Femoral anastomotic aneurysms: A continuing challenge

Femoral anastomotic aneurysms: A continuing challenge Jon Schellack, M.D., Atef Salam, M.D., M a h m o u d A. Abouzeid, M.D., Robert B. Smith HI, M.D., Mark T. Stewart, M.D., and Garland D. Perdue, M.D., Atlanta and Decatur, Ga. The methods used in management of 102 femoral anastomotic aneurysms (FAAs) were analyzed, and a case control study was performed in an effort to define potential etiologic factors. Most FAAs resulted from host vessel degeneration, although broken sutures, infection, and prosthetic graft dilatation contributed in some cases. Patients forming FAAs after aortofemoral bypass more often were hypertensive, had progression of distal disease, and showed diffuse atherosclerosis when compared with control patients. The use of braided synthetic sutures, woven Dacron grafts, and concomitant femoral endarterectomy correlated with FAA development, whereas diabetes mellitus, multiple femoral operations, local wound-healing problems, and occlusion of the superficial femoral artery did not correlate with the formation of FAAs. Ninety FAAs (88%) were treated surgically with an operative mortality rate of 3%. The most common surgical technique was aneurysmectomy with interposition prosthetic graft replacement. Durability of the repair was better if a simultaneous outflow procedure was performed and if the reconstruction was done before compficatious developed. Complicated FAAs are still responsible for significant morbidity and loss of life despite aggressive surgical management. Elective FAA repair is the preferred method of treatment. (J VAsc SoRG 1987;6:308-17.)

Despite improvement in surgical technique, femoral anastomotic aneurysms (FAAs) continue to produce significant morbidity among a minority of patients undergoing lower extremity vascular reconstruction. Because of the propensity of FAAs to produce serious life- or limb-threatening complications early, elective operative correction has become the mainstay of management. Although multiple causative factors have been incriminated in the pathogenesis of these aneurysms, the exact cause of most FAAs remains controversial. PATIENTS AND METHODS Records of all patients with FAAs who came to the Atlanta Veterans Administration Medical Center and the Emory University Hospital from 1971 to 1985 were retrospectively reviewed. Fifty-eight men and seven women were identified with 102 FAAs. Their mean age was 62 years (range 47 to 83 years).

From the Departmentof Surgery,EmoryUniversitySchoolof Medicine, Atlanta, and the VeteransAdministrationMedical Center, Decatur. Presented at the EleventhAnnualMeetingof the SouthemAssociation for VascularSurgery,Scottsdale,Ariz., Jan. 28-31, 1987. Reprint requests:Atef Salam,M.D., The EmoryClinic, Department of Surgery,1365 CliftonRoad, NE, Atlanta,GA 30322. 308

Fifteen percent were diagnosed from 1971 to 1975, 27% from 1976 to 1980, and 53% from 1981 to 1985. Eighty-two primary FAAs developed after femoral inflow procedures and 12 after femoral outflow procedures. Eight recurrent FAAs were also treated. The initial operative records of a subgroup of patients with FAAs developing after aortofemoral bypass (AFB) were analyzed for potential etiologic factors and compared with a matched control group that did not have FAAs. Group I: Femoral inflow operations. Eightytwo primary FAAs and six recurrent FAAs developed in 53 patients after the initial inflow operation at a mean interval of 73 months (Table I). In 22 cases (27%) multiple femoral reconstructive procedures had been performed before the formation of the false aneurysm. Occlusive arterial disease was the initial pathologic process in 71% of patients, aneurysmal disease in 10%, and combined disease in 19%. Among the 41 patients who had aortobifemoral prostheses, 29 (70%) had bilateral FAAs. Eight of the 48 patients (17%) whose grafts originated from the aorta had proximal anastomotic aneurysms in addition to the FAA. Diagnosis of FAA was made from the results of direct physical examination in all but two patients whose lesions were found incidentally during femoral artery exposure for other vascular

Volume 6 Number 3 September 1987

Femoral anastomotic aneu~sms

309

Table I. Femoral anastomofic aneurysms after femoral inflow operations

Aneurysm status

Associated ana~omotie aneurysms

Patient No.

