Chronic limb-threatening ischemia in the pediatric population is a rare phenomenon. When open repair is necessitated, an autogenous conduit is preferred. However, venous grafts are prone to their own long-term complications. We have presented the case of a 10-year-old boy with chronic limb-threatening ischemia due to popliteal artery thrombosis that was treated with an ipsilateral great saphenous vein bypass. Seven years after the initial procedure, the venous graft had developed aneurysmal degeneration with acute thrombosis, necessitating bypass revision. Through the present case, we have discussed the surgical approach and highlighted the importance of long-term postoperative surveillance after open repair in the pediatric population.

Background: Thoracic outlet syndrome (TOS) results from compression of neurovascular structures supplying the upper extremity as they exit the thoracic outlet. Depending on the clinical presentation, surgical decompression may be required. Objectives: Transaxillary (TA) and supraclavicular (SC) approaches are both widely utilized and deemed effective. Our objective was to review the outcomes for both approaches at our institution. Methods: A retrospective review was conducted on patients who underwent thoracic outlet decompression between 2010 and 2015. Data on demographics, comorbidities, presenting symptoms, and type of TOS (neurogenic, venous, or arterial) were collected. Operative times, length of hospital stay, perioperative complications, and outcomes were also studied. Results: A total of 82 thoracic outlet decompression procedures were performed during the study period: 42% neurogenic TOS, 46% venous TOS, and 12% arterial TOS. In total, 49% underwent TA approach and 51% underwent SC approach. Adjunct procedures were performed in 13% of patients. There were no significant differences in average operative time (151.3 ± 54.1 minutes versus 126.1 ± 36.1 minutes, P = .11) or hospital stay (2.3 ± 1.9 days versus 2.4 ± 1.4 days, P = .23) between both groups, respectively. Minor complications were seen in 6% of patients with no significant difference in both groups, whereas 6% had major complications. No perioperative or 30-day mortalities were observed. In total, 49% of patients had complete resolution of symptoms, 46% had partial improvement, and 5% had no improvement. There was no difference in symptom resolution between either group. Conclusions: TA and SC approaches are equally safe and effective for the treatment of TOS. SC decompression allows for adjunct procedures and vascular reconstructions.

Importance:Surgical site infections increase patient morbidity and health care costs. The Centers for Disease Control and Prevention emphasize improved basic preventive measures to reduce bacterial transmission and infections among patients undergoing surgery.Objective:To assess whether improved basic preventive measures can reduce perioperative Staphylococcus aureus transmission and surgical site infections.Design, Setting, and Participants:This randomized clinical trial was conducted from September 20, 2018, to September 20, 2019, among 19 surgeons and their 236 associated patients at a major academic medical center with a 60-day follow-up period. Participants were a random sample of adult patients undergoing orthopedic total joint, orthopedic spine, oncologic gynecological, thoracic, general, colorectal, open vascular, plastic, or open urological surgery requiring general or regional anesthesia. Surgeons and their associated patients were randomized 1:1 via a random number generator to treatment group or to usual care. Observers were masked to patient groupings during assessment of outcome measures.Interventions:Sustained improvements in perioperative hand hygiene, vascular care, environmental cleaning, and patient decolonization efforts.Main Outcomes and Measures:Perioperative S aureus transmission assessed by the number of isolates transmitted and the incidence of transmission among patient care units (primary) and the incidence of surgical site infections (secondary).Results:Of 236 patients (156 [66.1%] women; mean [SD] age, 57 [15] years), 106 (44.9%) and 130 (55.1%) were allocated to the treatment and control groups, respectively, received the intended treatment, and were analyzed for the primary outcome. Compared with the control group, the treatment group had a reduced mean (SD) number of transmitted perioperative S aureus isolates (1.25 [2.11] vs 0.47 [1.13]; P = .002). Treatment reduced the incidence of S aureus transmission (incidence risk ratio; 0.56; 95% CI, 0.37-0.86; P = .008; with robust variance clustering by surgeon: 95% CI, 0.42-0.76; P < .001). Overall, 11 patients (4.7%) experienced surgical site infections, 10 (7.7%) in the control group and 1 (0.9%) in the treatment group. Transmission was associated with an increased risk of surgical site infection (8 of 73 patients [11.0%] with transmission vs 3 of 163 [1.8%] without; risk ratio, 5.95; 95% CI, 1.62-21.86; P = .007). Treatment reduced the risk of surgical site infection (hazard ratio, 0.12; 95% CI, 0.02-0.92; P = .04; with clustering by surgeon: 95% CI, 0.03-0.51; P = .004).Conclusions and Relevance:Improved basic preventive measures in the perioperative arena can reduce S aureus transmission and surgical site infections.Trial Registration:ClinicalTrials.gov Identifier: NCT03638947.

