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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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140 Section 8: Aortoiliac Disease
49. RATIONALE
Double IVC in a patient with AAA.
The incidence of a double inferior vena cava is 0.3%–0.5% in the general population. The most
common venous anomaly associated with AAA is a retroaortic renal vein as a result of persistence of the dorsal limb during development and a circumaortic venous collar due to persistence of both dorsal and ventral venous limbs. Normally the left renal vein is formed by the
persistence of the ventral limb and regression of the dorsal limb of the venous collar. Anomalies
of both renal segments of the inferior vena cava are classified as type A-persistent right posterior
cardinal vein (retrocaval ureter), type B-persistent right subcardinal vein (normal IVC), type
C-persistent left subcardinal vein (left IVC), and type BC-persistent right and left supracardinal
and subcardinal veins (double IVC). In most patients with double inferior vena cava, mobilization of the left inferior vena cava, especially at the neck of the aneurysm, is important, as the
left-sided vena cava crosses toward the right anteriorly and should be carefully mobilized in
order to prevent injury to the vein, which may result in significant hemorrhage. A small tear
in the tributary of the inferior vena cava may result in serious intraoperative hemorrhage and
hypotension with multiple organ dysfunction. Inadvertent ligation of one of the paired channels
will result in thrombosis causing edema of the lower extremity and serious sequelae of venous
hypertension.
Section 8: Aortoiliac Disease 141
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Correct Answer B Mobilization of the left-sided inferior vena cava near the aortic neck
Reference
Hans, S. S. (2020). Open repair of abdominal aortic aneurysm in a patient with double inferior vena
cava. In S. S. Hans (Ed.), Challenging arterial reconstructions: 100 clinical cases (pp. 23–26).
Cham, Switzerland: Springer International Publishing AG.
50. RATIONALE
Marrocco-Trischitta et al. reported on 25 patients who underwent open AAA repair in the presence of biopsy-proven cirrhosis of the liver. They did not observe any difference in perioperative
complications between cirrhotic patients and controls. However, there was higher intraoperative blood loss, longer operative time, and increased length of stay in patients with liver cirrhosis. From their study they concluded that in patients with compensated cirrhosis of the liver,
open AAA repair can be safely performed. However, the reduced life expectancy in cirrhotic
patients with MELD score >10 suggests that the repair should not be offered in this group of
patients as their life expectancy is short. Patients undergoing open repair for intact AAA have
increased operative bleeding, transient liver dysfunction, and increased length of stay but satisfactory survival. Patients presenting with ruptured AAA in the presence of liver cirrhosis have a
uniformly poor prognosis.
Correct Answer B Incidence of perioperative complications in patients with compensated cirrhosis of the liver is similar to those without cirrhosis but there is greater blood loss,
increased operative time, and increased length of stay
Reference
Marrocco-Trischitta, M. M., Kahlberg, A., Astore, D., Tshiombo, G., Mascia, D., & Chiesa, R. (2011).
Outcome in cirrhotic patients after elective surgical repair of infrarenal aortic aneurysm. J Vasc
Surg, 53(4), 906–911. PMID: 21215574
51. RATIONALE
Paraplegia following infrarenal aortic reconstruction is rare and is multifactorial, with interruption of the abnormally located greater radicular artery (localized at the level of T9–-T12 in 75%,
T5–T8 in 15%, and L1–L2 in 10%), as the predominant factor. Atheroembolization, prolonged
suprarenal clamping, shock, and interruption of pelvic arterial circulation are other important
factors in causing spinal cord ischemia. In this patient the most probable cause of paraplegia
was lack of antegrade flow into both hypogastric arteries. In the presence of thrombosed left
hypogastric artery aneurysm, ligation of the right hypogastric artery effectively resulted in loss
of arterial supply to the conus medullaris. In this patient a separate bypass from the right limb
of the graft to the hypogastric artery after resection of the right hypogastric aneurysm should
have been performed in order to maintain antegrade arterial flow to at least one hypogastric
artery. Gloviczki et al. described six types of ischemic injuries to the spinal cord, with type I
representing complete infarction of the dorsal spinal cord, manifesting as complete motor and
sensory loss distal to the lesion, and type VI with infarction of the posterior one-third of the cord
with preservation of motor function but with loss of proprioception and loss of sense of vibration. The remaining types (type II to type V) represent varying degrees of neurological deficits
in the lower extremities.
