artery during internal carotid artery cross-clamp, as an indicator of cross-clamp intolerance, will lead to unnecessary shunting.

Although sound evidence is lacking, many surgeons claim that stripping of the long saphenous vein (LSV) is best performed by invagination. The aim of this prospective, randomized study was to test the hypothesis that invaginating stripping of the LSV is associated with less pain, smaller haematomas and less frequent injury to the saphenous nerve. Thirty patients with bilateral varicose veins and incompetent LSV, but normal short saphenous veins and deep venous systems, were treated by high ligation and stripping of the LSV and multiple stab avulsions. At one side the stripping was performed by invagination (group I), while a classic stripping was done on the other side (group C), so that one leg served as the control of the other. The results were analysed on an intention to treat basis. The median surface of the thigh haematoma between post-operative day seven and ten was 115 cm2 in group I and 135 cm2 in group C (NS). The median pain score was 0.25 and 1.75 respectively (NS). The incidence of saphenous nerve injury was 13% in group I and 17% in group C (NS). At one month 23% of patients stated that the leg with the invaginating stripping had been the more painful, while 33% of patients claimed that the side of the classic stripping had been more painful. The results show that the benefit of invaginating stripping is not as obvious as is generally suggested.

We report a unique case of chronic contained thoraco-abdominal aneurysm rupture presenting as a Grynfeltt lumbar hernia. A 79-year-old man presented with backpain and a bluish swelling in the left lumbar region in the presence of a non tender aortic aneurysm. CT scan confirmed contained rupture of a type IV thoraco-abdominal aortic aneurysm. The peri-aortic haematoma protruded through the lumbar wall causing a Grynfeltt lumbar hernia. The aneurysm was replaced through a thoraco-phreno-lumbotomy. The patient survived and is doing well six months postoperatively.

In this clinical case we report the use of the superficial femoral vein as an autologous venous interposition graft for the reconstruction of the iliofemoral vein in a 21-year-old female who presented with an asymptomatic primary aneurysm of the left iliofemoral vein. The choice of surgical technique used is discussed.

The authors present a retrospective study on 30 patients with prosthetic graft infection. Included are 25 patients with aortic graft infection, three with infection of a femorodistal bypass and two with infected axillofemoral grafts. There were 23 isolated primary prosthetic graft infections and seven aorto-enteric fistulas. Treatment consisted of graft excision and replacement with cryopreserved arterial homografts, harvested from brain-death multi-organ donors. The in situ technique was used in 27 cases. Eight patients died postoperatively and two deaths were from allograft related complications. The operative mortality rate was 11% for isolated aortic graft sepsis and the early limb salvage rate was 100%. Persistent or recurrent infection was noted in two cases. The mean follow-up of the series was 24.5 months and occlusive complications occurred in five patients (23%), which resulted in two major amputations. Serial CT scans showed abnormalities in six of the 22 survivors, all of them related to the aortic segment of the allograft. It is concluded that in situ reconstruction with cryopreserved arterial allografts represents an acceptable alternative, especially in the treatment of isolated aortic graft sepsis. Continued follow-up towards late deterioration and/or occlusive complications remains mandatory.

PURPOSE AND METHODS: In this retrospective non-randomized study the results of the FELDER technique (n = 29) were compared to two endoscopic techniques for ligation of incompetent perforating veins: using a mediastinoscope (n = 19) and laparoscopic instruments (n = 57). The indication was a venous ulcer in nine, five and thirteen patients respectively, lipodermatosclerosis in thirteen, five and twenty-four, and simple varicose veins in the remaining patients (NS). RESULTS: The mean number of interrupted perforating veins was 4.2, 2.4 and 3.8 (p < 0.05). The mean hospital stay was 3.5, 1.9 and 1.6 days (p < 0.0001). The mean period of convalescence was 8.7, 4.1 and 3.7 weeks (NS). The number of complications was 9 (suralis lesion 4, pain/swelling 4, wound problem 1), 6 (saphenous lesion 3, pain/swelling 3) and 15 (pain/swelling 14, deep venous thrombosis 1) (NS). Ten patients were lost to follow-up (five, two and three). Respectively 19, 12 and 45 patients were satisfied with the end-result. The condition had worsened in one, two and three patients (NS). During the short follow-up period all ulcers healed and there was no recurrence. CONCLUSIONS: The endoscopic techniques produce results comparable to the FELDER procedure, with smaller scars and a tendency towards a faster recovery.

