- Email: [email protected]
Repair of an Anastomotic Pseudoaneurysm with a Novel Hybrid Technique
Selected Technique Repair of an Anastomotic Pseudoaneurysm with a Novel Hybrid Technique Abdallah Naddaf, Ravishankar Hasanadka, Douglas Hood, and Kim Hodgson, Springfield, Illinois
Introduction: Anastomotic false aneurysms are a late complication of aortic grafting. Treatbridement of the degenerated tissue and placement of a short interment usually consists of de position graft. In infectious situations, graft excision is required. Patient History: An 80-year-old frail man with numerous comorbidities presented to clinic with an anastomotic pseudoaneurysm (PSA) between the left limb of an aortobifemoral Dacron graft and the common femoral artery (FA). Technical Details: The superficial FA (SFA) and deep FA (PFA) were exposed and controlled from an anterior thigh approach. Sheaths were inserted in each artery. An Amplatzer II vascular plug (Abbott, Abbott Park, IL) was deployed in the PFA. A Viabahn (Gore, Flagstaff, AZ) was first deployed in the left limb of the Dacron graft and into the proximal SFA. A Viabahn VBX stent (Gore, Flagstaff, AZ) was then deployed from inside the Viabahn and going proximally further into the limb of the bifurcated Dacron graft. The proximal end of the Viabahn VBX was flared with a larger balloon. The arteriotomies in the SFA and PFA were then used to create a sideto-side anastomosis. There were no immediate complications. On 6 months follow-up, the PSA sac was noted to have decreased in size, and the stents to be patent with no endoleak. Discussion: Elective surgical repair of anastomotic PSAs is preferred since emergent repair has significantly higher morbidity and mortality. Still, open elective repair has its own mortality and limb loss risks in addition to postoperative wound infection, seroma, hematoma, and recurrence, along with myocardial infarction and stroke. The novel procedure we performed eliminated the risk factors of redo groin incision and added easier-to-control vessels in a clean field. With this procedure being performed more often in the future, these changes will hopefully prove to reduce complications while preserving flow in both the SFA and PFA.
INTRODUCTION Anastomotic false aneurysms are a late complication of aortic grafting in 1e5% of cases1,2 secondary to structural fatigue or fabric degeneration. Many such aneurysms are related to infection, with
Staphylococcus species being the predominant organisms identified in culture. Given the potential complications of thrombosis, embolization, or rupture, repair is generally recommended for femoral false aneurysms larger than 2 cm. Treatment usually consists of debridement of the degenerated tissue and placement of a short interposition graft. In infectious situations, graft excision is required.3
Division of Vascular Surgery, Southern Illinois University School of Medicine, Springfield, IL. Correspondence to: Abdallah Naddaf, MD, Division of Vascular Surgery, SIU School of Medicine, P.O. Box 19638, Springfield, IL 627949638, USA; E-mail: [email protected]
PATIENT HISTORY
Ann Vasc Surg 2019; -: 1–4 https://doi.org/10.1016/j.avsg.2019.07.019 Ó 2019 Elsevier Inc. All rights reserved. Manuscript received: May 8, 2019; manuscript accepted: July 26, 2019; published online: - - -
This patient was an 80-year-old man who presented to clinic as a referral for a left groin pulsatile mass. He had a ruptured abdominal aortic aneurysm repaired with a bifurcated Dacron graft 13 years earlier and 1
2 Naddaf et al.
Annals of Vascular Surgery
Fig. 1. Preoperative 3D reconstruction on the left showing the pseudoaneurysm involving the left femoral bifurcation. On the right, an axial CT image reveals the maximal extent of the pseudoaneurysm.
was lost to follow-up for a decade. A duplex ultrasound revealed the mass to be an anastomotic pseudoaneurysm (PSA) between the left limb of the graft and the common femoral artery (FA), measuring 5.8 cm in maximal dimension. Contrast-enhanced computed tomography (CT) imaging demonstrated a 5.1 cm PSA without any mural thrombus (Fig. 1). The patient was frail and had numerous comorbidities, namely chronic obstructive pulmonary disease on 3 L of oxygen at home. He did not have any signs or symptoms of an infectious process by history or physical examination, and his CT scan did not suggest infection.
