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Neoaortoiliac System Procedure for Treatment of an Aortic Graft Infection

Historical Background Dissatisfaction with traditional single-stage or multistage extraanatomic bypass followed by resection of infected aortic grafts arises from aortic stump blowout after excision of the infected graft and more importantly from compromised long-term performance of axillofemoral reconstructions. Ehrenfeld and colleagues reported their experience with in situ reconstruction of the aorta using endarterectomized arterial autografts in 1979. Limitations with available arterial conduit prevented widespread adoption of…

Total Graft Excision and Extraanatomic Repair for Aortic Graft Infection

Historical Background Many early series recognized that aortic graft infection is difficult to diagnose, is associated with substantial amputation and mortality risks, and has a tendency to recur if inadequately treated. It was recognized early on that inadequately treated aortic graft infection could lead to systemic sepsis or, in propagating to the anastomosis, could lead to pseudoaneurysm and hemorrhage from anastomotic disruption. The 0.2% to 2%…

Spine Exposure

Historical Background Anterior intervertebral body fusion was described in 1932 by Carpenter and promoted by Hodgson and Stock in 1956 as a definitive treatment of anteriorly oriented spine pathology while avoiding posterior element injury. Anterior discectomy, decompression, and intervertebral fusion are usually combined with supplemental posterior fixation to increase the rate of complete spinal fusion. Spine exposure for lumbosacral (LS) pathology was originally performed through an…

Special Problems in the Endovascular Treatment of Aortoiliac Occlusive Disease

Historical Background In recent years there has been a shift in the treatment of aortoiliac occlusive disease (AIOD) from open surgical treatment to endovascular interventions. Endovascular treatment for Trans-Atlantic Inter-Society Consensus (TASC) class A lesions is considered standard. Recommendations are not as clear for more complex disease, including TASC class B and C lesions, but even these are often treated with interventional therapy with excellent results.…

Endovascular Treatment of Aortoiliac Occlusive Disease

Historical Background In 1964 Dotter and Judkins first reported percutaneous transluminal angioplasty as a technique for treating atherosclerotic stenoses and occlusions. Application of this method for the treatment of iliac occlusive disease was reported in 1974. In February 1974 Grüntzig and Hopff introduced the clinical use of a new balloon catheter, and in 1979 Grüntzig and Kumpe reported a 2-year patency rate of 87% for treatment…

Extraanatomic Repair of Aortoiliac Occlusive Disease

Historical Background Extraanatomic procedures were developed as alternatives to direct aortofemoral bypass for patients deemed to be at high risk for direct aortic surgery or for those presenting with a “hostile” abdomen, an infection of the native aortoiliac arterial system, or prior prosthetic replacement of the aortoiliac system. The first extraanatomic procedure to be described for treatment of aortoiliac occlusive disease was the femoral-femoral bypass, which…

Direct Surgical Repair of Aortoiliac Occlusive Disease

Historical Background The distal aorta and iliac segments are among the most common sites of chronic atherosclerotic disease. This disease is usually segmental, generally produces a constellation of characteristic symptoms, and is amenable to durable surgical reconstruction. Direct surgical correction of aortoiliac occlusive disease (AIOD) has developed rapidly since the 1940s and 1950s. Although AIOD commonly coexists with disease below the inguinal ligament, correction of inflow…

Endovascular Treatment of Aneurysms of the Juxtarenal and Pararenal Aorta

Historical Background Juxtarenal aneurysms refer to abdominal aortic aneurysms with an infrarenal neck less than or equal to 1 cm in length, and pararenal aneurysms refer to abdominal aortic aneurysms that involve one or both orifices of the renal arteries. Browne and associates first described the design of a fenestrated graft in 1999 in which holes were placed within an endograft for deployment of uncovered balloon-expandable…

Special Problems in the Endovascular Treatment of the Infrarenal Aorta

Historical Background Aortic endograft technology has evolved significantly since the initial U.S. commercial release in late 1999. Second- and third-generation endografts have come to market, providing improvements in fixation, sizing, versatility, tractability, and delivery profile. These device improvements have made it possible to treat challenging anatomy that would not have been feasible in the early days of endovascular aneurysm repair (EVAR). However, anatomic limitations continue to…

Endovascular Treatment of Aneurysms of the Infrarenal Aorta

Historical Background Volodos and colleagues performed the first stent graft repair of an aortic pathology in 1987 in Kharkov, Union of Soviet Socialist Republics, but Parodi, Palmaz, and Barone are credited with pioneering and popularizing the technique in the early 1990s. Scott and Chuter were the first to repace the early single tube structure with a bifurcated device, extending the ability to exclude more complex aortoiliac…

