Steve Jobs is credited with popularizing the saying credited to Pablo Picasso, “good artists copy, great artists steal.” While its provenance may be apocryphal, it makes an excellent point about how we learn. Even in the lack of understanding, it is still possible to learn by copying. Toddlers do this. We, as land mammals, are hard wired to copy.
Take for example this patient below with Leriche syndrome with a triad of smoking, claudication, and impotence.
Because of his relative youth, being his 50’s, I felt the most appropriate procedure was an aortobifemoral bypass.
The only real complexity to manage was the severe stenosis he had in his left renal artery.
The options included
renal endarterectomy as part of aortic thromboendarterectomy
renal artery bypass from the aortic graft
reimplantation of renal artery
Something Else: The complexity of renal revascularization creates risk. An antegrade endarterectomy of the renal artery would be done below a suprarenal clamp, adding to clamp time. A bypass would require the kidney to bide its time during the proximal aortic anastomosis, and the anastomosis for a jump graft, then the anastomosis to the left renal artery. This renal ischemia time can be extended by cooling the kidneys with cold (5 degree) LR, but why risk it? A renal endarterectomy can devolve into a visceral segment endarterectomy. After an hour, a nephrectomy.
That’s where this whole copying concept comes into play. Back in 2012, I worked with Dr. Jeanwan Kang, who had just come out of training with Dr. Richard Cambria. We were doing a type IV thoracoabdominal aortic aneurysm, and the right renal artery had a ostial stenosis. While I was figuring out the best way to manage this, Dr. Kang asked for a 6x18mm renal stent and an insufflator. She stuck the stent into the renal orifice and deployed the stent, opening the orifice. I had to find my jaw which had dropped to the floor.
Now, ten years on, that’s how I managed this patient’s ostial renal artery stenosis.
The patient’s thrombotic plaque went up to the renal origins and needed to be endarterectomized, but embarking on a renal endarterectomy adds potentially harmful renal ischemia time. Therefore, through the vertical aortotomy, I was able to get a clean end point to the aortic thromboendarterectomy and position a stent in the renal orifice and deploy it.
Once the stent was deployed, the aorta was partially closed primarily to allow the clamp to be moved below the renal arteries. This all took less than ten minutes of ischemia time. The aortic graft was then sewn end to side to the remaining aortotomy.
The patient recovered and was discharged on POD#6 with normal renal function. In followup, his CTA showed excellent graft and stent patency.
The centerline view of the renal stent shows it to be widely patent.
The patient is walking well without limitations and has improved blood pressure control, achieving normotensions at times.
If you are curious about the results from MGH, I refer you to their paper on 67 patients treated with open hybrid revascularization of the renal artery during complex aortic reconstructions (reference). At a mean followup of a year, they reported a 98% stent patency.
There is a comfort in sticking to what you know. The extreme example of this is the practitioner who graduates with a skill set from training and never expands on it. Yet there is an opportunity cost to blind devotion to sticking what you know and that is never growing. I recall this in the panel discussions during the VEITH Symposia I used to sneak into as a resident in the 90’s where great authorities pooh-poohed or condemned anything endovascular.
It’s a sign of a nimble mind that Dr. Cambria, after learning endovascular techniques mid-career, adapted these skills to his open surgical toolkit. His trainee, Dr. Kang, soon after, taught me.
Or was I just looking over her shoulders taking notes?
Patel R, Conrad MF, Paruchuri V, Kwolek CJ, Cambria RP. Balloon expandable stents facilitate right renal artery reconstruction during complex open aortic aneurysm repair. J Vasc Surg. 2010 Feb;51(2):310-5. doi: 10.1016/j.jvs.2009.04.079. Epub 2009 Oct 22. PMID: 19853403.
Recently, in clinic, my nurse handed me the patient sheet with the comment, “this is for iliac stents.” This caught my attention as “iliac stents” does not make sense as a chief complaint. The patient had been sent with a vascular lab report. It was a duplex scan documenting peak systolic velocities over 300cm/s in the common iliac arteries, appropriately diagnosing 50-99% stenoses. The patient had hip and thigh pain with walking short distances. I could have been excused for just cancelling the visit and booking an angiogram, except that would make me just a technician responding to a request. So I talked to the patient.
The patient was a nice lady over 70 years of age with recent onset of hip and thigh pain with walking 50-100 feet. This was incapacitating her as she was used to living an active and independent lifestyle. Her pulse examination was normal, not an uncommon finding with aortoiliac occlusive disease which manifests as a hemodynamic phenomena best explained as “small pipes.” Except she had never smoked, and had only hypertension and mild hypercholesterolemia. The review of systems was notable for fatigue and arm and shoulder pain. While she had not lost weight, strangely, her jaws hurt when chewing food.
