chapter review anastomotic aneurysms l.
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Chapter review: anastomotic aneurysms. Incidence. 30 year experience 6090 aorto-iliofemoral anastomoses 2.4% femoral arteries, 0.4% aorta, 0.8% iliac arteries 20 year follow-up of 518 with ultrasonography or angiography 13.6% femoral arteries, 4.8% aorta, 6.3% iliac arteries. Etiology.

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incidence
Incidence
  • 30 year experience 6090 aorto-iliofemoral anastomoses
    • 2.4% femoral arteries, 0.4% aorta, 0.8% iliac arteries
  • 20 year follow-up of 518 with ultrasonography or angiography
    • 13.6% femoral arteries, 4.8% aorta, 6.3% iliac arteries
etiology
Etiology
  • Suture line disruption
    • Anastomic strength depends of suture coaptation of the graft to vessel wall
    • Silk, very high rate of anastomotic aneurysms within 5 to 10 years when used with prosthetic grafts
    • Dacron, good strength but poor incorporation, persistent inflammatory reaction, and suture ‘drag’
etiology4
Etiology
  • Nylon, lose significant amount of tensile strength, but readily formable to thin sutures 9-0 and 10-0, lack of brittle qualities
  • PTFE, little inflammatory reaction, does not have same cross-sectional strength as polypropylene
  • Polypropylene, minimally reactive, incorporates into tissue well, maintains strength over time, low coefficient of friction, resistant to bacterial films
etiology5
etiology
  • Nonsuture methods of anastomosis
    • Adhesives, stents, rings, vascular clips, and laser welding
    • Vascular clips promising for autogenous tissue anastomoses not involving an endarterectomy
etiology graft failure
etiology – graft failure
  • Earlier generations of PTFE and dacron found to fail over time
  • Possibility of edge fraying of woven velour dacron grafts
    • Take big bites or thermally seal edges
etiology arterial wall failure
Etiology – arterial wall failure
  • Can deteriorate and lead to pseudoaneurysm
  • Difficult to determine if false or true aneurysm by imaging
  • Assume lesion is a pseudoaneurysm for surgical planning
etiology inflammation
Etiology - inflammation
  • 45 pseudoaneurysms
    • Bacterial cultures positive for 60% of cases
    • 89% of cases were coagulase neg staph
etiology technical errors
Etiology – technical errors
  • Adequate number of suture loops, adequate bites of tissue, following curve of needle important aspects
  • Endarterectomy – can lead to aneurysmal degeneration because intima and media are removed
etiology physical stress
Etiology – physical stress
  • Include hypertension, direct trauma, and compression and distraction forces with anastomosis across a joint
  • Size mismatch can also be a factor, prosthetic grafts generally less compliant than native tissue
    • Lateral forces generate stress preferentially on the native tissue
    • Physical stresses increase as aneurysm size increases
clinical presentation
Clinical presentation
  • Generally asymptomatic, but are usually found on physical exam
  • Can cause symptoms fullness, pain, pulsatility, and symptoms associated with local compression (weakness from compression of an adjacent nerve….)
  • Clinical problems include rupture and bleeding into adjacent tissues, embolization from mural thrombus, thrombosis with distal ischemia, and venous congestion or thrombosis from compression of an adjacent vein
  • Emergency operative intervention carries a higher morbidity and mortality
  • Median time to indentification is 6 years, earlier manifestations should prompt an investigation into an infectious etiology including high resolution ct angio and esr rate
femoral artery anastomosis
Femoral artery anastomosis
  • Most prevalent site of anastomotic pseudoaneurysms
  • Most cases are diagnosed as an asymptomatic pulsatile mass in up to 44% of cases; less than 10% require surgical intervention
    • These should be monitored until they have a significant growth rate or the size is 2 to 2.5cm
    • These should never be catheterized
    • Can be monitored by ultrasound study, both sides should be investigated
  • Endoluminal repair not an option as this is over a hip joint
abdominal aorta anastomosis
Abdominal aorta anastomosis
  • More common with aneurysmal pathology vs. occlusive disease, occur in 2 to 5% of patients with aortic grafts
  • Imaging study should be performed every 5 to 10 years
  • Patients may present with back or abdominal pain, also rupture with hemorrhage, thrombosis or embolism, and less commonly erosion into an adjacent structure such as bowel or vena cava
  • Indications for intervention
    • Symptomatic aneurysm
    • Patient presenting with complications of anastomotic aneurysm
    • Diameter greater than twice the diameter of the graft or more than 4 cm
    • Also presence of a saccular rather than a fusiform aneurysm
  • Retroperitoneal approach in preferrable providing better exposure for suprarenal/supraceliac control
  • In noninfected cases endoluminal repair should be considered
iliac artery anastomosis
Iliac artery anastomosis
  • Can erode into small bowel or colon, not duodenum like the aorta
  • Compression of iliac vein can lead to lower extremity swelling or DVT, also desmoplastic reaction around the anastomosis can lead ureteral obstruction and hyrdronephrosis
  • Indication for repair include presence of symptoms, presence of complication, aneurysmal size 2.5 to 3 cm
  • Iliac artery anastomotic aneurysms most suitable to endoluminal repair
    • Need low probability of infectious cause
    • Aneurysm does not need to be debulked
    • No contraindication to internal iliac artery coil embolization
    • Can be used for acute rupture depending on surgeon experience
carotid artery pseudoaneurysms
Carotid artery pseudoaneurysms
  • Incidence is rare 0.6%
    • Due to technical problems, use of poor quality vein for patch, very bulbous reconstruction of the arteriotomy or infective process for prosthetic patch
  • Can present as painful pulsatile cervical mass, also TIA’s
  • Workup by ultrasound and CT angio, regular angiography not helpful
  • Even small asymptomatic pseudoaneurysms should be fixed as they may degenerate and produce small thrombus and embolic material
  • Author recommends bypass around aneurysm and endoluminal repair is contraindicated due to significant debris in lumen