In 1991 European Homograft Bank (EHB) initiated a program of cryopreservation and distribution of large arteries to meet a new demand for quality-controlled arterial homo grafts of various sizes. From May 1991 to June 1995, 308 arteries have been registered from 136 donors: 122 brain death cases and 14 cadavers (mean age 34 years, male/female ratio 1.52/1); 263 arteries were cryopreserved (113 aortas, 64 aortic bifur cations, and 86 femoral); 19 were discarded for atherosclerosis (6.7%); 10 batches of arteries were partially or totally discarded because of persistent contamination and further eight batches for positive or doubtful viral serology. One hundred patients were treated in nine European centers with one (N = 69) or more EHB homografts. Indications were: infected prosthesis 70 (17 with aortoenteric fistula); mycotic aneurysm 19 (four ascending aortas, two with bronchial fistula); neoplastic infiltration of subrenal aorta one; extracardiac reconstructions/shunts 10. (continued on next page) (Abstract continued) Results from homograft reconstructions in infected prosthesis or mycotic aneurysm were available in 90 patients. There were 19 early deaths and 24 early complications, three were directly graft-related and included a fatal case of homograft rupture. Sixty- seven vascular cases were followed up from 1 month onward (mean: 16 months): 50 were uneventful; there were nine late deaths, of which two resulted from graft-related digestive hemorrhage; there were eight cases of late complications; three arteries were partly explanted as a result of focal thrombosis. Four patients were lost to follow-up. In the cases of aortoenteric fistula, however, the results were disappointing with only five late survivors of the 16 treated patients. Finally, these results show that cryopreserved arteries seem to perform as well in the midterm as the fresh ones. Both the banking activity of cryopreserved homografts and the short- to mid-term performances of the implants in cases of prosthetic or native arterial infection are very satisfactory, provided no aortoenteric fistula is present. Cryopreserved arteries can also be used for extracardiac shunts and reconstructions.

Background. Peripheral mycotic aneurysm development is a rare systemic complication of infective endocarditis. Case report. We report on a case of a mycotic aneurysm of the superior mesenteric artery in a 66-year-old man with infective endocarditis of the mitral valve. After the mitral valve was replaced by a mechanical valve, a laparotomy was performed. The mycotic aneurysm was excised and the vessel was repaired by sewing an autologous venous patch at the neck of the aneurysm. Five years after the operation, the patient is doing fine, with a normal morphology and patency of the superior mesenteric artery. Conclusion. Our case demonstrates that simultaneous valve surgery and repair of a superior mesenteric artery mycotic aneurysm by sewing a vein patch in the neck of the artery is a viable treatment option.

We report an unusual case of a ureteroiliac fistula due to prolonged ureteral stenting for hydronephrosis combined with an aortic-bifemoral stent graft in an inflammatory abdominal aortic aneurysm (AAA), treated with an endovascular stent graft. In a 77-year-old man ureteral J-stents were placed for bilateral hydronephrosis due to retroperitoneal fibrosis caused by an inflammatory AAA. The aneurysm was treated with an endovascular aortic-bifemoral stent graft. Three months later, the patient suffered from severe hypovolemic shock. Emergency angiography showed a fistula between the right ureter and the right common iliac artery just distal to the right leg of the stent graft. The ureteroiliac fistula was treated with a wall graft (10F). The patient recovered well and remained asymptomatic. Ureteroiliac fistula remains a rare complication of ureteral stenting. Several risk factors have been described before. This case emphazes the increased risk of an arterial-ureteral fistula due to an indwelling ureteral stent and an inflammatory AAA, especially in combination with an additional stent graft for this inflammatory AAA.

