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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3710_Библиотеки_им_академика_М_И_Перельмана.pdf
94
Fig. 24.2 CTA showing large right hypogastric artery
aneurysm and spigelian hernia
24 Rupture ofHypogastric Artery Aneurysm
Amplatzer™ plug was found lying freely in the
aneurysmal sac. At that time the outow vessels
from the hypogastric aneurysm were also ligated.
The left spigelian hernia was also repaired prior
to closure. Intraoperatively we encountered signicant venous bleeding, and the patient had a
1500 cc blood loss. He received ve units of
packed red blood cells during the procedure.
Postoperatively, the patient was admitted to the
intensive care unit where his recovery was complicated by an acute DVT of the left lower
extremity, aspiration pneumonia, and prolonged
ileus with malnutrition requiring short-term total
parenteral nutrition. Following discharge, the
patient was sent to a rehab facility and home 3
weeks later. He was seen in re-evaluation 6
months postoperatively, and a repeat CT scan
demonstrated a stable hematoma post-ligation
without evidence of extravasation with a therapeutic INR. Patient is alive 9 years following
open repair.
Fig. 24.3 CTA showing ruptured right hypogastric
aneurysm
The patient presented to the emergency
department 5 weeks later with acute onset
abdominal pain and urinary retention. The patient
was on warfarin treatment for atrial brillation
and on admission had an international normalized ratio (INR) of 5.4. A CT angiogram scan of
the abdomen was obtained demonstrating recurrence of the previously treated hypogastric aneurysm (now 7.2 cm × 7.2 cm) with evidence of
contrast extravasation (Fig.24.3).
The patient received ve units of fresh frozen
plasma and was taken emergently to the operating room. He underwent an exploratory laparotomy with isolation and ligation of the ruptured
right hypogastric artery aneurysm. The
Discussion
Isolated hypogastric aneurysms are rare, with an
incidence rate of 0.4% of all aortoiliac aneurysms. The incidence of rupture is as high as 33%
[2]. Rupture of the hypogastric aneurysm is often
reported at the initial presentation and therefore
carries a high mortality rate of up to 58% [1, 3].
The average size of hypogastric aneurysms found
incidentally is 4–5cm. The average size of rupture of hypogastric aneurysms is 6.0cm. Repair
is recommended in any hypogastric aneurysm
larger than 3cm in anterior-posterior/transverse
diameter [1, 4].
Most patients with hypogastric and aneurysm
are asymptomatic and found incidentally. Patients
may present with symptoms caused by compression of pelvic structures and may include genitourinary tract obstruction, thrombosis of the iliac
vein, or lumbosacral nerve root compression.
Various treatment techniques are reported in
the literature, with none clearly superior to the
others; this is likely due to the small number of
reported cases. Endovascular repairs are becoming a more common treatment option, even in
Invited Commentary fromJonathan R.Thompson, MD, andIraklis I.Pipinos, MD
95
the emergent setting, with improved technical
skills and equipment becoming more readily
available. When performed electively, this
approach carries a less than 1% mortality rate.
In the emergent setting, endovascular repair has
been associated with a 50% incidence of subsequent rupture with a 7% incidence of type I
endoleak [7–10]. In our patient failure of endovascular exclusion was due to the short aneurysmal neck. The angulated neck and large size
precluded us from embolizing all the outow
tracts. The most common complication following endovascular repair is a reported 30–40%
incidence of buttock claudication due to complete occlusion of the hypogastric artery and in
many cases all collateral outow tracts [5]. An
additional technical consideration for our case
would have been placement of a covered stent
from common iliac to the external iliac, thereby
further occluding the inow to the hypogastric
artery. Given the technical challenge and orientation of the aneurysmal neck in this case, this
alternative may have decreased the risk of subsequent rupture. In this case rupture of the aneurysm post-endovascular intervention was
primarily due to blood ow from the outow
tract vessels in the setting of supra-therapeutic
anticoagulation.
The alternative to endovascular repair is standard open repair. This option carries a mortality
rate of up to 13% [5, 6], as patients typically
undergoing open procedures are those that present initially with rupture and are unstable. Open
repair options include simple ligation, interposition graft if necessary, or aortoiliac reconstruction. The latter is usually reserved for those
patients with concomitant distal aortoiliac occlusive or aneurysmal disease [11, 12].
In this case, a better occlusion of the outow
branches of hypogastric artery along with optimal control of INR in the post-intervention period
may have resulted in a more successful outcome
from an endovascular approach in this case.
Using an endovascular approach may have
avoided the prolonged hospital stay and complications of emergent open procedure in this
elderly male with multiple comorbidities.
Ultimately management approach must be indi-
vidualized according to anatomy of the aneurysm
and general condition of the patient.
