Chapter%20review:%20anastomotic%20aneurysms - PowerPoint PPT Presentation
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Chapter%20review:%20anastomotic%20aneurysms
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Chapter review: anastomotic aneurysms – PowerPoint PPT presentation
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Title: Chapter%20review:%20anastomotic%20aneurysms
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Chapter review anastomotic aneurysms
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Incidence
- 30 year experience 6090 aorto-iliofemoral
anastomoses - 2.4 femoral arteries, 0.4 aorta, 0.8 iliac
arteries - 20 year follow-up of 518 with ultrasonography or
angiography - 13.6 femoral arteries, 4.8 aorta, 6.3 iliac
arteries
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Etiology
- Suture line disruption
- Anastomic strength depends of suture coaptation
of the graft to vessel wall - Silk, very high rate of anastomotic aneurysms
within 5 to 10 years when used with prosthetic
grafts - Dacron, good strength but poor incorporation,
persistent inflammatory reaction, and suture
drag
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Etiology
- Nylon, lose significant amount of tensile
strength, but readily formable to thin sutures
9-0 and 10-0, lack of brittle qualities - PTFE, little inflammatory reaction, does not have
same cross-sectional strength as polypropylene - Polypropylene, minimally reactive, incorporates
into tissue well, maintains strength over time,
low coefficient of friction, resistant to
bacterial films
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etiology
- Nonsuture methods of anastomosis
- Adhesives, stents, rings, vascular clips, and
laser welding - Vascular clips promising for autogenous tissue
anastomoses not involving an endarterectomy
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etiology graft failure
- Earlier generations of PTFE and dacron found to
fail over time - Possibility of edge fraying of woven velour
dacron grafts - Take big bites or thermally seal edges
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Etiology arterial wall failure
- Can deteriorate and lead to pseudoaneurysm
- Difficult to determine if false or true aneurysm
by imaging - Assume lesion is a pseudoaneurysm for surgical
planning
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Etiology - inflammation
- 45 pseudoaneurysms
- Bacterial cultures positive for 60 of cases
- 89 of cases were coagulase neg staph
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Etiology technical errors
- Adequate number of suture loops, adequate bites
of tissue, following curve of needle important
aspects - Endarterectomy can lead to aneurysmal
degeneration because intima and media are removed
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Etiology physical stress
- Include hypertension, direct trauma, and
compression and distraction forces with
anastomosis across a joint - Size mismatch can also be a factor, prosthetic
grafts generally less compliant than native
tissue - Lateral forces generate stress preferentially on
the native tissue - Physical stresses increase as aneurysm size
increases
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Clinical presentation
- Generally asymptomatic, but are usually found on
physical exam - Can cause symptoms fullness, pain, pulsatility,
and symptoms associated with local compression
(weakness from compression of an adjacent
nerve.) - Clinical problems include rupture and bleeding
into adjacent tissues, embolization from mural
thrombus, thrombosis with distal ischemia, and
venous congestion or thrombosis from compression
of an adjacent vein - Emergency operative intervention carries a higher
morbidity and mortality - Median time to indentification is 6 years,
earlier manifestations should prompt an
investigation into an infectious etiology
including high resolution ct angio and esr rate
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Femoral artery anastomosis
- Most prevalent site of anastomotic
pseudoaneurysms - Most cases are diagnosed as an asymptomatic
pulsatile mass in up to 44 of cases less than
10 require surgical intervention - These should be monitored until they have a
significant growth rate or the size is 2 to 2.5cm - These should never be catheterized
- Can be monitored by ultrasound study, both sides
should be investigated - Endoluminal repair not an option as this is over
a hip joint
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Abdominal aorta anastomosis
- More common with aneurysmal pathology vs.
occlusive disease, occur in 2 to 5 of patients
with aortic grafts - Imaging study should be performed every 5 to 10
years - Patients may present with back or abdominal pain,
also rupture with hemorrhage, thrombosis or
embolism, and less commonly erosion into an
adjacent structure such as bowel or vena cava - Indications for intervention
- Symptomatic aneurysm
- Patient presenting with complications of
anastomotic aneurysm - Diameter greater than twice the diameter of the
graft or more than 4 cm - Also presence of a saccular rather than a
fusiform aneurysm - Retroperitoneal approach in preferrable providing
better exposure for suprarenal/supraceliac
control - In noninfected cases endoluminal repair should be
considered
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Iliac artery anastomosis
- Can erode into small bowel or colon, not duodenum
like the aorta - Compression of iliac vein can lead to lower
extremity swelling or DVT, also desmoplastic
reaction around the anastomosis can lead ureteral
obstruction and hyrdronephrosis - Indication for repair include presence of
symptoms, presence of complication, aneurysmal
size 2.5 to 3 cm - Iliac artery anastomotic aneurysms most suitable
to endoluminal repair - Need low probability of infectious cause
- Aneurysm does not need to be debulked
- No contraindication to internal iliac artery coil
embolization - Can be used for acute rupture depending on
surgeon experience
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Carotid artery pseudoaneurysms
- Incidence is rare 0.6
- Due to technical problems, use of poor quality
vein for patch, very bulbous reconstruction of
the arteriotomy or infective process for
prosthetic patch - Can present as painful pulsatile cervical mass,
also TIAs - Workup by ultrasound and CT angio, regular
angiography not helpful - Even small asymptomatic pseudoaneurysms should be
fixed as they may degenerate and produce small
thrombus and embolic material - Author recommends bypass around aneurysm and
endoluminal repair is contraindicated due to
significant debris in lumen
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