Correct Answer D Interruption of hypogastric arterial flow
142 Section 8: Aortoiliac Disease
Reference
Gloviczki, P., Cross, S. A., Stanson, A. W., et al. (1991). Ischemic injur y to the spinal cord or lumbosacral
plexus after aorto-iliac reconstruction. Am J Surg, 162(2), 131–136. PMID: 1862833
52. RATIONALE
Postoperative CTA showing patent in-line left aortofemoral and crossover right iliofemoral graft following remote
removal of infected aortofemoral graft.
The incidence of prosthetic aortic graft infection ranges from 0.6% to 3%.1 Management
options in patients with aortic graft infections include explantation of the graft and
reconstruction by extra-anatomic bypass (axillofemoral), rifampin-soaked prosthetic
graft, and cryopreserved aortic allograft. In situ autologous aortoiliac/femoral reconstruction using superficial femoral veins and popliteal veins have been championed by Clagett
et al. Selection of revascularization strategy depends on the type of bacterial flora isolated
from the graft, extent of graft infection, and presence or absence of aortoenteric fistula.
Charlton Ouw et al. reported on 28 patients with infected infrarenal abdominal aortic graft
with in situ reconstruction in 79% of patients using a prosthetic graft, cadaver homograft,
and native femoral-popliteal veins with in-hospital mortality of 7% and reinfection
rate of 25%.
2
Section 8: Aortoiliac Disease 143
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Correct Answer C Aortofemoral reconstruction using a left flank retroperitoneal approach
with bilateral groin incisions with a prosthetic graft as a conduit
References
1. Chung, J., & Clagett, G. P. (2011). Neoaortoiliac System (NAIS) procedure for the treatment of the
infected aortic graft. Semin Vasc Surg, 24(4), 220–226. PMID: 22230677
2. Charlton-Ouw, K. M., Sandhu, H. K., Huang, G., et al. (2014). Reinfection af ter resection and revascularization of infected infrarenal abdominal aortic grafts. J Vasc Surg, 59(3), 684–692. PMID:
24239115
53. RATIONALE
Results from the GLOBAL STAR database (2007–2010) from experienced institutions in the UK
evaluated 318 patients from 14 countries with deployment of a fenestrated aortic graft. The primary procedural success rate was 99%, perioperative mortality was 4.1%, and intraoperative target vessel loss was 0.6%.1 Fenestrated endovascular aneurysm repair (FEVAR) is an independent
predictor of the need for postoperative transfusion.1 FEVAR promotes positive infrarenal neck
remodeling and greater sac shrinkage compared with standard endovascular aneurysm repair.
Correct Answer A Using a fenestrated endograft
References
1. Early results of fenestrated endovascular repair of juxtarenal aortic aneurysms in the United
Kingdom. (2012). Circulation, 125(22), 2707–2715. PMID: 22665884
2. Teter, K., Li, C., Ferreira, L. M., Ferrer, M., et al. (2022). Fenestrated endovascular aortic aneurysm
repair promotes positive infrarenal neck remodeling and greater sac shrinkage compared with
endovascular aortic aneurysm repair. J Vasc Surg, 76(2), 344–351.e341. PMID: 35276266
2
54. RATIONALE
The natural history of type II endoleaks is not well defined. It has been demonstrated that
in approximately 20% of patients, early type II endoleaks may persist, and persistent type II
endoleaks are associated with the need for secondary interventions, sac enlargement, and rupture of AAA. Delayed type II endoleaks are more likely to be associated with sac enlargement as
compared to early type II endoleaks. A significant number of patients require multiple interventions for type II endoleaks. Coil embolization via the superior mesenteric artery, iliolumbar
artery, or direct (translumbar) sac embolization are effective modalities for managing type II
endoleaks. A patient with type II endoleak and a rapid sac growth rate should raise the suspicion
of possible delayed type I or type III endoleak.
