Prior studies have described the delayed failure of the Endologix AFX Endovascular abdominal aortic aneurysm (AAA) system. Described repair options include relining with a contemporary endograft or graft explant; however, no direct comparisons have been performed between these treatments. The purpose of this study is to compare graft relining and graft explant in order to guide future decision-making for failing AFX devices. A retrospective review of all AFX endografts implanted at our tertiary care center from 2011 to 2019 was performed. Major remediations via endograft relining or graft explant through November 2023 were then identified. The primary composite end point was reintervention-free survival after remediation. Secondary end points included perioperative mortality, all-cause mortality, AAA-related mortality, and major and minor reinterventions. Exclusion criteria included reline with a recalled AFX device or use of additional non-AFX devices during the original aneurysm repair. Of a total of 217 AFX device implants, 52 patients (24%) underwent remediation with 36 devices relined (69%) and 16 grafts explanted (31%) (Table). The original devices were 40 AFX Strata, 8 AFX Duraply, and 4 AFX2. The indications for remediation were endoleak with sac growth (53%), endoleak only (4%), sac growth only (23%), and aneurysm rupture (17%). The devices used for relining were 16 AFX2, 10 Medtronic Endurant, 4 Gore Excluder, 2 Endologix Ovation/Alto, 1 Cook Z-Fen, and 3 that used a combination of devices. At the time of intervention, aneurysms that underwent explant compared with relining were more commonly juxta/pararenal (25% vs 6%, P < .05) and/or ruptured (38% vs 8%, P < .01). There were no significant differences in age, sex, comorbidities, original AFX device, endoleak type, and mean AAA size between the two cohorts. Perioperative mortality was higher after graft explant (25% vs 0%, < .01). However, there was no significant difference in 1-year survival (68% vs 77%, P = .35) or aneurysm-related mortality (27% vs 0%, P = .12). There were higher rates of reintervention following reline (explant: 0% vs reline: 13% at 1 year, P = .03), but there was no difference in reintervention-free survival (reline: 92% vs explant: 67%, P = .66) (Fig). Graft explant is the most durable repair option for failing AFX devices but has a higher risk of early mortality. Relining of failing AFX devices with a second endograft is a safe alternative for treatment but carries a significant risk of continued sac growth requiring additional reinterventions. Elective remediation for the Endologix AFX device should be considered and at minimum enhanced surveillance protocols should be employed.TableCharacteristics of 52 patients who had delayed AFX graft failure requiring remediation by reline or explantCharacteristicAll (n = 52)Reline (n = 36)Explant (n = 1 6)P valueAge, years, mean ± standard deviation76 ± 877 ± 774 ± 9.22Male46 (88)31 (86)15 (94).43Comorbidities Hypertension46 (88)31 (86)15 (94).43 Diabetes14 (27)11 (31)3 (19).38 Congestive heart failure17 (33)11 (31)6 (38).62 Coronary artery disease24 (46)14 (39)10 (63).12 Chronic obstructive pulmonary disease23 (44)16 (44)7 (44).96 Peripheral arterial disease15 (29)11 (31)4 (25).68 Chronic kidney disease28 (54)18 (50)10 (63).40Original graft type AFX Strata40 (77)29 (80)11 (69).35 AFX Duraply8 (15)5 (14)3 (19).65 AFX24 (8)2 (6)2 (12).39Aneurysm extent at remediation Infrarenal46 (88)34 (94)12 (75).04 Juxtarenal4 (8)1 (3)3 (19).05 Pararenal2 (4)1 (3)1 (6).55Indication for remediation Sac growth12 (23)10 (28)2 (13).23 Endoleak2 (4)2 (6)0 (0).34 Endoleak with sac growth28 (53)21 (58)7 (44).33 Rupture9 (17)3 (8)6 (38).01Endoleak type at remediation Type 19 (17)4 (11)5 (31).08 Type 337 (51)28 (78)9 (56).11 Type 2 or unknown5 (10)4 (11)1 (6).58Mean AAA size at intervention, cm, mean ± standard deviation7.2 ± 1.87.0 ± 1.87.7 ± 1.9.22AAA, Abdominal aortic aneurysm.Data are presented as number (%) unless otherwise indicated.Boldface P values represent statistical significance. Open table in a new tab