Streptococcus equi is an aerobic bacterium of animal origin comprising two subspecies: zooepidemicus and equi. Human infections with this bacterium are very uncommon and result from direct contact with an infected animal or consumption of unpasteurized dairy products subsp. Although the zooepidemicus subspecies has been reported to cause sporadic infections in humans. the equi subspecies rarely infects other animal species. We report a case of ruptured mycotic aortic aneurysm in an elderly gentleman caused by the equi subspecies. We also review the literature on human infections caused by the Streptococcus equi species.

Congenital absence of the common carotid artery is a rare vascular anomaly that is usually discovered incidentally in otherwise asymptomatic patients and can potentially pose significant diagnostic and therapeutic challenges. Although it has been typically associated with separate origins of the internal and external carotid arteries, a common origin of both arteries is exceedingly rare and has been reported in 6 cases to date. We present the case of a 70-year-old female, who was referred for a carotid ultrasound after a carotid bruit was auscultated. Carotid duplex scan identified the congenital absence of the right common carotid artery with no significant internal carotid stenosis. This was confirmed by a computed tomography angiography scan of the neck, which showed the right internal and external carotid arteries sharing a common origin off the distal brachiocephalic artery.

Traumatic aortic injuries in children and adolescents are rare. Although endovascular repair has become the preferred approach for such injuries in adults, open repair has endured as the gold standard in children owing mainly to the smaller aortic and access vessel diameter and the scarcity of long-term follow-up data. We report a successful endovascular repair of a traumatic thoracic aortic injury in an 8-year-old girl using a Zenith Alpha thoracic endograft (Cook Medical, Bloomington, IN). We also review the literature on endovascular treatment of traumatic aortic injuries in the pediatric population.

Thoracic outlet syndrome (TOS) results from compression of the neurovascular structures supplying the upper extremity as they exit through the thoracic outlet. Depending on the clinical presentation, surgical decompression may be required. The transaxillary (TA) approach has been the preferred approach, although the supraclavicular (SC) approach has become more widely used, especially when adjunct procedures are required. Our objective was to review the results with both approaches in our institution. A retrospective review of patients who underwent thoracic outlet decompression between 2009 and 2014 at the University of Iowa Hospitals and Clinics was conducted. Data on demographics, comorbidities, presenting symptoms, and type of TOS (neurogenic, venous, or arterial) were collected preoperatively. Operative times, hospital length of stay, perioperative complications, and outcomes were also studied. During the study period, 82 thoracic outlet decompression procedures were performed: 48% were for neurogenic TOS, 46% for venous TOS, and 6% for arterial TOS. Thirty-nine patients (47.5%) underwent the TA approach, and 43 (52.5%) underwent the SC approach. Adjunct procedures were performed in 16% of patients in addition to decompression, 85% of which were in the SC group. There was a significant difference in average operative time between TA and SC (124.5 vs 157 minutes; P < .05) but no differences in hospital length of stay. Minor complications were seen in 20% of patients, with no significant difference between the TA and SC groups. Major complications occurred in 6%, with four patients (3 TA and 1 SC) requiring re-exploration. There were no perioperative or 30-day deaths. On follow-up, 37% of patients with neurogenic TOS had complete resolution of symptoms, 54% had partial improvement, and 9% had no improvement. In both the venous and arterial TOS groups, 66% had complete symptom resolution and 34% had partial resolution. There was no difference in symptom resolution between the TA and SC groups. There is no significant difference between TA and SC approaches for TOS in perioperative complications, length of stay, and improvement of symptoms. Although operative time appears to be longer in the SC group, this can be attributed to adjunct procedures, including vascular reconstructions performed using this approach.