Correct Answer B 6%–8%
Reference
Sarac, T. P., Gibbons, C., Vargas, L., et al. (2012). Long-term follow-up of type II endoleak embolization
reveals the need for close surveillance. J Vasc Surg, 55(1), 33–40. PMID: 22056249
55. RATIONALE
Most experts agree that in patients presenting with a ruptured EVAR with suitable anatomy,
EVAR is preferable to open repair. A multicenter trial (IMPROVE) from 29 centers in the UK and
one in Canada randomized 613 patients with ruptured AAA: 316 to EVAR as the first strategy
144 Section 8: Aortoiliac Disease
(if aortic morphology was suitable; open repair if not) and 297 to open repair. At 1 year, all-cause
mortality was 41.5% for the endovascular group and 45.1% for the open repair group. There was
no survival benefit for the endovascular group over 1 year but it offered patients faster discharge
and better quality of life. The reintervention rate was similar in both groups. Several other
single-institution studies showed that EVAR for ruptured AAA is a suitable treatment option, but
its costs are prohibitive.
Correct Answer C 45% for open repair, 41% for EVAR
Reference
Powell, J. T., Sweeting, M. J., Thompson, M. M., et al. (2014). Endovascular or open repair strategy for
ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial. BMJ,
348, f7661. PMID: 24418950
56. RATIONALE
Type III endoleak repaired with a relining EVAR stent graft. Images are intraoperative angiography before (left) and after
(right) relining stent graft placement.
Maleux et al. reported a 2.1% incidence of type III endoleaks in 965 patients undergoing EVAR
from 1995 to 2014. In most cases the underlying mechanism was disconnection of the stent
graft components (56%) and a fabric defect in the remaining 44%.1 Type III endoleaks may result
in rupture of AAA or occasionally in aortoduodenal fistula. CT angiography is the best imaging modality for detection of type III endoleaks, though plain abdominal films can confirm a
disconnection of a stent graft limb and its components. Treatment consists of placement of a
covered stent across the separated graft components. If there is a fabric tear at the flow
divider, relining with conversion of the graft to aortobiiliac configuration is a better option.
Section 8: Aortoiliac Disease 145
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The FDA sent a notification (Oct. 28, 2019) regarding the greater risk of type III endoleak with
the Endologix AFX and Endologix STRATA device with close follow-up mandatory in patients
where those devices were deployed.
2
Correct Answer B 2%–3% of patients
References
1. Maleux, G., Poorteman, L., Laenen, A., et al. (2017). Incidence, etiology, and management of
type III endoleak after endovascular aortic repair. J Vasc Surg, 66(4), 1056–1064. PMID: 28434700
2. Update on Risk of Type III Endoleaks with Use of Endolog ix AFX Endovascular AAA Graft System.
(2022). U.S. Food and Drug Administration Safety Report. Retrieved from Inactive Link—https://
ww w.fda.gov/medical-devices/safety-communications/update-endologix-afx-endovascularaaa-graft-systems-and risk-and-type-iii-endoleak-fda-safety#publications
57. RATIONALE
Rupture of AAA in a patient with a prior endograft remains a lethal problem. It has been
reported that an existing endograph provides neither acute nor 1-year survival benefit after ruptured abdominal aortic aneurysm repair. Cho et al. reported 20% mortality of abdominal aortic
aneurysm in a patient with prior endovascular repair and 38.1% with open repair (P = 0.27) in
patients who had rupture of an abdominal aortic aneurysm with prior endovascular repair.
Similar several other retrospective studies showed similar mortality in patients with ruptured
AAA with prior endografts and those who had de novo rupture of abdominal aortic aneurysm.
Correct Answer D Provides neither acute nor 1-year survival benefit
Reference
Cho, J. S., Park, T., Kim, J. Y., et al. (2010). Prior endovascular abdominal aortic aneurysm repair provides
no survival benefits when the aneur ysm ruptures. J Vasc Surg, 52(5), 1127–1134. PMID: 20674248
58. RATIONALE
(a) Large saccular iliac anastomotic aneur ysm with kink in left iliac limb and left hypogastric artery occlusion.