TECHNICAL DETAILS The patient was brought to the hybrid operating room and general anesthesia was induced. The superficial FA (SFA) and deep FA (PFA) were exposed and controlled from a standard anterior thigh approach using a longitudinal incision and lateral retraction of the sartorius muscle. The midprofunda was found just posterior to the SFA. A longitudinal arteriotomy was then performed on the SFA and an 8-French sheath inserted. A similar longitudinal arteriotomy was then performed at the PFA and a 6-French (6Fr) sheath inserted. An 8 mm Amplatzer II vascular plug (Abbott, Abbott Park, IL) was deployed in the PFA through the 6Fr sheath, covering a small PFA branch. Two different covered stents were then selected to negotiate the size mismatch between the larger graft limb and the smaller SFA. A 6 100 mm Viabahn (Gore,
Fig. 2. Fluoroscopic photo of the inserted devices with arrows delineating the boundaries of each stent and pointing to the plug.
Flagstaff, AZ) was first deployed in the left limb of the Dacron graft at the level of the distal external iliac artery, through the common FA, and into the proximal SFA. This was followed by deployment of the 8 56 mm Viabahn VBX stent (Gore, Flagstaff, AZ) from inside the Viabahn and going proximally further into the limb of the bifurcated Dacron graft at the level of the mid-external iliac artery. The proximal end of the Viabahn VBX was postdilated with a 12 mm balloon to create a flare zone. Completion angiography revealed the absence of endoleak in the stent system and a patent SFA (Fig. 2). The arteriotomies in the SFA and PFA
Volume
-, -
2019
Repair of anastomotic pseudoaneurysm with novel hybrid technique 3
Fig. 3. Six months postoperatively, multiplanar reformatting on the left shows the stent grafts spanning the femoral bifurcation from the common to the SFA with an arrow pointing to the SFA to PFA side-to-side
anastomosis distally, which is providing continued patency of the PFA. On the right, an axial CT image reveals complete exclusion and shrinking of the PSA sac.
were then used to create a side-to-side anastomosis. Finally, there were unobstructed Doppler signals in the SFA, as well as in the PFA, indicating retrograde flow from the SFA into the proximal PFA. There were pedal signals at the foot as well. The patient recovered well from the procedure and had no immediate complications. He eventually developed an uncomplicated thigh seroma that did not require intervention and was observed. On 6 months follow-up, the PSA sac was noted to have decreased in size to 4.4 cm and the stents to be patent with no endoleak (Fig. 3).
inguinal ligament or through a retroperitoneal incision for left iliac limb control. Also, inadvertent entry into the PSA sac before proximal and distal control could have led to massive acute blood loss. These factors meant increased risks of mortality and morbidity to an open approach in this elderly frail patient. This novel procedure eliminated the risk factors of redo groin incision and added easierto-control vessels in a clean field. With this procedure being performed more often in the future, these changes will hopefully prove to reduce complications while preserving flow in both the SFA and PFA. We did perform this procedure under general anesthesia at the preference of our anesthesia colleagues, but this procedure can be done under either spinal anesthesia or sedation with regional nerve block in select patients. Stent grafting across anastomotic PSAs has been described before but was always limited to situations where one of the branches, either SFA or PFA, was occluded or intentionally excluded. Our review of the literature revealed only one small case series describing the deployment of the stent graft into the PSA in the setting of a patent femoral bifurcation and addressed the situation by surgical distal anastomosis to the femoral bifurcation itself to preserve flow into both the SFA and PFA.12 Moreover, current technology does not allow preservation of the femoral bifurcation and mandates extension of a stent graft across the PSA and into either of the femoral branches. Hence, a hybrid procedure, such
DISCUSSION Elective surgical repair of anastomotic PSAs is preferred since emergent repair has significantly higher morbidity and mortality.4 Still, open elective repair has its own mortality and limb loss risks ranging from 0 to 4.4%,5e8 and as high as 20% mortality in the presence of graft infection.4 Postoperative wound infection rate is reported at 6%, while seroma and hematoma rates are at 3 and 2%, respectively.8 Recurrence rates of 0e20% at the newly constructed suture lines when interposition grafting is performed have been reported.4,9e11 Postoperative stroke7 and myocardial infarction4,8,9 have also been reported. The large size of the PSA in our case would have mandated proximal control by incision of the
4 Naddaf et al.
as described aforementioned, can preserve the patency of both branches and decrease the morbidity encountered during an open repair. It should be mentioned that this technique requires the identification of a rather straight segment of PFA with a few to no branches, with the distance to the SFA being not too great to allow mobilization for the side-to-side anastomosis.
Annals of Vascular Surgery
5.
6. 7.
8.
