Search

Objective: To evaluate and compare studies reporting the outcomes of the use of covered balloon-expandable (CBE) stents for the treatment of aortoiliac occlusive disease. Methods: A systematic literature search was conducted to identify studies that investigated the use of CBE stents for the treatment of aortoiliac occlusive disease and were published between 2000 and 2019. Baseline demographic data, procedural variables, and long-term outcomes were extracted from publications for analysis. Results: A total of 15 published articles about 14 studies were included in the review. Of these, eight studies were prospective clinical trials and six studies were retrospective real-world studies. The articles included data regarding five different CBE stents, namely, the iCast/Advanta V12, Viabahn VBX, BeGraft, LifeStream, and JOSTENT. Lesion severity was higher in real-world studies, with more TransAtlantic Inter-Society Consensus Classification class D lesions and a higher percentage of occlusions. All studies showed high rates of technical success and patency over the course of 12 months. Long-term data were only available for the iCast/Advanta V12 device, which had a primary patency rate of 74.7% at 5 years. Conclusions: CBE stents are a viable treatment option for patients with complex aortoiliac lesions because of their high rates of technical success and favorable patency across all devices at 12 months. However, long-term data are only available for a single device, the iCast/Advanta V12. The results of using this device were favorable over the course of 5 years.

Objective There is a paucity of good-quality evidence comparing direct surgical (DS) with endovascular/hybrid (EVH) revascularization for aortoiliac occlusive disease (AIOD). We aimed to perform a meta-analysis of studies comparing DS and EVH revascularization for AIOD. Methods PubMed, Ovid MEDLINE, Cochrane, and Embase databases were searched for studies comparing DS and EVH revascularization for AIOD from 2000 to 2018. Risk of bias assessment was performed using the Methodological Index for Non-Randomized Studies. Demographics, clinical presentation, and comorbidities of the two groups were compared. Kaplan-Meier curves from selected studies were digitized with WebPlotDigitizer. Meta-analysis was conducted using Review Manager, and outcome measures were compared. Subgroup analysis was performed for primary patency in the EVH group. Results Eleven observational studies were identified comparing a sample of 4030 patients. The median Methodological Index for Non-Randomized Studies score was 19 of 24. A total of 1679 and 2351 patients underwent DS and EVH techniques, respectively. No significant difference was found between means for sex, claudication, rest pain, tissue loss, preoperative ankle-brachial pressure index, and TransAtlantic Inter-Society Consensus C and D lesions in the two groups averaged across studies. However, the DS group had significantly younger patients (average age, 61.83 vs 66.77; P = .0011). The risk factors of the two groups, such as smoking, diabetes, ischemic heart disease, hypertension, hyperlipidemia, renal failure, and chronic lung disease, were comparable. Average hospital stay was significantly higher for the DS group (7.76 days vs 3.12 days; P = .025). Change in ankle-brachial pressure index, 30-day mortality, and 30-day graft/stent thrombosis were not significantly different for the groups. Overall, primary patency for a median follow-up of 50 months favored the DS group (hazard ratio [HR], 0.51; confidence interval [CI], 0.36-0.73; P = .0002). There was moderate heterogeneity among studies (I2 = 46%). The HR for the subgroup for which endovascular procedures were combined with common femoral endarterectomy was 0.43 compared with 0.88 for endovascular revascularization alone. Limb salvage was similar in both groups (HR, 1.10; CI, 0.74-1.64; P = .63), but overall survival after the procedure favored the DS group (HR, 0.75; CI, 0.60-0.94; P = .01; I2 = 0%). Conclusions Moderate-quality studies showed that DS revascularization had significantly better primary patency than EVH revascularization for AIOD, although DS patients were younger and may have differed on other confounding variables. Both techniques had similar limb salvage rates, and the primary patency was better for endovascular revascularization combined with common femoral endarterectomy than for endovascular revascularization alone.

Recent vascular societal guidelines have recommended an abdominal aortic aneurysm (AAA) size threshold for elective intervention; however, limited data have documented how well these AAA diameter benchmarks are being met. The objective of this study was to analyze variation in management of AAAs based on diameter and to determine the physician's rationale for intervention on small AAAs in relation to recommended treatment guidelines.A retrospective review of a statewide vascular surgery registry of all elective endovascular or open surgical AAA repairs from January 2012 to January 2016 was performed. Patients were dichotomized on the basis of aortic diameter at time of intervention into either guideline size AAAs or small AAAs, which were defined as 5.5 cm in men, 5.0 cm in women, or with growth 1.0 cm/y. An internal review was conducted of all small AAAs to determine the physician's rationale for intervention. The primary outcomes were variation in adherence to recommended treatment guidelines and the physician's rationale for treatment of small AAAs. Risk-adjusted major complication and mortality rates were calculated at 30 days and 1 year using a propensity score matching analysis.Among the 3932 patients who underwent an elective AAA repair, 485 (12.3%) were repaired at diameters smaller than recommended by guidelines. The median AAA size in the small AAA cohort was 5.1 cm (interquartile range, 4.7-5.3 cm) vs 5.6 cm (interquartile range, 5.2-6.1 cm) in the guideline-based group. Percentage of small AAA repairs varied widely between hospitals from 1.4% to 44.4%. The physician's rationale for the majority of early interventions included the patient's anxiety (12.0%), combined aortoiliac occlusive disease (14.8%), aneurysm anatomy (28.2%), and does not adhere to guidelines (30%). The small AAA cohort had no significant difference in the 30-day or 1-year risk-adjusted mortality in comparison to guideline size AAAs.Despite well-established aortic diameter threshold guidelines, marked variation exists both at the hospital level and in terms of the physician's rationale for the management of elective AAA repairs. These findings demonstrate the challenge of providing uniform care for patients with AAAs despite established guidelines.

Background The Vascular Quality Initiative (VQI) Cardiac Risk Index (CRI) was developed to estimate the risk of postoperative myocardial infarction (POMI) for noncardiac vascular procedures. Whereas suprainguinal bypass carried the second highest odds of POMI, the performance of the all-procedure model declined when it was applied to the suprainguinal subset. We sought to improve the VQI CRI for application in this high-risk group undergoing open revascularization for aortoiliac occlusive disease. Methods The VQI Suprainguinal Bypass Registry was queried for elective procedures performed between January 2010 and March 2017. Logistic regression was used to create a model for estimating the risk of in-hospital POMI with preoperative variables including demographics, comorbidities, and planned inflow source. After adjustment for overfitting, internal validation was performed using both bootstrapping and 10-fold cross-validation methods. Results Among 8157 procedures, the incidence of POMI was 3.2% (n = 258). After bootstrapping variable selection, age, graft inflow, preoperative stress test, American Society of Anesthesiologists class, indication for procedure, and coronary artery disease were chosen for inclusion as predictors in the final risk model. The final model demonstrated good discrimination (area under the curve = 0.725). On internal validation, the model discriminated well (area under the curve = 0.713), with good calibration (plot intercept = 0.0006 and slope = 1.001). Using this model, POMI risk estimates ranged from 0.6% to 30.4%. Conclusions Whereas the incidence of POMI among all suprainguinal bypasses was 3%, model-based estimates ranged 50-fold, from 0.6% to 30.4%. This underscores the heterogeneity of this cohort and the need for patient-specific risk estimation. Although some of the strongest predictors were nonmodifiable (eg, age), the model provided specific estimates according to graft inflow and stress testing. This supraspecific VQI CRI module risk predictor may enhance preoperative counseling by influencing the decision to pursue preoperative stress testing and ultimately the type of revascularization strategy chosen.

