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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3742_Библиотеки_им_академика_М_И_Перельмана
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120 Section 8: Aortoiliac Disease
Correct Answer B The third and proximal fourth portions of the duodenum should be left
attached to the aneurysmal wall
Reference
Tang, T., Boyle, J. R., Dixon, A. K., & Varty, K. (2005). Inf lammatory abdominal aortic aneurysms. Eur J
Vasc Endovasc Surg, 29(4), 353–362. PMID: 15749035
19. RATIONALE
Major venous injury due to open aortic reconstruction is significantly more common during the
repair of ruptured AAA as compared to repair of intact AAA. Risk factors associated with major
venous injury during open aortic reconstruction are:
A. Periarterial inflammation
B. Repair of associated iliac artery aneurysm
In inflammatory AAA there is significant periarterial inflammation. There is increased risk
of iliac/femoral vein thrombosis following repair of iliac vein injury, and patients should have
evaluation by duplex venous study to rule out deep venous thrombosis.
Correct Answer D Duplex venous study of the right lower extremity
Reference
Hans, S. S., Vang, S., & Sachwani-Daswani, G. (2018). Iatrogenic major venous injur y is associated with
increased morbidity of aortic reconstruction. Ann Vasc Surg, 47, 200–204. PMID: 28887236
20. RATIONALE
Accurate positioning of the aortic stent graft ensures a proper landing zone, length, and
undisturbed perfusion to the aortic branch vessels. Preoperative planning and imaging
may predict optimal fluoroscopic visualization angles, utilized to eliminate parallax during deployment. Aortogram with device in place just prior to deployment is important to
perform, as additional rigidity of the device on the wires may alter aortic alignment. Some
devices such as the C3 Gore Excluder may allow for unidirectional repositioning after partial
deployment or proximal recapturing, which can allow for level and orientation adjustments.
Once fully deployed, graft repositioning may not be possible due to the radial forces of the
stent and/or proximal fixation struts, as the stent graft becomes fixed in place in most endografts. If deployment is too low, a proximal aortic cuff can be placed. If major branches of the
aorta such as renal, celiac, and SMA are at risk of malperfusion due to partial or complete
coverage, left brachial access should be obtained to assist with cannulation of the vessels at
risk so that either stenting or snorkeling with proximal extensions may be performed using
either bare-metal or covered stents if needed.
Correct Answer D Bare-metal, balloon-expandable stent using left brachial access into the
left renal artery
Reference
Cuff, L., & Lu, J. (2021). Complications of endovascular repair of infrarenal abdominal aortic aneu-
rysm. In S. S. Hans (Ed.), Vascular and endovascular complications — a practical approach
(pp. 62–67). Boca Raton, FL: CRC Press.
Section 8: Aortoiliac Disease 121
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21. RATIONALE
The use of a marker catheter for accuracy of limb measurement during deployment of the iliac
limb of a stent graft, especially in the presence of tortuous anatomy, is mandatory. If partial or
complete coverage of the internal iliac artery occurs, ipsilateral wire access into the internal
iliac artery may allow for distal limb extension, and internal iliac artery stenting that extends
into the external iliac artery may permit retrograde pelvic perfusion via the snorkel technique.
However, there is a risk of late type IB endoleak with use of this technique.
Correct Answer D Ipsilateral wire access into the right hypogastric artery via the right
femoral artery with distal limb extension and internal iliac artery stenting that extends into the
external iliac artery to permit retrograde perfusion via the snorkel technique
Reference
Cuff, L., & Lu, J. (2021). Complications of endovascular repair of infrarenal abdominal aortic aneu-
rysm. In S. S. Hans (Ed.), Vascular and endovascular complications — a practical approach
(pp. 62–67). Boca Raton, FL: CRC Press.
22. RATIONALE
Type IA endoleak.
122 Section 8: Aortoiliac Disease
A type IA endoleak may develop when there is suboptimal wall apposition of the stent graft
at the seal zone. In the case of type IA endoleak refractory to balloon angioplasty, a deployment of the balloon-expandable Palmaz stent (Cordis Corporation, Bridgewater, NJ) with
its high radial force allows better apposition of the stent graft to the aortic intima. Another
useful technique for management of type IA endoleak is to mechanically anchor the stent
graft to the landing zone using the Heli-Fx endovascular system (Aptus Endo Systems, Inc.,
Sunnyvale, CA). In cases where the graft is deployed flush with the lowest renal artery and
appears well opposed to the aortic wall, observation is reasonable in a few instances, as
there may be resolution of type IA endoleak at 1-month follow-up CT scan. Despite adjunctive intraoperative maneuvers, type IA endoleaks may persist and must be carefully monitored. Persistent type IA endoleaks may need branched or fenestrated endograft if anatomy
permits; otherwise, explantation of the endograft and open repair may be the only option
available.