(b) Exclusion of aneur ysm using iliac limb endograft.
146 Section 8: Aortoiliac Disease
In a population-based study (1959–1990), Hallet et al. reported on 307 patients who had undergone open AAA repair, and 9.4% had a graft-related complication. They reported a paraanastomotic false aneurysm (3%) at a follow-up of 6.1 years, three at the proximal anastomoses
and the remaining six at the iliac/femoral anastomosis. Femoral anastomotic aneurysms are
more common than iliac anastomotic aneurysms. Whenever anatomically feasible, endografting of the iliac and aortic anastomotic aneurysm is preferable to open repair. The iliac anastomotic aneurysm may be saccular and have associated redundancy of the iliac limb of the
prosthetic graft and may require brachial access with snaring of the guide wire from the femoral
approach as the wire tends to coil in a large aneurysmal sac. If the hypogastric artery is patent in
a patient with a large anastomotic iliac aneurysm, it should be coil embolized or an Amplatzer
plug be used to prevent retrograde flow into the aneurysm sac.
Correct Answer B Endovascular repair using a covered stent by left femoral and brachial
access with coil embolization of hypogastric artery if patent
Reference
Hallett, J. W., Jr., Marshall, D. M., Petterson, T. M., et al. (1997). Graft-related complications after
abdominal aortic aneurysm repair: reassurance from a 36-year population-based experience.
J Vasc Surg, 25(2), 277–284; discussion 285–276. PMID: 9052562
59. RATIONALE
Large hypogastric aneurysm following remote open AA A repair.
Section 8: Aortoiliac Disease 147
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Preservation of a hypogastric artery is almost impossible in patients with a large hypogastric
aneurysm. Open repair is difficult because of its location deep in the pelvis, with surrounding venous structures, and as ligation of the branches of the hypogastric artery is usually
necessary. Endovascular repair is preferable by first performing the coil embolization of the
hypogastric branches (anterior and posterior) followed by endograft coverage of the origin of
the hypogastric artery. Endografting of a hypogastric artery aneurysm is usually not feasible
because of the difficulty in obtaining satisfactory landing zones proximally and distally. The
risk of rupture of hypogastric artery aneurysm >3 cm in diameter is estimated to be 38% with
a mortality of 50%–60%. Implantation of IBD devices for the treatment of hypogastric artery
aneurysm in selected cases can yield good technical results with a high primary patency
and low rate of perioperative complications. However, there is a higher rate of reintervention
during midterm follow-up. Ipsilateral femoral access is preferable, as gaining access to the
ipsilateral iliac artery from contralateral access is difficult, if not impossible, in patients with
prior aortoiliac grafts.
Correct Answer D Ipsilateral femoral access with placement of coils in the outflow branches
of hypogastric artery and a covered stent across the outflow of the hypogastric artery
Reference
Kliewer, M., Plimon, M., Taher, F., et al. (2019). Endovascular treatment of hypogastric artery aneu-
rysms. J Vasc Surg, 70(4), 1107–1114. PMID: 31147136
60. RATIONALE
Spinal cord ischemia (SCI) is one of the most dreaded complications of thoracic aortic endovascular intervention, occurring in up to 10% of patients.
Factors that contribute to the risks of development of SCI are:
A. Length of aortic coverage
B. Prior aortic surgery (open and endovascular)
C. Occluded vertebral arteries and internal iliac arteries
D. Intraoperative hypotension
E. Perioperative anemia
Preoperative planning should carefully consider the necessary length of coverage of the
thoracic aorta. A proximal seal of at least 20 mm of healthy parallel-walled aorta is appropriate. If the coverage of the subclavian artery is necessary to achieve this, staged or
concomitant revascularization to preserve the collateral flow to the left vertebral arteries
is recommended by performing the left subclavian artery transposition into the left common carotid artery or subclavian-to-carotid bypass. Distally, a 20-mm seal is also desirable. Coverage of robust intercostals (if detected by CTA) that can be spared is desirable
while still maintaining an adequate seal. Cerebrospinal fluid (CSF) drainage, if the length
of the thoracic aorta to be covered is 20 cm or greater or in other high-risk settings, should
be placed preoperatively. Intraoperatively once the device is deployed, CSF drainage can
be initiated by simultaneously increasing the mean arterial pressure to >90 mmHg. CSF
drainage can be performed (up to 10–20 cc per hour) to maintain an intracranial pressure of
10 mmHg or less.
