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Primary Open Stenting to Simplify Distal Anastomosis on Heavily Calcified Artery: The POSE Technique
Selected Technique Primary Open Stenting to Simplify Distal Anastomosis on Heavily Calcified Artery: The POSE Technique Rapha€el Coscas,1,2 Pierre Maitrias,1,2 Isabelle Javerliat,1,2 Oleg Rouditch-pergola,1,2 Olivier Goeau-Brissonniere,1,2 and Marc Coggia,1,2 Boulogne-Billancourt and Villejuif, France
Despite improvements in surgical techniques, performing distal anastomosis on a heavily calcified artery (HCA) remains technically challenging. Clamping lesions and arterial wall trauma while suturing can lead to immediate or delayed arterial dissection and thrombosis. These issues are generally overcome by performing an extensive search for supple arterial zones, using sutureless techniques with covered stent-grafts and/or stenting the anastomosis under fluoroscopic guidance after unclamping. We describe a technique intended to simplify open surgical procedures on HCA. It consists of primary open stenting followed by localized endarterectomy (namely, the primary open stenting followed by localized endarterectomy [POSE] technique) to secure a distal anastomosis on an HCA. So far, we have successfully used the POSE technique in 24 patients but the durability of the technique remains to be determined.
INTRODUCTION Performing distal anastomosis on a heavily calcified artery (HCA) can be technically challenging and has a risk of complications.1 There are several ways of managing this situation such as the use of stronger needles, fracturing the arterial wall,2 or performing a primary localized endarterectomy. However, these techniques present a risk of residual intimal flap and subsequent distal arterial dissection, which may
compromise the patency of the anastomosis. ‘‘Open stenting’’ of an HCA can simplify complex procedures in several situations3e7 and prevent postoperative occlusion of a heavily calcified target artery. We present an alternative technique consisting of primary open stenting followed by an endarterectomy, or primary open stenting followed by localized endarterectomy (POSE) technique, to secure a distal anastomosis on an HCA.
TECHNIQUE Conflicts of Interest: None. 1 Department of Vascular Surgery, Ambroise Pare University Hospital, Assistance PubliquedH^opitaux de Paris (AP-HP), BoulogneBillancourt, France. 2 Universite Paris-Saclay, Universite Versailles Saint-Quentin en Yvelines, CESP, INSERM-U1018, Equipe 5, Villejuif, France.
Correspondence to: Rapha€el Coscas, MD, Department of Vascular Surgery, Ambroise Pare University Hospital, 9 Avenue Charles de Gaulle, Boulogne Cedex 92104, France; E-mail: [email protected] Ann Vasc Surg 2016; 30: 336–339 http://dx.doi.org/10.1016/j.avsg.2015.07.023 Ó 2016 Elsevier Inc. All rights reserved. Manuscript received: May 15, 2015; manuscript accepted: July 3, 2015; published online: October 28, 2015.
336
Between January 2012 and July 2014, 1,432 patients underwent conventional open or laparoscopic arterial surgery in our center. The POSE technique was performed in 24 patients (1.7%). The decision to perform the POSE technique was made either (1) preoperatively, in cases where the computed tomography (CT) scan showed circumferential heavy calcifications at the expected distal anastomosis site, or (2) intraoperatively, when confronted with unexpected calcifications at the distal anastomosis site, which were felt to render the distal suture at risk.
Volume 30, January 2016
The POSE technique 337
Fig. 1. Intraoperative views of the POSE technique. A balloon-expandable stent is set over a hydrophilic guidewire (A). The stent is then gently introduced in the distal artery under direct vision control (B). After
stent deployment, the localized endarterectomy is performed (C). End-to-end anastomosis is finally conducted using running polypropylene suture on a soft arterial wall (D).
When the POSE technique was planned, subjects gave informed consent. Approval from our ethics committee was not necessary as this publication only involves Conformit e Europ eenne (CE)approved medical devices and no new implantable materials. This article follows the principles outlined in the Declaration of Helsinki.