Correct Answer B Consider a large bare-metal stent (Palmaz) or endostapling
Reference
Millen, A. M., Osman, K., Antoniou, G. A., et al. (2015). Outcomes of persistent intraoperative type
Ia endoleak after standard endovascular aneurysm repair. J Vasc Surg, 61(5), 1185–1191. PMID:
25656591
23. RATIONALE
Early graft limb occlusion is usually due to kinking of the graft or excessive infolding of the
graft. Catheter-directed thrombolysis or mechanical thrombectomy followed by relining of
the previously placed limb with a covered stent in the distal end can be extended to just above
the common iliac bifurcation. If that’s not feasible, coil embolization of the right hypogastric
artery with extension of the iliac limb to the external iliac artery may be required. In general,
it is preferable to avoid extension of the graft to the external iliac artery, as this is a predictor of
late graft limb occlusion. Small-diameter external iliac artery and landing zone of the endograft
into the external iliac artery at the time of index procedure are independent risk factors for graft
occlusion.
Correct Answer B Thrombolysis and relining the endograft and extension of the graft to the
right external iliac artery with coil embolization of the hypogastric artery
Reference
Bogdanovic, M., Stackelberg, O., Lindström, D., et al. (2021). Limb graft occlusion following endo-
vascular aneurysm repair for infrarenal abdominal aortic aneurysm with the Zenith alpha,
excluder, and endurant devices: a multicentre cohort study. Eur J Vasc Endovasc Surg, 62(4),
532–539. PMID: 34266764
24. RATIONALE
The conventional approach that type II endoleak without sac enlargement can be
safely observed has been recently challenged. The Japanese Committee for Stent Graft
Management Registry data showed that the cumulative incidence rates of abdominal aortic
aneurysm (AAA)–related mortality, rupture, sac enlargement, and reintervention were
higher in patients with persistent type II endoleak. Specifically, the cumulative incidence
rates of rupture and AAA-related mortality increased to 2% at 10-year follow-up. Older age,
Section 8: Aortoiliac Disease 123
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female gender, dilated proximal neck, proximal neck diameter, and chronic kidney disease
are independent positive correlates of sac enlargement. These results suggest that persistent type II endoleaks are not benign. considering their long-term implications. The role
of preoperative and intraoperative embolization of the side branches of the AAA to reduce
incidences of type II endoleak is not well defined. In patients with significant sac enlargement due to type II endoleak from a patent IMA, superior mesenteric artery cannulation
followed by advancement of the microcatheter over the microwire with the marginal artery
of Drummond or the arc of Riolan and accessing the origin of the inferior mesenteric artery
with deployment of microcoils will help in resolution of IMA-associated type II endoleak.
Translumbar sac endoleak should be considered if a microcatheter technique via SMA is not
successful.
Correct Answer D Coil embolization of the inferior mesenteric artery via the superior mesenteric artery using a microcatheter
Reference
Seike, Y., Matsuda, H., Shimizu, H., et al. (2022). Nationwide analysis of persistent type II endoleak
and late outcomes of endovascular abdominal aortic aneurysm repair in Japan: a propensitymatched analysis. Circulation, 145(14), 1056–1066. PMID: 35209732
25. RATIONALE
Endovascular juxtarenal aortic aneurysm repair incurs a longer operative time and higher
doses of radiation and intravenous contrast than standard EVAR. Perioperative complications
for custom fenestrated endografts (FEVAR) and chimney/snorkel parallel grafting (ch. EVAR)
were studied in a meta-analysis for juxtarenal aneurysm repair. For FEVAR, cardiac complications occurred in 3.7%, pulmonary complications in 2.3%, sepsis in 0.6%, and ischemic stroke
in 0.3%. For ch. EVAR, cardiac complications occurred in 7.4%, pulmonary in 3.2%, and ischemic stroke in 3.2%. The higher incidence of ischemic stroke is due to upper extremity vascular access with additional manipulation of wires and catheters in the transverse arch of the
thoracic aorta.
Correct Answer C 3%–3.5%
Reference
Katsargyris, A., Oikonomou, K., Klonaris, C., et al. (2013). Comparison of outcomes with open, fenes-
trated, and chimney graft repair of juxtarenal aneurysms: are we ready for a paradigm shift?
