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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3710_Библиотеки_им_академика_М_И_Перельмана.pdf
Popliteal Venous Pseudoaneurysm
ab
andAssociated Arteriovenous
Fistula Following Knee
Arthroscopy
60
History andPhysical Examination
A 73-year-old female with a 6-month history of
chronic knee pain was found to have a medial
meniscus tear and underwent arthroscopy with a
partial posterior horn medial meniscectomy.
Three days postoperatively she developed
increased calf swelling and posterior knee and leg
pain and was unable to bear weight on the affected
extremity. On examination a palpable mass was
noted in the popliteal fossa without a thrill with
palpable distal dorsalis pedis and posterior tibial
pulses. Patient underwent a duplex ultrasound to
evaluate for deep venous thrombosis (DVT) and
was found instead to have a vascularized mass in
the popliteal fossa and without evidence of DVT.
Computed tomography angiography (CTA) of
the lower extremity demonstrated simultaneous
opacication in the arterial phase of both the
femoral artery and the femoral vein (Fig.60.1).
Within the popliteal fossa, a large vascular structure was seen consistent with a pseudoaneurysm
measuring 3.7 in its greatest anteroposterior
diameter. There was also noted to be an AV stula
Fig. 60.1 (a) CTA demonstrating proximal two vessel opacication at the level of the pelvis which extended to the
popliteal fossa. (b) Demonstrates the large pseudoaneurysm during arterial phase in the popliteal fossa
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_60
265
ab
60 Popliteal Venous Pseudoaneurysm andAssociated Arteriovenous Fistula Following Knee Arthroscopy
266
Fig. 60.2 (a) An angiographic image demonstrating AP
views in the arterial phase and with two vessel opacication and delayed lling of the pseudoaneurysm. (b)
Lateral projections demonstrate the arteriovenous stula
communication to the venous pseudoaneurysm
between the popliteal artery and the vein.
Arteriography demonstrated simultaneous lling
of the popliteal artery and vein and delayed lling of a large venous pseudoaneurysm (Fig.60.2).
The AV stula was again demonstrated just below
the pseudoaneurysm although its exact origin
was difcult to delineate. A high takeoff of the
anterior tibial artery was visualized.
monolament polypropylene suture (Ethicon,
Cincinnati). A large intramuscular hematoma was
evacuated from the medial head of the gastrocnemius muscle. The patient tolerated the procedure
well and was discharged home 5 days later.
On postoperative day 12, the patient returned
to the emergency department with increased
swelling and pain. At this time, duplex demonstrated a posterior tibial vein thrombus and nonvascularized mass 4.0cm consistent with residual
Procedure
hematoma. The patient was considered high risk
for progression of DVT and therefore treated
Through a posterior popliteal fossa approach,
the patient underwent an operative ligation of the
arteriovenous stula and the venous pseudoaneurysm. Bleeding from the venous pseudoaneurysm was controlled by lateral venography using
with 3 months of anticoagulation with Coumadin.
She returned for follow-up duplex at that time
with no further evidence of DVT or hematoma
and has regained full function and weight- bearing
capacity of the left leg.
References
267
Discussion
Several known complications of knee arthroscopy including, bleeding, infection, deep venous
thrombosis have been reported [1]. Less common
complications include arterial or vascular injury,
nerve injury, and injury to the articular cartilage.
Delayed presentation of arterial pseudoaneurysms and arteriovenous stula following meniscectomy has been reported, but venous
pseudoaneurysm and AV stula arising from the
genicular artery have not been reported from our
review of the literature [2].
The most plausible explanation for this complication was the inadvertent laceration of the
genicular arteries during the placement of the
medial arthroscopic trocar. In this patient an arteriovenous stula formed between the genicular
artery and the vein with pulsatile ow into the
aneurysmal popliteal vein with resulting contained rupture and formation of a pseudoaneurysm. Alternatively during manipulation and
external rotation of the knee, the neurovascular
bundle approximates the attachment of the posterior horn of the meniscus and may be injured during the meniscectomy [3–5].This patient had a
preexisting popliteal venous aneurysm which
ruptured due to high pressure caused by the arteriovenous stula resulting in pseudoaneurysm
formation. The venous aneurysm ruptured into a
closed space creating pseudoaneurysm (PSA)
formation. However, a rare event vascular injury
must be considered in all patients with new onset
pain and evidence of popliteal fossa fullness or
mass post arthroscopy. In the previously reported
case of venous pseudoaneurysm of the popliteal
vein, the PSA was repaired with polypropylene,
but the arterial injury required a short segment
bypass graft [2]. In our patient bypass graft was
not required as the arterial injury was to the
genicular arteries sparing signicant trauma to
the popliteal artery.