0.035-in hydrophilic guidewire (Standard Radifocus, Terumo Europe, Leuven, Belgium) using adhesive tape. The floppy tip of the wire extended past the distal part of the stent by about 4 cm. When the distal plaque extended to an arterial bifurcation where both distal arteries were calcified, one stent was placed at the origin of each artery (‘‘kissing open stenting’’). The stent set over the wire was placed within the calcified target artery under direct vision. The proximal edge of the stent was positioned a half centimeter after the expected anastomosis site. The balloon and the stent were inflated to both impact the stent within the arterial wall and clamp the target artery. After stent placement, the balloon was temporary deflated to be repositioned 2 cm more distally and reinflated. This maneuver allowed complete visibility of the anastomosis site without being hampered by the inflated balloon and prevented perforation of the balloon by the needle during the anastomosis. A localized endarterectomy was performed down to the stent proximal edge, which directly secured the distal intimal flap. The anastomosis was then easily performed on a soft arterial wall using
Surgical Details The POSE technique is standardized (Fig. 1). After proximal bypass graft (Dacron or polytetrafluorethylene) anastomosis, the distal target artery was left unclamped. The arteriotomy was performed in a standard fashion according to the expected type of the distal suture (end-to-end or end-to-side). Covered or uncovered balloon-expandable stents (Advanta V12, Atrium, Mijdrecht, The Netherlands, or Express LD, Boston scientific, Natick, MA) were used. Stent diameters were matched to target vessel diameters, which were determined preoperatively on the basis of the CT scan or intraoperatively. There was no oversizing. Stent lengths were short and never exceeded 40 mm. The stent was set over a
338 Coscas et al.
Annals of Vascular Surgery
Table I. Indication and surgical details of the 24 patients of the series Surgical details
Planning of the POSE technique Preoperative planning of the POSE technique Intraoperative decision to use the POSE technique Repair indication Occlusive disease, including Critical limb ischemia Disabling claudication Carotid stenosis Abdominal aortic aneurysm Surgical approach Longitudinal groin incision Midline laparotomy incision Transversal groin incision Left lumbotomy incision Longitudinal cervicotomy Location of the POSE technique Femoral bifurcation Iliac arteries Iliac bifurcation Aortic bifurcation Carotid artery
N (%)
17 (71) 7 (29)
14 10 3 1 10
(58) (42) (13) (4) (42)
12 8 2 1 1
(50) (33) (8) (4) (4)
14 3 3 3 1
(58) (13) (13) (13) (4)
running polypropylene suture. Before completing the anastomosis, the balloon was deflated and partially retrieved. The stent proximal edge was remodeled with additional inflation before achieving the suture. Personal Experience Among the 24 patients treated with the POSE technique, there were 15 (63%) men. Median age was 76 years (range, 52e98 years). Indication and surgical details are summarized in Table I. The technique mainly concerned the femoral bifurcation and the aortoiliac segment. Technical success was 100%. No intraoperative complication was noted. Three (13%) patients died in the postoperative period of nonvascular complications. An asymptomatic dissection at the distal end of an iliac stent was noted in 1 case (4%) on a systematic postoperative CT scan after complex open aortic repair. The dissection was successfully managed with a 3-month anticoagulation therapy without reintervention. Median hospital stay was 8 days (range, 5e14 days). With a median follow-up of 12 months (range, 3e18), there was 1 asymptomatic superficial femoral artery stent occlusion 6 months after a kissing open stenting at the femoral bifurcation. No
other vascular complication occurred. All other repairs remained patent with satisfactory distal flows (Fig. 2).