Invited Commentary fromJonathan
R.Thompson, MD, andIraklis
I.Pipinos, MD
Hypogastric or internal iliac artery aneurysms in
isolation are very rare. Based upon a classication scheme developed by Sandhu etal. [13], this
would be a type D aneurysm as it solely involves
the internal iliac artery. Most vascular surgeons
will not ever see a ruptured isolated internal iliac
artery aneurysm. Incidence of these aneurysms is
estimated at 0.4%. Prevalence is estimated to be
even lower at 0.03%. In a large review, rupture
only occurred in aneurysms greater than 5.0cm
and most often at even larger diameters [14].
We agree with the author regarding an endovascular rst approach. We disagree with the
author regarding the incidence of claudication. A
large review estimated the overall complication
rate for internal iliac artery occlusion in vascular
surgery patients to be 45%, 21.2% of these were
buttock claudication [15]. Other devastating
complications including buttock necrosis, colon
ischemia, and spinal cord ischemia should be
considered. The Society for Vascular Surgery
recommends preservation of the internal iliacs
when possible [16]. Sometimes this is not possible. With a patent contralateral internal iliac
artery, sacricing a unilateral internal iliac may
actually be the best option for some patients.
Our approach endovascularly would have
been different. Preoperative planning is paramount for these cases. A high-quality CT angiogram is necessary to identify all of the outows
of the internal iliac aneurysm. Embolization
should take place in a hybrid room with 3D overlay capabilities if possible. In our hands contralateral femoral access with a large sheath placed
into the internal iliac artery is preferred. Using a
selective catheter, all outow vessels are selected
and coiled with various sized detachable coils
such as the Ruby coil system (Penumbra Inc.,
Alameda, CA) or Azur Peripheral HydroCoil
Embolization System (Terumo, Somerset, NJ).
96
24 Rupture ofHypogastric Artery Aneurysm
After all outow is occluded, we recommend
packing the remnant sac with large coils to induce
thrombosis and nally covering the origin of the
internal iliac with a stent graft. This would likely
have prevented the failure described here.
When open repair is absolutely required, we
recommend ureteral stent placement preoperatively [17]. A transperitoneal approach is
acceptable. In a rupture scenario, simple ligation and hemorrhage control is acceptable. In
an elective scenario, if reconstruction is possible (based upon preoperative planning), this is
preferred to prevent the complications described
above.
References
1. Parry DJ, Kessel D, Scott DJ.Simplifying the inter-
nal iliac artery aneurysm. Ann R Coll Surg Engl.
2001;83:302–8.
2. Kelckhoven BJ, Bruijninckx BMA, Knippenberg B,
Overhagen HV. Ruptured internal iliac artery aneurysm: staged emergency endovascular treatment in the
interventional radiology suite. Cardiovasc Intervent
Radiol. 2007;30:774–7.
3. Dix FP, Titi M, AL Khaffaf H.The isolated internal
iliac artery aneurysm; a review. Eur J Endovasc Surg.
2005;30:1119–29.
4. McCready RA, Pairolero PC, Gilmore JC, Kazmier
FJ, Cherry KJ Jr, etal. Isolated iliac artery aneurysm.
Surgery. 1983;93:699–703.
5. Kashi C. Spontaneous rupture of hypogastric artery
aneurysm into the bladder: a case report and review of
the literature. Ann Vasc Surg. 2006;20:134–7.
6. Zimmer PW, Raker EJ, Quigley TM.Isolated hypogastric artery aneurysms. Ann Vasc Surg. 1999;13:545–9.
7. Kim JK, Noll RE Jr, Sternbergh WC 3rd, Tonnessen
BH. Endovascular repair of a ruptured internal iliac
arterial aneurysm with a novel application of the
aorto-uni-iliac converter device. Vasc Endovasc Surg.
2008;42:466–70.
8. Chandra A, Kansal N. Hybrid repair of isolated
internal iliac artery aneurysm. Vasc Endovasc Surg.
2009;43:583–8.
9. Cheong SK, Varcoe RL.A tapered contralateral endurant stent graft limb, deployed “up-and-over” to treat
a symptomatic internal iliac aneurysm. Vasc Endovasc
Surg. 2010;44:475–8.
10. Brin BJ, Busuttil RW. Isolated hypogastric artery
aneurysms. Arch Surg. 1982;117:1329–33.
11. Sorelli PG, Thomas D, Hoque H. A surgical emergency. BMJ. 2009;339:b2302.
12. McFarlane MEC. Internal iliac artery aneurysmocolonic stula: a rare presentation of massive lower
gastrointestinal hemorrhage: report of a case. Eur
Surg. 2009;41:129–31.