J Endovasc Ther, 20(2), 159–169. PMID: 23581756
26. RATIONALE
There are several leak points related to the bridging stents that are unique to fenestrated and
branch type aortic repairs (B/FEVAR). This primarily includes type III leaks from the graftbranch interface and type IC leak from the branch-target vessel interface. With appropriate
sizing and planning, these are relatively uncommon. In a series of 650 patients undergoing
B/FEVAR with 1679 total branches, the rates of branch-related endoleak requiring intervention
were 2.5% for renal, 3.9% for SMA, and 2.8% for celiac branches. Accurate diagnosis of those
leaks is made difficult by the proximal location of the branches within the main body of the
graft, as they occur early and simultaneously with type IA endoleak on both angiography and
CT scan.
124 Section 8: Aortoiliac Disease
Correct Answer C 2%–3%
References
1. Mastracci, T. M., Greenberg, R. K., Eagleton, M. J., & Hernandez, A. V. (2013). Durability of
branches in branched and fenestrated endografts. J Vasc Surg, 57(4), 926–933; discussion 933.
PMID: 23433817
2. Swerdlow, N. J., McCallum, J. C., Liang, P., Li, C., O’Donnell, T. F. X., Varkevisser, R. R. B., &
Schermerhorn, M. L. (2019). Select type I and type III endoleaks at the completion of fenestrated endovascular a neurysm repair resolve spontaneously. J Vasc Surg, 70(2), 381–390. PMID:
30583892
27. RATIONALE
A prospective multicenter trial to evaluate the safety and effectiveness of the Zenith fenestrated
graft (Cook Medical, Bloomington, IN) for the treatment of juxtarenal AAAs looked at
67 patients with a total of 178 visceral arteries requiring incorporation with small fenestrations
in 118, scallops in 51, and large fenestrations in 9, with technical success in all (100%). Of a total
of 129 renal arteries targeted by a fenestration, there were 4 (3%) renal artery occlusions and
Section 8: Aortoiliac Disease 125
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12 (9%) stenoses. Fifteen patients (22%) required secondary intervention for renal artery with
type I endoleak in one patient. At 5 years, patient survival was 91% ± 4% and freedom from major
adverse events was 79% ± 6%. Primary and secondary patency of targeted renal arteries was
81% ± 5% and 97% ± 2%.
Correct Answer B 22% of patients
Reference
Oderich, G. S., Greenberg, R. K., Farber, M., et al. (2014). Results of the United States multicenter
prospective study evaluating the Zenith fenestrated endovascular graft for treatment of
juxtarenal abdominal aortic aneurysms. J Vasc Surg, 60(6), 1420–1428.e1421–1425. PMID:
25195145
28. RATIONALE
Evaluation of the use of intraoperative guidance by means of C-arm cone-beam computed
tomography (CBCT) and the use of postoperative CBCT in patients undergoing FEVAR
in 40 patients revealed a significantly lower dose of contrast with no significant difference in operative time or fluoroscopy time. Postdeployment CBCT is of sufficient quality
to evaluate successful aneurysm exclusion and for detection of early complications after
FEVAR.
Correct Answer C Lower contrast dose
Reference
Dijkstra, M. L., Eagleton, M. J., Greenberg, R. K., et al. (2011). Intraoperative C-arm cone-beam com-
puted tomography in fenestrated/branched aortic endografting. J Vasc Surg, 53(3), 583–590.
PMID: 21129898
29. RATIONALE
Iliac artery aneurysm occurs in 40% of patients with abdominal aortic aneurysms.
Approximately 80% affect the common iliac artery, with 20% involving the right internal iliac
artery. External iliac artery aneurysms are extremely rare. Iliac aneurysms are usually diagnosed incidentally and are asymptomatic in most instances. Some iliac aneurysms can cause
abdominal pain with obstructive symptoms involving the GI tract and GU tract, pelvic vein
obstruction, and limb ischemia. Limb ischemia may occur secondary to acute thrombosis of
the aneurysm. Rupture of iliac aneurysms is associated with significant morbidity and mortality. The expansion rate of common iliac aneurysms has been reported at 0.5–1.5 mm/yr in
those less than 3 cm diameter as compared with 2.5–2.8 mm/yr in those measuring greater
than 3 cm. The reported incidence of rupture of hypogastric aneurysm is high (38%–49%).
The threshold for repair of common iliac aneurysm is 3.5 cm or larger and for hypogastric
aneurysm is 3.0 cm.