DISCUSSION The POSE technique simplifies distal anastomosis on an HCA without compromising graft patency. For several decades, performing a distal anastomosis on an HCA has been recognized as a technical challenge with the potential for serious complications.1 We developed the POSE technique to overcome surgical situations where standard clamping and suturing of an HCA were both highly challenging. First, conventional external arterial clamping of an HCA can mandate primary manual plaque fracturing2 with a risk of distal arterial dissection. Encircling the artery with vessel loops allows atraumatic external clamping of the artery8 but might sometimes be insufficient to achieve satisfactory hemostasis. The POSE technique uses principles of endoluminal clamping, as previously described with Fogarty catheters or Garrett dilators.9 With the POSE technique, simultaneous stenting of the clamping zone also limits the risk of endoluminal lesions after balloon inflation. Second, suturing an HCA can be technically difficult. Needles may not pass through the arterial wall. Intimal plaque fracturing and use of stronger needles can be associated with arterial damage. Isolated endarterectomy is at risk of intimal flap and subsequent arterial dissection. Stabilizing HCA walls with a stent after suturing can be performed10 but requires fluoroscopic guidance, iodinated contrast media injection, and smooth wire introduction to avoid dissection, along with precise stent deployment. Moreover, when performed as a rescue procedure, secondary stenting may be challenging in the setting of a deeply located artery due to inadequate patient installation. The POSE technique avoids extensive endarterectomy of an HCA. The arterial lumen is primarily stabilized with the stent to allow secure localized endarterectomy. The technique is performed under direct vision, without fluoroscopic guidance or iodinated contrast media injection. Displacing the balloon more distally allows circumferential view of the anastomosis whereas performing the suture on a soft arterial wall. In some cases, the POSE technique allowed to perform a unique distal anastomosis on an arterial bifurcation instead of a more complex and distal repair mandating several anastomoses. We perceive the POSE technique as an alternative to sutureless options described to perform
Volume 30, January 2016
The POSE technique 339
Fig. 2. Postoperative CT scans with 3-dimensional reconstructions of 3 patients who underwent the POSE technique. In the first case (A), the POSE technique has been used to perform the distal anastomosis of an aortobi-iliac bypass on the distal common iliac artery after kissing open stenting of the internal and external iliac arteries. In the second case (B), surgical dissection of a calcified aortic bifurcation was felt at risk in this patient who presented an inflammatory juxtarenal aortic aneurysm with bilateral renal stenosis. He underwent a
POSE technique at the level of the aortic bifurcation to achieve an aortoeaortic bypass with a retrograde bifurcated bypass to the renal arteries. The third case (C) illustrates the case of an unplanned femoroefemoral bypass at the end of a bifurcated aortic endograft procedure due to a localized dissection of the common femoral artery. Since the plaque extended distally to the profunda femoral artery (PFA), the POSE technique has been used to avoid a more distal anastomosis on the PFA.
repairs on an HCA.4e6 The Viabahn Padova Sutureless techniques4,5 consist of deploying the distal part of a Viabahn stent-graft (W.L. Gore, Flagstaff, AZ) into the transected distal artery under direct vision. Recent hybrid grafts and the Viabahn Open Revascularization TEChnique use similar principles.6,11 Of note, these techniques mandate a distal sealing zone within the target artery. Therefore, their use is restricted at the level of arterial bifurcations (83% of lesions involved in our series) because of the risk of covering 1 of the 2 target vessels.6 Of note, although we use balloon-expandable stents, the POSE technique could be performed with self-expandable stents. In such cases, an endoluminal clamping with a balloon should be performed first. Then, the balloon should be deflated and temporary removed to insert and deploy the stent before reinflating the balloon to suture the graft. Several limits may exist with the POSE technique. A distal dissection was observed in 1 patient. The reason for this complication may be related to endoluminal trauma whereas introducing the wire or the stent. We now use floppy J-tip wire to limit this risk. As the POSE technique is a hybrid treatment combining conventional suturing with endoluminal stenting, its durability remains uncertain. In a 12-month follow-up, we observed 1 stent occlusion. A longer follow-up observation period could reveal other late intrastent restenoses. Therefore, the durability of the POSE technique is yet to be determined.