I do not claim any kind of magic skills when it comes to diagnostics, but these other complaints did not fit. And it is not uncommon for someone to have several common conditions. Maybe she had TMJ, shoulder arthritis, early heart failure, and aortoiliac occlusive disease, to fit all of her complaints. Why was I wasting my time diving into nonvascular ephemera when I could be sending her to be scheduled for an aortogram and iliac angioplasty and stent?
I’ve carried with me this notion that all physicians can be mapped on x-y axes with one axis representing degrees of intelligence peaking at perfectly smart. Perfectly smart doctors have seemingly magical skills. While they are not rolling back their eyes while waving their hands over the patient, the handful of perfectly smart physicians I have worked with can quietly listen and digest a case and come up with the diagnosis, no matter how obscure and rare. On the other axis is compulsion, with the perfectly compulsive marching their patients through every test and algorithm to rule out every diagnosis on a exhaustively long differential list.
Those striving to be perfectly smart hope to bring efficiency to the clinical process -such as for this patient, it would have made sense for efficiency’s sake to move forward with an exercise treadmill ABI test and booking for an aortogram. Those stuck in perfect compulsion never quite reach a diagnosis, even after ordering batteries of tests, but rarely make mistakes, which is the point of perfect compulsion, because if you carpet bomb the diagnostic possibilities, something will hit. They are especially bulletproof to malpractice, particularly when patients choose not to have any more tests out of exhaustion. Their patients are rarely happy having to go through a myriad of tests to paint away the rule-outs while never quite identifying the disease. Those who play around with being perfectly smart get burned by that which are unknown and unfamiliar. They get blindsided. You want to revert to compulsion when you are tired and overloaded. You want to be smart, all the time.
The point of training, which never ends, is you have strive to be both perfectly smart and selectively compulsive, but it’s better to be lucky than good. It was my luck that I recently reviewed temporal arteritis. Every few weeks, I get asked to remove temporal arteries, and choosing not to be just a technician (although admittedly in the workup of TA, we kind of are), I plowed into UpToDate and Pubmed, seeing if there was a way out of doing these procedures -there really is not, except in the requests for temporal artery biopsy in younger patients -go read it yourself. It was here that I refreshed myself on polymyalgia rheumatica, which has as its symptom complex, muscle pain, lethargy, and jaw claudication. Out of duty, and compulsion, I ordered a CTA, because I knew that the patient had risk for atherosclerosis and arteries stiffened by calcium can have elevated velocities without critical stenoses. Out of curiosity, and after a quick call to one of the Clinic’s rheumatologists who order these temporal artery biopsies, I ordered an ESR and CRP.
The CTA came back with calcium at the aortic bifurcation and origins of the common iliac arteries where the outside duplex showed elevated velocities, but only revealed mild disease on the CTA. Both ESR and CRP came back very elevated. I referred the patient to our rheumatologist, and with steroid therapy, all of her symptoms resolved. Without an aortogram or stents.
I sat and thought about this for a while before posting. The patient was quite happy to give her permission. I cannot fault the outside vascular lab for their diagnosis of iliac stenosis because the diagnostic criteria are basically the same as our labs. It has made me think that approaching this case as a revenue opportunity as increasingly happens would not necessarily have been in error if I had performed an aortogram as long as I did not place stents. I can’t imagine the pressures put upon physicians who have put themselves into situations where they are paying for costly angio suites or their own 90th percentile salaries and lifestyles from not over-calling a stenosis and deploying stents, particularly when there is no oversight.
41 percent of my patients with median arcuate ligament syndrome present missing their gallbladders because biliary colic was the diagnosis that was both familiar and vaguely fit the complaints (reference 1). Not much harm can come from taking out a gallbladder, no? We know that a minority of operators harvest a significant share of the Medicare pie when it comes to peripheral interventions (link to terrific OPED, reference 2). Oh, I am sure each of these cases can be “justified.” Pleading justification from limits of knowledge means I proceed to treat what I am familiar and comfortable with -vascular disease, rather than an unfamiliar disease (at least to vascular surgeons) like polymyalgia rheumatica. If I can fail to recognize my ignorance, who can fault the perfectly compulsive? Like a broken clock that can be correct twice a day, someone of poor intelligence but perfect compulsion can be more effective than a greedy hack seeking to be perfectly smart and efficient.
Dunning and Kruger found that those with lower competence overestimate their ability, and those with higher competence underestimate their ability. Medicine is a perfect laboratory of Dunning Kruger. To be effective, you have to be correct and assertive. The problem is you are trained to project that confidence in the early stages of training and career when you are not ready. What patient would seek an unconfident physician? What person truly knows what they don’t know? The hardest step in medicine is both admitting what we don’t know but also applying hard-gained knowledge and experience with audacity. True humility comes from self knowledge and awareness. False modesty is externally directed, but true humility is internally focused. I don’t have a pat answer, but to become perfectly smart, you have to be perfectly compulsive about filling your knowledge and experience base. You have to submit your complications for peer review, you have seek and collaborate with sound partners, and you have to avoid financial traps that bias you to bad behavior. Above all, you have to stay curious.