Treatment strategies vary depending on the
type and location of injury. Increasing popularity
of endovascular control of post arthroscopy arterial pseudoaneurysms has been reported using
covered stents in the popliteal region with good
results [6]; however this case highlights the
importance of getting lateral views during arteriography to conrm the origin of the pseudoaneurysm before planning intervention. If in doubt an
open repair and direct ligation should be performed with or without short segment bypass
depending on the degree of arterial trauma.
Persistent pain and swelling of the lower
extremity following knee arthroscopy should
raise suspicion about vascular complications
such as popliteal vein thrombosis or arterial
pseudoaneurysm, and prompt duplex ultrasound
of the knee should be obtained.
References
1. Sherman OH, Fox JM, Snyder SJ, Del Pizzo W,
Friedman MJ, Ferkel RD, Lawley MJ.Arthroscopy–
“no-problem surgery”. An analysis of complications in
two thousand six hundred and forty cases. J Bone Joint
Surg Am. 1986;68(2):256–65.
2. Saint-Lèbes B, Chastonay E, Borens O, Dubuis C,
et al. Popliteal venous pseudoaneurysm and arte-
riovenous stula after orthopedic surgery. World J
Cardiovasc Surg. 2013;3(1):1–7.
3. Mullen DJ, Jabaji GJ.Popliteal pseudoaneurysm and
arteriovenous stula after arthroscopic meniscectomy.
Arthroscopy. 2001;17(1):E1.
4. Coleman R. Combined arteriovenous stula and
venous aneurysm following knee arthrodesis. ANZ J
Surg. 2006;76(11):1030–2.
5. Bernard M, Grothues-Spork M, Georgoulis A, Hertel
P. Neural and vascular complications of arthroscopic
meniscal surgery. Knee Surg Sports Traumatol
Arthrosc. 1994;2(1):14–8.
6. Alserr AH, Antonopoulos CN, Papapetrou A,
Kakisis JD, Brountzos E, Liapis CD.Endovascular
repair of popliteal artery pseudoaneurysm with
arteriovenous stula after knee arthroscopy: case
report and literature review. Vasc Endovasc Surg.
2014;48(2):166–70.
Part XVI
Endovascular Aneurysm Repair for Intact
Abdominal Aortic Aneurysm
Endovascular Aneurysm Repair
inaPatient withSevere Aortic
Neck Angulation Using Aorx™
Device
61
Physical Examination
A 91-year-old, extremely active male, was found
to have 7.5 cm transverse diameter abdominal
aortic aneurysm (AAA) with severe aortic neck
angulation (close to 90°) on non-contrast CT
scan of the abdomen and pelvis. Non-contrast CT
scan was performed as patient had chronic kidney disease (stage V) with a BUN 54 and creatinine 2.7mg/dL.Associated medical comorbidities
included hypertension, chronic obstructive pulmonary disease (former smoker), and remote
nicotine abuse. 2D echocardiogram showed left
ventricular ejection fraction of 60%. He underwent abdominal aortography following intravenous hydration with 10 cc of contrast medium
(Isovue 350 and CO2). Imaging of the abdominal
aorta and iliac arteries was performed with the
help of an Omniush catheter, right renal artery
was patent, and left renal artery could not be
visualized and probably appeared to be occluded
(Fig.61.1).
Procedure
On August 8, 2013, patient underwent endovascular aneurysm repair (EVAR) using Aorx™
device (Lumbard Medical, Oxfordshire, UK)
because of severe aortic neck angulation. The
main body was 27×12×126mm, contralateral
limb 90×14mm, and right iliac extension limb
of 56 ×14 mm. We encountered difculty in
capturing the gate from the left femoral sheath;
therefore using RIM catheter we tried to snare
the wire. Although the wire was successfully
snared (180 cm long), however during the
retrieval with the snare, the wire got dislodged.