Osteoporosis and cardiovascular disease are global health burdens, with postmenopausal women being at great risk. Dried plums/prunes (DPs) have been reported to provide bone health benefits in animal models, which is consistent with in vitro models. Data from human studies suggest that DP intake can enhance lipid metabolism, anti-inflammatory, and oxidant defense systems, which can impact cardiovascular health. We tested the hypothesis that short-term consumption of low and reasonable levels of DPs augments bone resorption and vascular function. Twenty-seven healthy, postmenopausal women were randomly assigned to consume six DPs (∼42 g) or two DPs (∼14 g) per day for 2 weeks, then a 2-week washout period and then crossed over. Serum C-telopeptide, beta-crosslinked (CTX) was used as a measure of bone resorption. Peripheral artery tonometry (PAT) was used to assess microvascular function. The pattern of changes in CTX in the second 2-week period (no change or decline) differed significantly from the pattern in the first 2 weeks (increases in both groups; F = 9.26, P = .006), suggesting a trend in CTX reduction (i.e., a decrease in bone resorption) in those consuming six DPs per day in the second phase. No effects on vascular function were noted. A significant interaction was observed for the augmentation index, a measure of arterial stiffness, between treatment and years after menopause (P = .045). The results suggest a potentially favorable impact of DPs on bone health when assessed with a short-term, crossover study design in postmenopausal women. Given the novel assessments used in this study, follow-up studies are warranted.

BACKGROUND: Diabetes mellitus is a worldwide pandemic that impacts more than 387 million people, with 29 million individuals affected in the United States alone. Diabetic patients have a 25% lifetime risk of developing a diabetic foot ulcer (DFU). Having a DFU is associated with a risk of recurrence approaching 70%. In addition, 1 in 6 patients with DFU will have a lower-limb amputation, with an associated increase in mortality ranging from 47% to 70%. Therefore, limb salvage is critical in patients with DFU. CASE STUDY: This article describes the case of a 70-year-old man with diabetes mellitus, end-stage renal disease, and peripheral arterial occlusive disease who presented with a 1.5% total-body-surface-area, third-degree burn to the left hallux with dry gangrene extending to the midfoot. Ankle brachial indexes were 0.66 on the left and 0.64 on the right. Toe pressures on the left were absent because of extensive dry gangrene. His right foot had a prior transmetatarsal amputation. Using a retrograde pedal approach, a chronic total occlusion of the left posterior tibial artery was recanalized with balloon angioplasty. He then underwent a transmetatarsal amputation with closure, except that the plantar medial side could not be closed without tension. Therefore, an autologous full-thickness skin graft, from the amputation specimen, was used to bridge the defect. DISCUSSION: At 32-week follow-up, the wound was healed, the graft had fully incorporated, and the patient was ambulating well using custom orthotic footwear. The creative use of amputated tissue to assist with wound coverage has not been well described in the literature.

Mangos are rich in mangiferin, a phenolic acid that has multiple bioactive effects. Combined with carotenoids, fiber and other nutrients, mangos may be of benefit to vascular health. This study assessed whether a short-term (14 days) or acute (two hours) intake of mangos can influence: 1) microvascular function and the augmentation index, determined by peripheral arterial tonometry; 2) blood pressure; 3) optical platelet aggregometry, and 4) gut fermentation, determined by breath hydrogen and methane, in healthy adult women. 25 healthy postmenopausal females (BMI 25-40 kg/m) were assessed at three study visits. Study visit 1 (SV1) started a run-in period of 14 d during which no mangos were consumed, with baseline and two-hour measures taken. At study visit 2 (SV2), baseline (0 hour) measures were taken, followed by ingestion of 300 gm (two cups) of fresh, frozen mangos, and data were collected two hours later. Participants then consumed 300 g of mangos daily for 14 days, followed by assessment at study visit 3 (SV3), which followed the same protocol as SV2. Breath samples were collected at baseline at each study visit.