Objective Thoracofemoral bypass (TFB) is used infrequently but is an alternative for selective patients with aortoiliac occlusive disease. There is limited data in the existing literature regarding TFB, with all studies being small, single-center series. We aim to describe perioperative and long-term survival, patency, and rate of major perioperative complications following TFB in a large national registry. Methods The Vascular Quality Initiative (VQI) suprainguinal bypass module was used to identify patients undergoing TFB for occlusive disease from 2009-2019. A descriptive analysis was performed to provide rates of survival, patency, major complications, and freedom from major amputation in the perioperative period and at 1-year follow up. Major complications were compared by procedure indication with categorical variables analyzed using chi-square tests while continuous variables were analyzed using ANOVA. Kaplan Meier curve analysis was used to estimate survival at 1 and 5-year follow up intervals as well as freedom from major amputation at 1 year. Results There were 154 TFB procedures identified. Fifty-nine patients (38.3%) had prior inflow bypass while 22 patients (14.2%) had prior leg bypass. Procedure indications included claudication (42.9%, n=66), rest pain (38.3%, n=59), tissue loss (12.3%, n=19), and acute limb ischemia (6.5%, n=10). Major complication (wound infection, respiratory, major stroke, new dialysis, cardiac, embolic, major amputation, occlusion) occurred in 31.2% of the cohort, and when examined by indication, acute limb ischemia and claudication cohorts had increased rate of major complication (acute limb ischemia: 60.0%, claudication: 34.8%, critical limb ischemia: 24.4%; p=.05). Survival at 30 days was 95.5% with Kaplan Meier estimated 1-year survival of 92.7% ± 2.2%. Primary patency at discharge from the index hospitalization was 92.9% and 89.0% at 1 year. Postoperative major amputation occurred in 1 patient during index hospitalization with Kaplan Meier estimated freedom from major amputation at 1-year follow up of 97.1% ± 2.2%. Two patients developed in-hospital bypass occlusion and 3 additional patients had occlusion occurring within 1 year for an overall freedom from occlusion rate of 96.8% at 1 year. Conclusion Thoracofemoral bypass is associated with a high rate of perioperative major complications; however, long-term survival and patency following the procedure remain acceptable when performed for limb salvage. High perioperative complication rates of TFB procedures performed for claudication suggest this procedure should be used rarely in this population. These data can be used to counsel patients and aid in decision making prior to operative intervention.

Objective Axillofemoral bypasses (AxFBs) have been used since 1962 to treat aortoiliac disease. In the past, reported patency rates (37%-76%) for these extra-anatomic grafts have been inferior to those for anatomic aortic grafting. Reported low survival rates after AxFB (40%-50%) have confirmed that these procedures have been used primarily in patients at high risk for complications from aortofemoral bypass. However, modern medical and anesthesia management, preoperative scanning, donor artery preparation, postoperative graft surveillance, and graft technology may improve outcomes after AxFB, possibly supporting expansion of its use. We therefore report our last 15-year experience with AxFB. Methods Ring-reinforced, 8-mm expanded polytetrafluoroethylene grafts were used in all cases. The cross-femoral limb of axillobifemoral bypass (AxBFB) grafts was preconstructed. Heparin was administered intraoperatively, with protamine reversal. Loss of primary patency was defined as graft thrombosis of part or all of the inserted graft. Five-year primary patency rates were calculated by Kaplan-Meier analysis. Results Between February 1991 and June 2016, a total of 161 grafts were inserted (85 AxBFBs and 76 axillounifemoral bypasses [AxUFBs]) in 91 male and 70 female patients (median age, 72.6 years; mean age, 73 years; range, 41-94 years). Indications for treatment were rest pain (49.6%), ischemic lesions (26%), claudication (22.3%), failed prior revascularization (9.3%), infection (3.7%), and dissecting aneurysm (1.2%). Reasons for performing AxFB rather than aortofemoral bypass were hostile aorta (44.1%), high risk (19.2%), prior failed reconstruction (12.4%), advanced age (8.7%), infection (4.3%), hostile abdomen (4.3%), aortic dissection (0.6%), and morbid obesity (0.6%). During follow up, 63 patients died, 17 within the first year; but only 3 patients died within 30 days of surgery (performed to treat an acute aortic occlusion). The 5-year survival rate was 55%. Five-year patency rates were 83.7% for all procedures, 81.8% for AxBFB, and 85.5% for AxUFB; the difference between AxBFB and AxUFB was not significant. Conclusions Our data indicate that AxBFB and AxUFB performed with the use of modern protocols and technology may render them an acceptable valid primary intervention in patients in whom endovascular treatment has failed or is unlikely to offer long-term success. The simplicity of performing these grafts and their low mortality and morbidity lend their application to surgeons with limited open aortic experience. Because AxUFB and AxBFB have similar patency rates, AxBFB should be reserved for bilateral indications.