REFERENCES 1. Brewster DC. Complications of aortic and lower extremity procedures. In: Strandness DE, van Breda A eds. Vascular Disease: Surgical and Interventional Therapy. New York: Churchill Livingstone, 1994. p 1151. 2. Hagino RT, Taylor SM, Fujitani RM, et al. Proximal anastomotic failure following infrarenal aortic reconstruction: late development of true aneurysms, pseudoaneurysms, and occlusive disease. Ann Vasc Surg 1993;7:8. 3. Menard MT, Shah SK, Belkin M. Aortoiliac disease: direct reconstruction. In: Rutherford’s Vascular Surgery and Endovascular Therapy. 9th ed. Philadelphia: Elsevier, 2019. pp 1397e415. 4. Demarche M, Waltregny D, van Damme H, et al. Femoral anastomotic aneurysms: pathogenic factors, clinical
9.
10.
11.
12.
presentations and treatment. A study of 142 cases. Cardiovasc Surg 1999;7:315e22. Szilagyi ED, Smith RF, Elliott JP, et al. Anastomotic aneurysms after vascular reconstruction: problems of incidence, etiology, and treatment. Surgery 1975;78:800e16. Hollier LH, Batson RC, Cohn I. Femoral anastomotic aneurysms. Ann Surg 1980;191:715e20. Dennis JW, Littooy FN, Greisler HP, et al. Anastomotic pseudoaneurysms, a continuing late complication of vascular reconstructive procedures. Arch Surg 1986;121:314e7. Lawrence PF, Harlander-Locke MP, Oderich GS, et al. The current management of isolated degenerative femoral artery aneurysms is too aggressive for their natural history. J Vasc Surg 2014;59:343e9. Ernst CB, Elliott JP Jr, Ryan CJ, et al. Recurrent femoral anastomotic aneurysms. A 30-year experience. Ann Surg 1988;208:401e9. Satiani B, Kazmers M, Evans WE. Anastomotic arterial aneurysms: a continuing challenge. Ann Surg 1980;192: 674e82. Sharma NK, Chin KF, Modgill VK. Pseudoaneurysms of the femoral artery: recommendation for a method of repair. J R Coll Surg Edinb 2001;46:195e7. Rancic Z, Pecoraro F, Pfammatter T, et al. Less invasive (common) femoral artery aneurysm repair using endografts and limited dissection. Eur J Vasc Endovasc Surg 2013;45: 481e7.
Introduction: Anastomotic false aneurysms are a late complication of aortic grafting. Treatbridement of the degenerated tissue and placement of a short interment usually consists of de position graft. In infectious situations, graft excision is required. Patient History: An 80-year-old frail man with numerous comorbidities presented to clinic with an anastomotic pseudoaneurysm (PSA) between the left limb of an aortobifemoral Dacron graft and the common femoral artery (FA). Technical Details: The superficial FA (SFA) and deep FA (PFA) were exposed and controlled from an anterior thigh approach. Sheaths were inserted in each artery. An Amplatzer II vascular plug (Abbott, Abbott Park, IL) was deployed in the PFA. A Viabahn (Gore, Flagstaff, AZ) was first deployed in the left limb of the Dacron graft and into the proximal SFA. A Viabahn VBX stent (Gore, Flagstaff, AZ) was then deployed from inside the Viabahn and going proximally further into the limb of the bifurcated Dacron graft. The proximal end of the Viabahn VBX was flared with a larger balloon. The arteriotomies in the SFA and PFA were then used to create a sideto-side anastomosis. There were no immediate complications. On 6 months follow-up, the PSA sac was noted to have decreased in size, and the stents to be patent with no endoleak. Discussion: Elective surgical repair of anastomotic PSAs is preferred since emergent repair has significantly higher morbidity and mortality. Still, open elective repair has its own mortality and limb loss risks in addition to postoperative wound infection, seroma, hematoma, and recurrence, along with myocardial infarction and stroke. The novel procedure we performed eliminated the risk factors of redo groin incision and added easier-to-control vessels in a clean field. With this procedure being performed more often in the future, these changes will hopefully prove to reduce complications while preserving flow in both the SFA and PFA.