Objective: In the last decade, there has been a dramatic increase in the number of women entering vascular surgery. Our goal was to evaluate the differences in career paths based on gender and to determine some of the factors that influence career decisions among young vascular surgeons.Methods: A 17-item web-based survey focusing on current employment status, reasons for choosing academic vs nonacademic positions, and career satisfaction was distributed to 900 members of the Society for Vascular Surgery who completed vascular surgery training in the past 10 years.Results: A total of 199 individuals responded to the survey (22.1%). The cohort included 49 (24.6%) women and 149 (74.9%) men. The majority of the respondents were non-Hispanic white (66.3%). Sixty-four percent of all respondents were younger than 40 years. Overall, 72.9% of women had applied to academic positions after their training compared with 58.8% of men. Women were more likely to apply for and to work in an academic setting (P = .0266 and P = .0198, respectively) and cited mentorship more frequently (P = .0474) as the reason for choosing an academic practice. Women respondents were less likely to have a spouse or children (P = .0269 and P < .001, respectively). More than 87.4% of all respondents were very satisfied or somewhat satisfied with their careers. However, men were more likely to be very satisfied compared with women (P = .0345).Conclusions: Career satisfaction remains high among young vascular surgeons. In this cohort of vascular surgery graduates, we found that women were more likely to pursue academic positions than men, with mentorship, ability to teach, and complexity of cases commonly cited as reasons for this career choice. However, whether young women stay in academia and what factors affect academic retention will need further evaluation.

There has been a dramatic increase in the number of female trainees in vascular surgery programs in the last decade. Recent studies have shown that academic surgery is a popular career goal for vascular surgery trainees. However, there remains a significant gender gap in academic surgery. Our goal was to evaluate the differences in career paths based on gender and factors that influence career decisions among young vascular surgeons. A 17- item Web-based survey was distributed to 900 members of the Society for Vascular Surgery who had completed vascular surgery training in the past 10 years. The survey focused on current employment status, reasons for choosing academic vs nonacademic positions, and career satisfaction. A total of 196 individuals (21.7%) responded to the survey. The cohort included 148 men(75.5%) and 48 women (24.5%). The majority of the respondents were non-Hispanic white (65.31%). The cohort included 39 Asians (19.9%), 16 Hispanics (8.16%), 7 blacks (3.57%), 1 American Indian (0.51%), and 5 others (2.55%). Sixty-two percent of all respondents were <40 years of age, and the majority (77.8%) were board certified. Overall, 72.9% of women applied to academic positions after completion of training, whereas only 58.8% of men applied to academic positions. Women were more likely than men to be in academic practice (54.1% vs 37.1%; P = .038) and cited mentorship more frequently than men (54.1% vs 32.4%) as the reason for choosing an academic practice. The Table represents other major factors for choosing academics. Over 85% of all respondents were very satisfied or somewhat satisfied with their careers. Although men were more likely to be very satisfied than women (53% vs 37.5%), this did not reach statistical significance (P = .055). Career satisfaction remains high among young vascular surgeons. In this cohort of vascular surgery graduates, we found that women were more likely to pursue academic positions than men. Mentorship was a common reason for this career path, as were the ability to teach and complexity of case volume. Although a large number of female vascular graduates pursue academics, whether they stay in academics and what factors affect those decisions needs further evaluation.TableFactors cited for choosing academic practiceWomen, %Men, %Research opportunities47.932.4Mentorship54.232.4Teaching opportunities58.339.2Diversity/complexity of case load52.136.5Ability to subspecialize4.28.8Larger call pool8.316.9Other2.12 Open table in a new tab

Mixed arterial venous disease is estimated to affect up to 26% of patients with lower extremity ulcerations. However, its clinical significance and pathophysiology are incompletely understood. Furthermore, there is no consensus on the optimal treatment modality, whether conservative or operative. In this review paper, we describe the current understanding of the pathophysiology of mixed arterial venous lower extremity ulcers. Guidelines for diagnostic tests for patients with mixed arterial venous diseases are discussed. We review some of the newer biological skin substitutes for conservative wound care. Finally, we propose a treatment algorithm based on current available data.

