- •Vascular Surgery
- •SECTION AND BOARD OF VASCULAR SURGERY
- •Foreword to the First Edition
- •Preface to the First Edition
- •Preface to the Second Edition
- •Preface to the Third Edition
- •Contents
- •Contributors
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •1.1 Commentary
- •1.2 Beta-Adrenergic Antagonists
- •1.3 3-Hydroxy-3-Methylglutaryl Coenzyme A Reductase Inhibitors (Statins)
- •1.4 Percutaneous Revascularization
- •1.5 Coronary Artery Bypass Grafting
- •References
- •2: Abdominal Aortic Aneurysm
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •2.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •Question 10
- •Question 11
- •Question 12
- •Question 13
- •Question 14
- •3.1 Commentary
- •3.2 Case Analysis Quiz
- •References
- •4: Ruptured Abdominal Aortic Aneurysm
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •4.1 Commentary
- •References
- •5: Thoracoabdominal Aortic Aneurysm
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •Question 10
- •5.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •Question 10
- •Question 11
- •Question 12
- •Question 13
- •6.1 Commentary
- •References
- •7: Aortic Dissection
- •7.1 Dissection: Stanford A
- •Question 1
- •Question 2
- •Question 3
- •7.2 Dissection: Stanford B
- •Question 4
- •Question 5
- •7.3 Commentary
- •References
- •8: Popliteal Artery Aneurysms
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •8.1 Popliteal Artery Aneurysm
- •References
- •9: Renal Artery Aneurysm
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •9.1 Commentary
- •References
- •10: Anastomotic Aneurysms
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •10.1 Commentary
- •10.2 Indications for Intervention
- •10.3 Treatment for Anastomotic Aneurysms
- •10.4 Infection in Anastomotic Aneurysms
- •10.5 Outcome
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •11.1 Commentary
- •References
- •12: Acute Thrombosis
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •12.1 Commentary
- •References
- •13: Arterial Embolism
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •13.1 Commentary
- •References
- •14: Blast Injury to the Lower Limb
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •14.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •15.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Smoking
- •Antiplatelet Agents
- •Blood Pressure (BP)
- •Glucose Status
- •Lipids
- •Emerging Risk Factors
- •Question 4
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •Question 10
- •Question 11
- •17.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •18.1 Commentary
- •18.2 Clinical Assessment
- •18.3 Imaging Techniques
- •18.4 Revascularization Options
- •18.5 Aortobifemoral Bypass
- •18.6 Iliac Angioplasty and Stenting
- •18.7 Iliac Stenting Combined with Profunda Femoris Artery Revascularization
- •18.8 Rationale for Angioplasty of “Donor” Iliac Artery Prior to Femorofemoral Crossover Bypass
- •18.10 Supervision and Follow-up of the Patient
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •Question 10
- •Question 11
- •Question 12
- •19.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •20.1 Commentary
- •References
- •21: Bypass to the Popliteal Artery
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •21.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •22.1 Commentary
- •References
- •23: Popliteal Artery Entrapment
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •23.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •24.1 Commentary
- •References
- •25: The Obturator Foramen Bypass
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •25.1 Commentary
- •25.2 Preoperative Measures
- •25.3 The Concept of the Obturator Foramen Bypass
- •25.4 Obturator Foramen Bypass Technique
- •References
- •26: Diabetic Foot
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •Question 10
- •Question 11
- •26.1 Commentary
- •References
- •27: Chronic Visceral Ischemia
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •27.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •28.1 Commentary
- •References
- •29: Renovascular Hypertension
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •29.1 Commentary
- •29.4 Intra-arterial Angiography
- •29.5 Duplex Ultrasonography (DU)
- •29.6 Treatment
- •29.6.1 Medical Treatment
- •29.6.2 Revascularization
- •29.7 Prognosis
- •References
- •30: Midaortic Syndrome
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •30.1 Commentary
- •References
- •31: Management of Portal Hypertension
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •31.1 Commentary
- •31.2 General Considerations
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •32.1 Commentary
- •References
- •33: The Carotid Body Tumor
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •33.1 Commentary
- •33.2 Clinical Presentation
- •33.3 Treatment
- •33.4 Summary
- •References
- •Question 1
- •Question 2
- •Question 3
- •34.1 Commentary
- •34.2 Vertebrobasilar Ischemia: Low-Flow Mechanism
- •Question 1
- •Question 2
- •34.3 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •35.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •36.1 Commentary
- •References