13. Sandhu RS, Pipinos II. Isolated iliac artery aneurysms. Semin Vasc Surg. 2005 Dec;18(4):209–15.
14. Dix FP, Titi M, Al-Khaffaf H. The isolated internal
iliac artery aneurysm--a review. Eur J Vasc Endovasc
Surg. 2005 Aug;30(2):119–29.
15. Chitragari G, Schlosser FJ, Ochoa Chaar CI,
Sumpio BE. Consequences of hypogastric artery
ligation, embolization, or coverage. J Vasc Surg.
2015;62:1340–7.
16. Chaikof EL, Dalman RL, Eskandari MK, Jackson
BM, etal. The Society for Vascular Surgery practice
guidelines on the care of patients with an abdominal
aortic aneurysm. J Vasc Surg. 2018;67(1):2–77.e2.
17. Kusaka J, Matsumoto S, Hagiwara S, Koga H,
Noguchi T. Use of perioperative ureteral stent in
abdominal aortic aneurysm with retroperitoneal brosis – a report of two cases. Korean J Anesthesiol.
2012;63(1):76–9.
Part IV
Open Repair of Femoral Artery
and Femoral Anastomotic Aneurysms
Contained Rupture ofFemoral
Anastomotic Aneurysm
25
Physical Examination andHistory
An 81-year-old female presented to the emergency room of the hospital in April 2017 after
sustaining a fall and was found to have a hematoma in the right groin. CTA of the abdomen
and pelvis was performed which showed contained rupture from a right femoral anastomotic aneurysm (Figs.25.1 and 25.2). In 2006,
patient underwent open aneurysm repair of a
4.5 cm infrarenal saccular abdominal aortic
aneurysm with neck angulation of about 50°
and small diameter external iliac arteries. The
right external iliac artery measured 5.2 mm
transverse diameter, and the left external iliac
artery measured 4.7 mm transverse diameter.
At the time of her initial abdominal aortic
aneurysm repair (aorto- bifemoral graft) in
2006, she developed postoperative respiratory
failure secondary to history of chronic obstructive pulmonary disease (nicotine abuse). She
was on ventilatory support for 4 days and had
evidence of uid overload which improved
with diuretics, chest physiotherapy, and antibiotics for superimposed pneumonia (Figs.25.1
through 25.3).
Fig. 25.1 CTA-3D reconstruction of infrarenal AAA Fig. 25.2 CTA abdominal aortic aneurysm (axial image)
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_25
99
100
Fig. 25.3 Follow up CTA 11years later after initial open
AAA repair
25 Contained Rupture ofFemoral Anastomotic Aneurysm
Procedure
She was taken to the operating room for repair of
a contained rupture of right femoral anastomotic
aneurysm. A right ank incision was made in the
right lower quadrant of the abdomen, and an
extraperitoneal approach was selected. Dacron
graft was exposed; it was well incorporated. It is
to be noted that the patient had a placement of an
aorto-bifemoral 16 × 8mm Dacron graft. After
the proximal control was obtained, aneurysm was
opened in the groin through a hockey stick incision, and supercial femoral artery was exposed.
There was bleeding from the native common
femoral artery, which was controlled, distal common femoral artery was very friable, deep femoral artery could not be identied, and a direct
end-to-end anastomosis of a new 8mm knitted
Dacron graft to the proximal supercial femoral
artery was performed. Prior to that, an end-to-end
anastomosis of the previously placed well incorporated 8mm limb of the Dacron graft was anastomosed to the new interposition graft at the
proximal anastomosis (8 mm Dacron graft)
(Fig.25.4).
Her postoperative course was uneventful. She
was discharged to the rehabilitation center. In 1
week, she was ambulating with the help of a
walker; however patient expired 3 months later
from cardiac arrest.
Discussion
Femoral anastomotic aneurysms are one of the
common late complications of aortofemoral
graft reconstruction [1–3]. These aneurysms do
not need repair unless they reach 3 cm transverse diameter or the patient is symptomatic. If
the aneurysm continues to enlarge, it can result
in symptoms of pain and paresthesia secondary
to femoral neuropathy. Thrombosis of the anastomotic aneurysm can result of thrombosis of
the limb of the graft secondary to poor outow.
Continued rupture of the aneurysm is extremely
uncommon unless the aneurysm is large. In this
patient, the aneurysm measured 4.5 cm transverse diameter. Femoral anastomotic aneurysms
usually occur due to degeneration in the arterial
wall with repeated hip exion and extension
resulting in gradual disruption of the anastomosis and formation of a pseudocapsule.