Background: Endovascular procedures are being increasingly performed for peripheral arterial disease (PAD), exceeding the number of open surgical bypass procedures. Previously, it had been demonstrated that there is a disparity in access to and outcomes of PAD treatment based on race/ethnicity. Blacks have been shown to be more likely to undergo amputation and less likely to undergo revascularization procedures for limb salvage compared to whites. The aim of this study was to determine if there is disparity in the outcomes of endovascular PAD procedures based on race/ethnicity in this contemporary population-based study. Methods: We used the Patient Discharge Data (PDD) from California's Office of Statewide Health Planning and Development (OSHPD) to identify all patients >35 years of age who underwent a lower extremity arterial intervention from 2005 to 2009. OSHPD has been recording ambulatory surgery data since 2005. A look back period of five years was used to exclude patients with prior lower extremity endovascular or open bypass procedures. Cox proportional hazards regression was used to compare amputation-free survival and logistic regression was used to compare 12-month reintervention rate among the racial groups adjusting for age, gender, insurance status, severity of illness, and comorbidities. Results: Between 2005 and 2009, 41,507 individuals underwent lower extremity arterial interventions; 25,635 (61.7%) underwent endovascular procedures. There were 11,389 women (44.2%) and 14,246 men. This cohort included 17,433 (68%) non-Hispanic (NH) whites, 4,417 (17.3%) Hispanics, 1,979 (7.7%) blacks, 1,163 (4.5%) Asian/Native Hawaiians, and 643 (2.5%) others. The Hazard ratio for amputation or death was 1.69 in Hispanics (95%CI 1.50-1.89) and 1.65 in blacks (95%CI 1.42-1.92) compared to NH whites ( p <0.001). The 12-month reintervention rate was significantly associated with race/ethnicity ( p =0.001). The odds ratio for 12-month reintervention was 1.18 in Hispanics (95% CI 1.06-1.31) and 1.08 in blacks (95%CI 0.95-1.22) compared to NH whites following endovascular procedures. Conclusions: Our study demonstrates that Hispanics and blacks have worse amputation-free survival than NH whites following endovascular PAD procedures in this contemporary state-wide database. However, Hispanics and blacks were more likely than NH whites to undergo reintervention. Further research is needed to understand if the higher reintervention rate is secondary to more severe illness and/or poor access to proper follow-up care and cardiovascular risk factor modifications.

Background: An active abdominal aortic aneurysm (AAA) screening program at a regional Veterans Affairs (VA) health system identifies patients at risk for AAA. The purpose of this study is to evaluate unique risk factors associated with the AAA diagnosis upon AAA screening examination to identify the most at risk patients for AAA.Methods: Data were extracted from a regional VA health care system to identify patients who underwent AAA screening within a 3-year period. An aortic diameter >= 3.0 cm was defined as an AAA. Patient risk factors included age, body mass index, total cholesterol, estimated glomerular filtration rate (eGFR), statin use, and active smoking status; the presence of hypertension, diabetes, coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), or peripheral vascular disease (PVD) was also evaluated. Risk factors were compared in a multivariate analysis between patients with AAA and patients with a normal aorta.Results: A total of 6,142 patients (mean +/- SD age: 72.7 +/- 5.3 years) were screened for AAA between January 2007 and December 2009. A total of 469 patients (7.6%) with AAA were identified. The following risk factors were significantly associated with a diagnosis of AAA: age >75 years (39.6% vs. 28.9%; P < 0.001), prevalence of CAD (43.1% vs. 28.5%; P < 0.001), COPD (26% vs. 11.4%; P < 0.001), PVD (37.3% vs. 7.7%; P < 0.001), eGFR < 60 mL/min (36.7% vs. 24.3%; P < 0.001), and current smoking (23.2% vs. 15.3%; P < 0.001). The risk factors significantly associated with normal aortic size were the presence of diabetes (18.6% vs. 27.4%; P < 0.001) and total cholesterol >= 200 mg/dL (10.4% vs. 15%; P = 0.04).Conclusions: The diagnosis of AAA in a large screening study is typically identified in patients who are at high risk for cardiovascular disease. The presence of diabetes is a major cardiovascular risk factor that is more associated with normal aorta when compared to patients with the AAA diagnosis. Total cholesterol >= 200 mg/dL was associated with decreased AAA risk, and renal insufficiency was associated with increased AAA risk.

