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Endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) using a branched stent graft is a technically challenging procedure. A 64-year-old man with multiple medical problems, including severe renal impairment, is presented with a ruptured type IV TAAA. He underwent emergency repair using an off-the-shelf branched stent graft and carbon dioxide as the exclusive contrast agent.

Technical advances in Vascular Surgery have led to an increased use of prostheses (grafts, patches, stents, stent grafts etc.) and improved results for the patient. Despite routine antibiotic prophylaxis, infection, although rare, remains a serious complication, with catastrophic consequences. Vascular infections are divided into 3 groups according to Szilagyi (Table 1.), depending on the extent of the inflammation: the superficial, the deep and the mixed type.[1] Samson (Table 1.), as well as Karl and Storck (Table 1.) , have modified the widely used classification system of Szilagyi.[1-3] While the superficial type is restricted to the skin and subcutaneous tissue, the deep infection involves the vessels or a prosthetic graft. The mixed type of vascular infection is the combination of the above types affects all the tissue layers and can produce trauma disruption. Vascular infections can be classified by appearance time into: a) early ( 4 weeks). Samson’s and Karl’s modifications take into consideration further clinical parameters, which define the treatment (Table 2.). [2,3] When infection involves a graft anastomosis or the suture line of a patch, there is high risk of vessel rupture, septic hemorrhage or pseudoaneurysm formation. [4-6] Other serious complications are septic thrombosis, endocarditis, etc. [7] In severe cases, treatment can be problematic and mortality remains high, despite the use of antibiotics and surgical treatment. Keys to successful outcome include early and accurate diagnosis, identification of the infecting organism, and extent of graft infection, administration of culture-specific antibiotic therapy, and excision or replacement of the infected graft.

Objective Fenestrated endovascular aortic aneurysm repair (f-EVAR) of juxtarenal aneurysms requiring cannulation of the superior mesenteric artery and renal arteries is technically challenging, has a long operating time, and requires bilateral large-caliber sheath insertion into the femoral arteries. Consequently, the risk of lower limb ischemia and subsequent reperfusion injury is increased. We describe the use of an adjunct temporary axillobifemoral bypass graft (TABFBG) for f-EVAR and propose that it be used as a strategy to avoid ischemia–reperfusion injury in patients anticipated as being at increased risk. Methods Consecutive patients from a tertiary referral center undergoing f-EVAR, between October 2008 and August 2011, were retrospectively analyzed. Patients with lower limb arterial occlusive disease and those with difficult anatomy had an adjunct TABFBG. Results All patients presenting with a juxtarenal aortic aneurysm were treated endovascularly, regardless of aneurysm anatomy and technical difficulties. There were 37 patients without TABFBG (group 1) and 27 with TABFBG (group 2). No patients required open conversion. Sex and age were not significantly different between the groups. The median ankle-brachial pressure index was significantly higher in group 1 ( P = .0001). The groups had similar median blood loss, percentage of target vessel cannulation, and median stay in the intensive therapy unit. Morbidities were similar in both groups. There were no significant differences in cardiac, renal, or respiratory complications between the groups. The 30-day mortality was 10.8% (n = 4) in group 1 and 0% in group 2 ( P = .046). Conclusions Our series has demonstrated a significant reduction in mortality (10.8% absolute risk reduction) and no increase in morbidity with the use of a TABFBG for fenestrated grafts. This is likely a result of the reduction in ischemia and ischemia–reperfusion injury in these patients. We therefore recommend the use of TABFBG in patients with proximal severe stenotic or occlusive disease and those in whom an operative time of >4 hours is predicted (typically those for whom three or more target fenestrations is planned).