Side

V2

R

Asymptomatic

None

V3

R

Infected, expanding

None

V4

R

None

V5

L

Asymptomatic Asymptomatic

None

Type initial operation

Months to anastomotic aneurysm formation

44

Good

23

Dacron interposition

10

Aorto-right femoral Aortobifemoral

72

Dacron interposition Dacron interposition, SF angioplasty Dacron interposition, SF angioplasty Dacron wrapping, FP bypass Saphenous patch, FP bypass Dacron interposition, profundaplasty, FP bypass PTFE interposition, profundaplasty Dacron interposition

Infected graft excised at 7 mo, no amputation Good

101

Aortobifemoral

101

V6

L

None

L

Aortobifemoral Iliofemoral

70

V7 V8

R

Asymptomatic Asymptomatic Expanding

Femoral

Aortobifemoral

54

Asymptomatic Expanding

Femoral

Aortobifemoral Aortobifemoral

54

Asymptomatic Expanding

Femoral

R L

V10

R

Femoral

Femoral

17

81

Aortobifemoral Aortobifemoral Aortobifemoral

81 18

2

Good

1

Good

8

Good

10

Good

43

Good

9

Good

55

Dacron interposition Saphenous patch, profundaplasty Observation

55

Graft clotted at 4 mo, successful reoperation Good

53

Good

53

Aneurysm thrombosis at 39 mo; limb amputation Graft clotted at 10 mo; limb ampntation Good

Asymptomatic

Femoral

L

Expanding

Femoral

Aortobifemoral

74

Dacron interposition

27

R

Femoral

Aortobifemoral Aortobifemoral

74

Dacron interposition IYFFE interposition, SF angioplasty

27

L

Thrombosed Expanding

R

Expanding

Femoral

38

V15

R

None

V16

R

Thrombosed Expanding

IYFFE interposition, SF angioplasty Dacron interposition Dacron interposition

Asymptomatic

Femoral

V13

L

Femoral

Femoral

Aortobifemoral Aortobifemoral Aortobifemoral

Aortobife"moral

18

112

L

V12

Final result

Dacron patch, FP bypass

Femoral

V9

postop observation

22

Asymptomatic

L

Management

Aorto-right femoral,-left iliac Axillobifemoral

R

None

Monm of

34

34 134 84

120

Observation

39

0.5 43

5

Graft clotted at 4 mo; reoperation successful Good Postop death from MI Graft clotted at 6 mo; reoperation temporarily successful; no amputation Good

FP = femoropopliteal; SF = superficial femoral; IYrFE = polytetrafluoroethylene; MI = myocardial infarction; BK = below-knee; FT femorotibial. Continued on page 310

310

Joumal of VASCULAR SURGERY

Schdlack et al.

Table I . C o n t ' d Type initial operation

Months to anastomotic a~urysrc#

Months of postop observation

Patient No.

Side

V 17

R

&symptomatic

Femoral

Aortobifemoral

34

Dacron interposition

126

L

&symptomatic

Femoral

Aortobifemoral

34

Dacron interposition

126

R

&symptomatic

Femoral

Aortobifemoral

23

Resuture prosthesis

9

L

&symptomatic

Femoral

Aortobifemoral

23

Observation

9

V 19

L

Infected, ruptured

Aortic

Aorta-left femoral, aorta-right iliac

52

PTFE interposition

9

V20

R

Distal embolization

None

Aortobife-

96

Dacron interposition FP bypass

Aortic

Aorta-right femoral Femoralfemoral

132

Resuture prosthesis

58

18

Aortic, femoral Aortic, femoral None

Aortobifemoral Aortobifemoral Aortobifemoral

126

Dacron interposition, proftmdaplasty New aortobifemoral

Recurrent aneurysm at 30 too; graft clotted at 44 too; successful reoperations Recurrent aneurysm at 39 and 96 mo, graft dotted and limb amputation at 105 mo Infected graft excised at 7 too, limb amputation Aneurysm thrombosis at 1 month, limb amputation Infected graft excised, limb amputation, death at 9 mo, ruptured aortic aneurysm BK amputation despite patent femoral prosthesis Postop death, MI Good

68

Good

126

New aortobifemoral

68

Good

Dacron interposition, FP bypass

14

Aortobffe-

168

PTFE interposition, FT bypass

24

Infected graft excised at 4 too, limb amputation Good

Umbilical vein interposition, FP bypass PTFE interposition, FP bypass PTFE interlx~sition , FP bypass Observation