Background: Over the last decade, the number of endovascular procedures for peripheral arterial disease (PAD) has surpassed the number of open surgical bypass procedures. Yet, the effectiveness of endovascular procedures in comparison to open procedures is not fully understood. The aim of this study was to compare the outcomes of open and endovascular procedures for PAD in a population-based study. Methods: We used the Patient Discharge Data (PDD) from California’s Office of Statewide Health Planning and Development (OSHPD) to identify all patients >35 years of age who underwent a lower extremity arterial intervention from 2005 to 2009. OSHPD has been recording ambulatory surgery data since 2005. The PDD is linked to the death database. A look back period of five years was used to exclude patients with prior lower extremity endovascular or open procedures. Cox proportional hazards regression was used to compare amputation-free survival and logistic regression was used to compare 12-month reintervention rate between the endovascular and open groups adjusting for age, gender, race/ethnicity, insurance status, severity of illness, and comorbidities. Results: Between 2005 and 2009, 41,507 individuals underwent lower extremity arterial interventions. 25,635 (61.7%) underwent endovascular procedures and 15,872 underwent open procedures. There were 17,942 women (43.2%) and 23,565 men. 4,094 (25.8%) of the patients in the open group and 8,593 (33.5%) of patients in the endovascular group underwent reintervention for PAD. The 12-month reintervention rate was significantly associated with endovascular procedures ( p <0.001). The odds ratio for 12-month reintervention was 1.38 in the endovascular group (95% CI 1.32-1.45) compared to the open group. However, there was no difference in the amputation-free survival following endovascular procedures compared to open procedures ( p =0.154); the hazard ratio was 1.07 in the endovascular group (95%CI 0.97-1.15) compared to the open group. Conclusions: Nearly a third of all patients who undergo a lower extremity arterial revascularization procedure require reintervention within the first year. Our results demonstrate that although endovascular procedures are more likely than open procedures to require reintervention, the amputation-free survival is not improved with endovascular procedures. Cost analysis of multiple reinterventions can be beneficial in understanding the cost-effectiveness of endovascular procedures. Further research is also needed to understand patient characteristics that distinguish patients who benefit more from endovascular procedure for PAD.

In 2007, Medicare guidelines were established to identify persons at risk for the presence of an abdominal aortic aneurysm (AAA). The purpose of this study was to evaluate the implementation of the SAAAVE Act in identifying patients at risk for AAA within a 5-year period in clinical practice. Data was extracted from a regional Veterans Affairs Healthcare Network to identify all veteran males 65-75 years of age who smoked greater than 100 cigarettes during their lifetime. In 2007, a AAA screening mandate was implemented allowing patients meeting screening criteria to be evaluated for AAA as part of the patient's health maintenance. AAA is identified as an aortic diameter size of 3.0 cm or greater. Clinician adherence to screening protocols and timely referral for aneurysms greater than 5.5 cm were also evaluated. A total of 9788 patients (71.5 ± 5.6 years of age) were screened for an AAA over a 5 year period from January 1, 2007 to December 31, 2011. A total of 698 aneurysms (7.1%) were found (See Table). Timely referrals were made on 44 patients with aneurysms greater than 5.5 cm. A total of 2828 patients (28.9%) were inappropriately screened: 421 patients were too young, 2250 patients were too old, 36 patients were women, and 121 patients without aneurysms had multiple screenings.Fig The long implementation of the AAA screening has allowed greater deviation from Medicare guidelines that increased the number of inappropriate screenings, mandating further AAA screening education for primary care providers.

