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Abdominal Aortic Coarctation and Hypoplasia

Focal developmental narrowings of the distal thoracic and abdominal aorta are rare anomalies accounting for less than 2% of all aortic coarctations. Most physicians have limited experience with the management of these unusual lesions. Abdominal aortic coarctations are categorized by the most superior extent of the aortic narrowing. Among these aortic coarctations, 69% are suprarenal ( Figure 1 ). Narrowings originating in the intrarenal aorta occur…

Combined Laparoscopic and Endovascular Treatment of Aortic Diseases

Endoleaks, endotension, and graft migration are the major problems of endovascular aneurysm repair (EVAR) when treating abdominal aortic aneurysms (AAAs). There are patients with endotension and aneurysms that increase in diameter without any evidence of patent lumbar arteries or a patent inferior mesenteric artery (IMA). Endovascular coiling of patent lumbar arteries or of the IMA is cumbersome, often requiring several treatment sessions by experienced interventionists. Laparoscopy…

Open and Endovascular Treatment of Anastomotic Aneurysms after Aortoaortic, Aortoiliac, and Aortofemoral Bypass

Anastomotic aneurysms result from a disruption of the native artery–to–graft anastomosis. They are characterized by type (true or false), location (aortic, iliac, or femoral), and etiology (mycotic or nonmycotic). The majority are false aneurysms (pseudoaneurysms), with blood extravasation contained by periarterial tissue. True aneurysms can develop as the native artery itself dilates. Retroperitoneal anastomotic aneurysms often lead to life-threatening complications because of potential for rupture, and…

Aortic Graft Limb Occlusion

Aortofemoral bypass (AFB) has been recognized as a durable and effective form of vascular reconstruction for aortoiliac occlusive disease. With the advent of balloon angioplasty and intraluminal stents in the last 20 years, there has been a decrease in the number of patients treated by AFB procedures. However, it is still the treatment of choice for selected patients with extensive bilateral and calcific aortoiliac occlusive disease.…

Acute Aortic Occlusion

Acute aortic occlusion is a true vascular emergency associated with significant morbidity and mortality secondary to the underlying etiology, the related comorbidities, and the ischemia–reperfusion injury resulting from revascularization. Indeed, the morbidity and mortality rates are comparable to those associated with a ruptured abdominal aortic aneurysm (AAA). The optimal management requires early recognition and definitive treatment, similar to most vascular surgical emergencies. Despite the evolution of…

Management of Juxtarenal Aortic Occlusive Disease by Retroperitoneal and Transperitoneal Exposure of the Pararenal and Suprarenal Aorta

The perivisceral aorta can be involved in a variety of pathologic conditions. These diverse conditions include atherosclerotic occlusive disease of the aorta and its visceral branches, aneurysmal degeneration, trauma (both penetrating and blunt), and congenital problems (e.g., midabdominal coarctation). The exposure of the paravisceral aorta is also relevant for reoperative aortic surgery such as open conversion after failed endovascular aneurysm repair or failed aortobifemoral bypass. Adequate…

Aortofemoral Bypass for Atherosclerotic Aortoiliac Occlusive Disease

Aortoiliac disease (AOID) is usually segmental in distribution and therefore amenable to effective treatment. Even in patients with multilevel disease, successful correction of hemodynamically significant inflow disease often provides adequate revascularization of the extremities and satisfactory clinical relief of ischemic symptoms. Procedure Selection Numerous options exist for revascularization in patients with AOID. Selection of the most appropriate method depends largely on two factors: the patient’s surgical…

Percutaneous Arterial Angioplasty with and without Stenting for Atherosclerotic Aortic and Iliac Artery Occlusive Disease

The comparative ease and success of endovascular management of aortoiliac occlusive disease (AIOD) has greatly reduced the need for its open surgical repair. Factors such as reduced patient morbidity, discomfort, and length of convalescence have resulted not only in increased acceptance by patients but often in patients’ insistence on this mode of therapy. Potential cost savings is another factor favoring endovascular treatments, although the expense of…

Selecting Treatment for Patients with Aortoiliac Occlusive Disease

Patients with aortoiliac occlusive disease (AIOD) represent a subset of patients with peripheral artery disease whose condition can involve the infrarenal aorta, common and/or external iliac arteries, and the common femoral arteries. Since the turn of the century there has been a rapid increase in the number of endovascular interventions performed for revascularization of patients with AIOD and a concomitant decline in the number of open…