Direct Surgical Repair of Juxtarenal and Suprarenal Aneurysms of the Abdominal Aorta

Historical Background The surgical management of abdominal aortic aneurysms was first pursued by direct aortic ligation as reported by Matas in 1923. Likewise, beginning in 1906, Halsted and Reid at the Johns Hopkins Hospital attempted to treat suprarenal aortic aneurysms in five patients by the placement of partially occlusive metal bands. Subsequent strategies included the induction of partial or complete thrombosis of aortic aneuryms by translumbar…

Direct Surgical Repair of Aneurysms of the Infrarenal Abdominal Aorta and Iliac Arteries

Historical Background Abdominal aortic aneurysms were first described by the sixteenth-century anatomist Vesalius. Before the advent of modern surgical techniques, numerous management methods focusing on aneurysm ligation, induced thrombosis, or wrapping were attempted, all with little success. It was not until 1951, when Dubost and associates performed the first successful abdominal aortic aneurysm repair using an aortic homograft, that the management of abdominal aortic aneurysms entered…

Endovascular Treatment of Traumatic Thoracic Aortic Disruption

Historical Background Traumatic aortic injury is the result of a high-velocity or deceleration injury to the wall of the aorta, which most commonly occurs at the level of the ligamentum arteriosum, proximal to the third intercostal artery. Of those patients who reach the hospital, the lesion is most often a noncircumferential injury limited to the intima and media. It may range from subintimal hemorrhage, with or…

Endovascular Treatment of Aortic Dissection

Historical Background Acute dissection of the thoracic aorta was first described by Nichools (1699-1778) in referring to the autopsy findings of King George II. Traditionally, acute uncomplicated type B dissection has been managed medically with an effective medical regimen directed toward lowering blood pressure and dP/dt first introduced by Palmer and Wheat in 1967. The 30-day mortality for acute uncomplicated type B dissection decreased from 40%…

Endovascular Treatment of Thoracic Aneurysms

Historical Background Aneurysms of the descending thoracic aorta (DTA) affect an estimated 3 to 4 per 100,000 adults. The surgical treatment of DTA aneurysms began in the 1950s through pioneering work by DeBakey, Cooley, and others. Over the years, a number of advances have been made in the surgical techniques and perioperative care of patients with DTA aneurysms. Cerebrospinal fluid (CSF) drainage is now routinely applied,…

Endovascular Repair of the Aortic Arch and Thoracoabdominal Aorta

Historical Background The first multibranched stent grafts, like the first bifurcated stent grafts, were of unibody design, whereby the entire stent graft was inserted whole and deployed using a system of catheters. Downstream access to the branches made the arch version slightly simpler than the thoracoabdominal version, but both showed a high degree of irreducible complexity that has limited application to a small group of highly…

Direct Surgical Repair of Aneurysms of the Thoracic and Thoracoabdominal Aorta

Historical Background The first surgeon to repair a thoracoabdominal aortic aneurysm (TAAA) was Etheredge in 1955 in a patient with a Type IV TAAA using a homograft. In 1956 DeBakey and associates reported the surgical treatment of four patients with TAAA by resection and homograft replacement. A Dacron graft was used as a shunt between the descending thoracic aorta and infrarenal abdominal aorta. Sequentially, the celiac…

Endovascular Therapy for Subclavian-Axillary Vein Thrombosis

Historical Background Subclavian-axillary vein thrombosis, also referred to as Paget-Schroetter syndrome or “effort thrombosis,” refers to primary thrombosis of the subclavian vein at the costoclavicular junction. Primary subclavian-axillary vein thrombosis is relatively rare, with a yearly incidence in the United States of 3000 to 6000 cases. A recent analysis suggests that less than 1000 first rib resections are performed for venous thoracic outlet syndrome yearly. This…

Transaxillary Rib Resection for Thoracic Outlet Syndrome

Historical Background The first anatomic descriptions of the thoracic outlet can be traced to 150 ad when Galen identified the presence of a cervical rib in human dissections. However, it was not until 1742 that Hunauld established the association between a cervical rib and upper extremity symptoms. In 1821 Cooper characterized the constellation of neurovascular symptoms involving the thoracic outlet. Ochsner called this the scalene santicus…

Supraclavicular Approach for Surgical Treatment of Thoracic Outlet Syndrome

Historical Background Thoracic outlet syndrome (TOS) is recognized to encompass three conditions: (1) neurogenic TOS, caused by compression of the brachial plexus nerve roots within the scalene triangle, subcoracoid space, or both; (2) venous TOS, caused by compression of the axillary, subclavian, or both veins and leading to the effort thrombosis syndrome; and (3) arterial TOS, caused by compression of the subclavian artery and leading to…