Brachial artery was exposed at the left elbow,
and using a long sheath, an exchanged length
260cm long angle stiff glidewire was advanced
into the contralateral limb and is retrieved via
e-snare from the left femoral sheath. Completion
arteriogram using iodinated contrast and CO
arteriography showed successful exclusion of
the aneurysm with signicant decrease in the
angulation of the aortic neck with good lling
of both hypogastric arteries, the right renal
artery and superior mesenteric artery, without
any evidence of endoleak (Fig. 61.2). During
the operation, both CO
contrast media were used. Patient’s postoperative course was uneventful. Because of chronic
kidney disease (stage V), he was followed by
duplex imaging 1 month after the operation and
then after every 6 months. Last duplex imaging
in June 2018 showed residual aneurysm sac to
be markedly decreased in size (4.2× 4.1 cm)
with no evidence of endoleak. Renal function
remained stable, with creatinine ranging from
2.5 to 3mg%. Patient died on October 5, 2018,
from carcinoma of the lung.
and small amount of
2
2
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_61
271
61 Endovascular Aneurysm Repair inaPatient withSevere Aortic Neck Angulation Using Aorx™ Device
272
Fig. 61.1 CO2 and contrast aortogram showing large AAA severe angulation of aortic neck
Discussion
mise the success of an EVAR by affecting proximal endograft xation. The use of Aorx
In the contemporary vascular surgical practice,
endovascular aneurysm repair (EVAR) has not
been performed in greater than 75% of patients
needing AAA repair. Because EVAR is less
invasive, the procedure is extremely useful in
patients whose risk is deemed too high for open
repair. Endovascular aneurysm repair has lower
morbidity and mortality as compared to open
repair. However, the use of EVAR is limited by
the anatomical constraints of the AAA and the
access arteries. Hostile neck anatomy – large
angulated and short aortic neck– can compro-
endovascular device was designed to be highly
conrmable for application to severely angulated (greater than 60°) aortic necks and has
been shown to have good long-term success as
compared to other endografts. Wang et al.
reported 205 AAA treated with Aorx device.
They observed that aortic neck diameter and the
seal zone inner curve were the best predictors of
endograft-related complications which occurred
in 17.6% patients after 5 years of follow-up.
Larger aortic neck had more complications with
a 22% increase in the complication risk with
Invited Commentary fromM.Ashraf Mansour, MD, MBA, FACS
duplex ultrasound imaging was performed in this
patient for follow-up. During the deployment of
endograft, we used both iodinated contrast and
CO2 to decrease the incidence of contrast in used
nephropathy. Criado etal. reported 114 consecutive patients who underwent EVAR with CO2 (72
with CO2 alone and 42 with CO2 and iodinated
contrast). They concluded that CO2 EVAR is
safe, eliminates or reduces the amount of contrast, and avoids deterioration of the renal function [3]. To avoid contrast-induced nephropathy,
follow-up duplex ultrasound was performed for
this patient. Pineda et al. reported 156 patients
who were monitored with duplex ultrasound
Fig. 61.2 Completion aortogram showing satisfactory
exclusion of AAA with good conformability of the stent
graft to the aortic neck
imaging for a minimum of 5 years after
EVAR.They reported that approximately one in
four patients after EVAR (mean 7.5 years) will
require intervention at some point during the follow- up period [4]. First-time interventions were
each 1 millimeter increment diameter of the aortic neck [1].
Gate cannulation by a retrograde technique
involving the passage of a combination of wire
necessary in 22% of all patients in the rst 5
years and in 6% of patients after 5 years, thus the
need for continued grafts surveillance beyond 5
years.
(soft glidewire) and catheter (Kumpe, VanSchie
5, Multipurpose, Cobra) from the contralateral
access to selectively pass the wire through the
gate into the body of the endograft and its con-
Invited Commentary fromM.Ashraf
Mansour, MD, MBA, FACS
rmation is done by twirling the Omniush
catheter 360° into the body of the endograft.
Titus etal. reported on a prospective randomized study comparing contralateral snare versus
retrograde gate cannulation in EVAR.They concluded that if retrograde cannulation was not
successful in the rst few minutes, the chances
of eventual success decrease signicantly, and
crossover to snare was more efcient [2]. Using
snare technique, we were able to snare the wire,
but unfortunately the wire was short (180cm),
and we could not advance a catheter over the
wire. It is important to use exchange length
(260cm) wire if contralateral snare technique is
selected. Ultimately, we were able to cannulate
the gate by left brachial approach. Left brachial
approach can be helpful in cannulation of the
gate if conventional methods are unsuccessful.