Correct Answer B Common iliac artery, hypogastric artery, external iliac artery
Reference
Sandhu, R. S., & Pipinos, II. (2005). Isolated iliac artery aneurysms. Semin Vasc Surg, 18(4), 209–215.
PMID: 16360578
126 Section 8: Aortoiliac Disease
30. RATIONALE
In patients with isolated common iliac aneurysms with adequate proximal and distal landing zones (10–15 mm), the aneurysm can be excluded with a covered stent or endograft limb.
However, if there is a concomitant AAA or the landing zone is less than 10–15 mm, a bifurcated
endograft is required. If the common iliac aneurysm extends to its bifurcation, a variety of
options exist to obtain a distal seal. Optimally, antegrade flow is maintained in the internal iliac
artery to prevent symptoms of pelvic ischemia.
The common techniques used are:
A. Coil embolization/plug with endograft extension into the external iliac artery
B. Bell-bottom iliac limb
C. IBD
D. Snorkel technique
E. External iliac artery to internal iliac artery bypass with endograft extension
F. Combined open and endovascular approach
When considering IBD, the aortic-to-iliac bifurcation length must be >5 cm, common iliac bifurcation inner diameter >16 mm, internal iliac artery diameter >5–12 mm, with a landing zone of
>10 mm, and minimal proximal common iliac diameter of 17 mm. In terms of the placement, a
16 Fr Gore drySeal Flex introducer sheath is advanced over a Cook Lundquist extra stiff wire
guided in the contralateral side. A buddy catheter is introduced via the 16 Fr sheath, and an Indy
Section 8: Aortoiliac Disease 127
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snare is advanced in the contralateral 12 Fr sheath. The Cook tracer metro wire guide is snared
establishing through and through femoral access. The IBE is loaded into the Lundquist guide
wire and the IBE is advanced into position over both wires. Limited contrast angiography can be
obtained through the 16 Fr ipsilateral sheath to demonstrate the level of the aortic bifurcation. The
iliac branch portal is deployed 1–1.5 cm above the iliac bifurcation to aid in the internal iliac artery
cannulation. The 12 Fr sheath is advanced up and over the iliac bifurcation. The sheath is positioned at the distal end of the iliac portal. A buddy catheter and guide wire are used to catheterize
the internal iliac artery. The IBE is introduced and deployed in the internal iliac artery, and angioplasty is performed with a 14-mm angioplasty balloon while the external iliac stent portion of the
device is deployed. The delivery catheter is removed and kissing balloon angioplasty is performed
for the external iliac artery. In patients with internal iliac artery aneurysms after deployment of
IBD, the sheath is advanced and the anterior division is excluded using an Amplatzer plug or coil.
The posterior division of the internal iliac artery is catheterized. A proximal stent is placed into
the posterior branch, and a self-expanding stent graft is placed in the posterior division. Freedom
from IBD occlusion is reported to be 83%–86% at 5 years.
Correct Answer C Iliac branch device (IBD)
Reference
Fargion, A. T., Masciello, F., Pratesi, C., et al. (2018). Results of the multicenter pELVIS Registry for iso-
lated common iliac aneurysms treated by the iliac branch device. J Vasc Surg, 68(5), 1367–1373.
e1361. PMID: 30072046
31. RATIONALE
Abdominal compartment syndrome (ACS) develops as a result of increased intraabdominal
pressure secondary to massive fluid administration associated with ongoing hemorrhage and
reperfusion of the splanchnic bed. As a result of increased intraabdominal pressure, there is
decreased venous return due to compression of the IVC resulting in decreased cardiac output.
The compression of the kidneys results in a decrease in renal blood flow and oliguria. There
is increase in the airway pressure with a decrease in pulmonary compliance. Intraabdominal
pressure >20 mmHg develops in 50% of patients, and of those 20% develop multiple organ
failure following open repair of ruptured AAA. Medical therapy includes neuromuscular
blockade, positive PEEP, albumin, and diuretics. Dilutional coagulopathy tends to occur in
the first 24 hours following repair. After 24 hours of repair, decompressive laparotomy should
be considered. In some patients with ACS the abdomen should be kept open, avoiding adhesions between the intestines and abdominal wall. Vacuum-assisted wound closure followed by
delayed primary fascial closure is often necessary.