13

Good

9

Good

12

Good

12

Good

Dacron interposition, profundaplasty

44

Good

V 18

Aneurysm status

Associated anastomotic ~urysm$

f~aon

moral

V21

R

Ruptured

V22

R

Expanding None

V23

R

&symptomatic

L

&symptomatic

V25

R

Distal embolization

V26

L

Distal embolization &symptomatic

None Femoral

Aortobifemoral

84

&syrup-

Femoral

Aortobifemoral Aortobifemoral Aortobifemoral Aortobifemoral

84

V28

R L

V29

R L

E1

R

tomatic &symptomatic &symptomatic Asymptomatic

45

moral

Femoral Femoral Femoral

110 110 54

Management

26

0.5

Find result

Volume 6 Number 3 September 1987

Femoral anastomotic aneurysms

311

T a b l e I. C o n t ' d

initial operation

Months to anastomotic aneurysm formation

Femoral

Aortobifemoral

54

Infected, expanding Asymptomatic

None

Aortobifemoral

26

Femoral

Aortobifemoral

30

Infected, expanding Asymptomatic

None

Aortobifemoral

2

Femoral

Aortobifemoral

43

Asymptomatic Expanding

Femoral

Aortobifemoral

Femoral

Asymptomatic Asymptomatic

L L

Patient No.

Side

E1

L

Asymptomatic

E2

L

E5

L

E6

R

E7

L R

E8

R L

El0

E 11

R

R El2

L

El3

L R

Aneurysm status

Associated anastomotic aneurysms

Type

103

Dacron patch

30

Aortobifemoral

108

54

Good

Femoral

Aortobifemoral

108

52

Good

Aortic, femoral

Aortobifemoral

108

13

Good

Asymptomatic

Aortic, femoral

Aortobifemoral

108

13

Good

Distal embolization Asymptomatic Expanding

Femoral

Aortobifemoral

111

Dacron interposition, FP bypass Dacron interposition, FP bypass New aortobifemoral, SF angioplasty New aortobifemoral, SF angioplasty Dacron interposition, FP bypass

50

Good

Femoral

Aortobifemoral

111

Observation

50

Good

None

Aortobifemoral

46

23

Good

Thromhosed Thrombosed &symptomatic

Femoral

Aortobifemoral

142

58

Good

Femoral

Aortobifemoral

142

25

Good

None

Aortobifemoral

107

Dacron interposition Dacron interposition Dacron interposition Dacron interposition, profundaplasty Dacron interposition Observation

60

Good

3

Good

3

Good

Dacron patch, FP bypass Resuture prosthesis

63

Good

2

Good

IrFFE interposition Dacron interposition Observation

13 2

Good Good

2

Good

Saphenous patch Observation, suppressive antibiotics PTFE interposition, profundaplasty

10 1

Good Good

24

Good

Femoral

Aortobifemoral

155

R

Femoral

Aortobifemoral

155

None

Aortobifemoral

95

None

Iliofemoral

71

None Femoral, aortic Femoral, aortic Femoral Femoral

Aortobifemoral Aortobifemoral

23 75

Aortobifemoral

75

Aortobifemoral Aortobifemoral

36 45

Femoral

Aortobifemoral

45

E23

R L

Asymptomatic Thrombosed Asymptomatic Ruptured Asymptomatic Asymptomatic Infected Infected

E24

R

Expanding

R R L

Good

29

Expanding

E21 E22

4

Dacron interposition

L

R

Good

47

El6

E20

44

PTFE interposition, FP bypass

R

R

Dacron interposition, profimdaplasty Transobturator iliopopliteal bypass Resuture prosthesis

Final result

Graft clotted at 17 mo, successful reoperation Graft clotted at 5 too, limb amputation Graft clotted at 23 mo, no amputation Good

El4

El7

Management

Months of postop observation

121

Continued on page 312

312

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Schellack et al.

T a b l e I. C o n t ' d

Patient No.

