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• W2949207582 abstract "A 75-year-old morbidly obese man presented with increasing diameter of a known abdominal aortic aneurysm (AAA) and right common iliac artery aneurysm. He was diagnosed with these aneurysms at the age of 69 years while undergoing computed tomography for evaluation of pancreatic cancer. At the time of diagnosis, the AAA diameter was 3.9 cm. His past medical history was significant for hypertension and hyperlipidemia. He was observed with serial aortoiliac duplex ultrasound scans. By November 2018 (6 years after the original diagnosis), the AAA diameter increased to 6.3 cm and the right common iliac artery diameter increased to 3 cm. Because the risk of rupture outweighed the potential risks of elective surgery, he was offered an operation. A dedicated computed tomography angiography study was obtained and revealed that the aortic neck was favorable for endovascular aneurysm repair (EVAR); however, the common and external iliac arteries were found to be excessively tortuous (A/Cover and B). The patient gave permission to submit this case report. Because of concerns for kinking of the iliac limbs, the patient was offered open AAA repair. He underwent exploratory laparotomy; an infrarenal aortic clamp was placed, the aorta below the renal arteries was transected, and an end-to-end anastomosis was made to a 16- × 8-mm Dacron graft. The left limb was sewn to the left common iliac artery. The right common iliac artery aneurysm was opened, and an end-to-end anastomosis was made to the right external iliac artery. A jump graft was then sewn to the left internal iliac artery (C). The patient's postoperative course was uneventful. EVAR has largely replaced open AAA as the first-line modality for treatment of AAAs. Perceived benefits of EVAR include improved perioperative morbidity and mortality, shorter length of hospital stay, and improved short-term health-related quality of life.1Liakishev A.A. [Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm, 30-day operative mortality results: randomised controlled trial. Results of the EVAR 1 trial].Kardiologiia. 2004; 44: 90Google Scholar, 2Blankensteijn J.D. de Jong S.E. Prinssen M. van der Ham A.C. Buth J. van Sterkenburg S.M. et al.Two-year outcomes after conventional or endovascular repair of abdominal aortic aneurysms.N Engl J Med. 2005; 352: 2398-2405Crossref PubMed Scopus (839) Google Scholar Limb occlusion after EVAR leading to limb ischemia is a known complication of EVAR.3Maldonado T.S. Rockman C.B. Riles E. Douglas D. Adelman M.A. Jacobowitz G.R. et al.Ischemic complications after endovascular abdominal aortic aneurysm repair.J Vasc Surg. 2004; 40 (discussion: 709-10): 703-709Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar, 4Erzurum V.Z. Sampram E.S. Sarac T.P. Lyden S.P. Clair D.G. Greenberg R.K. et al.Initial management and outcome of aortic endograft limb occlusion.J Vasc Surg. 2004; 40: 419-423Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 5Carroccio A. Faries P.L. Morrissey N.J. Teodorescu V. Burks J.A. Gravereaux E.C. et al.Predicting iliac limb occlusions after bifurcated aortic stent grafting: anatomic and device-related causes.J Vasc Surg. 2002; 36: 679-684Abstract Full Text PDF PubMed Scopus (162) Google Scholar Most EVAR limb occlusions occur within 6 months of the index operation,6Cochennec F. Becquemin J.P. Desgranges P. Allaire E. Kobeiter H. Roudot-Thoraval F. Limb graft occlusion following EVAR: clinical pattern, outcomes and predictive factors of occurrence.Eur J Vasc Endovasc Surg. 2007; 34: 59-65Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar suggesting a role of technical factors contributing to graft limb occlusion. Cochennec et al6Cochennec F. Becquemin J.P. Desgranges P. Allaire E. Kobeiter H. Roudot-Thoraval F. Limb graft occlusion following EVAR: clinical pattern, outcomes and predictive factors of occurrence.Eur J Vasc Endovasc Surg. 2007; 34: 59-65Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar identified graft limb kinking to be associated with a significant risk of subsequent graft thrombosis. We considered both endovascular and open surgical options for this patient. Iliac tortuosity can be straightened with insertion of superstiff wires. Tortuosity of the native iliac arteries is not an absolute contraindication to EVAR; however, with multiple, significant curves in bilateral iliac arteries, we were concerned that after removal of the stiff wires, the excessive tortuosity of bilateral iliac arteries would lead to iliac limb occlusions. Hence, the patient was treated with open AAA repair. This case highlights the fact that despite the national trends of increasing numbers of endovascular AAA repairs, certain anatomic criteria still continue to play a significant role in recommending open AAA repair for these patients." @default.
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• W2949207582 date "2019-07-01" @default.
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• W2949207582 title "Excessive tortuosity of the iliac arteries is an indication for open abdominal aortic aneurysm repair" @default.
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• W2949207582 doi "https://doi.org/10.1016/j.jvs.2019.04.439" @default.
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