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False Aneurysms in the Groin
Symposium on Surgery at the Lahey Clinic
False Aneurysms in the Groin David P. Boyd, MD.*
Like infected grafts discussed elsewhere in this volume, the subject of false aneurysms in the groin has received scant attention in the literature.
ETIOLOGY The cause of secondary aneurysm in the femoral region after prosthetic bypass grafting is not entirely clear. We have encountered at least six instances of false aneurysm in the groin in five patients. A typical case is shown in Figure 1. In two of our patients, the anastomosis had been made with silk sutures, which were probably the cause of breakdown. Since some plastic prostheses are not incorporated into the fabric of living tissue but are simply stored rather than infiltrated, sutures must serve a perpetual function. One false sac occurred with woven Teflon, a fabric notoriously associated with graft failure.! Three instances involved knitted Dacron sutured with Dacron-Teflon material. Because two of these three instances occurred in the same patient, we blamed degenerative disease. However, technical factors may have been responsible. At reoperation, it appeared that the original anastomoses, both right and left, might have been constructed under tension. Furthermore, operative notes indicate that extensive endarterectomies of the common femoral arteries had been performed and that the surgeon had difficulty making the sutures hold.
PREVENTION OF FALSE ANEURYSMS Plastic sutures not subject to degeneration are mandatory if a plastic graft is sutured to living tissue. Despite the success of some workers with woven Teflon grafts, the failure rate is so high that we believe this material has no place in vascular surgery except, perhaps, as a temporary shunt. 4
':'Section of Thoracic and Cardiovascular Surgery, Lahey Clinic Foundation, Boston, Massachusetts
Surgical Clinics of North America-Vol. 56, No.3, June 1976
749
750
DAVID
P.
BOYD
Figure 1. False aneurysm in groin 3 years after aortoiliac bypass graft.
The part played by degenerative disease in causing false aneurysms in the femoral artery is doubtful. Certainly, the common and superficial femoral arteries are a typical site of advanced plaquing, especially posteriorly and laterally. Calcific and ulcerative changes are frequent. The temptation to strip this away is great. In many cases it is better left alone except for the 'profunda orifice. Endarterectomy performed in the im-' mediate region of the takeoff of the profunda artery is rewarding. Meticulous care is essential to avoid injury to the adventitia, especially at the femoral bifurcation. The experienced vascular surgeon can best judge the extent of necessary endarterectomy and the need for tacking sutures by palpation between the tip of the index finger and the thumb. Despite the desirability of visualizing the orifice of the profunda, I attempt to construct the original anastomosis high in the common femoral artery even if this artery must be closed partially or patched close to the profunda. In the rare instance of infection in the groin or when false sacs develop, the more clearance above the critical profunda the better the result. Most patients who require aortofemoral bypass have advanced disease, and the incidence of occlusion of the distal femoral and popliteal systems is high. On the other hand, the profunda femoris artery has an uncanny dispensation except near its origin. A voidance of injury to the degenerated parent artery is of paramount importance, particularly when recurrent operations on the groin are required. Endarterectomy of the common femoral artery should be omitted unless significant narrowing exists. If the adventitia is injured, it simply
FALSE ANEURYSMS IN THE GROIN
751
will not hold sutures. This may be the most critical factor in the cause of' secondary aneurysm when Dacron grafts and sutures have been used. Meticulous technique has been emphasized by Linton 5 and Darling,3 including avoidance oftension and proyision of a skew angle of 15° or less.
TREATMENT I have attempted plastic repair of false aneurysms ofthe groin in two cases. The aneurysmal wall seemed strong and held sutures superbly. In both instances, the repair seemed satisfactory, but the aneurysm recurred. In another instance, reconstruction appeared impossible because of distal disease, although femoral-popliteal bypass was performed. Amputation followed (the only instance ofloss oflife or limb in this series). In all other cases, the surgical technique described has resulted in cure up to this time. The sac need not be removed totally, but it must be exposed widely, and the entire anastomosis redone. This procedure requires a specific sequence of technical steps. Broad-spectrum antibiotic coverage is instituted before operation to achieve a high blood level. Initiation of antibiotic treatment should coincide with the principles advocated by Burke. 2 Antimicrobial agents administered in the recovery room cannot be relied upon to counteract contamination when a massive foreign body exists. A small suprainguinal incision is made with sufficient exposure for observation and protection of the ureter as it crosses the iliac limb of the graft. Injury to the ureter is a particular hazard in secondary aortoiliac surgery. It can be catastrophic, particularly if unrecognized. Proximal control ofthe iliac limb is secured with pump tapes. N ext, the common femoral artery is isolated or, more often, the superficial and profunda branches close to the sac. Avoidance of injury to the profunda and to its early branches is crucial. The dissection may be extremely difficult. Exposure of the distal profunda beyond the area of prior surgery has proved helpful; the surgeon then operates from below and behind. This maneuver has been the key to success in several instances. Manipulation of the aneurysmal sac should be minimal until distal control is obtained to reduce the hazard of separation of its contents. Distal control is best maintained with tapes or with delicate bulldog clamps. Short balloon catheters, such as are used in the biliary ducts, may be helpful although the early branching of profunda limits their usefulness. The sac is then opened widely, the thrombus removed, and heparin, 5000 units, administered intravenously. The edges of the sac are trimmed, and attention is given to the profunda orifice as previously described. The prosthetic graft is separated completely from the aneurysm and trimmed back, and a new segment of knitted Dacron is interposed. The distal end ofthe new graft is cut to a size that does not produce tension and is beveled so that an appropriate skew angle is formed. 3
752
DAVID
P.
