Extra-anatomic arterial reconstruction with ligation of common iliac arteries and embolization of the aneurysm for the treatment of abdominal aortic aneurysms in high-risk patients

Arterioureteral Fistula in the Setting of Radical Cystoprostatectomy and Ileal Conduit Creation

Arterioureteral fistulas (AUF) following ileal conduit reconstruction are rare and not well-studied. We present a life-threatening bleed from an AUF due to an ileal conduit urinary diversion. In addition, we identify the challenges in the diagnostic process as well as management strategies. We present a 63-year-old male with ileal conduit reconstruction for bladder cancer with an AUF developing years after the reconstruction, which was ultimately managed with angioplasty.

A unique technique for intentional occlusion of an abdominal aortic aneurysm

We report the case of a 78-year-old man with coronary artery disease, chronic obstructive pulmonary disease, and chronic renal insufficiency with an enlarging 6.7-cm infrarenal abdominal aortic aneurysm. He also had a 4-cm right common iliac artery aneurysm, and right external iliac artery occlusion. The patient had a history of an axillobifemoral bypass graft placed 10 years prior for aortoiliac occlusive disease. We describe the use of an infrarenal aorto-uni-iliac graft and subsequent intentional graft occlusion as an endovascular solution to treat aneurysmal disease in this sick patient. He remains asymptomatic after surgery, with demonstrated occlusion of his aneurysms.

Nonresective repair for abdominal aortic aneurysm

BACKGROUND

In this report, we present our experience with nonresective repair of abdominal aortic aneurysm in selected patients who were unsuited for other surgical approaches and would benefit from repair.

METHODS

Seven patients with abdominal aortic aneurysm underwent nonresective repair comprising aneurysm embolization followed by the creation of an axillary-femoral, femoral-femoral bypass with a polytetrafluoroethylene (PTFE) graft.

RESULTS

Between April 2006 and March 2009, seven patients (mean age: 85 years) underwent surgery. Of these, four (57%) are currently alive and healthy, with a mean follow-up of 15.7 months, the remaining three died.

CONCLUSION

Nonresection may be used as an alternative surgical treatment in certain high-risk patients.

Axillobifemoral bypass and aortic embolization for the treatment of two patients with ruptured infrarenal aortic aneurysms

We report two cases of hemodynamically stable patients with contained, ruptured, juxtarenal abdominal aortic aneurysm that were both successfully treated by nonresectional therapy including axillobifemoral bypass with externally supported polytetrafluoroethylene graft, followed by coil embolization of the aneurysm sac and bilateral common iliac arteries. The patients were elderly with multiple comorbidities and complex aneurysm morphology not amenable to endovascular repair. In both cases complete thrombosis of the aneurysm was verified by computed tomography. Both patients are alive at follow-up without evidence of an increase in aneurysm size, postoperative leak, or rupture or impairment of renal function. To our knowledge these are the first reported cases in which this modality has been successfully used in patients presenting with ruptured abdominal aortic aneurysms. Earlier results of nonresectional therapy for abdominal aortic aneurysm have reported a significant incidence of postoperative aneurysm rupture and renal failure. Growing experience at our institution with nonresectional therapy for high risk patients with abdominal aortic aneurysms suggests that nonresectional therapy can be a valuable treatment modality for high risk patients including those with contained rupture of the aneurysm who are hemodynamically stable.

Infrarenal Abdominal Aortic Aneurysms

Screening programs should be instituted to identify patients with small asymptomatic abdominal aortic aneurysms (AAAs) in the community. Screening for AAAs reduces the rate of aneurysm rupture and reduces death from aneurysmal disease in the population. The indications for aneurysm surgery have been defined by two recent randomized clinical trials. Patients with symptomatic or ruptured AAAs should be treated by urgent or emergency surgery. Patients with asymptomatic AAAs should not undergo surgical repair until the aneurysm exceeds 5.4 cm in maximum diameter. The most appropriate surgical option for the majority of patients with AAAs is conventional inlay grafting. This may be approached transperitoneally, although the retroperitoneal approach is favored for inflammatory or juxtarenal aneurysms. Conventional aneurysm repair may be performed with acceptable mortality and good long-term durability in specialized centers with a high volume of cases. The place of endovascular aneurysm repair remains to be defined. Endovascular repair is the best option in high-risk patients with suitable aneurysm morphology. The questions over the long-term durability of endovascular aneurysm surgery in preventing aneurysm rupture make it unsuitable for young patients. Randomized trials will define the indications for this technique. Endovascular surgery is likely to become the most appropriate treatment for ruptured aneurysms in the next decade.