Correct Answer C 20%
Reference
Bjorck, M. (2012). Management of the tense abdomen or diff icult abdominal closure af ter operation for
ruptured abdominal aortic aneurysms. Semin Vasc Surg, 25(1), 35–38. PMID: 22595480
32. RATIONALE
SCI in the form of paraplegia or paraparesis is more common following open repair of ruptured
AAA than unruptured AAA. This is often related to prolonged hypotension. It may also result
from interruption of the blood supply to the spinal cord due to the abnormally low origin of
128 Section 8: Aortoiliac Disease
the blood supply to the spinal cord (artery of Adamkiewicz) or embolization into the hypogastric artery. The incidence of SCI following repair of ruptured AAA varies from 0.26% to 0.74%.
The incidence is much lower in patients undergoing an abdominal aortic aneurysm repair for
unruptured AAA. Recovery from neurological function is usually poor.
Correct Answer A <1% of patients
Reference
Gialdini, G., Parikh, N. S., Chatterjee, A., et al. (2017). Rates of spinal cord infarction after repair of
aortic aneurysm or dissection. Stroke, 48(8), 2073–2077. PMID: 28655811
33. RATIONALE
In patients with profound hypotension, free rupture is suspected, and obtaining rapid proximal control is of paramount importance to avoid circulatory collapse; therefore, anesthetic
induction and intubation should be withheld until the incision is ready to be made. Induction
of general anesthesia relieves pain, relaxes the abdominal wall musculature, and releases the
sympathetic tone, which are all protective mechanisms to maintain blood pressure. In most
patients with small- to moderate-sized periaortic hematoma, blunt finger dissection around the
aortic neck aids in positioning of the proximal clamp. However, in patients with extensive retroperitoneal hematomas and shock, proximal control at the supraceliac level is preferable. The left
lobe of the liver is retracted toward the right following division of the left triangular ligament.
Section 8: Aortoiliac Disease 129
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The dissection is done via an opening made in the gastrohepatic omentum. The esophagus with
the NG tube is retracted to the left with a Penrose drain. Deep blades of the surgical retractor
system are inserted to expose the right crus of the diaphragm. The muscular fibers of the crus
are separated with the help of long Metzenbaum scissors, and a 5- to 6-cm-long opening is made
in the right crus. The index and the middle fingers of the right hand are introduced through
the opening in the crus, and fascia surrounding the lower descending thoracic aorta is divided.
A long-angled aortic clamp is guided with the left hand to be applied to the supraceliac aorta.
Although balloon occlusion can be obtained using femoral artery access, in many patients the
arteries are extremely tortuous, and passage of the wire can be difficult and valuable time may
be lost. Balloon occlusion using brachial artery access is difficult to achieve because of the large
size of the balloon in a small artery.
Correct Answer C Laparotomy and supraceliac control
Reference
Hans, S. S., & Huang, R. R. (2003). Results of 101 ruptured abdominal aortic aneurysm repairs from a
single surgical practice. Arch Surg, 138(8), 898–901. PMID: 12912750
34. RATIONALE
In a patient with injury to the left renal vein medial to the gonadal and adrenal vein, the injured
vein can be divided and ligated. But in patients with injury lateral to the gonadal and adrenal
veins, ligation will result in renal vein thrombosis and loss of function of the left kidney. Even if
the injury is medial to the gonadal vein and adrenal vein, lateral venorgraphy in a hemodynamically stable patient should be carried out. Ligation of the left renal vein medial to the adrenal
and gonadal vein results in renal deterioration in the early postoperative period, but long-term
renal function is not affected. Since this patient’s blood pressure is relatively low, one should
complete the proximal anastomosis and then perform lateral repair of the injured left renal
vein, as attempting repair of the lacerated vein may result in further blood loss with persistent
hypotension and potential for multiple organ dysfunction.
Correct Answer D Vascular clamps on either side of the left renal vein and repair after proximal aortic anastomosis is completed
Reference
Pandirajan, K., Katsogridakis, E., Sidloff, D., et al. (2020). Effects of left renal vein ligation during open
abdominal aortic aneurysm repair on renal function. Eur J Vasc Endovasc Surg, 60(6), 829–835.
PMID: 32912760
35. RATIONALE
Warshaw and O’Hara reported a 12% incidence of acute pancreatitis following open repair of
intact AAA and 20% following repair of ruptured AAA. Duodenal obstruction occurs from the
mass effect due to significant enlargement of the pancreas and from hematoma in the paraduodenal area.1 Postoperative amylase, lipase levels, and CT scan of the abdomen should be
obtained if the patient has persistent ileus following open repair of AAA. Nasogastric tube
placement, management of adequate volume status, and total parenteral nutrition are usually
required. Reoperation may be necessary if duodenal obstruction does not resolve with conservative management.
2
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