REFERENCES 1. Bunt TJ, Manship L, Moore W. Iatrogenic vascular injury during peripheral revascularization. J Vasc Surg 1985;2:491e8. 2. Ascer E, Veith FJ, Flores SA. Infrapopliteal bypasses to heavily calcified rock-like arteries. Management and results. Am J Surg 1986;152:220e3. 3. Patel R, Conrad MF, Paruchuri V, et al. Balloon expandable stents facilitate right renal artery reconstruction during complex open aortic aneurysm repair. J Vasc Surg 2010;51:310e5. 4. Piazza M, Bonvini S, Ferretto L, et al. Modification of the Viabahn Padova sutureless technique for challenging anastomosis between a prosthetic graft and a circumferentially calcified target artery. J Endovasc Ther 2012;19:457e60. 5. Bonvini S, Ricotta JJ, Piazza M, et al. ViPS technique as a novel concept for a sutureless vascular anastomosis. J Vasc Surg 2011;54:889e92. 6. Greenberg G, Szendro G, Mayzler O, et al. Use of ViaBahn open revascularisation technique for above-knee femoropopliteal anastomosis: a technical note. Eur J Vasc Endovasc Surg 2011;42:202e5. 7. Chiesa R, Melissano G, Civilini E, et al. Video-atlas of open thoracoabdominal aortic aneurysm repair. Ann Cardiothorac Surg 2012;1:398e403. 8. Semel L, Schu W, Aust JC, et al. Atraumatic control in calcified arteries. Ann Vasc Surg 1988;2:73e4. 9. Swedenborg J. Critical limb ischemia with totally calcified arteries. In: Branchereau A, Jacobs M eds. Unexpected challenges in vascular surgery. Oxford: Wiley-Blackwell, 2005. pp 205e10. 10. Rabellino M, Garcı´a-Nielsen L, Zander T, et al. Primary stenting immediately after surgery in occluded anastomoses of aortoaortic tube graft: a case report. Cardiol Res Pract 2010;2010. 11. Chiesa R, Kahlberg A, Mascia D, et al. Use of a novel hybrid vascular graft for sutureless revascularization of the renal arteries during open thoracoabdominal aortic aneurysm repair. J Vasc Surg 2014;60:622e30.
Despite improvements in surgical techniques, performing distal anastomosis on a heavily calcified artery (HCA) remains technically challenging. Clamping lesions and arterial wall trauma while suturing can lead to immediate or delayed arterial dissection and thrombosis. These issues are generally overcome by performing an extensive search for supple arterial zones, using sutureless techniques with covered stent-grafts and/or stenting the anastomosis under fluoroscopic guidance after unclamping. We describe a technique intended to simplify open surgical procedures on HCA. It consists of primary open stenting followed by localized endarterectomy (namely, the primary open stenting followed by localized endarterectomy [POSE] technique) to secure a distal anastomosis on an HCA. So far, we have successfully used the POSE technique in 24 patients but the durability of the technique remains to be determined.
INTRODUCTION Performing distal anastomosis on a heavily calcified artery (HCA) can be technically challenging and has a risk of complications.1 There are several ways of managing this situation such as the use of stronger needles, fracturing the arterial wall,2 or performing a primary localized endarterectomy. However, these techniques present a risk of residual intimal flap and subsequent distal arterial dissection, which may
compromise the patency of the anastomosis. ‘‘Open stenting’’ of an HCA can simplify complex procedures in several situations3e7 and prevent postoperative occlusion of a heavily calcified target artery. We present an alternative technique consisting of primary open stenting followed by an endarterectomy, or primary open stenting followed by localized endarterectomy (POSE) technique, to secure a distal anastomosis on an HCA.
TECHNIQUE Conflicts of Interest: None. 1 Department of Vascular Surgery, Ambroise Pare University Hospital, Assistance PubliquedH^opitaux de Paris (AP-HP), BoulogneBillancourt, France. 2 Universite Paris-Saclay, Universite Versailles Saint-Quentin en Yvelines, CESP, INSERM-U1018, Equipe 5, Villejuif, France.