BoYD
The distal anastomosis may be made into profunda alone or into profunda after a bifurcation angioplasty with the superficial femoral artery. The anastomosis should not be difficult provided the adventitia has not been harmed. To reduce the incidence of postoperative serous and other collections, particularly in patients operated on repeatedly or in whom large lymph nodes are encountered, overnight drainage of the groin is added. If the behavior of the wound suggests that drainage may be profuse, wound suction is used.
POSTOPERA TIVE CARE Postoperative care does not differ significantly from that of other major vascular surgery. If the anastomosis is technically satisfactory and the groin is healing well, the patient is ambulated after a few days and is permitted to sit, stand, and walk. Sometimes limited sitting is advised, but I do not consider this necessary in most instances.
SUMMARY We have found six instances of false aneurysm in the groin in five patients. This is a low incidence (perhaps 2 per cent), but a review of these cases implies that it is largely preventable. Simple aneurysmorrhaphy was unsuccessful in the two instances in which it was attempted. The most important factor in prevention and therapy offalse aneurysms in the groin is a meticulous anastomosis. The avoidance of injury to the sutureholding adventitia of the recipient vessels is particularly important.
REFERENCES 1. Boyd, D. P., Midell, A. I.: The use of Teflon in arterial surgery. Surg. Clin. North Am.
53:351-354 (April) 1973. 2. Burke, J. F.: Preoperative antibiotics. Surg. Clin. North Am. 43:665-676 (June) 1963. 3. Brener, B. J., Darling, R. C.: The end-to-end anastomosis of blood vessels in differing diameters. Surg. Gynecol. Obstet. 138:249-250 (Feb.) 1974. 4. Hermon, J. W., Hoar, C. S., Jr.: Cloth femoral-popliteal bypass grafts in 29 diabetic patients. Arch. Surg. 106:283-285 (March) 1973. 5. linton, R. R.: Atlas of Vascular Surgery. Philadelphia, W. B. Saunders, 1973, 504 pp. Lahey Clinic Foundation 605 Commonwealth A venue Boston, Massachusetts 02215
False Aneurysms in the Groin David P. Boyd, MD.*
Like infected grafts discussed elsewhere in this volume, the subject of false aneurysms in the groin has received scant attention in the literature.
ETIOLOGY The cause of secondary aneurysm in the femoral region after prosthetic bypass grafting is not entirely clear. We have encountered at least six instances of false aneurysm in the groin in five patients. A typical case is shown in Figure 1. In two of our patients, the anastomosis had been made with silk sutures, which were probably the cause of breakdown. Since some plastic prostheses are not incorporated into the fabric of living tissue but are simply stored rather than infiltrated, sutures must serve a perpetual function. One false sac occurred with woven Teflon, a fabric notoriously associated with graft failure.! Three instances involved knitted Dacron sutured with Dacron-Teflon material. Because two of these three instances occurred in the same patient, we blamed degenerative disease. However, technical factors may have been responsible. At reoperation, it appeared that the original anastomoses, both right and left, might have been constructed under tension. Furthermore, operative notes indicate that extensive endarterectomies of the common femoral arteries had been performed and that the surgeon had difficulty making the sutures hold.
PREVENTION OF FALSE ANEURYSMS Plastic sutures not subject to degeneration are mandatory if a plastic graft is sutured to living tissue. Despite the success of some workers with woven Teflon grafts, the failure rate is so high that we believe this material has no place in vascular surgery except, perhaps, as a temporary shunt. 4
':'Section of Thoracic and Cardiovascular Surgery, Lahey Clinic Foundation, Boston, Massachusetts
Surgical Clinics of North America-Vol. 56, No.3, June 1976
749
750
DAVID
P.
BOYD
Figure 1. False aneurysm in groin 3 years after aortoiliac bypass graft.