Despite advancements, aortofemoral bypass (AFB) remains the most durable option for aortoiliac occlusive disease. Although runoff has been shown to be associated with AFB patency, the association of the Society for Vascular Surgery (SVS) thigh runoff scoring system with patency has not been assessed. The aim of the present study was to evaluate the association between the SVS runoff scoring system and limb-based primary patency after AFB.Institutional data for patients undergoing AFB with preoperative runoff imaging available from 2000 to 2017 were queried. Runoff scores were assigned according to the presence of occlusive disease in the superficial femoral artery and profunda femoris artery (minimum, 1; maximum, 10) as described by the 1997 SVS reporting standards for lower extremity ischemia. Limb-based patency was the primary endpoint. Kaplan-Meier analysis was used to compare the long-term limb-based patency and freedom from reintervention between limbs with runoff scores ≥6 and those with runoff scores 6. Propensity score-weighted Cox proportional hazards modeling was used to evaluate the association between a runoff score of ≥6 and primary patency loss, controlling for other factors associated with primary patency.In 161 patients, 316 limbs had undergone revascularization. The mean patient age was 66.7 ± 11.3 years, and 51.6% were women. Most limbs had undergone revascularization for claudication (56.5%). Most (89.4%) had TransAtlantic InterSociety Consensus class D lesions, 27.3% had required suprarenal or higher clamping, and 11.2% had undergone concomitant mesenteric intervention. A femoral outflow adjunct and concurrent lower extremity bypass was required in 41.8% and 2.9% of limbs, respectively. Those with a runoff score of ≥6 had experienced greater rates of 30-day myocardial infarction (11% vs 1%; P = .005), respiratory failure (11% vs 1%; P = .005), and mortality (8% vs 0%; P ≤ .006). The median follow-up period was 4.0 years (interquartile range, 6.5 years). The 1-, 3-, and 5-year primary patency was 94.6% (95% confidence interval [CI], 91.9%-97.3%), 89.2% (95% CI, 85.4%-93.2%), and 81.4% (95% CI, 76.0%-87.1%), respectively. The 5-year primary-assisted patency, secondary patency, and freedom from reintervention were 84.9% (95% CI, 79.7%-90.5%), 91.7% (95% CI, 87.3%-96.3%), and 83.3% (95% CI, 78.3%-88.7%), respectively. Patients with a runoff score of ≥6 had lower primary (log-rank P .01), primary-assisted (P .01), and secondary patency (P = .01). The factors associated with the loss of primary patency included a high runoff score (runoff score of ≥6: hazard ratio [HR], 4.1; 95% CI, 2.1-8.0; P .01), simultaneous mesenteric endarterectomy (HR, 13.5; 95% CI, 1.9-97.8; P = .01), and chronic kidney disease (HR, 4.6; 95% CI, 1.5-14.6; P = .01). Increasing age (HR, 0.94 per year; 95% CI, 0.91-0.97; P .01) and hyperlipidemia (HR, 0.44; 95% CI, 0.23-0.85; P = .01) were protective.The SVS femoral runoff score is an important factor associated with long-term AFB limb patency. Scores of ≥6 portend for worse limb outcomes and a greater incidence of operative complications. The SVS score can be determined from preoperative axial imaging studies and serve as a guide in decision-making and operative planning.

Objective This study aimed to develop risk predictive models of 30-day mortality, morbidity, and major adverse limb events (MALE) after bypass surgery for aortoiliac occlusive disease (AIOD) and to compare their performances with a 5-Factor Frailty Index. Methods The American College of Surgeons National Surgical Quality Improvement Program 2012-2017 Procedure Targeted Aortoiliac (Open) Participant Use Data Files were queried to identify all patients who had elective bypass for AIOD: femorofemoral bypass, aortofemoral bypass, and axillofemoral bypass (AXB). Outcomes assessed included mortality, major morbidity, and MALE within 30 days postoperatively. Major morbidity was defined as pneumonia, unplanned intubation, ventilator support for >48 hours, progressive or acute renal failure, cerebrovascular accident, cardiac arrest, or myocardial infarction. Demographics, comorbidities, procedure type, and laboratory values were considered for inclusion in the risk predictive models. Logistic regression models for mortality, major morbidity and MALE were developed. The discriminative ability of these models (C-indices) were compared with that of the 5-Factor Modified Frailty Index (mFI-5): a general frailty tool determined from diabetes, functional status, history of chronic obstructive pulmonary disease, history of congestive heart failure, and hypertension. Calculators were derived using the most significant variables for each of the three risk predictive models. Results A total of 2612 cases (mean age 65.0, 60% male) were identified, of which 1149 (44.0%) were femorofemoral bypass, 1138 (43.6%) were aortofemoral bypass, and 325 (12.4%) were axillofemoral bypass. Overall, the rates of mortality, major morbidity, and MALE were 2.0%, 8.5%, and 4.9%, respectively. Twenty preoperative risk factors were considered for incorporation in the risk tools. Apart from procedure type, age was the most statistically significant predictor of both mortality and morbidity. Preoperative anemia and critical limb ischemia were the most significant predictors of MALE. All three constructed models demonstrated significantly better discriminative ability (P Conclusions Our models outperformed the mFI-5 in predicting 30-day mortality, major morbidity, and adverse limb events in patients with AIOD undergoing elective bypass surgery. Calculators were created using the most statistically significant variables to help calculate individual patient's postoperative risks and allow for better informed consent and risk-adjusted comparison of provider outcomes.

Despite endovascular advancements, aortofemoral bypass (AFB; aortounifemoral and aortobifemoral bypass) remains the most durable option for aortoiliac occlusive disease. Whereas AFB reduces vascular aortoiliac reintervention, the impact of laparotomy-associated and groin wound complications on morbidity and reintervention is unclear. The aim of this study was to establish the incidence of nonvascular complications after AFB and to determine their effect on reintervention.Institutional data for AFB (2000-2017) were queried. Primary end points included laparotomy-associated and groin wound complications. Total reintervention was defined as the composite outcome of reinterventions for laparotomy and groin wound complications and graft patency. Kaplan-Meier analysis estimated freedom from reintervention. Fine-Gray method for competing long-term risk determined predictors of laparotomy complications. Logistic regression, adjusting variability for patient-level clustering, determined predictors of wound complications.There were 553 limbs in 281 patients (272 aortobifemoral and 9 aortounifemoral bypasses; age, 67.6 ± 11.0 years; 50.5% female). Ninety (32%) patients had prior abdominal surgery, 3.2% had prior ventral hernia (VH) repair, 2.9% had untreated VH, and 0.7% had history of small bowel obstruction. The majority of patients underwent AFB for claudication (66.2%); 87.2% had TransAtlantic Inter-Society Consensus (TASC) D lesions, 31.4% required a suprarenal clamp or higher, 16.4% had concomitant renovisceral revascularization, and 6.4% were receiving anticoagulation. Sixty-seven (12.1%) limbs had redo femoral artery exposures, 32.4% required femoral outflow adjunct, and 1.8% had simultaneous lower extremity bypass. The 30-day mortality was 2.9%. During median follow-up of 5.3 years (interquartile range, 7.3 years), 21% had laparotomy complications (VH, 15.3%; small bowel obstruction, 7.5%; other, 2.1%), including 10.0% requiring operative intervention. Sixty-seven (12%) groins had a wound complication; 4.9% required intervention. Unadjusted 1-, 3-, and 5-year freedom from graft reintervention was 93.3% (95% confidence interval [CI], 90.1%-96.5%), 85.3% (80.7%-90.2%), and 79.6% (74.1%-85.5%), respectively. Freedom from total reintervention at 1 year, 3 years, and 5 years was 82.1% (95% CI, 77.4%-87.1%), 73.6% (68.0%-79.6%), and 65.1% (58.7%-72.2%). Predictors of laparotomy complications were untreated VH (P = .01) and hypertension (P = .01). Protective factors were thoracoabdominal approach (P .01) and aortounifemoral bypass (P .01). Predictors of wound complications included body mass index (per kg, 1.07; CI, 1.01-1.15; P = .018), anticoagulation (2.59; CI, 1.01-8.37; P = .049), and previous iliac stents (2.60; CI, 1.36-4.94; P = .004).Whereas AFB is a durable reconstruction with infrequent need for graft reintervention, laparotomy- and groin wound-associated complications contribute significantly to morbidity and reintervention after AFB. Predictive factors for laparotomy and groin wound complications should be considered in preoperative planning and selection of patients for AFB and in the discussion of outcomes.

