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180 Section 8: Aortoiliac Disease

(a) Near-focal occlusion of distal abdominal aorta. (b) Treated with kissing, balloon-expandable covered stents from distal aorta to common iliac arteries.

Open aortic reconstruction in the form of aortoiliac endarterectomy and aortobifemoral grafting is associated with 2%–4.5% 30-day mortality and significant morbidity (15%–20%). Primary patency at 5 years has been reported from 85% to 92% and at 10 years from 80% to 85% in a large series. Patients have an increased length of stay, and it usually takes 10–12 weeks to resume presurgical activities. Endovascular therapy for these types of lesions is highly successful with minimal morbidity and a very short length of hospital stay. Balloon-expandable covered stents in distal abdominal and proximal iliac artery occlusion lesions are preferable because of their stronger radial force. In patients with continued nicotine abuse with small-size arteries, in-stent stenosis may occur, requiring secondary intervention. Long-term data available for the Icast/ Advanta V12 device for such lesions appears to be satisfactory.

Correct Answer D Bilateral kissing, covered, balloon-expandable stents from the distal abdominal aorta extending into each common iliac artery

Reference

Mwipatayi, B. P., Ouriel, K., Anwari, T., et al. (2020). A systematic review of covered balloon-expand-

able stents for treating aortoiliac occlusive disease. J Vasc Surg, 72(4), 1473–1486.e1472. PMI D: 32360678

Section 8: Aortoiliac Disease 181

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105. RATIONALE

In a multicenter database of 2012 consecutive patients undergoing aortoiliac stenting among 18 centers in Japan (2005–2009), associated factors for periprocedure (30 days) complications were examined. Using multivariate logistic regression analysis, advanced age (>80 years), critical limb ischemia, and Transatlantic Inter-Societal Consensus (TASC II) Class C and D were independently associated with periprocedure complications with adjusted odds ratio and 95% confidence intervals (CI) of 1.9 (1.3–2.9), 2.3 (1.5–3.4), and 2.4 (1.6–3.4), respectively.

Correct Answer D Age greater than 80, patients with critical limb ischemia, TASC C&D lesions

Reference

Iida, O., Soga, Y., Takahara, M., et al. (2014). Perioperative complications after aorto-iliac stenting:

associated factors and impact on follow-up cardiovascular prognosis. Eur J Vasc Endovasc Surg, 47(2), 131–138. PMID: 24611185

SECTION 9: LOWER EXTREMITY ARTERIAL DISEASE

MCQs 1–50

Q1. The optimal management of a

leaking femoral anastomotic aneurysm is by:

A. Endovascular approach using brachial

and retrograde superficial femoral artery access

B. Direct open repair C. Open repair with proximal control

obtained by a retroperitoneal approach by a transverse incision 2–3 cm above the groin

D. Open repair with proximal balloon

occlusion of the ipsilateral graft limb with access from the contralateral graft limb in the groin

Q2. A 68-year-old man was found to

have a 3.2-cm right common femoral artery aneurysm. The incidence of contralateral synchronous femoral aneurysm is:

A. <25% B. 25%–50% C. 51%–60% D. A contralateral femoral artery aneurysm

is likely if the patient has AAA

DOI: 10.1201/9781003389897-9

Q3. Popliteal aneurysms present as a

rupture in:

A. <2% of patients B. 3%–7% of patients C. 8%–10% of patients D. Rupture of popliteal aneurysm occurs

only if the patient sustains trauma

Q4. A 60-year-old man undergoes staged

open repair of a popliteal aneurysm. At the time of repair, there was no evidence of synchronous AAA. Which statement reflects the best surveillance strategy?