Endovascular aortic aneurysm repair (EVAR) is
an elegant and relatively simple operation to treat
an abdominal aortic aneurysm (AAA) in a minimally invasive fashion. There are several factors
that could potentially stand in the way of managing a patient presenting with AAA, broadly categorized into anatomical and physiological
factors. The anatomical factors that complicate
EVAR include proximal neck angulation, short or
conical proximal neck, iliac artery tortuosity,
multiple renal arteries or horseshoe kidney, and
an assortment of rarer conditions. The main
physiologic factor, besides cardiopulmonary status, that interferes with EVAR is chronic kidney
disease (CKD) with impaired renal ltration. The
case report herein presents two of these impediments: angulated proximal neck and CKD.
This is usually necessary only in small percentage of cases.
surgeons in the United States, a variety of
273
Because of stage V chronic kidney disease,
As EVAR became more familiar to vascular
61 Endovascular Aneurysm Repair inaPatient withSevere Aortic Neck Angulation Using Aorx™ Device
274
endografts became available, and an increasing
number of patients were offered this less invasive
procedure. In 2005, roughly half of all AAA
repairs in the United States were EVARs, with a
steady increase until 2015 when nearly 80% were
EVARs [5]. In order to accomplish a safe and
durable repair, a variety of endograft attributes is
necessary, including small delivery size, exibility and ability to conform to difcult angulations,
and a durable xation method. In this case, the
proximal angulation was navigated easily by the
Aorx device (Lombard Medical). This is a crucial technical point to be made here, as few
devices exist on the market in the United States
with this capability. Once the endograft is delivered, the next challenge is to capture the contralateral gate. In most straight AAAs, this is not a
problem. However, when the neck is tortuous and
the AAA sac is large, it becomes very difcult to
direct wires and catheters relying only on twodimensional imaging. This part of the operation
is often the most frustrating and challenging for
the surgeon. Experienced operators will typically
set a threshold, and if crossed, alternative techniques are deployed, such as snaring the wire at
the graft bifurcation from the contralateral side or
using the brachial approach. The remainder of
the operation is relatively simple, adding iliac
extensions.
In a patient with CKD, it is advisable to try to
avoid accelerating the need for hemodialysis
because of contrast-induced nephropathy (CIN).
When renal function is normal, CIN can be
avoided by limiting the amount of contrast and
liberally hydrating the patient. In this case, this
luxury is not afforded and alternative imaging is
required. The two methods that have been used in
these circumstances, to avoid contrast use, are
CO
angiography and intravascular ultrasound
2
(IVUS). In this case, CO2 angiography was used
successfully and minimal contrast dose was used.
The case report does not comment on the patient’s
renal function postoperatively and whether dialysis was used at all.
Vascular surgeons should always remember
that the purpose of AAA repair is to prevent the
patient’s death from rupture. Therefore, when
evaluating a patient for AAA repair, an actuarial
calculation of life expectancy is needed [6]. In
other words, if the patient is expected to survive 1
or 2 years only because of other comorbidities,
accepting a 7–9% annual risk of AAA rupture is
not unreasonable. In this case, the patient survived 5 years and died of lung cancer, unrelated
to his AAA.
In summary, this case illustrates the many
aspects of clinical decision making to repair an
AAA.It also illustrates that in vascular surgery,
there is no “one size ts all”!
References
1. Wang S, Hicks CW, Malas MB.Neck diameter and
inner curve seal zone predict endograft-related com-
plications in highly angulated necks after EVAR
repair using the Aorx endograft. J Vasc Surg.
2018;17:760–9.
2. Titus JM, Cragg A, Alden P, Alexander J, etal. A pro-
spective randomized comparison of contralateral snare
versus retrograde gate cannulation in endovascular
aneurysm repair. J Vasc Surg. 2017;66(2):387–91.
3. Criado E, Upchurch GR, Young K, Rectenwald JE,
etal. Endovascular aneurysm repair with carbon diox-
ide guided angiography with patients with renal insuf-
ciency. J Vasc Surg. 2012;55(6):1570–5.
4. Pineda DM, Phillips ZM, Calligaro KD, Krol E.The
fate of endovascular aneurysm repair after ve years
monitored with duplex ultrasound imaging. J Vasc
Surg. 2017;66(2):392–5.