Background: Uncomplicated type B dissections have historically been treated medically with hemodynamic control. Early progression of the disease and late aneurysmal dilation have been considered as indications for intervention. The aim of this study is to analyze growth rate patterns of type B dissections based on computed tomography (CT) measurements over time. Methods: We conducted a retrospective review of patients with acute type B dissection from 2008 to 2014 who had at least 2 follow-up CT scans. Patients with rapid progression requiring interventions were also included. Using M2S software (M2S, Lebanon, NH), we calculated the mean centerline diameter of the true and false lumens at 3 different sites of the descending aorta. Growth rate was calculated as the change in maximal diameter between the first interval and last available CT scans. Primary outcome was to compare the growth rate pattern between the 2 time intervals. Secondary outcomes included early and delayed aortic intervention and overall mortality (OM). Results: A total of 108 patients were included. Average age of patients was 58.7 years. Median follow-up time was 3 months for the first CT and 32 months for the second. OM was 27.8% (n = 30), whereas the disease-specific mortality was 11.1% (n = 12). Thirty-seven percent (n = 40) required operative intervention (18 open and 22 endovascular repair): 20 at 30 days, 12 at 12 months, and 8 patients at > 1 year. Mean aortic growth rate was higher in the first time interval compared with the second: 0.89 vs. 0.19 mm/month (P < 0.05) at the proximal descending aorta, 1.01 vs. 0.18 mm/month (P < 0.05) at the mid-descending aorta, and 0.65 vs. 0.28 mm/month; (P < 0.05) at the distal descending aorta. Those who underwent intervention had a higher aortic growth rate at early and late interval (P < 0.05). Age and number of comorbidities were associated with OM. Thrombosis of the false lumen did not affect the mortality and intervention rate. Conclusions: Type B dissection is associated with aortic growth over time. The overall growth rate was not linear with a more prominent initial phase. Faster aortic growth rate is associated with an increased intervention rate, whereas advanced age and number of comorbidities are associated with increased mortality. Prospectively designed studies are needed to identify the subgroup of patients who may benefit from early intervention based on growth rate measurements.

This study describes our experience with using the visceral branch snorkel technique to allow emergency endovascular repair of ruptured descending thoracic or visceral aortic aneurysms. Since February 2011, we have treated three patients with ruptured or leaking aortic aneurysms with visceral involvement. All were hemodynamically compensated, with two patients requiring pressors support. Prophylactic spinal drainage was performed in one patient who had prior open abdominal aortic aneurysm repair. All three procedures were technically successful and all had resolution of their symptoms and were discharged home. The first treated patient, presenting with the combination of an infrarenal aortic aneurysm and a leaking saccular aneurysm of the pararenal aorta, was managed with an Excluder bifurcated stent graft with an aortic cuff extension into the suprarenal segment in conjunction with two retrograde renal artery snorkels. On follow-up 3 months later, enlargement of the saccular aneurysm was noted without demonstrable endoleak, and a mycotic pathology was suspected. He died in hospice care 6 months after the procedure. The second patient presented with a ruptured type V descending thoracic aortic aneurysm. He had a prior open repair of a juxtarenal abdominal aortic aneurysm with a short intervening nonaneurysmal pararenal zone. His thoracic aneurysm was excluded using two overlapped TAG stent grafts, in conjunction with three visceral snorkels (two long retrograde snorkels to the CA and SMA, and one short retrograde snorkel to the right renal artery; Fig). The third patient, presenting with a leaking aneurysm related to giant renal artery stumps, was treated with a TAG stent graft in conjunction with two antegrade visceral snorkels (CA and SMA). Both patients are doing well on follow-up, with a small type II endoleak noted in the first one. Endovascular exclusion of ruptured aortic pathologies in conjunction with snorkel visceral branch revascularization offers the advantages of simplicity, customizability to individual scenarios, and reliance on readily available off-the-shelf components. However, it requires advanced endovascular skills and experience. It may represent a reasonable option where fenestrated or branch stent graft technologies are unavailable.