INTRODUCTION Anastomotic false aneurysms are a late complication of aortic grafting in 1e5% of cases1,2 secondary to structural fatigue or fabric degeneration. Many such aneurysms are related to infection, with
Staphylococcus species being the predominant organisms identified in culture. Given the potential complications of thrombosis, embolization, or rupture, repair is generally recommended for femoral false aneurysms larger than 2 cm. Treatment usually consists of debridement of the degenerated tissue and placement of a short interposition graft. In infectious situations, graft excision is required.3
Division of Vascular Surgery, Southern Illinois University School of Medicine, Springfield, IL. Correspondence to: Abdallah Naddaf, MD, Division of Vascular Surgery, SIU School of Medicine, P.O. Box 19638, Springfield, IL 627949638, USA; E-mail: [email protected]
PATIENT HISTORY
Ann Vasc Surg 2019; -: 1–4 https://doi.org/10.1016/j.avsg.2019.07.019 Ó 2019 Elsevier Inc. All rights reserved. Manuscript received: May 8, 2019; manuscript accepted: July 26, 2019; published online: - - -
This patient was an 80-year-old man who presented to clinic as a referral for a left groin pulsatile mass. He had a ruptured abdominal aortic aneurysm repaired with a bifurcated Dacron graft 13 years earlier and 1
2 Naddaf et al.
Annals of Vascular Surgery
Fig. 1. Preoperative 3D reconstruction on the left showing the pseudoaneurysm involving the left femoral bifurcation. On the right, an axial CT image reveals the maximal extent of the pseudoaneurysm.
was lost to follow-up for a decade. A duplex ultrasound revealed the mass to be an anastomotic pseudoaneurysm (PSA) between the left limb of the graft and the common femoral artery (FA), measuring 5.8 cm in maximal dimension. Contrast-enhanced computed tomography (CT) imaging demonstrated a 5.1 cm PSA without any mural thrombus (Fig. 1). The patient was frail and had numerous comorbidities, namely chronic obstructive pulmonary disease on 3 L of oxygen at home. He did not have any signs or symptoms of an infectious process by history or physical examination, and his CT scan did not suggest infection.
TECHNICAL DETAILS The patient was brought to the hybrid operating room and general anesthesia was induced. The superficial FA (SFA) and deep FA (PFA) were exposed and controlled from a standard anterior thigh approach using a longitudinal incision and lateral retraction of the sartorius muscle. The midprofunda was found just posterior to the SFA. A longitudinal arteriotomy was then performed on the SFA and an 8-French sheath inserted. A similar longitudinal arteriotomy was then performed at the PFA and a 6-French (6Fr) sheath inserted. An 8 mm Amplatzer II vascular plug (Abbott, Abbott Park, IL) was deployed in the PFA through the 6Fr sheath, covering a small PFA branch. Two different covered stents were then selected to negotiate the size mismatch between the larger graft limb and the smaller SFA. A 6 100 mm Viabahn (Gore,
Fig. 2. Fluoroscopic photo of the inserted devices with arrows delineating the boundaries of each stent and pointing to the plug.
Flagstaff, AZ) was first deployed in the left limb of the Dacron graft at the level of the distal external iliac artery, through the common FA, and into the proximal SFA. This was followed by deployment of the 8 56 mm Viabahn VBX stent (Gore, Flagstaff, AZ) from inside the Viabahn and going proximally further into the limb of the bifurcated Dacron graft at the level of the mid-external iliac artery. The proximal end of the Viabahn VBX was postdilated with a 12 mm balloon to create a flare zone. Completion angiography revealed the absence of endoleak in the stent system and a patent SFA (Fig. 2). The arteriotomies in the SFA and PFA
Volume
-, -
2019
Repair of anastomotic pseudoaneurysm with novel hybrid technique 3
Fig. 3. Six months postoperatively, multiplanar reformatting on the left shows the stent grafts spanning the femoral bifurcation from the common to the SFA with an arrow pointing to the SFA to PFA side-to-side
anastomosis distally, which is providing continued patency of the PFA. On the right, an axial CT image reveals complete exclusion and shrinking of the PSA sac.
were then used to create a side-to-side anastomosis. Finally, there were unobstructed Doppler signals in the SFA, as well as in the PFA, indicating retrograde flow from the SFA into the proximal PFA. There were pedal signals at the foot as well. The patient recovered well from the procedure and had no immediate complications. He eventually developed an uncomplicated thigh seroma that did not require intervention and was observed. On 6 months follow-up, the PSA sac was noted to have decreased in size to 4.4 cm and the stents to be patent with no endoleak (Fig. 3).