Side

E24

L

E25

L

E26

R L

E27

L

R

Aneurysm status

Associated anaaomotic

Type initial operation

Months to anastomotic aneurysm formation

Management

Months of postop observation

Final result

Asymptomatic Asymptomatic

Femoral

Aortobifemoral

45

Observation

24

Good

Femoral

Aorta-left femoral

29

PTFE interposition, FP bypass

57

Asymptomatic Asymptomatic Asymptomatic

Femoral

Aortobifemoral

40

Resuture prosthesis

14

Graft clotted at 19 mo, successful rcoperation Good

Femoral

Aortobifemoral

40

14

Good

Femoral

Aortobifemoral

39

Dacron interposition Resuture prosthesis

96

131

Resuture prosthesis

4

Recurrent aneurysm at 43 mo, successful reoperation Good

125

Asymptomatic Asymptomatic

Femoral

Aortobifemoral

Aortic, lilac

Aorto-left femoral, aorta-right iliac

59

Resuture prosthesis

Dacron interposition Dacron interposition

E28

L

E29

L

Expanding

Femoral

Aortobifemoral

93

R

Expanding

Femoral

Aortobifemoral

95

E30

R

Expanding

None

Axillobifemoral

68

Dacron interposition

17

E31

R

Asymptomatic Asymptomatic Asymptomatic

Femoral

Aortobifemoral

28

12

Femoral

Aortobifemoral

37

Dacron interposition Observation

3

Good

None

106

Dacron interposition, FP bypass

70

Good

Femoral

Aorta-left femoral, aorta-right iliac Aortobifemoral

17

Good

15

Good

24

L E32

L

E33

R L

E34

R

L E38

R L

39 25

Recurrent aneurysms at 24 and 44 mo, thrombosis at 123 mo; successful reoperations Good Clotted graft at 6 mo, successful reoperation Clotted graft at 13 mo, limb amputation Good

Asymptomatic Asymptomatic Asymptomatic

Femoral

Aortobifemoral

89

Femoral, aortic

Aortobifemoral

70

PTFE interposition, FP bypass PTFE patch, FP bypass Observation

Asymptomatic Asymptomatic Asymptomatic

Femoral, aortic Femoral, aortic Femoral, aortic

Aortobifemoral

82

Observation

12

Aneurysm thrombosis at 12 mo, no amputation Good

Aortobifemoral

150

17

Good

Aortobifemoral

150

New aortobifemoral prosthesis New aortobifernoral prosthesis

17

Good

o p e r a t i o n s . Sixty-one p e r c e n t o f F A A s w e r e asymptomatic, w h e r e a s 32 ( 3 9 % ) were c o m p l i c a t e d b y acute expansion, t h r o m b o s i s , infection, distal embolization, or rupture. Seventy p r i m a r y F A A s were t r e a t e d surgically.

89

F o r t y - s e v e n o p e r a t i o n s involved a n e u r y s m e c t o m y f o l l o w e d b y i n s e r t i o n o f an i n t e r p o s i t i o n prosthesis b e t w e e n the o l d graft a n d the femoral artery. Less c o m m o n o p e r a t i o n s w e r e p a t c h a n g i o p l a s t y (eight); r e s u t u r i n g o f the o l d graft t o the h o s t vessel (seven);

Volume 6 Number 3 September 1987

Femoral anastomotic aneu~sms

313

100.

i I

80

NONCOMPLICATED ANEURYSMS COMPLICATED ANEURYSMS

60

%

PATENT 40

20

' 0

'

I 12

'

I 24

~

~

'

I 36

'

'

I 48

MONTHS

Fig. 1. Kaplan-Meier patency plots of femoral anastomotic aneurysm repairs segregated according to preoperative aneurysm status. Top graph represents primary cumulative patency after repair of noncomplicated aneurysms (N = 39); bottom curve after repair of complicated aneurysms (N -- 31). ,nsertion of a new aortobifemoral prosthesis (three); aneurysm wrapping (one); and graft excision with transobturator bypass (one). Concomitant distal bypass was performed in 20 instances, profundaplasty in nine, and proximal superficial femoral angioplasty in six. The most common finding noted at operation consisted of separation of the inflow graft from the femoral vessel with intact sutures remaining attached to the prosthesis. Frequently only the medial or lateral portion of the suture line was described as being "pulled away" with the opposite side of graft hood remaining afftxed to the artery. Broken sutures were described on only three occasions and diffuse graft dilatation once. The most frequent complication after FAA repair was ipsilateral femoral inflow occlusion. During the 15-year study interval early or late graft closure developed in 13 of 70 prosthetic limbs after FAA repair. Four additional femoral prostheses were excised as a result of infection. Lower extremity arterial perfusion was successfully restored and maintained in eight of these 17 graft failures by surgical revision or total graft replacement. Nine prosthetic graft failures were not successfully reversed, resulting in seven major amputations; in the other two patients mild ischemia was treated without limb loss. In addition to graft thrombosis and infection significant postoperative