National data evaluating outcomes for occlusive abdominal aortic reconstructions are well described. The relative effect of operative indication as well as the presence of concomitant abdominal aortic aneurysm (AAA) on in-hospital mortality is not well defined.The Nationwide Inpatient Sample was queried to identify patients who underwent open aortic surgery (2003-2010). Indication for surgery was classified by International Classification of Diseases, Ninth Revision diagnostic codes to identify isolated occlusive indications as well as combined occlusive disease and AAA. Primary outcome was in-hospital mortality. Secondary outcomes were complications and discharge disposition.Overall, 56,374 underwent aortic reconstruction, 48,591 for occlusive disease (86.2%) and 7783 for combined occlusive disease with AAA (13.8%). Intermittent claudication was the most common indication for intervention (60.9%), whereas 39.7% underwent intervention for critical limb ischemia (22.2% rest pain, 17.6% gangrene). Patients with intermittent claudication had more concomitant AAAs (17.3%) than did patients with critical limb ischemia (8.4%). The baseline characteristics for those with occlusive disease and combined occlusive with AAA disease were similar in terms of obesity (4.8% vs 4.2%; P = .27) and congestive heart failure (6.6% vs 6.3%; P = .65) but differed by age (62.2 years vs 68.4 years; P .0001) and hypertension (65.4% vs 69.1%; P = .005). Patients with combined occlusive and AAA disease had higher mortality than those with occlusive disease alone (3.9% vs 2.7%; P = .01). On multivariable regression, factors associated with in-hospital mortality included gangrene with AAA compared with gangrene alone (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.6-4.7; P .0002), age65 years age (OR, 3.1; 95% CI, 2.4-4.1; P .0001), renal failure (OR, 2.7; 95% CI, 1.9-3.8; P .0001), and concurrent lower extremity revascularization (OR, 1.3; 95% CI, 1.1-1.7; P .02).Intermittent claudication or critical limb ischemia with concomitant AAA carries a higher mortality than intermittent claudication or critical limb ischemia alone, especially in older patients with gangrene requiring revascularization and renal insufficiency. Preoperative risk stratification strategies should focus on the indication for surgery as well as the presence of concomitant AAA.

Objective To evaluate and compare studies reporting the outcomes of the use of covered balloon-expandable (CBE) stents for the treatment of aortoiliac occlusive disease. Methods A systematic literature search was conducted to identify studies that investigated the use of CBE stents for the treatment of aortoiliac occlusive disease and were published between 2000 and 2019. Baseline demographic data, procedural variables, and long-term outcomes were extracted from publications for analysis. Results A total of 15 published articles about 14 studies were included in the review. Of these, eight studies were prospective clinical trials and six studies were retrospective real-world studies. The articles included data regarding five different CBE stents, namely, the iCast/Advanta V12, Viabahn VBX, BeGraft, LifeStream, and JOSTENT. Lesion severity was higher in real-world studies, with more TransAtlantic Inter-Society Consensus Classification class D lesions and a higher percentage of occlusions. All studies showed high rates of technical success and patency over the course of 12 months. Long-term data were only available for the iCast/Advanta V12 device, which had a primary patency rate of 74.7% at 5 years. Conclusions CBE stents are a viable treatment option for patients with complex aortoiliac lesions because of their high rates of technical success and favorable patency across all devices at 12 months. However, long-term data are only available for a single device, the iCast/Advanta V12. The results of using this device were favorable over the course of 5 years.

The benefit of statins in reducing perioperative cardiovascular events in patients undergoing suprainguinal bypass is still controversial. The purpose of this study was to evaluate the association between statin use and perioperative mortality in patients undergoing aortobifemoral bypass (ABFB) for aortoiliac occlusive disease.We retrospectively analyzed all patients who had ABFB in the American College of Surgeons National Surgical Quality Improvement Program data set from 2011 to 2016. Univariable (t-test, χA total of 4445 patients underwent ABFB. Of those, 3032 (68.2%) were taking statins. Compared with nonstatin users, statins users were older (median [interquartile range], 67 years [59-74 years] vs 63 years [56-72 years]; P .01) and more likely to be diabetic (31% vs 16%) and hypertensive (84% vs 63%) and to have a history of chronic obstructive pulmonary disease (20% vs 17%; all P .05). Statin users had lower rates of 30-day mortality (3.4% vs 4.7%; P = .03) and renal complications (2.5% vs 3.7%; P = .04) compared with nonstatin users. After adjustment for patients' demographics (age, sex, race), comorbidities (diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, dialysis, bleeding disorder), smoking, clinical presentation (claudication vs critical limb ischemia), and elective surgery status, statin use was associated with 32% reduction in 30-day mortality (odds ratio, 0.68; 95% confidence interval, 0.47-0.96; P = .03). Propensity score matching showed similar results (odds ratio, 0.63; 95% confidence interval, 0.41-0.95; P = .03).This is the largest study to date demonstrating an association between preoperative statin use and lower 30-day mortality after ABFB for aortoiliac occlusive disease. This study highlights an area of potential quality improvement as one-third of the patients undergoing this procedure are not receiving statins.

Objective Thoracofemoral bypass (TFB) is an alternative to aortofemoral bypass (AFB) or extra-anatomic bypass for severe aortoiliac occlusive disease (AIOD). TFB may be particularly useful in select patients with concurrent visceral aortic branch vessel disease, infrarenal aortic occlusions, or after failed AFB. However, there are few contemporary series describing the indications and outcomes for TFB. Therefore, the purpose of this analysis was to review our experience with TFB. Methods All patients undergoing TFB for occlusive disease from 2002 to 2017 were reviewed. All patients underwent left thoracoretroperitoneal exposure of the supraceliac aorta with division of the diaphragmatic crus and supraceliac cross-clamping. An end-to-side aortic anastomosis was created and each graft limb was tunneled in the retroperitoneum to the femoral bifurcation. Adjunctive visceral/infrainguinal revascularization was performed selectively based on symptoms, end-organ function, and/or preoperative imaging. The primary end points were major complications and 30-day mortality. Secondary end points included limb patency, freedom from major adverse limb events, and survival. Kaplan-Meier methodology was used to characterize the end points. Results Forty-one patients (age 61 ± 9 years; 54% female; 7% in a hypercoaguable state) underwent TFB. The mean preoperative ankle-brachial index was 0.4 bilaterally. Indications included critical limb ischemia (56%), claudication (30%), acute limb ischemia (7%), and combined AIOD and mesenteric ischemia (7%). Seven patients (17%) had previously undergone AFB and 15 (38%) had previously undergone any prior aortic operation. Adjunctive visceral bypass occurred in 8 patients (20%; N = 14 grafts, n = 6 renal, n = 5 superior mesenteric artery, and n = 3 celiac). The postoperative duration of stay was 11 days (interquartile range [IQR], 7-16 days) and the 30-day mortality was 5% (n = 2). Major complications occurred in 34% of patients (N = 14; pulmonary, 15%; cardiac, 12%; bleeding, 7%; accidental splenectomy, 5%; renal, 5%; wound, 2%). The mean postoperative ankle-brachial index was 0.9 bilaterally. At a median follow-up of 7 months (IQR, 1-17 months), 5 patients (12%) underwent some form of reintervention (graft/limb related, n = 4 [n = 2 graft thrombosis, n = 2 graft infection], n = 1 mesenteric bypass revision). The estimated 3-year primary limb patency and freedom from major adverse limb events were 80 ± 10%, and 70 ± 10%, respectively. The estimated 5-year survival was 93 ± 5% (median, 27.3; IQR, 14.5-35.2; 95% confidence interval, 17.9-32.8). Conclusions This experience represents one of the largest and most current series of retroperitoneal TFB. We demonstrate that TFB can be performed with good outcomes for patients with severe AIOD, especially if concomitant visceral/infrainguinal reconstruction is warranted. These results support a continued role for TFB in select patients.