Section 9: Lower Extremity Arterial Disease 183

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A. Lifelong surveillance of abdomen

(abdominal aortic ultrasound), as AAA may develop years after popliteal aneurysm repair

B. Subclavian artery aneurysm should be

suspected

C. Yearly abdominal aortogram D. If the patient does not have a femoral

aneurysm, the chances of developing AAA are low

Q5. The optimal site for femoral anastomo-

sis during performance of a crossover femoral-femoral graft is:

A. Under the inguinal ligament at the junc-

tion of the external iliac and common femoral artery

B. Superficial femoral artery C. Distal common femoral artery D. Deep femoral artery

Q6. A crossover femoral-femoral graft with

inflow on the left is planned in a patient with extensive scarring in the suprapubic area from remote burns. The best alternative to a subcutaneous suprapubic tunnel is:

A. Excision of burn scar and coverage of the

prosthetic graft with rectus abdominus flap

B. Tunnel in the prevesical space C. Excision of burn scan and gracilis muscle

flap

D. Consider bilateral axillofemoral bypass

graft

Q7. During creation of a crossover femoral-

femoral graft in a patient with occlusion of the right limb of EVAR with patent superficial femoral arteries on both sides with near occlusion of right common femoral artery:

A. The distal anastomosis should always

be performed to the deep femoral artery

B. Distal anastomosis should always be per-

formed to the superficial femoral artery

C. Distal anastomosis to the proximal com-

mon femoral artery

D. Prior to distal anastomosis, a right

common femoral endarterectomy with a patch graft is performed, then the distal anastomosis of the femoralfemoral bypass is performed at the site of the distal arteriotomy in the patch graft

Q8. Wound complications following axillo-

femoral graft reconstruction are reported in:

A. 5% of patients B. 10% of patients C. 15% of patients D. 20% of patients

Q9. Five-year patency of an axillofemoral

bypass graft ranges from:

A. 25%–60% B. 30%–70% C. 35%–80% D. 40%–90%

Q10. Asymptomatic femoral artery pseu-

doaneurysm following percutaneous arterial access for coronary/peripheral interventions should be treated as the pseudoaneurysm reaches a transverse/ AP diameter of:

A. 10–12 mm B. 13–15 mm C. 16–20 mm D. >20 mm

Q11. The incidence of retroperitoneal

hemorrhage following femoral artery access is:

A. 0.2% B. 0.5% C. 1% D. 1.5%–2%

Q12. The incidence of arterial perforation

following orbital atherectomy for occlusive disease of femoral and popliteal arteries is:

A. <5% B. 0.5%–1.0% C. 0.5%–1.5% D. 0.5%–2.2%

184 Section 9: Lower Extremity Arterial Disease

Q13. The incidence of distal embolization

following percutaneous intervention of femoral-popliteal arteries is:

A. Similar in patients with critical limb isch-

emia as compared to those with intermittent claudication

B. Greater in patients with critical limb isch-

emia as compared to those with intermittent claudication

C. Lower in patients with critical limb isch-

emia as compared to those with intermittent claudication

D. Distal embolization occurs more fre-

quently with aortoiliac intervention than with femoral-popliteal intervention

Q14. Results of subintimal recanalization of

chronic total occlusion of long segment occlusion of femoral-popliteal arteries reveal a primary-assisted patency as well as secondary patency at 1 year to be approximately:

A. 50% B. 60% C. 70% D. 80%

Q15. Antegrade femoral approach for treat-

ment of popliteal and infrapopliteal arterial occlusive disease is best used for patients with:

A. Patients with high BMI B. Patients with high femoral artery

bifurcation

C. Recent closure device application in the

common femoral artery

D. Iliac artery tortuosity and with severe

calcification at the aortic bifurcation

Q16. The following statement regarding ante-

grade femoral access best reflects the outcomes:

A. The incidence of femoral artery stenosis

or occlusion is higher than retrograde access

B. The incidence of hematoma is higher in

patients with antegrade femoral artery access than with retrograde access

C. Most complications following antegrade

femoral access require intervention

D. The incidence of groin hematomas with

antegrade access is the same as with retrograde access, and most hematomas can be managed conservatively

Q17. The long-term primary and secondary

patency of popliteal artery aneurysm exclusion with saphenous vein graft is:

A. 70%–80% B. 80%–85% C. 80%–90% D. 80%–95%

Q18. Popliteal stent graft migration and

endoleak following popliteal aneurysm repair are caused by:

A. Insufficient overlap with normal artery in

the proximal and distal seal zone

B. Undersizing of the stent C. Forces due to repetitive knee flexion D. Insufficient overlap in the proximal and

distal seal zone, undersizing of the stent, and due to repetitive knee flexion

Q19. An independent predictor of stent graft

thrombosis for the exclusion of popliteal aneurysm using endovascular management is:

A. One-vessel runoff B. Use of longer stents C. Use of multiple stents D. Use of multiple and longer stents

Q20. Regarding endovascular repairs vs. open

repair of popliteal aneurysm, the following statement best reflects the outcome:

A. Primary patency of open repair is supe-

rior to endovascular repair at 1 year

B. At long-term follow-up (3 years), primary

patency of open and endovascular repair is similar

C. At long-term follow-up (3 years) the pri-

mary patency of open repair is superior

D. Most endovascular repairs are performed

for acute ischemia due to thrombosis of popliteal aneurysms

Q21. During popliteal artery balloon angioplasty

for near occlusion of the popliteal artery with one-vessel runoff, there is a dissection flap detected on arteriogram in the distal

Section 9: Lower Extremity Arterial Disease 185

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popliteal artery 2 cm proximal from its distal end. The best management option is:

A. Prolonged low pressure balloon inflation B. Deployment of a covered stent C. Deployment of Supera stent D. Bare-metal self-expandable stent

Q22. Antegrade recanalization of infrapopliteal

artery occlusion for critical limb ischemia has a failure rate of:

A. 10% B. 15% C. 20% D. 25%

Q23. The incidence of combined superficial

and deep surgical site infection following infrainguinal bypass is:

A. <5% B. 5%–18% C. 19%–22% D. 23%–25%

Q24. Ipsilateral greater saphenous vein as a

conduit for femoral-infrapopliteal bypass is inadequate in:

A. <5% patients B. 5%–10% patients C. 11%–14% patients D. 15%–20% patients

Q25. The reported 5-year patency of femoral-

popliteal bypass using an autologous saphenous vein is:

A. 90% above the knee, 80% below the knee B. 80% above the knee, 70% below the knee C. 75% above the knee, 65% below the knee D. 65% above the knee, 55% below the knee

Q26. The following statement regarding tourni-

quet occlusion during femoral-infrapopliteal bypass is correct:

A. Should not be used or it may result in

irreversible muscle ischemia

B. Improves visualization and avoids clamp-

ing of small, calcified target arteries

C. Results in better primary patency D. Results in better secondary patency

Q27. The incidence of early graft thrombosis

(within 30 days) following femoropopliteal bypass is:

A. <5% B. 5%–10% C. 11%–15% D. 16%–18%

Q28. Two weeks following a femoropopliteal

bypass with PTFE graft, there is breakdown of the wound in the groin. There is evidence of deep infection with cultures growing Pseudomonas. The optimal management consists of:

A. Antipseudomonal antibiotics, excisional

debridement in operating room, and negative pressure wound therapy

B. Partial removal of the proximal graft conver-

sion into a composite graft (vein and PTFE), excisional debridement, sartorius myoplasty, and antipseudomonal antibiotics

C. Complete removal of the graft with ex situ

revascularization, excisional debridement, and antipseudomonal antibiotics

D. Removal of PTFE graft, use of cryopre-

served vein as a new bypass, debridement, and antipseudomonal antibiotics

Q29. A 60-year-old woman presents to the

emergency room with a thrombosed left femoropopliteal graft (Rutherford type IIA ischemia) performed with a 7-mm PTFE prosthesis performed 29 months earlier. The best management option is:

A. Open thrombectomy B. Convert to autologous vein

reconstruction

C. Arteriography and thrombolytic therapy D. Anticoagulation

Q30. Two years following femoral tibial in situ

bypass, a severe (70%) focal stenosis near the distal anastomosis is detected on duplex imaging. Optimal management consists of:

A. Open repair with vein patch or Bove peri-

cardial patch

B. Percutaneous angioplasty C. Interposition vein graft at the distal

anastomosis

D. Surveillance with duplex imaging and

intervention if the stenosis progresses further

186 Section 9: Lower Extremity Arterial Disease

Q31. The most common cause of early (within

30 days) graft thrombosis with the use of the in situ technique for lower extremity bypass is:

A. Retained valve leaflets B. Residual arteriovenous fistula C. Inadequate vein segment D. Infection

Q32. Lower extremity edema following

infrainguinal arterial bypass using an autologous vein for chronic limb ischemia occurs in:

A. 10%–20% of patients B. 21%–35% of patients C. 36%–49% of patients D. 50%–100% of patients

Q33. The incidence of lymphatic fistula follow-

ing lower extremity arterial bypass is:

A. 0.1%–0.5% B. 0.6%–1.0% C. 1.1% D. 2%

Q34. The diagnostic study of choice when groin

swelling develops 2 months following femoral tibial bypass using an autologous vein is:

A. Ultrasonography B. MRI C. CT scan D. Lymphography with blue dye (isosulfan)

Q35. During femoral tibial in situ bypass

reconstruction for critical limb ischemia, the transected greater saphenous vein at the saphenofemoral junction cannot be brought to the common femoral artery. The common femoral artery has 70% stenosis. The most useful adjunct is:

A. Common femoral stent using contralat-

eral access

B. Common femoral atherectomy using

contralateral access

C. Common femoral endarterectomy with

patch grafting and placement of the proximal anastomosis of the in situ bypass over the distal portion of the patch

D. Use of common femoral artery to the

origin of the in situ vein bypass

Q36. A 68-year-old man with a previous his-

tory of multiple arterial constructions including aortobifemoral bypass (AFB) as an index operation presents with bleeding from the left groin. The patient is hemodynamically stable. CTA of the abdomen and pelvis shows normal body and right limb of the graft, but there is evidence of perigraft fluid around the distal 5 cm of the left limb of the AFB. WBC scan shows increased uptake in the groin. The best management option is:

A. Left axillofemoral graft with distal graft

anastomosis to the mid-superficial femoral artery routed naturally over the iliac crest and removal of the left limb of the AFB

B. Left axillofemoral bypass after removal

of the left limb of the AFB with the graft routed laterally over the iliac crest

C. Local debridement of perigraft tissue and

sartorius myography

D. Reconstruction with a new graft flush

from the origin of the left limb of the AFB with distal anastomosis to the mid-SFA via the obturator canal

Q37. During passage of a graft through the

obturator canal during performance of the obturator bypass, the tunneling of the graft in the thigh should be:

A. Posterior to the adductor longus B. Posterior to the vastus medialis C. Anterior to the adductor longus D. Posterior to the gracilis

Q38. A 30-year-old woman is seen in the emer-

gency room with grade 2A acute ischemia. She is in normal sinus rhythm. She does not have a history of atrial fibrillation or coronary artery disease. CTA shows filling defect in the right common femoral artery. Her younger sister had an embolectomy performed 1 year ago. At embolectomy, a lobulated piece of white yellow gelatinous material was removed. The most likely diagnosis is:

A. Paradoxical embolus B. Embolus from atrial myxoma

Section 9: Lower Extremity Arterial Disease 187

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C. Adventitious cystic disease of the com-

mon femoral artery

D. Angioleiomyoma

Q39. Acute limb ischemia resulting from arte-

rial embolis occurs in:

A. 5% B. 10% C. 15% D. 20%

Q40. A 66-year-old man is scheduled for femo-

ropopliteal bypass for ischemic rest pain controlled by analgesics not amenable for percutaneous intervention. In the preoperative suite he complains of cough and mild shortness of breath. SARS-CoV-2 test is positive. The next best course of action is:

A. Proceed with bypass, taking all the pre-

cautions for SARS/CoV-2 patients

B. Postpone the bypass for 2 weeks C. Postpone the bypass for 4 weeks D. Postpone the bypass for 7 weeks

Q41. The findings that best differentiate

Rutherford classification of category 2a from 2b ischemia are:

A. Intact sensation in 2b B. Inability to move the muscles in 2a C. Mottling of the skin in 2b D. Absence of muscle weakness, minimal

loss of motor function (toes) with absent sensory loss, and absence of pain at rest in 2a

Q42. The most common cause of acute aortic

occlusion is:

A. Saddle embolism B. In situ thrombosis C. Occluded aortoiliac graft D. Occlusion of aortic limbs of EVAR

Q43. Which of the following conditions is not

an absolute contraindication to catheterdirected thrombolysis for acute limb ischemia?