Recurrence of a femoral anastomotic aneurysm
after repair though uncommon can also occur
[2]. As the number of aortofemoral grafts being
performed for aortoiliac occlusive disease is
decreasing, the incidence of femoral anastomotic aneurysms needing repair will become
infrequent.
Ernst etal. surgically treated 36 recurrent femoral anastomotic aneurysms with 1 death [2].
Authors concluded that in the presence of wound
complications following initial aortofemoral
bypass or femoral anastomotic aneurysm, repair
increases the risk of recurrent femoral anastomotic aneurysm. Development of recurrent femoral anastomotic aneurysm within 4.5years after
aortofemoral bypass and female gender signicantly increased the risk of developing femoral
anastomotic aneurysm.
References
Fig. 25.4 Contained rupture of right femoral anastomotic aneurysm
101
References
1. Schellack J, Salam A, Abouzeid MA, etal. Femoral
anastomotic aneurysm: a continuing challenge. J Vasc
Surg. 1987;6:308–17.
2. Ernst CB, Elliot JP, Ryan CJ.Recurrent femoral anastomotic aneurysms. Ann Surg. 1988;108:401–9.
3. Vanden Akker P, Brand R, Vanschilfgaavde R, etal.
False aneurysms after prosthetic reconstructions of
aortoiliac disease. Ann Surg. 1989;210:658–66.
Open Repair ofRight Common
Femoral Artery Aneurysm
Physical Examination
A 73-year-old male was found to have a palpable
pulsatile mass in the right groin which measured
about 3cm in transverse diameter. An ultrasound
of the groin conrmed the presence of femoral
artery aneurysm. He also complained of symptoms of intermittent claudication on walking half
a block. Patient underwent arteriography
(Figs.26.1 and 26.2) which showed right femoral
artery aneurysm, occlusion of the right supercial femoral artery at its origin, and reconstitution
of the popliteal artery above the knee.
26
Procedure
Patient underwent open repair of common femoral artery aneurysm with an interposition of an
8mm knitted Dacron graft (July 2018). In order
to get proximal control, deep circumex iliac
vein crossing the distal external iliac artery was
ligated and divided, and silastic vessel loops were
passed in the distal external iliac artery, deep circumex iliac artery, and deep epigastric artery.
Following heparinization an 8mm knitted Dacron
graft was anastomosed end to end at the junction
of the common femoral external iliac artery and
inferiorly at the common femoral artery bifurcation. A non-reversed greater saphenous vein
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_26
Fig. 26.1 Arteriogram showing right supercial femoral
artery aneurysm and ush occlusion of right supercial
femoral artery. Right deep femoral artery is visualized
bypass from the proximal supercial femoral
artery to the popliteal artery above the knee was
performed with satisfactory results. Follow-up
duplex imaging (November 2018) revealed patent femoral popliteal bypass.
103
104
Fig. 26.2 Showing occlusion of right supercial femoral
artery with reconstruction of popliteal artery above the
knee
26 Open Repair ofRight Common Femoral Artery Aneurysm
patients per one hundred thousand. Recently,
from a larger study of isolated femoral artery
aneurysm, Lawrence etal. reported that complications do not occur in femoral artery aneurysms
unless the aneurysm is equal or greater to 3.5cm
(previous studies, repair was performed for a
maximum diameter of equal to or greater than
2.5cm) [1]. If the aneurysm is symptomatic with
a large amount of thrombus, repair is indicated
even in smaller aneurysms. One of the main reasons for recommending repair in this patient was
symptoms of disabling intermittent claudication
with associated femoral aneurysm. Repair of
femoral aneurysm did not add signicantly to the
morbidity of femoral popliteal bypass graft.
Association between femoral artery aneu-
rysm, abdominal aortic aneurysm, and iliac and
popliteal aneurysms is well established, but incidence varies between different reported series.
Synchronous femoral and aortic aneurysms occur
in 50–90%, synchronous popliteal artery aneurysms in 27–44%, and synchronous contralateral
femoral artery aneurysms in 26–50%. The patient
in this report had an associated supercial femoral artery occlusion with symptoms of intermittent claudication which necessitated
femoral-popliteal bypass with non-reversed
saphenous vein, and therefore femoral artery
aneurysm repair and femoral-popliteal bypass
were performed simultaneously. Patency of the
graft was conrmed by duplex imaging, and
patient has been symptom free from intermittent
claudication.
Reference
Discussion
Degenerative femoral artery aneurysms are
uncommon, and their reported incidence is ve
1. Lawrence PF, Harlander MP, Oderich GS, Humphries
MD, Landry GJ, et al. The current management of
isolated degenerative femoral artery aneurysms is
too aggressive for their natural history. J Vasc Surg.
2014;59:343–9.
Part V
Open Repair of Popliteal Artery Aneurysms