OBJECTIVE: Open surgery has given way to endovascular grafting in patients with aortoiliac occlusive disease. The growing use of endovascular grafts means that fewer patients with aortoiliac occlusive disease have open surgery. The declining open surgery caseload challenges the surgeon's operative skills, particularly because open surgery is increasingly used in those patients who are unsuitable for endovascular repair and hence technically more demanding. We assessed the early outcome after aortic bifurcated bypass procedures during two decades of growing endovascular activity and identified preoperative risk factors.METHODS: Data on patients with chronic limb ischemia were prospectively collected during a 20-year period (1993 to 2012). The data were obtained from the Danish Vascular Registry, assessed, and merged with data from The Danish Civil Registration System.RESULTS: We identified 3623 aortobifemoral and 144 aortobiiliac bypass procedures. The annual caseload fell from 323 to 106 during the study period, but the 30-day mortality at 3.6% (95% confidence interval [CI], 3.0-4.1) and the 30-day major complication rate remained constant at 20% (95% CI, 18-21). Gangrene (odds ratio [OR], 3.3; 95% CI, 1.7-6.5; P = .005) was the most significant risk factor for 30-day mortality, followed by renal insufficiency (OR, 2.5; 95% CI, 1.1-5.8; P = .035) and cardiac disease (OR, 2.1; 95% CI, 1.4-3.1; P < .001). Multiorgan failure, mesenteric ischemia, need for dialysis, and cardiac complications were the most lethal complications, with mortality rates of 94%, 44%, 38%, and 34%, respectively.CONCLUSIONS: Aortic bifurcated bypass is a high-risk procedure. Although open surgery has increasingly given way to endovascular repair, 30-day outcomes have remained stable during the past decade. Thus, it is still acceptable to consider an aortic bifurcated bypass whenever endovascular management is not feasible.

Item does not contain fulltext OBJECTIVE: Kissing stents (KS) are commonly used to treat aortoiliac occlusive disease, but patency results are often lower than those of isolated stents. The Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) technique was recently introduced to reconstruct the aortic bifurcation in a more anatomical and physiological fashion. The aim of this study is to compare the geometrical consequences of various stent configurations in vitro. METHODS: Anatomic vessel phantoms of the aortoiliac bifurcation were created to accommodate stent configurations. Self-expandable nitinol KS, balloon-expandable covered KS, and two versions of the CERAB configuration were deployed, one with the iliac legs positioned inside the tapered part of the aortic cuff (1) and one with the legs deployed above this level (2). Computed tomography data were obtained to assess the geometry. The conformation ratio (D-ratio) was calculated by use of the ratio of the major and minor axes. The proximal mismatch area, mean mismatch area, and total mismatch volume were calculated. RESULTS: The highest D-ratios were observed in the nitinol KS and the CERAB configuration, implying an ideal "double-D" shape. The proximal and mean mismatch areas were four- to sixfold lower in the CERAB (1) configuration when compared with nitinol KS and CERAB (2), respectively, whereas the covered KS had the highest mismatch area. Nitinol and covered KS had the largest mismatch volume, whereas the mismatch volume was the lowest in the CERAB (1) configuration. CONCLUSIONS: Although nitinol self-expandable stents have a high stent conformation, the lowest radial mismatch was found in the CERAB (1) configuration, supporting the hypothesis that the CERAB configuration is the most anatomical and physiological reconstruction of the aortic bifurcation. Within the CERAB configuration, the two limbs are ideally positioned inside the tapering portion of the cuff, minimizing mismatch.

Objective We reviewed our experience of total laparoscopic aortic bypass surgery performed for aortoiliac occlusive disease (AIOD), focusing on early 30-day mortality and morbidity and short-term and midterm outcomes. Methods A monocentric retrospective study was conducted between October 2002 and October 2011; we performed 173 total laparoscopic aortic surgeries to treat AIOD. Results Patients included 135 men and 38 women. The mean age was 57.2 years (range, 34-77 years). The median operative time was 205 minutes (range, 120-420 minutes), the median aortic clamping time was 50 minutes (range, 20-120 minutes), and the mean blood loss was 263 mL (range, 0-3200 mL). Conversion to open surgery was necessary in 12.1% of patients. The 30-day postoperative mortality rate was 2.3% (four of 173 patients). Major morbidity occurred in 6.9% of patients. Wound complications occurred in 8%. Four patients had a groin infection (2.3%), treated by surgical trimming in three patients and replacement of the prosthesis by venous bypass in one patient. Early graft thrombosis (within 30 days) occurred in one patient (0.6%), requiring reintervention. With a mean follow-up of 42 months (standard deviation, 37 months), 96% of bypasses were patent. Patency rates at 3 and 5 years were 97% and 85% respectively. Conclusions In selected patients, laparoscopic aortic bypass surgery for AIOD is a safe procedure with an acceptable morbidity rate, short intensive care unit and hospital stay, fast recovery, and early return to general diet. It is a good indication after failure of endovascular surgery.

Objective This study aimed to report the long-term limb salvage, survival and patency rates of endovascular treatment for aortoiliac occlusive disease (AIOD) when outflow was achieved through the profunda femoris artery (PFA) only vs both the PFA and superficial femoral artery (SFA). Methods From January 2008 to July 2016, patients with AIOD who underwent aortoiliac angioplasty at the Division of Vascular and Endovascular Surgery, Hospital do Servidor Publico Estadual, Sao Paulo, Brazil, were classified into two groups according to whether they had femoral outflow via the PFA only (group 1) or both the PFA and SFA (group 2) in the affected leg. The primary outcome was amputation-free survival. The secondary outcomes were the patency and overall survival rates. Results In total, 69 aortoiliac angioplasties were performed in 69 patients: 22 patients (31.8%) in group 1 and 47 (67.2%) in group 2. A total of 12 reinterventions (17.4%) were performed, seven (31.8%) in group 1 and five (10.2%) in group 2, without statistical significance between the groups (P = .063). The mean clinical follow-up period was 2500 ± 880.5 days. Both the primary and secondary patency rates analyzed at 1800 days were similar between groups 1 and 2 (80.2% vs 82.3%; P = .80 and 84.7% vs 97.6%; P = .10, respectively). Furthermore, the limb salvage rates at 1800 days were similar between groups 1 and 2 (91.3% vs 86.1%; P = .60), as were the survival rates (74.7% vs 78%; P = .80). The Bollinger score was worse in group 1 (P = .001), as expected, because of occlusion of the SFA. However, the PFA and popliteal artery scores were similar between the two groups. Occlusion of the SFA did not influence the limb salvage rate according to univariate analysis (P = .509) and multivariate Cox regression analysis (P = .671). Conclusions The patency of the SFA does not interfere with the outcomes of endovascular treatment for chronic AIOD. The PFA in conjunction with the popliteal artery as the sole outflow route for iliac endovascular treatment is associated with similar patency, survival, and limb salvage rates as those for outflow through both the PFA and SFA.