- •37: Acute Axillary/Subclavian Vein Thrombosis
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •37.1 Commentary
- •References
- •38: Raynaud’s Phenomenon
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •38.1 Commentary
- •References
- •39: Aortofemoral Graft Infection
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •Question 10
- •39.1 Commentary
- •References
- •40: Aortoenteric Fistulas
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •40.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •41.1 Commentary
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Questions 7 and 8
- •Question 9
- •Question 10
- •Comment
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •42.1 Commentary
- •References
- •43: Amputations in an Ischemic Limb
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •43.1 Commentary
- •References
- •44: Congenital Vascular Malformation
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •44.1 Clinical Evaluation
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •Question 10
- •Question 11
- •44.2 Commentary
- •References
- •45: Klippel-Trenaunay Syndrome
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •45.1 Commentary
- •Clinical Presentation
- •Evaluation
- •Treatment
- •References
- •46: Deep Venous Thrombosis
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •46.1 Commentary
- •References
- •47: Endoluminal Ablation of Varicose Veins
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •47.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •48.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •50.1 Commentary
- •References
- •51: Iliofemoral Venous Thrombosis
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •50.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •Question 10
- •Question 11
- •52.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •Question 10
- •53.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •54.1 Commentary
- •References
- •Index
|
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Anastomotic Aneurysms |
10 |
|
|
Jonothan J. Earnshaw |
|
|
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A 70-year-old woman presented with bilateral pulsatile groin masses (Fig. 10.1). Six years ago, she had an elective aorto-bifemoral graft for a 6-cm abdominal aortic aneurysm involving both iliac arteries, from which she made a full recovery. She first found the larger, right-sided mass 4 months ago, and she had noted gradual enlargement since then. She had no symptoms of claudication or leg ischemia. Her past medical history included a myocardial infarction (MI) 18 months ago, but without limitation to her exercise tolerance. On examination, she appeared well. There was a well-healed midline laparotomy scar from the previous operation. Abdominal examination was unremarkable, and there were no bruits on auscultation. Two well-defined expansile masses were palpable in the middle third of the femoral scars, measuring approximately 2 cm on the left and 4 cm on the right. The masses were not tender. There was no evidence of compromise to the distal circulation, and all pulses were palpable. Duplex imaging identified anastomotic false aneurysms in both groins, measuring 1.8 cm on the left and 3.5 cm on the right.
Fig. 10.1 Female patient with bilateral anastomotic aneurysms from an aortobifemoral graft
J.J. Earnshaw
Department of Surgery, Gloucestershire Royal Hospital, Gloucester, UK
G. Geroulakos and B. Sumpio (eds.), Vascular Surgery, |
97 |
DOI: 10.1007/978-1-84996-356-5_10, © Springer-Verlag London Limited 2011 |
|
98 |
J.J. Earnshaw |
|
|
Question 1
Which of the following statements regarding the etiology of anastomotic false aneurysms are correct?
A. Anastomotic false aneurysms occur in 3–5% of anastomoses to the femoral artery in the groin
B. Forty per cent are found in the groin
C. Primary degeneration of the arterial wall is an etiological factor D. Continued smoking is an etiological factor
E. At reoperation, approximately one-third will be found to be infected with pathogenic bacteria
Question 2
The patient wished to know the risks of leaving the aneurysm alone. Rank the potential complications of anastomotic aneurysms in order of frequency.
A. Rupture
B. Embolization
C. Pressure symptoms D. Pain
E. Secondary hemorrhage
Question 3
Which of the following non-operative treatments are also available?
A. Embolization
B. Ultrasound-guided compression C. Thrombin injection
D. Intravascular stent graft
The larger of the two aneurysms was repaired surgically. The previous surgical incision was reopened and extended. A large false aneurysm was confirmed; the graft appeared to have become detached from the artery. There were no signs of infection. The aneurysm was replaced by straight 8-mm gelatin-coated woven Dacron interposition graft (soaked in rifampicin solution 10 mg/mL) taken end to end from the old graft and sutured end to side over the common femoral bifurcation. The thrombus and old graft were sent for microbiology. The patient made a good postoperative recovery. All bacterial cultures were negative, so perioperative antibiotic prophylaxis was stopped after 48 h.