Perigraft hygroma is a known complication of prosthetic graft implantation. The specific etiology of perigraft hygromas is still unknown. We report 2 brothers who underwent open abdominal aortic aneurysm repairs with polytetrafluoroethylene grafts that developed progressively enlarging perigraft hygromas. This is the first case report of 2 brothers developing sac hygromas after open abdominal aortic aneurysm repair. This case demonstrates that there could be a genetic component associated with the development of perigraft hygromas and further investigation of genetic etiologies should be considered.

Objective: To evaluate our experience with the endovascular treatment of total occlusions of the mesenteric and celiac arteries.Methods: We performed a retrospective review of endovascular stenting of 27 nonembolic total occlusions of the superior mesenteric artery (SMA) and celiac artery (CA) between July 2004 and July 2011 (26 patients, 16 females; mean age, 62 +/- 13 years). A variety of demographic, lesion-related and procedure-related variables were evaluated for potential impact of technical success and patency. The follow-up protocol included clinical assessment, and color and spectral Doppler evaluation of the stented vessel(s).Results: The clinical presentation was chronic mesenteric ischemia in 12 patients, acute mesenteric vascular syndromes in 10 patients, foregut ischemia/ischemic pancreatitis in three patients, and prior to endovascular repair of aortic aneurysm in one patient. The treated vessel was SMA in 22 procedures, CA in three, and both SMA and CA in one. Technical success was achieved in 23 of the 27 attempted recanalizations (85%). Three patients who failed the attempt underwent open bypass, and another one underwent retrograde recanalization and stenting of the SMA. Procedure success was only significantly related to patient age <70 years or procedure performance after the year 2006. Notably, the presence of a stump, ostial plaque, extensive vascular calcification, recanalization route (intraluminal vs subintimal), occlusion length, and vessel diameter had no significant impact on procedure success. Traditional duplex criteria proved unreliable in predicting restenosis. Life table analysis of freedom from symptom recurrence showed a primary and assisted rates of 58% and 80% at 1 year, and 33% and 60% at 2 years, respectively. Clinical recurrences developed in six patients (four presented with abdominal angina and weight loss, two presented with abdominal catastrophe). There were six access-related complications and no procedural deaths. Four delayed deaths occurred during follow-up (two cardiac causes, two due to abdominal sepsis).Conclusions: Endovascular recanalization of mesenteric artery occlusion is both feasible and successful, provided careful planning is used. (J Vasc Surg 2012;55:1674-81.)

Purpose: Describe a hybrid approach to simplify management of complex aortoiliac occlusive disease (AIOD) extending into the common femoral artery (CFA). Methods: Retrospective review of 56 patients who underwent hybrid management of AIOD extending into CFA between January 2003 and February 2007. Two distinct hybrid approaches were compared: Inline (iliac stenting continuous with an open CFA reconstruction, 38 limbs in 37 patients) and tandem (noncontiguous stenting of an upstream iliac segment, 20 limbs in 19 patients). The median follow-up duration was 15 +/- 12 months in the inline group and 24 +/- 12 months in the tandem group. Results: Technical success was achieved in all but I procedure. Clinical and hemodynamic responses to the interventions and limb loss rates were comparable in both groups. Survival table analysis showed no significant difference between inline and tandem reconstructions. Conclusions: Inline stenting represents a lesser invasive revascularization choice in complex AIOD with contiguous involvement of the CFA.

A 59-year-old morbidly obese gentleman presented with a ruptured left common iliac artery aneurysm. His symptomats also included CHF, tense Lt lower extremity edema, and azotemia. CT showed contained rupture of an 8 cm Lt common iliac artery aneurysm and an aortoilio-caval fistula. This was initially treated endovascularity using a modular Gore Excluder device with coil embolization of the Lt hypogastric artery. The patient presented 2 weeks later with new worsening extremity symptoms. CT showed distal migration of the hypogastric coils with a type II endoleak as well as a persistent AV fistula. We used a transvenous approach through the fistuous communication (Fig) to occlude the proximal hypogastric artery using an Amplatzer plug occluder. Venography revealed disruption of the Lt iliac vein which was treated using a Gore Excluded limb placed via a transjugular venous approach. The patient's symptoms improved dramatically and he has continued to do well on his last followup more than two years later.