complications occurred in 12 patients. Four patients had myocardial infarctions, seven had local wound complications, and one patient had a postoperative urinary tract infection. Two of the patients having myocardial infarctions died, yielding a 30-day operative mortality rate of 3%. Durability of FAA reconstruction was evaluated by Kaplan-Meier plots of graft limbs remaining patent (Figs. 1 and 2). Surgical results were contingent on the status of the FAA at the time of operative repair. Among the 39 noncomplicated FAAs that were surgically corrected, only one graft limb occluded within the first 12 months (2.6%); however, in 31 FAAs complicated by thrombosis, rupture, embolization, infection, or expansion there were nine early failures (29%). Kaplan-Meier patency curves for complicated vs noncomplicated aneurysm repairs are illustrated in Fig. 1 and were significantly different (p = 0.0099) with the use of generalized Wilcoxon (Breslow) comparison. The addition of an outflow procedure to the FAA repair also improved graft patency: among 31 noninfected FAAs wherein correction included an outflow procedure, there was only one early failure, resulting in a 3-year cumulative patency rate of 91%; whereas in 33 noninfected FAAs corrected without a simukaneous outflow procedure there were five early graft closures, producing a 3-year cumulative patency rate of 66% (Fig. 2;

314

Journal of VASCULAR SURGERY

Schellack et al.

100

WITH OUTFLOW PROCEDURE 80

t I .

6O

% PATE NT 40

WITHOUT OUTFLOW PROCEDURE

20

i

0

i

i

I

12

~

=

=

I

24 MONTHS

i

=

~

I

36

=

i

i

I

48

Fig. 2. Kap!an-Meierpatency plots ofnoninfectedfemoral anastomotic aneurysmrepairs, which included a concomitant outflow procedure (N = 31; top graph) compared with those not including an outflow procedure (N = 33; bottom graph).

p = 0.0307). The mean follow-up of all patients after FAA repair was 35 months (range 1 to 126 months). During the study interval three patients formed four recurrent FAAs from 24 to 43 months after primary FAA repair (recurrence rate 6%). Twentynine percent of those aneurysms initially repaired by resuturing the graft to the host artery recurred vs only 4% of those repaired with interpolation prostheses. All four recurrent FAAs were repaired with a new prosthetic graft; nevertheless, two of these recurred a third time at 20 and 57 months and again required operation. Nonsurgical therapy was chosen in 12 cases. Seven false aneurysms were deemed too small to warrant correction; three patients were too ill to undergo operation; and two patients refused recommended surgical therapy. One patient who had initially refused to undergo repair of a 5 cm FAA had thrombosis of this aneurysm 1 year later. Despite severe limb ischemia, remedial vascular reconstruction was performed elsewhere and successfully maintained limb viability. Two additional patients suffered thrombosis of aneurysms but, because of advanced ischemia, required high thigh amputations. The other nine FAAs observed without operation remained asymptomatic for periods ranging from 1 to 50 months.

Case control analysis. A subgroup of patients who had undergone AFB (group II) was analyzed for potential etiologic factors. Twenty-eight of the group I patients who had undergone initial operations at other institutions were excluded from the case control study. Four other patients were excluded because they had extra-anatomic prostheses and three because no satisfactory control patient could be identiffed. Therefore, 18 patients who formed 27 FAAs after AFB were matched with control patients for gender, approximate date of AFB, and approximate age. All initial operations were performed by one of two operating surgeons (R. B. S. or G. D. P.) and the mean follow-up of the 18 control patients (88 months) was approximately equal to that of the patients with false aneurysms (90 months). Data from the case control study are presented in Table II. The mean age at AFB of patients in whom false aneurysms developed was 54.4 years (range 42 to 67 years), and among control subjects was 55.4 years (range 42 to 66 years). There were four women in each group. The type of arterial disease was similar as was the frequency of tobacco use and diabetes mellitus. Progression of peripheral vascular disease (p = 0.0047), the presence of either cerebrovascular or coronary disease (p = 0.0339), and the presence of hypertension (p = 0.0194) each occurred more frequently among patients with aneurysms when