Endovascular intervention has supplanted open bypass as the most frequently used approach in patients with aortoiliac segment atherosclerosis. We sought to determine whether this trend together with changing demographic and clinical characteristics of patients undergoing aortobifemoral bypass (ABFB) for aortoiliac occlusive disease (AOD) have an association with postoperative outcomes.Using a prospectively maintained institutional database, we identified patients who underwent ABFB for AOD from 1985 to 2015. Patients were divided into two cohorts: the historical cohort (HC) included patients who underwent ABFB for AOD from 1985 to 1999 and the contemporary cohort (CC) who underwent ABFB for AOD from 2000 to 2015. Medical and demographic data, procedural information, postoperative complications, and follow-up data were extracted. Cox proportional hazards regression was used to evaluate associations with the end point of primary patency. A similar analysis was performed for major adverse limb events (MALEs; the composite of above-ankle amputation, major reintervention, graft revision, or new bypass graft of the index limb) in the subset of patients with critical limb ischemia.There were a total of 359 cases: 226 in the HC and 133 in the CC. The CC had more women (56.4% vs 43.8%; P = .02), smokers (87.2% vs 67.7%; P = .001), and patients who failed prior aortoiliac endovascular intervention (17.3% vs 4.8%; P = .0001), but fewer patients with coronary artery disease (32.3% vs 47.3%; P = .005). Thirty-day mortality was less than 1% in both cohorts, but 10-year survival was higher in the CC (67.7% vs 52.6%; P = .02). Five-year primary, primary-assisted, and secondary patency were higher in the HC (93.3% vs 82.2%; P = .005; 93.8% vs 85.7%; P = .02; 97.5% vs 90.4%; P = .02, respectively). CC membership, decreasing age, prior aortic surgery, and decreasing graft diameter were significant independent predictors of loss of primary patency after adjustment (hazard ratio [HR], 7.03; 95% confidence interval [CI], 2.80-17.63; P .0001; HR, 0.93; 95% CI, 0.90-0.96; P .0001; HR, 18.80; 95% CI, 5.94-59.58; P .0001; and HR, 0.73; 95% CI, 0.55-0.95; P = .02, respectively). Similarly, CC membership, prior aortic surgery, and decreasing graft diameter were significant independent predictors of MALE in the critical limb ischemia cohort after adjustment (HR, 21.13; 95% CI, 4.20-106.40; P = .0002; HR, 40.40; 95% CI, 3.23-505.61; P = .004; and HR, 0.51; 95% CI, 0.30-0.86; P = .01, respectively).Compared with the pre-endovascular era, demographic and clinical characteristics of patients undergoing ABFB for AOD in the CC have changed. Although long-term patency is slightly lower among patients in the CC during which a substantial subset of AOD patients are being treated primarily via the endovascular approach, durability remains excellent and limb salvage unchanged. After adjustment, the time period of index ABFB independently predicted primary patency and MALE, as did graft diameter and prior aortic surgery. These changing characteristics should be considered when counseling patients and benchmarking for reintervention rates and other outcomes.

Endovascular intervention has become the mainstay for treatment of most patients suffering from peripheral vascular disease. We describe a patient with a known nickel allergy who underwent placement of a stainless steel stent for aortoiliac occlusive disease. Despite our attempt to avoid a nickel-containing stent, the patient developed a diffuse rash consistent with a nickel or metal allergy. A review of stainless steel metallurgy revealed that nickel, cobalt, and titanium are frequently used to provide anticorrosive properties to stainless steel. The clinical significance of the use of nickel-alloy stents in the setting of patients with a nickel allergy is discussed.

Objective Duplex ultrasound (DUS) arterial mapping of the aortoiliac area is limited by obesity, abdominal gas, and the need to use a low-frequency probe (and therefore poorer resolution) in the examination. The aim of this study was to analyze the degree of agreement between DUS mapping of the aortoiliac area and angiography or contrast-enhanced computed tomography angiography (CTA). Methods This was a retrospective observational study. Between November 2006 and June 2015, there were 173 patients with a surgical indication for aortoiliac occlusive disease included, with preoperative aortoiliac DUS mapping and subsequent CTA or intraoperative angiography. Sensitivity, specificity, positive predictive value, and negative predictive value of DUS as an arterial mapping test were analyzed, as was the degree of agreement with angiography/CTA and agreement between the surgical indication based on DUS and the final surgical technique performed. Results Of 173 DUS mapping tests, 155 were evaluated (89.6%); the remaining 18 were not able to be evaluated because of the patient's obesity or bowel gas. Overall accuracy of DUS for predicting significant artery lesions was as follows: 92% sensitivity (95% confidence interval [CI], 88%-95%), 96% specificity (95% CI, 95%-97%), 89% positive predictive value (95% CI, 86%-93%), and 97% negative predictive value (95% CI, 96%-98%). Agreement with angiography/CTA had a κ index of 0.81 (95% CI, 0.77-0.84), which reflects a good degree of agreement. Surgical indications based on DUS mapping were correct in 89% of cases (138/155). Conclusions DUS mapping of the aortoiliac territory could be used as a single preoperative imaging test in aortoiliac occlusive disease in patients whose DUS examination is able to be evaluated.