Infrarenal aortic graft infection is an uncommon but dramatic complication of reconstructive vascular surgery of the infrarenal aorta. Conventional treatment consists of complete excision of the infected prosthesis, suture ligation of the infrarenal aorta and clean plane revascularisation of the lower limbs with extraanatomic bypasses. Despite continuing progress in surgical and anaesthesiological techniques, these procedures remain associated with an operative mortality of 20-25% and an amputat ion rate of 10-15%. I'2 Itl situ reconstruction within the infected field may be offered as an alternative, but has received little attention in the past because of its technical complexity and the lack of suitable conduits. 3'4 We have been using the lower extremity deep veins as autogenous conduits in case of prosthetic infection since 1990 and this s tudy summarises our experience in 14 patients with aortic graft infection, who were treated by graft excision and in situ aortoiliofemoral reconstruction using lower extremity deep veins.

This report summarizes the technical feasibility and early results of endovascular iliofemoral stented grafts in the treatment of iliofemoral occlusive disease. Twenty-four patients (mean age 71 years) underwent 29 lower-extremity inflow procedures for claudication (n = 7) or limb threatening ischaemia (n = 17). The technical success rate for endovascular grafts was 93% (n = 27). Some 85% of the grafts originated from the aortoiliacjunction or the common iliac arteries. Outflow procedures were performed in all cases and consisted of profundaplasty (n = 17) and/or femorodistal grafting (n = 13). The operative mortality rate was 9% and one occlusion was noted in the early postoperative period. The mean (s.d.) primary and secondary cumulative patency rates after 1 year were 85(10)% and 95(5)% respectively. The corresponding limb salvage rate was 95(4)%. The authors conclude that endovascular iliofemoral stented grafts through a single groin incision are technically feasible and that early patency rates are acceptable. More experience is needed however before widespread application of these new techniques can be justified.

The Ehlers-Danlos syndrome is an inherited disorder of connective tissue, consisting of at least 10 different clinical subtypes. Type IV Ehlers-Danlos syndrome is an autosomal dominant condition characterized by the joint and dermal manifestations as in other forms of the syndrome but also by the proneness to spontaneous rupture of bowel and large arteries. The authors describe their experience with three patients presenting type IV Ehlers-Danlos syndrome: the first presented with several subsequent arterial ruptures, the second with multiple aneurysms, and the third with a dissection of the internal carotid artery. Clinical features, incidence, diagnosis, and treatment of the syndrome are discussed.

Purpose: To describe the successful stent-graft exclusion of a mycotic aneurysm of the superficial femoral artery. Case Report: A 78-year-old man presented with Salmonella arteritis and the formation of a mycotic false aneurysm of the superficial femoral artery. Antibiotics were administered; the aneurysm was excluded using 2 Hemobahn stent-grafts, and the surrounding hematoma was drained. One year postoperatively, there are no clinical or biochemical signs of infection. Ultrasound examination does not show any fluid around the patent stent-graft. Conclusions: Stent-graft placement might be an alternative to traditional surgery in selected cases of mycotic aneurysm.

Autogenous reconstruction is a well-accepted alternative treatment for prosthetic infection after reconstructive arterial surgery. Because of its technical complexity and the lack of suitable substitutes, the procedure remains limited to a few selected centers. We describe four patients with prosthetic infection after reconstructive surgery for lower limb ischemia. Treatment consisted of prosthetic excision and aortofemoral grafting with the use of the superficial femoral vein. All patients survived the operation and infection was eradicated in all cases. We conclude that the superficial femoral vein represents an acceptable arterial conduit in the treatment of these difficult cases.

Background To study the pathophysiology of esophageal necrosis after endoprosthesis was performed for a ruptured aneurysm and to define preventive measures and possible treatment options. Method A 72-year-old man with thoracoabdominal aneurysm type I and dysphagia underwent an emergent carotico-carotid bypass in combination with thoracic endovascular aortic aneurysm repair starting at a point distal to the brachiocephalic trunk and ending proximal to the superior mesenteric artery. On day 12, a decortication was performed for treating an infection in the remaining hematoma. However, further deterioration occurred as a result of mediastinitis secondary to the transmural necrosis of the middle third of the esophagus combined with accompanying mediastinitis. The patient’s family refused to give consent for further treatment by esophagectomy. He died 24 days after the initial operation. Conclusion Dysphagia aortica, mucosal abnormalities on esophagogastroscopy, and mediastinal compression by hematoma at the time of rupture draws our attention toward ischemia of the esophagus after thoracic endovascular aortic aneurysm repair. Repeated esophagoscopy can provide us with the opportunity to act before full thickness necrosis and mediastinitis occur.