Background: As surgical education programs develop surgical skills laboratories, it will be important to do so in the most efficient, cost-effective manner.Methods: We distributed a brief written survey to all general surgery residents at the University of Iowa Hospitals and Clinics regarding their perceptions of the usefulness of a surgical skills laboratory in training of both open and laparoscopic techniques. For the initial survey, we used analysis of variance to compare differences across groups. This was followed by a second survey to post-graduate year (PGY)-1 and PGY-2 residents assessing their knowledge, perceived skill, and rank preference of surgical skill sessions.Results: We received 100% responses rate from both surveys. Respondents to the first survey represented all levels of residency (PGY1-PGY5), and the number of respondents per level ranged from 4 to six. Although there was general agreement that surgical skills laboratories were beneficial for both open and laparoscopic procedures and for all levels of training, there was more support for using them to prepare junior residents. In addition, they were seen as especially beneficial for teaching about laparoscopic techniques. Junior residents did not think that residents should be required to demonstrate mastery in the skills laboratory before being allowed to operate, whereas senior residents were neutral about such requirements. A follow-up survey targeted junior level residents (PGY-1 and 2) to assess their perceived skill for various techniques, and their interest in improving skills through simulation. Results showed that perceived skill differed between the two groups, as did attitudes about the priority for different skills.Conclusion: As residency programs implement surgical skills laboratories, understanding local opinions about the potential benefits and sequencing may help to design the laboratories for maximal educational benefit. (Sim Healthcare 5:28-32, 2010)

PURPOSE:To report experience with aggressive recanalization approaches in chronic total arterial occlusion (CTO).METHODS:Chronic total arterial occlusion recanalization was attempted on 112 limbs in 99 consecutive patients between January 1999 and December 2006.RESULTS:There were 63 iliac arteries, 45 femoropopliteal arteries, and 4 occluded stents. Mean occlusion length was 8.7 ± 4.7 cm. Conventional recanalization was attempted first and was successful in 71 limbs (70%). Probing with the guidewire's stiff end was attempted in 33 of the 41 procedures where conventional techniques failed and was successful in 18 (54%), improving the overall procedural success rate to 80%. For the remaining 15 limbs, home-made directional sharp needle recanalization was attempted in 11 and was successful in 9 (82%), further improving the overall recanalization success to 88%. Procedural complications were self-limited or managed nonoperatively.CONCLUSIONS:Aggressive recanalization techniques in CTO following failure of traditional means are safe and can substantially improve procedural success rates.