Objective: In 2007, Medicare guidelines were established to identify persons at risk for the presence of an abdominal aortic aneurysm (AAA). The purpose of this study is to evaluate the 5-year outcomes of an AAA screening program in a regional Veterans Affairs (VA) health care system.Methods: Data were extracted from a regional VA health care network identifying all veteran males 65 to 75 years of age who smoked at least 100 cigarettes during their lifetime. In 2007, an AAA screening mandate was implemented allowing patients meeting screening criteria to be evaluated for AAA as part of the patient's health maintenance. AAA is identified as an aortic diameter size of 3.0 cm or greater. Clinician adherence to screening protocols and referral to a vascular surgeon for aneurysms >5.5 cm were also evaluated.Results: A total of 9751 patients (71.5 +/- 5.6 standard deviation years of age) were screened for an AAA over a 5-year period from January 1, 2007 to December 31, 2011. A total of 698 aneurysms (7.1%) were found. Referrals to a vascular surgeon were made on 45 patients with aneurysms >5.5 cm. Over a 5-year period, a total of 2754 patients (28.2%) were inappropriately screened: 416 patients were under 65 years old, 2243 patients were over 75 years old, 36 patients were women, and 123 patients without aneurysms had multiple screenings. In 2007, during the first year of implementation, 39.2% of patients were inappropriately screened. Over the next 4 years, inappropriate screenings decreased with 33.7% in 2008, 28.6% in 2009, 17.7% in 2010, and 14.3% in 2011.Conclusions: A large AAA screening program at the VA detects more aneurysms, but at smaller diameters than that published in clinical trials. Over time, the number of inappropriate AAA screenings has continued to decrease, demonstrating greater awareness and application of the AAA screening guidelines by primary care providers. Developing surveillance guidelines for small and medium aneurysms is a potential area for future research. (J Vasc Surg 2013; 57: 376-81.)

La combinaison de lésions aorto-iliaques classées D selon le consensus de la société transatlantique (TASC) et d’un anévrysme de l’aorte abdominal symptomatique (AAA) n’est pas fréquente. La maladie athérosclérotique avec calcifications extensives, les occlusions, et les segments ilio-fémoraux de petit calibre sont des situations où l’accès transfémoral pour traitement endovasculaire d’un anévrysme aortique (EVAR) est difficile, voir impossible. Nous présentons un cas où la « rupture contrôlée » de l’artère iliaque externe avec un stent couvert a permis la mise en place d’une endoprothèse aorto-uniiliaque par voie fémorale avec réalisation d’un pontage croisé fémorofémoral. Le patients, âgé de 60 ans, présentait un AAA symptomatique de 5.3 cm de diamètre avec une claudication serrée du membre inférieur droit. Un angioscanner préopératoire a révélé l’existence d’une occlusion de l’artère iliaque commune droite, des lésions calcifiées sténosantes des segments aorto-iliaques, et une artère iliaque externe gauche de petit calibre, mesurant 4,5 mm de diamètre dans sont segment le plus réduit. Malgré une discussion sur le problème posé par les axes iliaques pour un traitement endovasculaire, le patient a insisté sur cette option, pour réduire les risques de dysfonction sexuelle postopératoire ainsi que la durée d’hospitalisation. Les artères fémorales ont été exposées par incisions des deux Scarpas, et des tentatives de dilatation de l’artère iliaque gauche en utilisant un dilatateur de 16-French ont été réalisées mais sans succès. Un stent couvert auto-expandable de 8 mm × 5 cm a été déployé dans l’artère iliaque externe gauche pathologique de 4.5 cm de diamètre, suivi d’une angioplastie avec un ballon non compliant de 8 mm pour afin de rouvrir la lumière vasculaire. Cet endoconduit a permis la mise en place d’un introducteur de 18-French pour la mise en place d’une endoprothèse. L’intervention a été complétée par la réalisation d’un pontage fémorofémoral. Le flux dans les deux artères hypogastriques a pu être préservé. Nous pensons que l’utilisation de cette technique va permettre d’accroitre le nombre de patients éligibles et d’éviter des complications graves liées à l’accès vasculaire.