inguinal ligament or through a retroperitoneal incision for left iliac limb control. Also, inadvertent entry into the PSA sac before proximal and distal control could have led to massive acute blood loss. These factors meant increased risks of mortality and morbidity to an open approach in this elderly frail patient. This novel procedure eliminated the risk factors of redo groin incision and added easierto-control vessels in a clean field. With this procedure being performed more often in the future, these changes will hopefully prove to reduce complications while preserving flow in both the SFA and PFA. We did perform this procedure under general anesthesia at the preference of our anesthesia colleagues, but this procedure can be done under either spinal anesthesia or sedation with regional nerve block in select patients. Stent grafting across anastomotic PSAs has been described before but was always limited to situations where one of the branches, either SFA or PFA, was occluded or intentionally excluded. Our review of the literature revealed only one small case series describing the deployment of the stent graft into the PSA in the setting of a patent femoral bifurcation and addressed the situation by surgical distal anastomosis to the femoral bifurcation itself to preserve flow into both the SFA and PFA.12 Moreover, current technology does not allow preservation of the femoral bifurcation and mandates extension of a stent graft across the PSA and into either of the femoral branches. Hence, a hybrid procedure, such
DISCUSSION Elective surgical repair of anastomotic PSAs is preferred since emergent repair has significantly higher morbidity and mortality.4 Still, open elective repair has its own mortality and limb loss risks ranging from 0 to 4.4%,5e8 and as high as 20% mortality in the presence of graft infection.4 Postoperative wound infection rate is reported at 6%, while seroma and hematoma rates are at 3 and 2%, respectively.8 Recurrence rates of 0e20% at the newly constructed suture lines when interposition grafting is performed have been reported.4,9e11 Postoperative stroke7 and myocardial infarction4,8,9 have also been reported. The large size of the PSA in our case would have mandated proximal control by incision of the
4 Naddaf et al.
as described aforementioned, can preserve the patency of both branches and decrease the morbidity encountered during an open repair. It should be mentioned that this technique requires the identification of a rather straight segment of PFA with a few to no branches, with the distance to the SFA being not too great to allow mobilization for the side-to-side anastomosis.
Annals of Vascular Surgery
5.
6. 7.
8.
REFERENCES 1. Brewster DC. Complications of aortic and lower extremity procedures. In: Strandness DE, van Breda A eds. Vascular Disease: Surgical and Interventional Therapy. New York: Churchill Livingstone, 1994. p 1151. 2. Hagino RT, Taylor SM, Fujitani RM, et al. Proximal anastomotic failure following infrarenal aortic reconstruction: late development of true aneurysms, pseudoaneurysms, and occlusive disease. Ann Vasc Surg 1993;7:8. 3. Menard MT, Shah SK, Belkin M. Aortoiliac disease: direct reconstruction. In: Rutherford’s Vascular Surgery and Endovascular Therapy. 9th ed. Philadelphia: Elsevier, 2019. pp 1397e415. 4. Demarche M, Waltregny D, van Damme H, et al. Femoral anastomotic aneurysms: pathogenic factors, clinical
9.
10.
11.
12.
presentations and treatment. A study of 142 cases. Cardiovasc Surg 1999;7:315e22. Szilagyi ED, Smith RF, Elliott JP, et al. Anastomotic aneurysms after vascular reconstruction: problems of incidence, etiology, and treatment. Surgery 1975;78:800e16. Hollier LH, Batson RC, Cohn I. Femoral anastomotic aneurysms. Ann Surg 1980;191:715e20. Dennis JW, Littooy FN, Greisler HP, et al. Anastomotic pseudoaneurysms, a continuing late complication of vascular reconstructive procedures. Arch Surg 1986;121:314e7. Lawrence PF, Harlander-Locke MP, Oderich GS, et al. The current management of isolated degenerative femoral artery aneurysms is too aggressive for their natural history. J Vasc Surg 2014;59:343e9. Ernst CB, Elliott JP Jr, Ryan CJ, et al. Recurrent femoral anastomotic aneurysms. A 30-year experience. Ann Surg 1988;208:401e9. Satiani B, Kazmers M, Evans WE. Anastomotic arterial aneurysms: a continuing challenge. Ann Surg 1980;192: 674e82. Sharma NK, Chin KF, Modgill VK. Pseudoaneurysms of the femoral artery: recommendation for a method of repair. J R Coll Surg Edinb 2001;46:195e7. Rancic Z, Pecoraro F, Pfammatter T, et al. Less invasive (common) femoral artery aneurysm repair using endografts and limited dissection. Eur J Vasc Endovasc Surg 2013;45: 481e7.