Nous avons évalué la perméabilité à long terme de la reconstruction par stents en kissing de la bifurcation aortique et avons identifié les variables qui peuvent l'influencer. Nous avons rétrospectivement revu notre expérience des procédures de reconstruction par stents de la bifurcation aortique réalisées de janvier 1998 à juin 2005. L'impact des variables démographiques, des facteurs de risque vasculaires, du siège et des caractéristiques de la maladie, du matériel et de la conception des stents, et de la configuration du stenting sur la perméabilité des stents a été évalué en analyse multivariée et univariée. En particulier, nous avons évalué l'effet de la disparité géométrique entre la partie saillante des stents et la lumière aortique distale. Soixante-six patients ont eu une reconstruction aortobi-iliaque par stents. Les indications étaient des lésions de la bifurcation ou bilatérales des iliaques proximales chez 52 patients et une atteinte ostiale unilatérale exigeant une protection controlatérale chez 14 patients. Des lésions limitées (TASC A et B) étaient présentes au niveau de 40 membres chez 19 patients ; des lésions étendues/diffuses (TASC C et D) était présentes au niveau de 78 membres chez 47 patients. Des occlusions complètes étaient présentes au niveau de 37 membres chez 28 patients (bilatérales chez neuf patients). Des stents auto-expansibles ont été employés dans 56 procédures et des stents expansibles par ballonnet dans 10. Un croisement a été réalisé dans 43 procédures, alors qu'une configuration en abouchement était employée dans 23 procédures. Un succès technique a été obtenu chez 62 patients (94%), les quatre échecs étant dus à l'incapacité de franchir une occlusion chronique. Trois de ces patients ont eu un stenting aortouni-iliaque et un pontage fémoro-fémoral croisé, l'autre refusant une autre intervention. Le suivi combiné médian était de 37 ± 27 mois (extrêmes 0-102). Une resténose hémodynamiquement significative est survenue chez neuf patients (14%). Le traitement des resténoses a été endovasculaire chez huit patients et toujours réussi (dilatation par ballonnet dans quatre cas, restenting dans trois, thrombolyse et stenting dans un cas) et chirurgical chez un patient qui a développé une occlusion aortique et a eu un pontage aortobifémoral. L'analyse de table de survie a montré des taux primaires et assistés de perméabilité à 4 ans respectivement de 81% et de 94%. Dix-neuf décès sont survenus au cours du suivi (cause cardiaque huit fois, cause pulmonaire trois fois, cancer cinq fois). L'analyse univariée a montré que la disparité de diamètre (espace mort de lumière aortique autour du segment saillant des stents), le sexe féminin, une occlusion antérieure, et une sténose résiduelle étaient les facteurs prédictifs significatifs de resténose. L'analyse en régression logistique multivariée a montré que la disparité de diamètre était la seule cause déterminante significative de resténose, bien que la puissance statistique du modèle ait été limitée par le petit nombre des resténoses. La reconstruction par stents de la bifurcation aorto-iliaque pour lésions occlusives est efficace et durable, même en cas de lésions aorto-iliaques complexes et d'occlusions longues. La plupart des resténoses sont accessibles au traitement endovasculaire, avec une excellente perméabilité assistée à long terme. Les variables géométriques liées à l'anatomie aortique individuelle et le type de lésions (patient-dépendants) et la configuration du stenting (opérateur-dépendante) peuvent avoir un impact sur la perméabilité à long terme.

Evaluamos la permeabilidad a largo plazo de la reconstrucción mediante kissing stent de la bifurcación aortoilíaca e identificamos las variables que pueden afectarla. Revisamos de forma retrospectiva nuestra experiencia en los procedimientos de reconstrucción mediante stent de la bifurcación aortoilíaca desde enero de 1998 hasta junio de 2005. Se evaluó el impacto de las variables demográficas, los factores de riesgo vascular, la localización de la enfermedad y sus características, el material del stent y su diseño, y la configuración del stent en la permeabilidad mediante análisis de uni y multivariante. En particular, evaluamos el efecto de la discordancia geométrica entre el segmento que sobresale del stent y la luz aórtica distal. Sesenta y seis pacientes fueron sometidos a una reconstrucción con stent aortoilíaco. Las indicaciones fueron: enfermedad ilíaca proximal o de la bifurcación en 52 pacientes y enfermedad ostial unilateral que requirió protección contralateral en 14. Cuarenta extremidades de 19 pacientes presentaron enfermedad limitada (TASC A y B); 78 extremidades de 47 pacientes tenían afectación extensa/difusa (TASC C y D). Treinta y siete extremidades de 28 pacientes presentaron una oclusión completa (bilateral en 9 pacientes). Se utilizaron stents autoexpansibles en 56 intervenciones y stents expansibles con balón en 10. La configuración cruzada se utilizó en 43 intervenciones, mientras que la confluyente se utilizó en 23. El éxito técnico se logró en 62 pacientes (94%), con 4 fracasos debido a la imposibilidad de atravesar una extremidad con una oclusión crónica. En 3 de estos pacientes se colocó un stent aortomonoilíaco con un bypass protésico femorofemoral cruzado, y en el cuarto se decidió no realizar intervenciones adicionales. La media del seguimiento combinado fue de 37 ± 27 meses (intervalo 0-102). Se produjeron reestenosis hemodinámicamente significativas en 9 pacientes (14%). El tratamiento de las reestenosis fue endovascular en 8 y tuvo éxito en todos ellos (dilatación con balón en 4, nueva colocación de stent en 3, trombólisis y colocación de stent en 1) y quirúrgico en un paciente que presentó oclusión aórtica y se le practicó un injerto aortobifemoral. El análisis de la tabla de supervivencia mostró índices de permeabilidad primaria y asistida a los 4 años del 81 y el 94%, respectivamente. La tasa de mortalidad durante el seguimiento fue del 19%, por causas cardíacas en 8, causas pulmonares en 3, y neoplasias malignas en 5. El análisis univariantes mostró que la discordancia radial (espacio muerto de la luz aórtica alrededor del segmento que sobresale de los stent), el sexo femenino, la oclusión previa, y la estenosis residual fueron factores predictivos de reestenosis. El análisis de regresión logística multivariante mostró que la discordancia radial fue el único determinante significativo de reestenosis, aunque la potencia estadística del modelo se vio limitada por el bajo número de eventos. La reconstrucción mediante stent de la bifurcación aortoilíaca en la patología oclusiva es eficaz y duradera, incluso ante enfermedad aortoilíaca compleja y oclusiones de segmentos largos. La mayoría de las reestenosis son susceptibles de tratamiento endovascular, con una permeabilidad asistida a largo plazo excelente. Las variables geométricas relacionadas con la anatomía aórtica individual y el patrón de la enfermedad (dependiente del paciente) y la configuración del stent (dependiente del cirujano) podrían influir en la permeabilidad a largo plazo.