Correct Answer B Prior aortic surgery (open and endovascular)
148 Section 8: Aortoiliac Disease
Reference
Ullery, B. W., Cheung, A. T., Fairman, R. M., et al. (2011). Risk factors, outcomes, and clinical manifes-
tations of spinal cord ischemia following thoracic endovascular aortic repair. J Vasc Surg, 54(3),
677–684. PMID: 21571494
61. RATIONALE
Consensus guidelines from both the United States and Europe recommend TEVAR for:
A. Traumatic aortic injury and pseudoaneurysm
B. Penetrating aortic ulcer (>20 mm in diameter and 10-mm neck)
C. Intramural hematoma
D. Complicated type B aortic dissection
E. Thoracic aortic aneurysm >5.5 cm in transverse/AP dimension
Contraindications to TEVAR are limited mostly to anatomical considerations, inadequate proximal distal seal zones, or inadequate access vessels. Connective tissue disorders and contaminated fields are relative contraindications for TEVAR.
Correct Answer C TEVAR has a mortality of 19% and open repair 33%
Reference
Cheng, D., Martin, J., Shennib, H., et al. (2010). Endovascular aortic repair versus open surgical repair
for descending thoracic aortic disease a systematic review and meta-analysis of comparative
studies. J Am Coll Cardiol, 55(10), 986–1001. PMID: 20137879
62. RATIONALE
A meta-analysis of nearly 9000 patients undergoing TEVAR looked at the calculated incidence of
retrograde type A aortic dissection, which was observed to be 2.5% of patients, with associated
mortality of 37%.
Retrograde aortic dissection may be increased when TEVAR is used:
A. Among patients with Marfan syndrome
B. For acute/chronic dissection
C. With more proximal landing zones (zone 0–2)
D. When the proximal diameter is oversized >15%
E. When aggressive wire manipulation or balloon molding is performed
Correct Answer C 2.5% of patients
Reference
Chen, Y., Zhang, S., Liu, L., et al. (2017). Retrograde type A aortic dissection after thoracic endovascu-
lar aortic repair: a systematic review and meta-analysis. J Am Heart Assoc, 6(9):e004649. PMID:
28939705
63. RATIONALE
Posterior circulation strokes occur in approximately 3.1% of patients following TEVAR and typically occur in the context of coverage of the left subclavian artery. In more than 20% of aneurysms and dissections requiring endovascular repair, it is necessary to cover the left subclavian
Section 8: Aortoiliac Disease 149
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artery to achieve an adequate proximal seal. The left subclavian artery perfuses the brain via
the left vertebral artery, which is dominant in over 60% of patients. Coverage of the left subclavian artery without its revascularization dramatically increases the risk for posterior circulation
stroke (>5%) as compared to <2% with preoperative revascularization.
Anatomical factors that increase the risk of posterior circulation stroke include:
A. Dominant left vertebral artery in the setting of left subclavian artery coverage
B. Aberrant, hypoplastic, or absent right subclavian artery
C. Left vertebral artery terminating in the posterior inferior cerebellar artery
D. Anomalous origin of the left vertebral artery from the aortic arch
If there is a compelling reason to avoid preoperative revascularization of the left subclav ian arter y, it is
necessary to demonstrate a patent right vertebral arter y in continuity with a patent circle of Willis.
Correct Answer B 3%–3.5% of patients
Reference
Feezor, R. J., Martin, T. D., Hess, P. J., et al. (2007). Risk factors for perioperative stroke during thoracic
endovascular aortic repairs (TEVAR). J Endovasc Ther, 14(4), 568–573. PMID: 17696634
64. RATIONALE
Iliac artery rupture.
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