Correspondence to: Rapha€el Coscas, MD, Department of Vascular Surgery, Ambroise Pare University Hospital, 9 Avenue Charles de Gaulle, Boulogne Cedex 92104, France; E-mail: [email protected] Ann Vasc Surg 2016; 30: 336–339 http://dx.doi.org/10.1016/j.avsg.2015.07.023 Ó 2016 Elsevier Inc. All rights reserved. Manuscript received: May 15, 2015; manuscript accepted: July 3, 2015; published online: October 28, 2015.
336
Between January 2012 and July 2014, 1,432 patients underwent conventional open or laparoscopic arterial surgery in our center. The POSE technique was performed in 24 patients (1.7%). The decision to perform the POSE technique was made either (1) preoperatively, in cases where the computed tomography (CT) scan showed circumferential heavy calcifications at the expected distal anastomosis site, or (2) intraoperatively, when confronted with unexpected calcifications at the distal anastomosis site, which were felt to render the distal suture at risk.
Volume 30, January 2016
The POSE technique 337
Fig. 1. Intraoperative views of the POSE technique. A balloon-expandable stent is set over a hydrophilic guidewire (A). The stent is then gently introduced in the distal artery under direct vision control (B). After
stent deployment, the localized endarterectomy is performed (C). End-to-end anastomosis is finally conducted using running polypropylene suture on a soft arterial wall (D).
When the POSE technique was planned, subjects gave informed consent. Approval from our ethics committee was not necessary as this publication only involves Conformit e Europ eenne (CE)approved medical devices and no new implantable materials. This article follows the principles outlined in the Declaration of Helsinki.
0.035-in hydrophilic guidewire (Standard Radifocus, Terumo Europe, Leuven, Belgium) using adhesive tape. The floppy tip of the wire extended past the distal part of the stent by about 4 cm. When the distal plaque extended to an arterial bifurcation where both distal arteries were calcified, one stent was placed at the origin of each artery (‘‘kissing open stenting’’). The stent set over the wire was placed within the calcified target artery under direct vision. The proximal edge of the stent was positioned a half centimeter after the expected anastomosis site. The balloon and the stent were inflated to both impact the stent within the arterial wall and clamp the target artery. After stent placement, the balloon was temporary deflated to be repositioned 2 cm more distally and reinflated. This maneuver allowed complete visibility of the anastomosis site without being hampered by the inflated balloon and prevented perforation of the balloon by the needle during the anastomosis. A localized endarterectomy was performed down to the stent proximal edge, which directly secured the distal intimal flap. The anastomosis was then easily performed on a soft arterial wall using
Surgical Details The POSE technique is standardized (Fig. 1). After proximal bypass graft (Dacron or polytetrafluorethylene) anastomosis, the distal target artery was left unclamped. The arteriotomy was performed in a standard fashion according to the expected type of the distal suture (end-to-end or end-to-side). Covered or uncovered balloon-expandable stents (Advanta V12, Atrium, Mijdrecht, The Netherlands, or Express LD, Boston scientific, Natick, MA) were used. Stent diameters were matched to target vessel diameters, which were determined preoperatively on the basis of the CT scan or intraoperatively. There was no oversizing. Stent lengths were short and never exceeded 40 mm. The stent was set over a