5. Suckow BD, Goodney PP, Columbo JA, Kang R,
et al. National trends in open surgical, endovascular
and branched-fenestrated endovascular aneurysm
repair in Medicare patients. J Vasc Surg. 2018;67(6):
1690–7.
6. Schermerhorn ML, Buck DB, O'Malley AJ, Curran T,
McCallum JC, Darling J, Landon BE.Long-term out-
comes of abdominal aortic aneurysm in the Medicare
population. N Engl J Med. 2015;373(4):328–38.
Endovascular Aneurysm Repair
inaPatient withShort Aortic Neck
withUse ofEndoAnchors
62
Physical Examination andHistory
A 66-year-old female presented to the outpatient
clinic in December 2014 with CTA of the abdomen and pelvis requested by her primary care
physician. Aneurysm size was 5.8cm (AP/transverse); aneurysm was fusiform with a short aortic
neck (8mm). However, the neck was relatively
straight with less than 20° angulation. Medical
comorbidities included advanced chronic
obstructive pulmonary disease secondary to nicotine abuse and hypertension.
Procedure
On January 9, 2015, patient underwent endovascular aneurysm repair (EVAR) with Endurant®
endograft (Medtronic, Inc., Minneapolis,
MN, US); main body from the right side
was 36 × 16 × 166 mm and contralateral
limb 16 × 12 × 124 mm. Four EndoAnchors
(Heli-FX™, EndoAnchor™, Aptus/Medtronic,
Inc., Minneapolis, MN, USA) were deployed to
the aortic neck (Fig.62.1). Completion arteriogram showed satisfactory exclusion of abdominal aortic aneurysm (AAA) with no endoleak.
Patient underwent follow-up CTA of the abdomen and pelvis and duplex ultrasound. CTA
of the abdomen and pelvis on April 3, 2018,
showed satisfactory exclusion of the AAA
without endoleak, with largest dimension of
4.8×4.7cm (Fig. 62.2). During last follow-up
(November 2019), patient is doing well without
any complications related to EVAR. She complains of increasing shortness of breath due to
chronic obstructive pulmonary disease.
Discussion
In this patient with a short (less than 10 mm),
large- diameter, severely angulated aortic neck,
the risk of Type IA endoleak and migration of the
endograft is increased. EndoAnchors implantation can be a useful agent to EVAR to prevent
early and late Type IA endoleaks. EndoAnchors
have proven effective in treating Type IA
endoleak remote from the initial EVAR.DeVries
etal. during a 2-year period enrolled 319 patients
using Heli-FX aortic securement system global
registry (ANCHOR) study [1]. They reported
96.6% success in the prophylactically treated
subset (172 out of 178). Sac regression greater
than 5mm in patients with 1-year imaging was
observed in 26 of 66 patients (39%). Similarly,
Arko etal. identied 70 patients with short aortic
necks (4–10 mm) undergoing EVAR with
EndoAnchor implantation [2]. They observed
four Type IA endoleaks, and in three patients
Type IA resolved spontaneously. They did not
observe any migration in any of the endografts.
Recently, Varkevisser etal. identied all patients
undergoing elective AAA using Zenith fenestrated
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_62
275
276
Fig. 62.1 Intraoperative aortogram showing large AAA with EndoAnchors
62 Endovascular Aneurysm Repair inaPatient withShort Aortic Neck withUse ofEndoAnchors
Fig. 62.2 Postoperative CTA (3years later) showing satisfactory exclusion of AAA without endoleak. EndoAnchors
are seen at the neck
endovascular graft, open complex AAA repair,
and infrarenal EVAR between 2012 and 2016
within the American College of Surgeons
National Surgical Quality Improvement Program
[3]. They identied 6825 AAA repairs, 220
ZFENs, 181 open complex AAA repairs, and
6464 infrarenal EVAR. They concluded that
ZFEN is associated with lower perioperative
morbidity and mortality compared with open
complex AAA repair, and outcomes are comparable to those of infrarenal EVAR.
There was no evidence of Type IA endoleak at
5 years following EVAR in this patient.However,
some patients with short angulated neck will
develop endoleak 5–6 years following
EVAR. Therefore, it is very important that surveillance with imaging studies should be followed for a longer period of time after EVAR.