Physiologic and Noninvasive Studies to Document Severity and Extent of Aortoiliac Occlusive Disease

The evaluation of patients who come to the hospital with symptoms of aortoiliac occlusive disease (AIOD) in the setting of peripheral artery disease (PAD) routinely includes methods for determining the anatomic location of and physiologic significance of the occlusive process. The primary decision involves assessing how disabling the symptoms are for the patient. However, for any given level of ankle measured perfusion (e.g., ankle-to-brachial index [ABI]),…

Conventional Arteriography, Magnetic Resonance Angiography, and Computed Tomographic Arteriography of Aortoiliac Occlusive Disease

Three principal imaging techniques exist for evaluating the presence and extent of atherosclerotic occlusive disease of the abdominal aorta and iliac arteries. Conventional or catheter-based arteriography, usually with digital subtraction angiography (DSA), has long been considered the gold standard tool for assessing vascular disease. Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are alternative and complementary techniques for depicting the vasculature in these patients. Digital…

Endovascular Treatment of Popliteal Artery Aneurysms

Popliteal artery aneurysms (PAAs) are rare, occurring usually in men older than 60 years. The incidence is significantly higher in patients with an abdominal aortic aneurysm (AAA), where up to 30% may be affected. These aneurysms have a tendency to occur bilaterally. PAAs exhibit symptoms in up to 70% of the cases within 5 years. Symptomatic PAAs can manifest with progressive intermittent claudication as a result…

Open Surgical Treatment of Popliteal Artery Aneurysms

Popliteal artery aneurysms (PAAs) are uncommon, having an estimated incidence in the general population of 0.1%. They are the third most common aneurysmal pathology encountered in clinical practice, ranking behind both aortic and cerebrovascular aneurysms. Half to three quarters of patients with PAAs come to the hospital with bilateral lesions. Patients with PAAs have a 30% to 50% chance of a concomitant abdominal aortic aneurysm (AAA),…

Obturator Foramen Bypass Grafts in Groin Sepsis

In an era of rapid evolution and dramatic innovation in the diagnosis and management of vascular disease, infection remains one of the most serious life- and limb-threatening problems for the patient and difficult challenges for the surgeon. Although a variety of options have been used to treat vascular graft infection, including in situ replacement with autogenous conduits, antibiotic-impregnated synthetic grafts, cryopreserved grafts, homografts, and rotational muscle…

Infected Femoral Artery False Aneurysms

The infected femoral artery false aneurysm can produce life-threatening hemorrhage, loss of limb, and/or death. Surgical interruption of a single common, superficial, or profunda femoris artery offers definitive local treatment. When the preoperative status of limb viability is unclear, it may be determined intraoperatively. If an ankle Doppler signal cannot be detected after ligation, an arterial reconstruction may be necessary to prevent ischemic gangrene. Although the…

Arteriosclerotic Femoral Artery Aneurysms

Arteriosclerotic femoral artery aneurysms are relatively uncommon, but they are the second most commonly encountered peripheral arterial aneurysm. The exact incidence of femoral artery aneurysms in the general population has not been defined, but they are nearly as common as popliteal artery aneurysms and have been reported in 6.8% of patients with abdominal aortic aneurysms. Although limb loss is rarely attributed to complications of femoral artery…

Long-Term Alterations in Large-Caliber Arterial Prostheses Used for Aortic Repair

Large-caliber prostheses used for aortic replacement initiate blood–material interfacial processes that begin almost immediately upon establishment of circulatory flow. These processes lead to prosthetic encapsulation and structural alteration, occasionally a degree of degradation of synthetic polymers, and ultimately these events contribute to the long-term development of thrombosis, intimal hyperplasia, tissue incorporation, and dilatation of aortic prostheses. Early Host Responses to Implanted Materials Protein Deposition Almost immediately…

Endovascular Management of Isolated Iliac Artery Aneurysms

The traditional repair of isolated iliac artery aneurysms (IAAs) has been through an open surgical approach. The pelvic location of the isolated iliac aneurysm can increase the technical difficulty of open repair. The operative mortality for open elective repair of isolated iliac aneurysms has been reported as high as 10%, which is greater than the operative mortality associated with open abdominal aortic aneurysm repair. However, because…