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Challenging Arterial Reconstructions
100 Clinical Cases
Sachinder Singh Hans
123
Challenging Arterial Reconstructions
SachinderSinghHans
100 Clinical Cases
SachinderSinghHans Medical Director of Vascular and Endovascular Services Henry Ford Macomb Hospital Clinical Assistant Professor at Wayne State University School of Medicine Clinton Township MI, USA
ISBN 978-3-030-44134-0 ISBN 978-3-030-44135-7 (eBook)
https://doi.org/10.1007/978-3-030-44135-7
© Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microlms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specic statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional afliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Foreword

The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy.
Challenging surgical cases test skills and judgment of the surgeon and put limbs, organs, or the life of the patient in great danger. The true challenge for the surgeon is to establish correct diagnosis, recognize potential problems in advance, plan with care, and perform a successful operation with the least risk and maximum benet to the patient, using hospital resources prudently to achieve durable result. No matter how complex the situation looks, the surgeon must stay calm, think with a clear mind, and nd the safest, simplest, most effective way to solve the problem and proceed as planned.
Challenging Arterial Reconstructions: 100 Clinical Cases written by Sachinder Hans reects the lifetime experience of a master surgeon. All 100 cases, just 6 with participation of colleagues, were performed by the author, an exceptionally well-trained vascular and endovascular surgeon of a solo vascular practice. A graduate of the renowned fellowship program of the Beaumont Hospital in Royal Oak, MI, Dr. Hans currently works as the Medical Director of Vascular and Endovascular Services, Henry Ford Macomb Hospital, Clinton Township MI, formerly Chief of Vascular Surgery at Ascension Macomb, Oakland Hospital (Macomb Campus), Warren, MI.
This book is a gold mine of interesting cases of a rich and exciting vascu­lar surgery practice and reects expertise in almost the full spectrum of vas­cular and endovascular surgery. The chapters include difcult surgical problems of patients with aortic, visceral, and peripheral arterial aneurysms, with expert management of mycotic, inammatory, and ruptured aneurysms and major complications like aortoduodenal stula, graft infection, or infe­rior vena cava injury. Open aortoiliac and extra anatomic reconstructions are amply covered. The volume presents difcult cases of carotid artery surgery, discusses management of carotid body tumors, and describes the rarely used but helpful maneuver of mandibular subluxation.
There is ample evidence of an excellent surgical practice in this volume, with 30-year follow-up of aortofemoral grafts, with description of tips and techniques for lower extremity distal revascularization using spliced vein grafts or tourniquet occlusions. The reader will nd information on how to manage rare cases of popliteal adventitial cystic disease, popliteal arteriove­nous stula, or venous aneurysm. More than a third of the chapters are
—Martin Luther King, Jr.
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dedicated to endovascular interventions, including stent-graft repair of elec­tive, symptomatic, and ruptured aortic and iliac aneurysms, thoracic endovas­cular repairs, and stent grafting for popliteal artery aneurysms. Interventionists will enjoy reading about carotid artery stenting in challenging patients, like in those after radiation, with contralateral occlusion or following previous open surgery. This book concludes with cases of infrainguinal endovascular recon­structions and visceral and renal stenting and the expert management of a patient with arteriovenous stula of the axillary artery.
Some of the chapters are followed by insightful expert commentaries of Dr. Charles W.Acher, Professor of Surgery at the University of Wisconsin School of Medicine and Public Health. This book is nicely illustrated with black and white and colored photographs of the procedures, with imaging studies and drawings. The text is easy to read and is especially suitable for short review, before embarking in a surgical or endovascular intervention of a similar challenging case.
It is easy for me to recommend this book to all who just learn or regularly perform open surgical or endovascular interventions. Keep in mind, however, that your patient with a challenging problem relies on your judgment and competence. If you feel you can treat your patient, proceed. If you need con­sultation of your colleagues or of other specialties, do not delay. If you feel this challenge is beyond your expertise, refer the patient for appropriate care. Remember what you signed up for as a physician: you are committed to take care of your patient like you would want someone treat a member of your family.
This collection of cases is testimony that there are many situations when competent vascular specialists can appropriately handle even rare and chal­lenging patients. In some cases, referral is not even an option because of intraoperative problems requiring instant care, local issues, or long-distance travel. For appropriate management of all these cases, this book will be invaluable.
Peter Gloviczki, MD, FACS
Roberts Professor and Chair (Emeritus)
Division of Vascular and Endovascular Surgery
Mayo Clinic, Rochester, MN, USA
Editor in Chief, Journal of Vascular Surgery
Foreword