Objective The objective of this study was to demonstrate the 3-year outcome of the covered endovascular reconstruction of the aortic bifurcation (CERAB) technique for the treatment of extensive aortoiliac occlusive disease (AIOD). Methods Between February 2009 and July 2016, all patients treated with the CERAB technique for AIOD were identified in the local databases of two centers and analyzed. Demographics and lesion characteristics were scored. Follow-up consisted of clinical assessment, duplex ultrasound, and ankle-brachial indices. Patency rates and clinically driven target lesion revascularization were calculated by Kaplan-Meier analysis. Results Of 130 patients (69 male and 61 female) treated, 68% were diagnosed with intermittent claudication and 32% suffered from critical limb ischemia. The majority (89%) were TransAtlantic Inter-Society Consensus II D lesions, and the remaining were B and C lesions (both 5%). Median follow-up was 24 months (range, 0-67 months). The technical success rate was 97%, and 67% of cases were performed completely percutaneously. The ankle-brachial index improved significantly from 0.65 ± 0.22 preoperatively to 0.88 ± 0.15 after the procedure. The 30-day minor and major complication rate was 33% and 7%. The median hospital stay was 2 days (range, 1-76 days). At 1 year and 3 years of follow-up, 94% and 96% of the patients clinically improved at least one Rutherford category (2% and 0% unchanged, 4% and 4% worsened). Limb salvage rate was 98% at 1 year and 97% at 3 years of follow-up. Primary, primary assisted, and secondary patency was 86%, 91%, and 97% at 1 year; 84%, 89%, and 97% at 2 years; and 82%, 87%, and 97% at 3 years. Freedom from clinically driven target lesion revascularization was 87% at 1-year follow-up and 86% at both 2-year and 3-year follow-up. Conclusions The CERAB technique is a safe and feasible technique for the treatment of extensive AIOD with good 3-year results regarding patency and clinical improvement.

Objective Randomized trials and retrospective data suggest that covered balloon-expandable (CBE) stents have better short-term patency compared with balloon-expandable bare-metal stents (BMSs) in the treatment of iliac artery disease. This study evaluated midterm outcomes of BMSs vs CBE stents placed in the common iliac artery (CIA) for aortoiliac occlusive disease. Methods All endovascular interventions for symptomatic peripheral arterial occlusive disease performed at a single institution from 2006 to 2012 were reviewed. Patients undergoing stent placement in the CIA segment were included in the analysis. Demographic data, TransAtlantic Inter-Society Consensus (TASC) classification, stent type, patency, and limb reinterventions were compared. Results For treatment of de novo distal aorta or CIA stenosis, 254 procedures were performed in 162 patients. BMSs were used in 190 arteries; CBE stents were used in 64 arteries. There was no difference in age, gender, or TASC classification between the two groups. Mean follow-up was 22 ± 16 months. Primary patency, assisted patency, and secondary patency were significantly better in the BMS group. CIAs treated with covered stents were more likely at 1 year or longer to require repeated intervention (hazard ratio, 2.5; 95% confidence interval, 1.2-5.3; P = .009). TASC classification did not predict need for reintervention in either group. Multivariate analysis revealed dual antiplatelet therapy to be the only other factor to affect patency during long-term follow-up. Conclusions In this study, BMSs had significantly better patency compared with CBE stents for treatment of aortoiliac occlusive disease. A randomized trial comparing patency as well as restenosis rates with long-term follow-up is needed to determine if there is any benefit from use of covered stents in the aortoiliac segment.

Objective Aortoiliac arterial occlusive (AIOD) disease is common in India. The clinical presentation and etiology are different than in the West. Intervention is frequently required for advanced lower extremity ischemia, but the results have not been systemically evaluated. We studied the clinical profile and midterm results of patients undergoing aortobifemoral bypass for AIOD at a tertiary care center in south India. Methods Clinical data of patients undergoing aortobifemoral bypass for AIOD over a 6-year period from January 1, 2005 to December 31, 2010 were retrospectively analyzed. Clinical presentation and factors affecting outcome were evaluated. Graft patency and mortality were included as study end points. Results Ninety-nine patients (mean age, 52 years) with AIOD who underwent aortobifemoral bypass were included. Etiology included atherosclerosis in 79 patients, thromboangiitis obliterans in 15, Takayasu's arteritis in two, and hematological conditions in 3. Smoking (82%), hypertension (40%), and diabetes (30%) were the most common risk factors; ischemic heart disease (4%), obesity (2%), and dyslipidemia (3%) were rare. Eighty-one percent of patients presented with critical limb ischemia. Mean duration of symptoms was 22 months (range, 4 months to 9 years). Concomitant infrainguinal arterial occlusive disease was identified in 81%, but intervened upon in only 2%. In-hospital mortality was 3%. Causes of death included myocardial infarction in two and colon ischemia in one. Major morbidity included nonfatal myocardial infarction (3%), pneumonia/atelectasis (5%), and renal dysfunction (2%). Groin wound complications occurred in 20%, seroma/lymph leak in 13%, infection in 7%, and anastomotic hemorrhage in 2%. Multidrug-resistant and polymicrobial infections were common. Early graft thrombosis (30 days) occurred in 15 patients; 8 of 11 reintervened grafts were salvaged. Four more grafts thrombosed during a mean follow-up of 2 years (range, 0-5 years) and two became infected. Overall study major limb loss rate was 10% (primary, 2%; secondary, 8%). Delayed presentation and smoking were more common in patients developing complications. There was no significant difference in overall complication rates between patients with thromboangiitis obliterans and atherosclerosis ( P = .66). Conclusions Despite earlier age at presentation, atherosclerosis remains the predominant etiology of aortoiliac arterial occlusive disease in Indian patients. Results of open revascularization are comparable to those in the Western literature. Thromboangiitis obliterans is the underlying pathology in a minority of patients with no significant difference in operative outcome. Patients frequently present late with critical limb ischemia, but this does not affect outcome.

Background Endovascular treatment of aortoiliac occlusive disease entails the use of multiple stents to reconstruct the aortic bifurcation. Different configurations have been applied and geometric variations exist, as quantified in previous work. Other studies concluded that specific stent geometry seems to affect patency. These variations may affect local flow patterns, resulting in different wall shear stress (WSS) and oscillating shear index (OSI). The aim of this study was to compare the effect of different stent configurations on flow perturbations (recirculation and fluid stasis), WSS, and OSI in an in vitro setup. Methods Three different stent configurations were deployed in transparent silicone models: bare-metal kissing (BMK) stents, covered kissing (CK) stents, and the covered endovascular reconstruction of the aortic bifurcation (CERAB) configuration. Transparent covered stents were created with polyurethane to enable visualization. Models were placed in a circulation setup under physiologic flow conditions. Time-resolved laser particle image velocimetry techniques were used to quantify the flow, and WSS and OSI were calculated. Results The BMK configuration did not show flow disturbances at the inflow section, and WSS values were similar to the control. An area of persistent low flow was observed throughout the cardiac cycle in the area between the anatomic bifurcation and neobifurcation. The CK model showed recirculation zones near the inflow area of the stents with a resulting low average WSS value and high OSI. The proximal inflow of the CERAB configuration did not show flow disturbances, and WSS values were comparable to control. Near the inflow of the limbs, a minor zone of recirculation was observed without changes in WSS values. Flow, WSS, and OSI on the lateral wall of the proximal iliac artery were undisturbed in all models. Conclusions The studied aortoiliac stent configurations have distinct locations where flow disturbances occur, and these are related to the radial mismatch. The CERAB configuration is the most unimpaired physiologic reconstruction, whereas BMK and CK stents have their typical zones of flow recirculation.