10 Anastomotic Aneurysms |
99 |
|
|
Question 4
Rank the following surgical procedures in order of value for the management of anastomotic aneurysm in the groin (least useful first):
A. Resuture or local repair B. Ligation and bypass C. Prosthetic patch
D. Vein patch
E. Interposition graft
This patient at 2-year follow-up had no evidence of recurrence of the anastomotic aneurysm in her right groin. A follow-up ultrasound scan of her left groin revealed that the left anastomotic aneurysm remained 2 cm in maximum diameter.
Question 5
Which of the following statements are false.
A. Surgery cures 50% of all anastomotic aneurysms. B. Surgery cures 90% of all anastomotic aneurysms.
C. Surgery cures 50% of all recurrent anastomotic aneurysms. D. Surgery cures 90% of all recurrent anastomotic aneurysms.
E. Long-term follow-up of retroperitoneal anastomotic aneurysms is not necessary.
10.1 Commentary
The incidence of anastomotic aneurysms is increasing, due primarily to the increased frequency of prosthetic vascular reconstructions involving groin anastomosis. The overall incidence following vascular anastomoses is about 2%, but this increases to 3–8% when the anastomosis involves the femoral artery.1–4 Although they are most common after prosthetic bypass, anastomotic aneurysms occasionally occur after vein bypass, semi-closed endarterectomy, and open endarterectomy with a vein patch. Anastomotic aneurysms can occuranywhere,buttheyfrequentlydevelopneartoajoint.About80%occuratthegroin,1 presumably due to movement-related strains. [Q1: A, C, D, E]
The etiology is summarized in Fig. 10.2; there are three primary factors and a number of secondary factors. One of the first documented causes was suture failure, when braided silk was employed for vascular anastomoses.5 Since monofilament sutures have been used, suture failure has become a less common factor, although occasionally reported disasters highlight the importance of careful suture handling to avoid cracking of the polypropylene.6
100 |
J.J. Earnshaw |
|
|
Primary factors
Arterial |
Infection |
Suture failure |
|
degeneration |
|||
30% |
5% |
||
65% |
|||
|
|
Secondary factors |
|
Arterial weakness |
Increased forces across the anastomosis |
Endarterectomy |
|
Poor suture technique |
Hypertension |
Reoperative surgery |
Anastomotic tension |
Hyperlipidaemia |
Compliance mismatch |
Smoking |
Dacron dilation |
Distal disease progression |
High outflow resistance |
Poststenotic dilation |
Hip joint motion |
Steroid therapy |
Trauma |
Radiotherapy |
|
Fig. 10.2 Etiology of anastomotic aneurysms
Arterial degeneration is the most common primary factor. The disease process that mandated the bypass continues after its insertion.1,7,8 Histologically, a chronic inflammatory response can be identified at an anastomosis.9 Secondary factors are numerous and compound the process of arterial degeneration.10 Poor technique, failing to suture all layers of the artery, use of Dacron, and the need for endarterectomy all weaken the arterial graft complex.1 Hypertension and high outflow resistance may theoretically increase strains at the anastomosis, together with physical disruption from both hip motion and poststenotic dilation as the graft passes under the inguinal ligament.9 These and other factors can cause compliance mismatch, which may also be a factor.8 Anastomotic aneurysms can be caused by local infection. Infection with high-virulence bacteria, such as Staphylococcus aureus, usually presents early with clinical graft infection. Late anastomotic rupture is often caused by low-virulence organisms, such as Staphylococcus epidermidis. Up to 30% of anastomotic aneurysms can be shown to harbor pathogenic bacteria at reoperation.7 This has implications for surgical repair (see below). [Q2: D, C, B, A, E]
10.2
Indications for Intervention
Treatment of anastomotic aneurysms is aimed at controlling symptoms or preventing the onset of complications. Symptoms of pain are associated with the enlarging mass or