Preface

Lessons Learned from100 Challenging Arterial Reconstructions
The unpredictability of vascular reconstructions is such that a very small error in judgment in patient selection, or a technical error during execution of open or an endovascular reconstruction, can lead to poor outcome. With that in mind, 100 challenging cases encountered by the author since January 1980 through December 2019 are presented in this book. These cases have been selected from the author’s vascular registry of 7000 vascular reconstructions (endovascular and open). These reconstructions were primarily performed at 2 mid-sized (approximately 350 beds each) suburban teaching hospitals, which are representative of the “real-world” experience of vascular surgery in the United States. The selection of cases in this book was based on either dif­culty with case selection or complex operative or an endovascular tech­nique. The natural history of vascular reconstructions often leads to secondary reconstructions, which are far more complex and therefore are included in signicant numbers in this text.
I am keenly aware that certain cases in this book may not appear to be of a sufcient complexity to an experienced vascular surgeon, but to many recent vascular surgery trainees, these challenging arterial reconstructions will hopefully be valuable in their clinical practices. In this book, both and good and unsatisfactory results have been included, and the lessons learned from the poor outcomes are emphasized. Certain advanced vascular recon­structions (branched aortic endografts, open repair of Type II and Type III thoracoabdominal aneurysm repair) were not within the purview of my practice.
In order to keep uniformity in patient selection, technique, and post­intervention care, the cases presented in this book were selected only from my own vascular registry. Other treatment options selected by an experienced vascular surgeon may have worked equally as well, and I do not profess that my methods are the only way to have provided care for these patients. I am thankful to many physicians who also participated in some aspects of the patient’s care (Chaps. 1, 20, 41, 72, 80, 100).
Invited commentaries from leading experts in the eld have been added to a few chapters offering an alternate viewpoint in the management of patients with complex pathology. I am grateful to the contributors of the invited
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commentary for submitting their comments in a timely manner and being objective in their evaluation of the case management. Dr. Mary Lee, our Chief Surgery Resident (starting vascular fellowship in 2020), was involved in helping with multiple-choice questions (n100), and her contributions are appreciated.
I am extremely grateful to my patients and their families for their patience and understanding during some of the most trying times in their lives. I also owe a sense of gratitude to the house staff, nursing personnel, and our vascu­lar intervention lab for their immense contributions in care of our patients. My special thanks to Connie Walsh, Lillie Gaurano, and Richard Hruska (Springer) for their tireless help and support. My special thanks to Shagufta Din for her strong work in getting the chapters transcribed timely and ef­ciently. My wife, Dr. Bijaya Hans, an interventional radiologist, has been of great help and inspiration during the completion of this book as it was taking time away from the family.
I sincerely hope that this book will help vascular surgeons to learn from my successes as well as my failures.
Clinton Township, MI, USA SachinderSinghHans
Preface

Contents

Part I Open Repair of Intact Abdominal Aortic Aneurysm
1 Symptomatic Proximal Anastomotic Pseudoaneurysm
of Suprarenal Aorta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Invited Commentary from Charles W. Acher, MD . . . . . . . . . . . . 6
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2 Repair of Juxtarenal Abdominal Aortic Aneurysm
with Aortorenal Bypass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Invited Commentary from Timothy J. Nypaver, MD . . . . . . . . . . 12
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
3 Abdominal Aortic Aneurysm Repair in a Patient with Celiac
Artery Occlusion and a Large Inferior Mesenteric Artery . . . 15
Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Invited Commentary from Mitchell Ross Weaver, MD . . . . . . . . 17
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
4 Abdominal Aortic Aneurysm Repair in a Patient
with a Pelvic Kidney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Invited Commentary from Mitchell Ross Weaver, MD . . . . . . . . 21
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
5 Open Repair of Abdominal Aortic Aneurysm in a Patient
with Double Inferior Vena Cava . . . . . . . . . . . . . . . . . . . . . . . . 23
Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
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x
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Invited Commentary from Graham W. Long, MD . . . . . . . . . . . . 25
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
6 Mycotic Aneurysm of the Abdominal Aorta . . . . . . . . . . . . . . . 27
Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
7 Open Abdominal Aortic and Iliac Aneurysm Repair
in a Patient with Cirrhosis of the Liver . . . . . . . . . . . . . . . . . . . 31
Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
8 Major Venous Injury During Repair of Abdominal Aortic
and Iliac Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
History and Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
9 Secondary Aortoduodenal Fistula Following Abdominal
Aortic Aneurysm Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
History and Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . 35
Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Contents
10 Open Repair of an Inflammatory Abdominal Aortic
Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
History and Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . 39
Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
11 Right Subhepatic Approach for Inflammatory Aortic
Aneurysm in a Patient with Scoliosis . . . . . . . . . . . . . . . . . . . . 43
History and Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . 43
Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
12 Large Symptomatic Abdominal Aortic Aneurysm . . . . . . . . . . 47
Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48