The combination of Trans-Atlantic Intersociety Consensus (TASC) D aortoiliac occlusive disease as well as a symptomatic abdominal aortic aneurysm (AAA) is not a common occurrence. Extensive calcified atherosclerotic disease, occlusions, and small iliofemoral segmental arteries make transfemoral access difficult, if not impossible, for endovascular aneurysm repair (EVAR) in these patients. We present a case in which "controlled rupture" of the external iliac artery with a covered stent allowed transfemoral delivery of an aortouni-iliac stent graft with a completion femoral-to-femoral bypass. The patient is a 60-year-old male with a 5.3 cm symptomatic infrarenal AAA and a history of one block right leg claudication. Preoperative computed tomography angiography revealed the patient to have occlusion of the right common iliac artery, extensive calcified stenoses of his aortoiliac segments, and a prohibitively small left external iliac artery, which measured 4.5 mm at its narrowest diameter. The patient, despite discussions concerning the suitability of his iliac arteries as conduits for the delivery of the stent graft, insisted on an endovascular approach to lessen his chances of postoperative sexual dysfunction as well as minimize his length of stay. Access was obtained through bilateral femoral artery cutdowns, and attempts at dilating the left external iliac artery using 16-French dilators were performed without success. An 8 mm x 5 cm covered self-expanding stent was deployed in the diseased 4.5 mm left external iliac artery, followed by angioplasty performed with an 8 mm noncompliant balloon to disrupt the vessel. This endoconduit now allowed accommodation of our 18-French introducer for the aortouni-iliac stent graft. The operation was completed with a femoral-femoral bypass. Flow to both hypogastric arteries was preserved. We believe use of such techniques will ultimately expand the number of patients eligible for EVAR and avoid devastating access-related complications.

Superior mesenteric artery (SMA) aneurysms represent a minority of visceral aneurysms but may result in lethal complications if left untreated. Options for treatment include aneurysmorraphy, bypass, ligation, or embolization. Here we present a case of a man with a history of celiac graft thrombosis who presents with a recurrent symptomatic SMA aneurysm. Given his compromised celiac axis, ligation was not an option. His SMA aneurysm was repaired with a PTFE patch. However, to secure longstanding blood flow to the small bowel in the event of graft thrombosis, the distal SMA pedicle was dissected free of the ileocolic vessels and anastomosed to the aorta. Follow-up studies demonstrated an occluded PTFE patch with a patent SMA autotransplant. This case depicts a novel approach to the surgical management of complex recurrent SMA aneurysms.

Les anévrysmes de l'artère mésentérique supérieure (AMS) représentent une minorité des anévrysmes viscéraux mais ils peuvent entraîner des complications fatales en l'absence de traitement. Les options thérapeutiques incluent l'anévrysmorraphie, le pontage, la ligature ou l'embolisation. Nous présentons ici le cas d'un patient ayant un antécédent de pontage coeliaque thrombosé qui présentait un anévrysme récidivant symptomatique de l'AMS. L'option d'une ligature n'a pas été retenue en raison de la lésion du tronc coeliaque. L'AMS fut réparée avec un patch de PTFE. Néanmoins, afin d'assurer une perfusion intestinale durable en cas de thrombose du pontage, le pédicule distal de l'AMS fut libéré des vaisseaux iléo-coliques et anastomosé sur l'aorte. Les examens de contrôle ont montré l'occlusion du patch de PTFE avec une AMS autotransplantée restant perméable. Ce cas rapporte une approche nouvelle du traitement chirurgical des anévrysmes récidivants et complexes de l'AMS.