Intimal hyperplasia: Possible in vivo mechanisms and response to ω-3 fatty acids

Repair of Anastomotic Abdominal Aortic Pseudoaneurysm Utilizing Sequential AneuRx Aortic Cuffs in an Overlapping Configuration

Anastomotic aortic pseudoaneurysm is a known late complication following aortic repair and presents a considerable surgical challenge. We herein evaluate the endovascular alternative of using sequential AneuRx aortic cuffs to bridge the degenerative anastomotic pseudoaneurysms as a definitive treatment. Over a 3-year period, six patients with a mean age of 68.7 years (range 58-75) were identified who had proximal anastomotic aortic pseudoaneurysms secondary to previously implanted bifurcated aortic grafts (mean 15, range 12-20 years) following open surgical correction of aortoiliac occlusive disease. Five patients (83%) presented with concomitant palpable femoral anastomotic pseudoaneurysms and one patient (16%) had a pulsatile abdominal mass. All patients had computed tomographic (CT) scans confirming proximal anastomotic pseudoaneuryms without evidence of infection. The mean diameter of the pseudoaneurysms was 5.3 cm (range 4.0-7.0). Five patients were treated with endovascular methods, while one patient was not suitable for endovascular repair due to the diameter of the native aorta as seen on imaging study at the time of the procedure. AneuRx aortic extender cuffs (3.75 cm length) were deployed sequentially in five patients via a femoral approach. Devices were overlapped approximately 1.5 cm in order to achieve total exclusion of the pseudoaneurysms, and all concomitant femoral aneurysms were repaired surgically at the same time. Successful exclusion of the anastomotic pseudoaneurysm was achieved in four patients (80%) using a combination of two or three overlapping aortic cuffs. One patient had a small residual endoleak that had sealed by 1 month, evidenced by follow-up CT. The renal arteries were preserved in all patients. The average estimated blood loss and operative time were 355 +/- 25 cc and 84 +/- 21 min, respectively. The average length of hospital stay was 2.1 days, and there was no mortality or major morbidity. All patients underwent CT scanning surveillance at 6 and 12 months and yearly afterward. There was no evidence of late endoleak, aneurysmal expansion, or device migration during the mean follow-up of 10 months, ranging 6-27 months. Our study demonstrated that utilizing sequential AneuRx aortic cuffs applied in an overlapping configuration is an effective strategy for degenerative aortic anastomotic pseudoaneurysm from previously placed aortic grafts. Additionally, our study suggests this unique endovascular technique is an ideal alternative for creating a customized tube graft in challenging cases, particularly in high-risk patients.

Proximal anastomotic failure following infrarenal aortic reconstruction: late development of true aneurysms, pseudoaneurysms, and occlusive disease

Distal anastomotic failure of aortic reconstructions attributable to femoral pseudoaneurysm or outflow stenosis has been well described, but little is known about proximal aortic anastomotic graft failure. A retrospective review was performed between January 1987 and March 1992 to characterize the presentation and management of proximal aortic anastomotic failure. Of 329 consecutive aortic reconstructive operations during this period, 11 (3.3%) were performed to correct complications arising at or adjacent to the proximal anastomosis of an aortic prosthesis. These included anastomotic pseudoaneurysm (n = 6), true aneurysmal dilatation of the residual infrarenal or suprarenal aorta (n = 4), and stenosis of the residual infrarenal aorta (n = 1). The 11 patients had undergone prior infrarenal aortic reconstruction for either aneurysmal (n = 5) or occlusive (n = 6) disease an average of 120 months (range 36 to 175 months) before detection of proximal para-anastomotic graft failure. Eighty-two percent (n = 9) of the proximal lesions were asymptomatic and were discovered incidentally during unrelated medical evaluations. Excluding the six pseudoaneurysms, four of the remaining five lesions developed in a relatively long segment of residual infrarenal aorta, including aneurysm above the graft (n = 2), aneurysm below a proximal end-to-side anastomosis (n = 1), and progressive proximal aortic atherosclerosis (n = 1). Tube graft replacement of the proximal lesions was the most frequently performed operation (n = 7); renal artery reimplantation or bypass was necessary in five cases (45%). Although there was no operative mortality, significant surgical morbidity occurred in three patients (27%). Proximal aortic graft complications tended to be asymptomatic and difficult to repair.(ABSTRACT TRUNCATED AT 250 WORDS)