Volume 6 Number 3 September 1987

compared with control subjects. Between the two groups, there was no statistically significant difference in frequency of multiple femoral arterial reconstructive procedures, status of the superficial femoral artery at AFB, or the number of healing complications after AFB. Femoral vessels in which false aneurysms developed more often had been sewn with braided synthetic sutures (p = 0.0029) and had been endarterectomized (p = 0.0276). Woven, as opposed to knitted, Dacron prostheses had been used more often in the false aneurysm group when compared with the control group (p = 0.0143). Group III: Femoral outflow operations. During the 15-year study interval, 12 persons formed primary FAAs after femoral outflow operations and two had recurrent FAAs (Table III). In contrast to group I patients these patients more often had symptomatic enlarging aneurysms (83%) and more frequently harbored infected false aneurysms (33%). The type of remedial vascular reconstruction employed in these patients varied, depending on the presence or absence of bacterial infection, the severity of limb ischemia, and the patency of the initial prosthetic reconstruction. In the absence of established infection, remedial operations for this subgroup yielded satisfactory results. By contrast, half of the infected false aneurysms required major limb amputation and half recurred.

DISCUSSION Although infection, pathologic prosthetic dilatation, and defective suture material contribute to FAA formation in some patients, most appear to result from host vessel degeneration. 17 Separation of the prosthesis from the host vessel with intact sutures remaining attached to the graft provides circumstantial evidence that a degenerative process has occurred in the region of the arterial suture line. The present case control study, although limited by small numbers, suggests that patients forming false aneurysms have an aggressive form of atherosderosis often involving coronary and cerebral, as well as peripheral, arteries. Progressive atherosclerosis and systemic arterial hypertension appear to foster a tissue environment that promotes gradual development of arterial anastomotic degeneration after vascular reconstruction. Youkey et al.2 identified hyperlipidemia and continued tobacco abuse as additional risk factors for the formation of FAAs. The finding of bilaterality in 70% and of aortic false aneurysms in 17% of our patients supports the concept of a systemic factor that predisposes patients to the formation of false aneurvsms.

Femoral anastomotic aneurysms

315

Table II. Case control analysis

Arterial disease type Occlusive Aneurysmal Occlusive and aneurysmal Associated illnesses Hypertension* Coronary artery disease Cerebrovascular disease Either coronary or cerebrovascular disease* Progression o f distal diseaset Tobacco use Diabetes mellitus Warfarin use Surgical history Multiple femoral procedures Femoral endarterectomy* Suture material Polypropylene* Braided synthetict Postoperative healing complications Occluded superficial femoral artery at AFB Prosthetic material Teflon Dacron woven* Dacron knittedt Unspecified

Patients with femoral false aneurysras

Case controls

(N = 18)

(N = 18)

No.

%

No.

%

16 1 1

88 6 6

16 1 1

88 6 6

13 10

72 56

6 8

33 44

10

56

5

28

15

83

9

50

16

88

8

44

16 4 3

88 22 17

16 2 0

88 11 0

(N = 27) 7 26

(N = 36) 7 19

8

30

3

8

5 22 2

19 81 7

18 16 0

50 44 0

11

41

11

31

2 10 1! 4

7 37 41 15

0 4 32 0

0 11 89 0

AFB = aortofemoral bypass. *p<0.05. tp<0.005.

Local elements that have been implicated by other authors in the pathogenesis of FAA include excessive tension on the anastomosis, incorporating only a small portion of the host artery in the suture line, hip joint motion (causing stress on the suture line), compliance mismatch, multiple femoral arterial operations, local endarterectomy, postoperative anticoagulation, and fraying of woven graft material, ss'7.9 Some of these factors, although possibly important, could not be evaluated by our retrospective analysis of operative records. On the basis of the present review, a history of multiple femoral arterial procedures did not contribute to false aneurysm formation, but

Journal of VASCULAR SURGERY

316 Schdlack et al.

Table III. Femoral anastomotic aneurysms forming after femoral outflow operations Patient No.

Aneurysm status

V1 V11 V14

Infected, expanding Expanding Expanding

V24

Expanding

E3 E4

Expanding Expanding

El5

Asymptomatic Asymptomatic Expanding

El8 El9

Type initial operation

Patency of initial operation

Months to anasmmotic aneurysm formation

Management

Months of postop observation

Final result

Vein FP bypass

Patent

36

Resuture vein graft, antibiotics

109

Good

Dacron FP bypass Composite vein, Dacron FP bypass Dacron FP bypass

Patent Patent

48 75

PTFE interposition PTFE interposition

12 46

Good Good

Patent

108

0

Vein FP bypass PTFE femoral angioplasty PTFE FT bypass

Patent Patent

144 3

Clotted

96

Teflon FP bypass

Patent

156

Vein FP bypass

Clotted

72

Dacron interposition PTFE interposition Resuture prosthetic patch Dacron interposition New Dacron FP bypass New umbilical vein FP bypass Excise graft, saphenous femoral angioplasty, transobturator iliopopliteal bypass