Background We examined the reasons for missing a type III endoleak on conventional imaging and the pathophysiology of paraparesis after relining this stent graft. Methods and Results A 46-year-old man was treated with a thoracic stent graft for thoracic rupture of a chronic type B thoracoabdominal dissection with aneurysm formation. In a second intervention, retrograde revascularization of the visceral and renal arteries was performed in combination with insertion of an abdominal stent graft. After initial shrinkage of the aneurysmal sac, the thoracic aortic diameter started increasing again. Consecutive three-phase helical computed tomographic scans did not reveal any endoleak. Because of unbearable back pain, an open surgical exploration was performed. This showed a type III endoleak. Relining of the thoracic stent graft was performed, but paraparesis developed. Conclusion In patients with unexplained increase of the aneurysmal sac contrast-enhanced magnetic resonance imaging could help to illuminate the underlying endoleak. The collateral network concept can explain spinal cord injury by even minor hemodynamic changes.

Sixty patients in whom a prosthetic aorto-femoral bypass graft was inserted were pretreated with ticlopidine (250 mg b.i.d.) or placebo in a double-blind study. Blood loss and transfusion need were higher in ticlopidine treated patients. Platelet survival was partially corrected and platelet deposition on prosthetic surfaces was inhibited with ticlopidine. The study suggests that ticlopidine does not increase excessively the bleeding risk during peripheral vascular surgery and that the antiplatelet drug may have beneficial effects in the early phase after insertion of prosthetic vascular graft.

We report on a series of 930 patients who received an aortobifemoral Dacron graft between 1963 and 1988. The operative mortality was 5.6% and the mean follow-up reached 5.45 years (range one month to 23.6 years). Late occlusion was noted in 125 patients and the primary patency rate decreased to 74% and 69%, respectively at 10 and 15 years. Long-term patency was primarily (p less than 0.05) dependent on (1) the date of operation, (2) postoperative smoking habits, (3) distal occlusive disease, and (4) age of the patients at the time of surgery. Vascular reconstruction for late thrombosis was performed for 110 late occlusions in 103 patients. Included were 95 unilateral and 15 bilateral occlusions. The method of choice was graft limb thrombectomy (unilateral occlusion) or anatomical graft replacement (bilateral occlusion or unilateral occlusion when thrombectomy proved to be impossible). Associated outflow reconstructions consisted of profundaplasty in 73.3% of the cases. A mean yearly thrombosis rate of 9.4% (range 4-14%) resulted in a five year patency rate of 59%. Differences between graft thrombectomy and anatomical replacement were not statistically significant. Reconstruction for secondary occlusions was associated with a 25% thrombosis rate. Tertiary occlusion in six cases invariably led to major amputation. A total of 20 patients ultimately needed a major amputation, resulting in an eight year limb salvage rate of 79%.

Inflammatory abdominal aortic aneurysms may present a challenge to the surgeon, especially because of associated retroperitoneal fibrosis and possible ureteral complications. We present a case of inflammatory abdominal aortic aneurysm with bilateral ureteral entrapment and complete anuria, successfully treated by endovascular grafting and temporary ureteral stenting.

Red blood cell (RBC) quality and function during autotransfusion with the Solcotrans ® system were studied. Up to 64% (mean 999.5 ± 310 ml) of the total volume of blood lost (mean 1895 ± 707 ml) during operation in 10 patients undergoing elective abdominal aortic surgery was salvaged. No patient received homologous blood during surgery. Haemoglobin (Hb) and Haematocrit (PCV) values decreased but within acceptable limits. No evidence of DIC was found and renal function was unaffected. Mechanical and functional damage to the RBC was minimal and erythrocyte oxygen-carrying capacity was excellent. 2,3—DPG RBC concentration and RBC reduced glutathion were normal. The device was easy to handle and technical problems were not encountered. It was accurate in salvaging blood although the need for homologous blood was not entirely eliminated since four patients received homologous blood products in the postoperative period. No adverse clinical events occurred.