A. Major surgery including arterial bypass

graft within 2 weeks

B. Patient with a recent gastrointestinal

bleed or a significant risk of bleeding

C. Recent stroke or craniotomy or intraspi-

nal surgery within 4 months

D. Uncontrolled hypertension

Q44. In comparing endovascular peripheral

vascular intervention for acute limb ischemia versus chronic limb ischemia, patients with acute limb ischemia had:

A. Lower in-hospital event rates B. Lower technical failure C. Lower major amputation D. Similar mortality compared with their

chronic limb ischemia counterparts

Q45. Endovascular versus surgical revascu-

larization for acute limb ischemia (ALI) from a propensity-score matched analysis using a national inpatient sample database showed that endovascular revascularization has a:

A. Higher incidence of major bleeding B. Higher composite of death/myocardial

infarction/stroke

C. Greater need for transfusion D. Lower composite of death/myocardial

infarction/stroke

Q46. Combining catheter-directed thromboly-

sis (CDT) with percutaneous mechanical thrombectomy (PMT) results in:

A. Delay in clearing the thrombus B. Increase in the incidence of bleeding

complications

C. Lower incidence of myoglobinuria D. Fasciotomy for compartment syndrome

is less frequently required

Q47. The incidence of compartment syndrome

as a complication of reperfusion for acute lower limb ischemia is up to:

A. 5% B. 10% C. 15% D. 20%–21%

Q48. Fasciotomy for compartment syndrome of

the thigh needs decompression of the:

A. Anterior compartment B. Adductor (medial) compartment C. Posterior compartment D. All three compartments

188 Section 9: Lower Extremity Arterial Disease

Q49. The 5-year patency of an iliofemoral

bypass graft is:

A. 80% B. 85% C. 90% D. 93%

Q50. A 60-year-old woman with a history of

type II diabetes mellitus and hypertension presents with dry gangrene of right big toe with rest pain. She’s a current smoker. The ankle-brachial index on the right is

0.40 and the left is 0.8. Arteriogram shows right superficial femoral artery occlusion with reconstitution of the popliteal

artery runoff by the anterior tibial artery in continuity with the popliteal artery. Post-tibial artery and peroneal artery are occluded. She has adequate Great saphenous vein. The best management for revascularization is:

A. Endovascular recanalization using

artherectomy

B. Endovascular recanalization using drug

eluting stent

C. Right femoral-popliteal bypass using GSV D. Either endovascular or surgical bypass

should give equivalent results

RATIONALE 1–50

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1. RATIONALE

Section 9: Lower Extremity Arterial Disease 189

Contained rupture of a femoral anastomotic aneurysm is rare unless the aneurysm is large (larger than 4.5 cm). Femoral anastomotic aneurysms are usually asymptomatic but may present with pain due to compression of surrounding nerves; occasionally, thrombosis of the femoral anastomotic aneurysm may result in acute ischemia of the lower extremity. Most patients require open repair with an interposition graft (Dacron or PTFE) with reimplantation of the deep femoral artery into the graft. Anastomosis of the new interposition graft is done with the proximal end-to-end anastomosis to the remotely placed prosthetic graft and distal anastomosis to the proximal superficial femoral artery. Endovascular options are limited, as maintenance of patency of the profunda femoris artery is important. Recurrent femoral anastomotic aneurysm may occur after repair and is almost three times greater in women than in men.

Correct Answer C Open repair with proximal control obtained by a retroperitoneal approach by a transverse incision 2–3 cm above the groin

Reference

Munie, S. T., Shepard, A. D. (2018). Open repair or femoral and femoral anastomotic aneurysms.

In S. S. Hans (Ed.), Endovascular and open vascular reconstruction: a practical approach (pp. 263–268). Boca Raton, FL: Taylor & Francis.

2. RATIONALE

Degenerative femoral artery aneurysms are uncommon with a reported incidence of 5 patients per 100,000. Lawrence et al. reported that complications related to femoral artery aneurysms do

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