0.5

Postop death, MI

22 31

Good Good

22

Good

15

Good

58

Good

72

Recurrent femoral aneurysm at 2 mo, successful reoperation; graft clotted at 10 mo, limb amputation Recurrent femoral aneurysm at 60 mo, successful reopemtion Limb amputation

E35

Infected, expanding

Vein FP bypass

Patent

E36

Infected, expanding

Dacron profundaplasty

Patent

11

Excise Dacron, saphenous profundaplasty

64

E37

Infected, expanding

F I F E FP bypass

Patent

2

Excise PTFE graft, ligate femoral artery, limb amputation

22

For abbreviations see Table I.

such a history did increase the likelihood of graft failure occurring after repair. Femoral endarterectomy, proposed by many to be an important antecedent of false aneurysms, was carried out in only 30% of cases in the present series but was performed significantly more often than in control arteries. ~'2'~° Use of braided synthetic suture does correlate significantly with FAA formation, a fact noted by other authors.la'11'lz Despite abandonment of braided vascularsuture material the incidence of FAAs does not appear to have decreased; however, the mean interval between the original operation and the appearance of the false aneurysm has increased. In the early 1970s reports by Christensen and Bernatz 1° and Stoney et al.lS reported mean intervals of 3 and 2 years, respectively. More recent reports show mean intervals of 5.5 to 6.5 years, findings more in keeping with the present experience.5 7" In a recent review Szilagyi et al.as found the incidence of FAAs after aorto-

femoral reconstruction to have remained remarkably constant (5%) during 30 years of study. The increase in numbers of FAAs reported herein probably reflects a parallel increase in the number of primary lower extremity vascular reconstructions being performed, as well as a change in referral patterns since a larger proportion of recent patients had their initial procedures performed elsewhere. As with any pathologic entity effective management includes appropriate preventive measures. Suggested techniques include avoidance of excessive tension on the graft-artery anastomosis, incorporation of generous portions of the artery wall into the suture line, the use of suture material of adequate strength and size, the minimal use of endarterectomy, and placement of the graft-artery anastomosis above the inguinal ligament when the iliac runoff appears adequate. 16 This article confirms the observation that excel-

Volume 6 Ntnnber 3 September 1987

lent long-term results can be expected after elective repair of FAAs. However, once complications ensue, surgical reconstruction is less satisfactory. Complicated FAAs are responsible for significant morbidity and loss of life despite aggressive surgical management. Elective FAA repair should be recommended to acceptable operative candidates. The current analysis demonstrates that significant femoral outflow obstruction frequently accompanies the development of FAAs and that repair without a concomitant outflow procedure is less durables Recurrence after FAA repair may be minimized by placement of a new prosthesis between the old graft and the femoral artery; repair by simply resumring the old graft back to the host artery is not satisfactory and risks recurrence.lSa9

Femoral anastomotic aneu~sms

7. 8.

9. 10. 11.

12.

13. REFERENCES

1. Szilagyi DE, Smith RF, EUiott JP, Hageman JH, Dall'olmo CA. Anastomotic aneurysms after vascular reconstruction. Surgery 1975;78:800-16. 2. Youkey JR, Clagett GP, Rich NM, Brigham RA, Orecchia PM, Salander JM. Femoral anastomotic false aneurysms. An 11-year experience analyzed with a case control study. Ann Surg 1985;199:703-7. 3. Mehigan DG, FitzpatrickB, Browne HI, Bouchier-Hayes DJ. Is compliance mismatch the major cause of anastomotic arterial aneurysms? Analysis of 42 cases. J Cardiovasc Surg 1985;26:147-50. 4. Richardson JV, McDowell HA Jr. Anastomotic aneurysms following arterial grafting. A 10-year experience. Ann Surg 1976;184:179-82. 5. Satiani B, Kazmers M, Evans WE. Anastomotic arterial aneurysms. A continuing challenge. Ann Surg 1980;192: 674-82. 6. McCabe CJ, Moncure AC, Malt RA. Host-artery weakness

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