Pelvic collateral pathway during endovascular aortoiliac aneurysm repair with internal iliac artery interruption: a retrospective observational study

Managing infected femoral artery pseudoaneurysm after thoraco-bifemoral bypass with an innovative configuration

An infected femoral artery pseudoaneurysm after aortic reconstruction is a devastating surgical complication associated with the morbidity of limb loss and pelvic ischemia with a reinfection rate of ≤10%. In the present case report, we have described a unique approach for an infected femoral pseudoaneurysm after thoraco-bifemoral bypass using an innovative configuration, in addition to an obturator bypass technique, in a patient with a complex vascular history. This unique approach made use of an existing limb of a thoraco-bifemoral bypass graft to provide inflow to two outflow conduits, the external iliac artery and superficial femoral artery, allowing for preservation of both pelvic and lower extremity perfusion.

A Novel Clinically Based Classification System for the Profunda Femoris Artery and the Circumflex Femoral Arteries

OBJECTIVE

The profunda femoris artery (PFA) supplies important collateral branches to both the ipsilateral internal iliac and the distal superficial femoral artery (SFA). The size and patency of these collateral pathways can determine the risk of pelvic malperfusion, spinal cord ischemia, and lower extremity limb loss following vascular interventions. Despite its importance, the anatomy of the PFA is rarely characterized in clinical studies involving the pelvic or lower extremity circulation. This discussion may be limited by the lack of a comprehensive classification system. Our objective was to describe the most common PFA anatomic variants and present a classification system based on its branching patterns.

METHODS

We dissected 155 fixed and non-fixed femoral artery systems from 88 cadavers. Seventy-seven female and 78 male femoral exposures were performed. Vessel diameters, branch configurations and relative distances between the inguinal ligament, PFA, lateral circumflex femoral artery (LCFA), and medial circumflex femoral artery (MCFA) were recorded.

RESULTS

The mean diameters of the common femoral artery, SFA and PFA in males were 10.3mm, 8.0mm and 6.9mm, and 8.9mm, 6.9mm and 6.1 in females, respectively (p < 0.05). The mean distances from the inguinal ligament for PFA, MCFA and LCFA were 41mm, 41.7mm and 52.5mm respectively. No significant differences were noted relative to laterality or fixation. We developed a clinically applicable classification system based on the orientation of the PFA, LCFA, and MCFA. Six PFA, 5 LCFA and 5 MCFA variations were identified and ranked by frequency. The five most common combinations accounted for 56.1% of our cadaver series.

CONCLUSION

The anatomic orientation of the PFA and its branches is highly variable. We propose a novel classification system of this rich collateral system to facilitate consistent communication in academic and clinical vascular surgery.

Custom-made iliac fenestrated endoprosthesis for the treatment of internal iliac artery aneurysm with preservation of the superior gluteal artery

A 56-year-old man with huge bilateral internal iliac artery aneurysms (IIAAs) had emergently undergone right common iliac artery replacement. Intermittent claudication was induced by 8 minutes of walking on postoperative day 16. Endovascular repair using a custom-made iliac fenestrated endoprosthesis for the treatment of the left IIAA with preservation of the superior gluteal artery was performed on postoperative day 20 without discharging the patient. The patient had no ischemic complications. When an IIAA with a short length (<55 mm) and large diameter (>21 mm) of the common iliac artery is anatomically suitable, the placement of a custom-made iliac fenestrated endoprosthesis is a feasible and effective technique.