The part played by degenerative disease in causing false aneurysms in the femoral artery is doubtful. Certainly, the common and superficial femoral arteries are a typical site of advanced plaquing, especially posteriorly and laterally. Calcific and ulcerative changes are frequent. The temptation to strip this away is great. In many cases it is better left alone except for the 'profunda orifice. Endarterectomy performed in the im-' mediate region of the takeoff of the profunda artery is rewarding. Meticulous care is essential to avoid injury to the adventitia, especially at the femoral bifurcation. The experienced vascular surgeon can best judge the extent of necessary endarterectomy and the need for tacking sutures by palpation between the tip of the index finger and the thumb. Despite the desirability of visualizing the orifice of the profunda, I attempt to construct the original anastomosis high in the common femoral artery even if this artery must be closed partially or patched close to the profunda. In the rare instance of infection in the groin or when false sacs develop, the more clearance above the critical profunda the better the result. Most patients who require aortofemoral bypass have advanced disease, and the incidence of occlusion of the distal femoral and popliteal systems is high. On the other hand, the profunda femoris artery has an uncanny dispensation except near its origin. A voidance of injury to the degenerated parent artery is of paramount importance, particularly when recurrent operations on the groin are required. Endarterectomy of the common femoral artery should be omitted unless significant narrowing exists. If the adventitia is injured, it simply
FALSE ANEURYSMS IN THE GROIN
751
will not hold sutures. This may be the most critical factor in the cause of' secondary aneurysm when Dacron grafts and sutures have been used. Meticulous technique has been emphasized by Linton 5 and Darling,3 including avoidance oftension and proyision of a skew angle of 15° or less.
TREATMENT I have attempted plastic repair of false aneurysms ofthe groin in two cases. The aneurysmal wall seemed strong and held sutures superbly. In both instances, the repair seemed satisfactory, but the aneurysm recurred. In another instance, reconstruction appeared impossible because of distal disease, although femoral-popliteal bypass was performed. Amputation followed (the only instance ofloss oflife or limb in this series). In all other cases, the surgical technique described has resulted in cure up to this time. The sac need not be removed totally, but it must be exposed widely, and the entire anastomosis redone. This procedure requires a specific sequence of technical steps. Broad-spectrum antibiotic coverage is instituted before operation to achieve a high blood level. Initiation of antibiotic treatment should coincide with the principles advocated by Burke. 2 Antimicrobial agents administered in the recovery room cannot be relied upon to counteract contamination when a massive foreign body exists. A small suprainguinal incision is made with sufficient exposure for observation and protection of the ureter as it crosses the iliac limb of the graft. Injury to the ureter is a particular hazard in secondary aortoiliac surgery. It can be catastrophic, particularly if unrecognized. Proximal control ofthe iliac limb is secured with pump tapes. N ext, the common femoral artery is isolated or, more often, the superficial and profunda branches close to the sac. Avoidance of injury to the profunda and to its early branches is crucial. The dissection may be extremely difficult. Exposure of the distal profunda beyond the area of prior surgery has proved helpful; the surgeon then operates from below and behind. This maneuver has been the key to success in several instances. Manipulation of the aneurysmal sac should be minimal until distal control is obtained to reduce the hazard of separation of its contents. Distal control is best maintained with tapes or with delicate bulldog clamps. Short balloon catheters, such as are used in the biliary ducts, may be helpful although the early branching of profunda limits their usefulness. The sac is then opened widely, the thrombus removed, and heparin, 5000 units, administered intravenously. The edges of the sac are trimmed, and attention is given to the profunda orifice as previously described. The prosthetic graft is separated completely from the aneurysm and trimmed back, and a new segment of knitted Dacron is interposed. The distal end ofthe new graft is cut to a size that does not produce tension and is beveled so that an appropriate skew angle is formed. 3
752
DAVID
P.
BoYD
The distal anastomosis may be made into profunda alone or into profunda after a bifurcation angioplasty with the superficial femoral artery. The anastomosis should not be difficult provided the adventitia has not been harmed. To reduce the incidence of postoperative serous and other collections, particularly in patients operated on repeatedly or in whom large lymph nodes are encountered, overnight drainage of the groin is added. If the behavior of the wound suggests that drainage may be profuse, wound suction is used.
POSTOPERA TIVE CARE Postoperative care does not differ significantly from that of other major vascular surgery. If the anastomosis is technically satisfactory and the groin is healing well, the patient is ambulated after a few days and is permitted to sit, stand, and walk. Sometimes limited sitting is advised, but I do not consider this necessary in most instances.
SUMMARY We have found six instances of false aneurysm in the groin in five patients. This is a low incidence (perhaps 2 per cent), but a review of these cases implies that it is largely preventable. Simple aneurysmorrhaphy was unsuccessful in the two instances in which it was attempted. The most important factor in prevention and therapy offalse aneurysms in the groin is a meticulous anastomosis. The avoidance of injury to the sutureholding adventitia of the recipient vessels is particularly important.
REFERENCES 1. Boyd, D. P., Midell, A. I.: The use of Teflon in arterial surgery. Surg. Clin. North Am.
53:351-354 (April) 1973. 2. Burke, J. F.: Preoperative antibiotics. Surg. Clin. North Am. 43:665-676 (June) 1963. 3. Brener, B. J., Darling, R. C.: The end-to-end anastomosis of blood vessels in differing diameters. Surg. Gynecol. Obstet. 138:249-250 (Feb.) 1974. 4. Hermon, J. W., Hoar, C. S., Jr.: Cloth femoral-popliteal bypass grafts in 29 diabetic patients. Arch. Surg. 106:283-285 (March) 1973. 5. linton, R. R.: Atlas of Vascular Surgery. Philadelphia, W. B. Saunders, 1973, 504 pp. Lahey Clinic Foundation 605 Commonwealth A venue Boston, Massachusetts 02215