338 Coscas et al.
Annals of Vascular Surgery
Table I. Indication and surgical details of the 24 patients of the series Surgical details
Planning of the POSE technique Preoperative planning of the POSE technique Intraoperative decision to use the POSE technique Repair indication Occlusive disease, including Critical limb ischemia Disabling claudication Carotid stenosis Abdominal aortic aneurysm Surgical approach Longitudinal groin incision Midline laparotomy incision Transversal groin incision Left lumbotomy incision Longitudinal cervicotomy Location of the POSE technique Femoral bifurcation Iliac arteries Iliac bifurcation Aortic bifurcation Carotid artery
N (%)
17 (71) 7 (29)
14 10 3 1 10
(58) (42) (13) (4) (42)
12 8 2 1 1
(50) (33) (8) (4) (4)
14 3 3 3 1
(58) (13) (13) (13) (4)
running polypropylene suture. Before completing the anastomosis, the balloon was deflated and partially retrieved. The stent proximal edge was remodeled with additional inflation before achieving the suture. Personal Experience Among the 24 patients treated with the POSE technique, there were 15 (63%) men. Median age was 76 years (range, 52e98 years). Indication and surgical details are summarized in Table I. The technique mainly concerned the femoral bifurcation and the aortoiliac segment. Technical success was 100%. No intraoperative complication was noted. Three (13%) patients died in the postoperative period of nonvascular complications. An asymptomatic dissection at the distal end of an iliac stent was noted in 1 case (4%) on a systematic postoperative CT scan after complex open aortic repair. The dissection was successfully managed with a 3-month anticoagulation therapy without reintervention. Median hospital stay was 8 days (range, 5e14 days). With a median follow-up of 12 months (range, 3e18), there was 1 asymptomatic superficial femoral artery stent occlusion 6 months after a kissing open stenting at the femoral bifurcation. No
other vascular complication occurred. All other repairs remained patent with satisfactory distal flows (Fig. 2).
DISCUSSION The POSE technique simplifies distal anastomosis on an HCA without compromising graft patency. For several decades, performing a distal anastomosis on an HCA has been recognized as a technical challenge with the potential for serious complications.1 We developed the POSE technique to overcome surgical situations where standard clamping and suturing of an HCA were both highly challenging. First, conventional external arterial clamping of an HCA can mandate primary manual plaque fracturing2 with a risk of distal arterial dissection. Encircling the artery with vessel loops allows atraumatic external clamping of the artery8 but might sometimes be insufficient to achieve satisfactory hemostasis. The POSE technique uses principles of endoluminal clamping, as previously described with Fogarty catheters or Garrett dilators.9 With the POSE technique, simultaneous stenting of the clamping zone also limits the risk of endoluminal lesions after balloon inflation. Second, suturing an HCA can be technically difficult. Needles may not pass through the arterial wall. Intimal plaque fracturing and use of stronger needles can be associated with arterial damage. Isolated endarterectomy is at risk of intimal flap and subsequent arterial dissection. Stabilizing HCA walls with a stent after suturing can be performed10 but requires fluoroscopic guidance, iodinated contrast media injection, and smooth wire introduction to avoid dissection, along with precise stent deployment. Moreover, when performed as a rescue procedure, secondary stenting may be challenging in the setting of a deeply located artery due to inadequate patient installation. The POSE technique avoids extensive endarterectomy of an HCA. The arterial lumen is primarily stabilized with the stent to allow secure localized endarterectomy. The technique is performed under direct vision, without fluoroscopic guidance or iodinated contrast media injection. Displacing the balloon more distally allows circumferential view of the anastomosis whereas performing the suture on a soft arterial wall. In some cases, the POSE technique allowed to perform a unique distal anastomosis on an arterial bifurcation instead of a more complex and distal repair mandating several anastomoses. We perceive the POSE technique as an alternative to sutureless options described to perform
Volume 30, January 2016
The POSE technique 339
Fig. 2. Postoperative CT scans with 3-dimensional reconstructions of 3 patients who underwent the POSE technique. In the first case (A), the POSE technique has been used to perform the distal anastomosis of an aortobi-iliac bypass on the distal common iliac artery after kissing open stenting of the internal and external iliac arteries. In the second case (B), surgical dissection of a calcified aortic bifurcation was felt at risk in this patient who presented an inflammatory juxtarenal aortic aneurysm with bilateral renal stenosis. He underwent a
POSE technique at the level of the aortic bifurcation to achieve an aortoeaortic bypass with a retrograde bifurcated bypass to the renal arteries. The third case (C) illustrates the case of an unplanned femoroefemoral bypass at the end of a bifurcated aortic endograft procedure due to a localized dissection of the common femoral artery. Since the plaque extended distally to the profunda femoral artery (PFA), the POSE technique has been used to avoid a more distal anastomosis on the PFA.