We assessed the long-term patency of kissing stent reconstruction of the aortoiliac bifurcation and identified variables that may influence it. We retrospectively reviewed our experience with stent-reconstruction procedures of the aortoiliac bifurcation from January 1998 through June 2005. The impact of demographic variables, vascular risk factors, disease location and characteristics, stent material and design, and stenting configuration on stent patency was assessed using univariate and multivariate analysis. In particular, we evaluated the effect of geometric mismatch between the protruding segment of the stents and the distal aortic lumen. Sixty-six patients underwent aortobi-iliac stent reconstruction. Indications were bifurcation or bilateral proximal iliac disease in 52 patients and unilateral ostial disease requiring contralateral protection in 14 patients. Limited disease (TASC A and B) was present in 40 limbs in 19 patients; extensive/ diffuse disease (TASC C and D) was present in 78 limbs in 47 patients. Complete occlusions were present in 37 limbs in 28 patients (bilateral in nine patients). Self-expanding stents were used in 56 procedures and balloon-expandable stents in 10. Crossing configuration was used in 43 procedures, while abutting configuration was used in 23 procedures. Technical success was achieved in 62 patients (94%), with all four failures due to inability to cross a chronically occluded limb. Three of these patients underwent aortomono-iliac stenting with a crossover femoral-femoral bypass graft, with the remaining one opting for no further interventions. Median combined follow-up was 37 +/- 27 months (range 0-102). Hemodynamically significant restenosis developed in nine patients (14%). The management of restenosis was endovascular in eight patients and was successful in all (balloon dilation in four, restenting in three, thrombolysis and stenting in one) and operative in one patient who developed aortic occlusion and underwent aortobifemoral grafting. Survival table analysis showed primary and assisted patency rates at 4 years of 81% and 94%, respectively. The mortality rate during follow-up was 19 (cardiac cause in eight, pulmonary cause in three, and malignancy in five). Univariate analysis showed radial mismatch (aortic lumen dead space around the protruding segment of the stents), female gender, prior occlusion, and residual stenosis to be significant predictors of restenosis. Multivariate logistic regression analysis showed radial mismatch to be the only significant determinant of restenosis, although the statistical power of the model was limited by the small number of restenoses. Stent reconstruction of the aortoiliac bifurcation for occlusive disease is effective and durable, even with complex aortoiliac disease and long segment occlusions. Most restenoses are amenable to endovascular treatment, with excellent long-term assisted patency. Geometric variables related to individual aortic anatomy and disease pattern (patient-dependent) and stenting configuration (operator-dependent) may have an impact on long-term patency.