In an era of increasing emphasis on minimally invasive surgery, distal embolization remains a concern in the absence of distal flow control. We present a case using an endovascular flow control technique that can be used for reducing distal embolic events during endovascular recanalization of aortoiliac occlusive disease. This technique has been used in four patients so far (two with native anatomy and two with aorto-bi-iliac grafts) with no evidence of angiographic or clinical embolic complications.

Objective Published reports of robotic-assisted aortic surgery involve a combination of laparoscopy for aortic dissection and a robotic system for vascular reconstruction. The objective of this study is to determine the feasibility and advantage of a total robotic-assisted aortic dissection and vascular reconstruction vs robotic-assisted aortic procedures for aortoiliac occlusive disease (AIOD) and abdominal aortic aneurysm (AAA). Methods From February 2006 to August 2010, 21 patients were selected for robotic-assisted aortic procedures: aortobifemoral bypass in 12, AAA repair in 6, iliac aneurysm repair in 1, and ligation of type II endoleak after endovascular aneurysm repair in 2. Inclusion criteria included AAA >5 cm, iliac aneurysm >3 cm, and AIOD TransAtlantic InterSociety Classification (TASC) C or D lesions. The da Vinci S Surgical System (Intuitive Surgical Inc, Sunnyvale, Calif) was used for the abdominal aortic dissection in all cases and for the aortic anastomosis in three cases. Results The 21 patients (6 women, 15 men) were an average age of 65.7 years (range, 44-86 years), had a body mass index (BMI) of 27.23 kg/m 2 , and 90.4% were American Society of Anesthesiologists (ASA) class 3 or 4. Robotic dissection of the abdominal aorta was successful in 20 patients (95.2%). One patient required full conversion to open AAA repair due to trocar injury. Of the remaining 20 patients, the average robotic dissection time of the infrarenal aorta was 113.1 minutes, and the average aortic clamp time was 86 minutes. The procedure in 15 patients was performed with a minilaparotomy using an average abdominal incision of 13 cm to implant the Dacron or polytetrafluoroethylene graft. Five patients underwent a total robotic-assisted procedure with robotic aortic reconstruction or ligation of a type II endoleak. The 30-day survival rate was 100%. Median length of stay was 7.5 days. All grafts were patent at a median follow-up of 32.0 months. Conclusions For aortic procedures completed total robotically without an abdominal incision, the estimated blood loss was significantly less than in robotic-assisted procedures with a minilaparotomy. In these selected patients, robotic-assisted technology may be part of the armamentarium for the vascular surgeon as another less invasive method for the treatment of complicated occlusive disease or aneurysm.

BackgroundAbdominal aortic aneurysms (AAAs) and abdominal wall hernias represent chronic degenerative conditions. Both aortic aneurysms and inguinal hernias share common epidemiologic features, and several investigators have found an increased propensity for hernia development in patients treated for aortic aneurysms. Chronic inflammation and dysregulation in connective tissue metabolism constitute underlying biological processes, whereas genetic influences appear to be independently associated with both disease states. A literature review was conducted to identify all published evidence correlating aneurysms and hernias to a common pathology.MethodsPubMed/Medline was searched for studies investigating the clinical, biochemical, and genetic associations of AAAs and abdominal wall hernias. The literature was searched using the MeSH terms “aortic aneurysm, abdominal,” “hernia, inguinal,” “hernia, ventral,” “collagen,” “connective tissue,” “matrix metalloproteinases,” and “genetics” in all possible combinations. An evaluation, analysis, and critical overview of current clinical data and pathogenic mechanisms suggesting an association between aneurysms and hernias were undertaken.ResultsAmple evidence lending support to the clinical correlation between AAAs and abdominal wall hernias exists. Pooled analysis demonstrated that patients undergoing aortic aneurysm repair through a midline abdominal incision have a 2.9-fold increased risk of developing a postoperative incisional hernia compared with patients treated for aortoiliac occlusive disease (odds ratio, 2.86; 95% confidence interval, 1.97-4.16; P < .00001), whereas the risk of inguinal hernia was 2.3 (odds ratio, 2.30; 95% confidence interval, 1.52-3.48; P < .0001). Emerging evidence has identified inguinal hernia as an independent risk factor for aneurysm development. Although mechanisms of extracellular matrix remodeling and the imbalance between connective tissue degrading enzymes and their inhibitors instigating inflammatory responses have separately been described for both disease states, comparative studies investigating these biological processes in aneurysm and hernia populations are scarce. A genetic predisposition has been documented in familial and observational segregation studies; however, the pertinent literature lacks sufficient supporting evidence for a common genetic basis for aneurysm and hernia.ConclusionsInsufficient data are currently available to support a systemic connective tissue defect affecting the structural integrity of the aortic and abdominal wall. Future investigations may elucidate obscure aspects of aneurysm and hernia pathophysiology and create novel targets for pharmaceutical and gene strategies for disease prevention and treatment.

Background Since the end of the 20th century, robot-assisted surgery has been finding its role among other minimally invasive methods. Vascular surgery seems to be another specialty in which the benefits of this technology can be expected. Our objective was to assess the learning curve of robot-assisted laparoscopic aortofemoral bypass grafting for aortoiliac occlusive disease in a group of 40 patients. Methods Between May 2006 and January 2010, 40 patients (32 men, 8 women), who were a median age of 58 years (range, 48-75 years), underwent 40 robot-assisted laparoscopic aortofemoral reconstructions. Learning curve estimations were used for anastomosis, clamping, and operative time assessment. For conversion rate evaluation, the cumulative summation (CUSUM) technique was used. Statistical analysis comparing the first and second half of our group, and unilateral-to-bilateral reconstructions were performed. Results We created 21 aortofemoral and 19 aortobifemoral bypasses. The median proximal anastomosis time was 23 minutes (range, 18-50 minutes), median clamping time was 60 minutes (range, 40-95 minutes), and median operative time was 295 minutes (range, 180-475 minutes). The 30-day mortality rate was 0%, and no graft or wound infection or cardiopulmonary or hepatorenal complications were observed. During the median 18-month follow-up (range, 2-48 months), three early graft occlusions occurred (7%). After reoperations, the secondary patency of reconstructions was 100%. Data showed a typical short learning curve for robotic proximal anastomosis creation with anastomosis and clamping time reduction. The operative time learning curve was flat, confirming the procedure's complexity. There were two conversions to open surgery. CUSUM analysis confirmed that an acceptable conversion rate set at 5% was achieved. Comparing the first and second half of our group, all recorded times showed statistically significant improvements. Differences between unilateral and bilateral reconstructions were not statistically significant. Conclusions Our results show that the success rate of robot-assisted laparoscopic aortofemoral bypass grafting is high and the complication rate is low. Anastomosis creation, one of the main difficulties of laparoscopic bypass grafting, has been overcome using the robotic operating system and its learning curve is short. However, the endoscopic dissection of the aortoiliac segment remains the most difficult part of the operation and should be addressed in further development of the method to reduce the operative times. Long-term results and potential benefits of this minimally invasive method have to be verified by randomized controlled clinical trials.