repairs on an HCA.4e6 The Viabahn Padova Sutureless techniques4,5 consist of deploying the distal part of a Viabahn stent-graft (W.L. Gore, Flagstaff, AZ) into the transected distal artery under direct vision. Recent hybrid grafts and the Viabahn Open Revascularization TEChnique use similar principles.6,11 Of note, these techniques mandate a distal sealing zone within the target artery. Therefore, their use is restricted at the level of arterial bifurcations (83% of lesions involved in our series) because of the risk of covering 1 of the 2 target vessels.6 Of note, although we use balloon-expandable stents, the POSE technique could be performed with self-expandable stents. In such cases, an endoluminal clamping with a balloon should be performed first. Then, the balloon should be deflated and temporary removed to insert and deploy the stent before reinflating the balloon to suture the graft. Several limits may exist with the POSE technique. A distal dissection was observed in 1 patient. The reason for this complication may be related to endoluminal trauma whereas introducing the wire or the stent. We now use floppy J-tip wire to limit this risk. As the POSE technique is a hybrid treatment combining conventional suturing with endoluminal stenting, its durability remains uncertain. In a 12-month follow-up, we observed 1 stent occlusion. A longer follow-up observation period could reveal other late intrastent restenoses. Therefore, the durability of the POSE technique is yet to be determined.
REFERENCES 1. Bunt TJ, Manship L, Moore W. Iatrogenic vascular injury during peripheral revascularization. J Vasc Surg 1985;2:491e8. 2. Ascer E, Veith FJ, Flores SA. Infrapopliteal bypasses to heavily calcified rock-like arteries. Management and results. Am J Surg 1986;152:220e3. 3. Patel R, Conrad MF, Paruchuri V, et al. Balloon expandable stents facilitate right renal artery reconstruction during complex open aortic aneurysm repair. J Vasc Surg 2010;51:310e5. 4. Piazza M, Bonvini S, Ferretto L, et al. Modification of the Viabahn Padova sutureless technique for challenging anastomosis between a prosthetic graft and a circumferentially calcified target artery. J Endovasc Ther 2012;19:457e60. 5. Bonvini S, Ricotta JJ, Piazza M, et al. ViPS technique as a novel concept for a sutureless vascular anastomosis. J Vasc Surg 2011;54:889e92. 6. Greenberg G, Szendro G, Mayzler O, et al. Use of ViaBahn open revascularisation technique for above-knee femoropopliteal anastomosis: a technical note. Eur J Vasc Endovasc Surg 2011;42:202e5. 7. Chiesa R, Melissano G, Civilini E, et al. Video-atlas of open thoracoabdominal aortic aneurysm repair. Ann Cardiothorac Surg 2012;1:398e403. 8. Semel L, Schu W, Aust JC, et al. Atraumatic control in calcified arteries. Ann Vasc Surg 1988;2:73e4. 9. Swedenborg J. Critical limb ischemia with totally calcified arteries. In: Branchereau A, Jacobs M eds. Unexpected challenges in vascular surgery. Oxford: Wiley-Blackwell, 2005. pp 205e10. 10. Rabellino M, Garcı´a-Nielsen L, Zander T, et al. Primary stenting immediately after surgery in occluded anastomoses of aortoaortic tube graft: a case report. Cardiol Res Pract 2010;2010. 11. Chiesa R, Kahlberg A, Mascia D, et al. Use of a novel hybrid vascular graft for sutureless revascularization of the renal arteries during open thoracoabdominal aortic aneurysm repair. J Vasc Surg 2014;60:622e30.