Weber JM, Boules M, Fong K, Abraham B, Bena J, El-Hayek K, Kroh M, Park WM. Median Arcuate Ligament Syndrome Is Not a Vascular Disease. Ann Vasc Surg. 2016 Jan;30:22-7. doi: 10.1016/j.avsg.2015.07.013. Epub 2015 Sep 10. PMID: 26365109.
Sheaffer WW, Davila VJ, Money SR, Soh IY, Breite MD, Stone WM, Meltzer AJ. Practice Patterns of Vascular Surgery’s “1%”. Ann Vasc Surg. 2021 Jan;70:20-26. doi: 10.1016/j.avsg.2020.07.010. Epub 2020 Jul 29. PMID: 32736025.
One of the greatest surgical texts, Cope’s Early Diagnosis of the Acute Abdomen, is something every surgical resident, vascular or general, should read. The mid-century edition which I owned during my residency, has since been updated, but the central message of the book is this: every complaint or pain the patient has comes from a nerve, either peripheral or visceral, and understanding the nature of the pain, you narrow the diagnosis to only a few possibilities. Irritation of the psoas muscle results in a characteristic pain that years of diagnosing appendicitis the old fashioned way -by exam, then operation, makes it easy to recognize, like Marilyn Manson showing up as your substitute teacher (I would have said Alice Cooper, but that completely dates me). When the psoas muscle is irritated, by a hematoma, injury, inflammation, or abscess, the muscle relays intense pain localized to the retroperitoneum. Stretching the muscle worsens the pain, and the patient is often seen with the ipsilateral hip flexed. The genitofemoral nerve which rides on top of the psoas, is triggered and there is pain referred to the groin and proximal anterior thigh. Seeing this, and fitting the story allows for a diagnosis, before imaging. Without this insight, there is no swift vector to treatment and resolution.
The patient, a middle aged man, had undergone a redo-iliac angioplasty and stent for left iliac in-stent restenosis. He relayed that on the table, he felt immediate left lower quadrant abdominal pain and the desire to flex his left hip. He was restrained, sedated, and the procedure finished -a covered stent had been placed. When he came to my office a month after his initial procedure done elsewhere, he was in wheel chair, unable to straighten his leg. He claimed before coming to see me, he had gone to another hospital, where he had a CT scan and was told nothing was wrong (will have to confirm). He was having subjective fevers at home.
On examination, he sat on the exam table with left hip flexed. His pedal pulses were easily palpable. He had furuncles in his groins which he relayed he had had all of his life. I sent him for CTA and subsequently admitted him for surgery.
The CT showed a large collection around the left iliac artery and stents and on the psoas muscle, an abscess. The blood cultures on admission were positive for Staphylococcus lugadensis sensitive to penicillin.
Putting the story together after the fact is much easier than when you are in the moment, but being aware of the location and type of pain should give you a clue. Very likely, he had a brief rupture on the angiosuite table resulting in his sudden pain, drowned out by the sedatives typically given in response to a patient moving when a stent is deployed. Inflating a balloon in an artery typically causes some discomfort -as the vessels are lined with visceral nerve fibers which are quite sensitive but less localizable than say a pin poking on the index finger. If you ever had bloating with gas, that general discomfort localizable to the mid abdomen, that nausea and discomfort is from stretched visceral pain fibers. If you have ever had dull aching pain of distended spider veins, that is visceral pain. It’s there, but you would not be able to pinpoint it exactly. That is not what this patient had when he flexed his hip on the angio suite table. While the covered stent was deploying, he likely briefly ruptured causing both somatic and visceral pain around his left common iliac artery and iliopsoas muscle. Additionally, if the sheath had been entered through an area of a skin abscess, likely the sheath, wires, and gloves were contaminated. Any handling of the balloon expandable stent graft, which I highly discourage, would have contaminated it, resulting in a device infection, which was made more likely due to his diabetes. As the hematoma got infected, it resulted in the worsening symptoms he was having of left lower quadrant abdominal pain, groin pain, thigh pain, and inability to straighten his hip without pain.
I took him to the operating room and drained his abscess, assisted by Dr. Andrew Tang, chief resident headed to CT Surgery fellowship here at the Clinic, and Dr. Jenny Chang, PGY 2 Surgery. I gave Dr. Chang a copy of Cope’s with the admonition to read it soon and pass it on, as most of the current generation claim no knowledge of this important text. While I am not against interventional drainage, it takes time to drain the collection through a tube whereas sticking your hand in, sampling the collection, observing the injury, and breaking up collections and washing out with brown-bubbly -a mix of betadine/peroxide diluted in saline, I believe speeds the recovery from the infection. His drainage was done through a retroperitoneal approach from the left side and notably, his psoas muscle while viable, did not retract to cautery energy, suggesting some degree of rhabdomyolysis. The iliac artery was an indurated, thickened, and hard from the calcium and plaque that was the original problem affecting his distal aorta and iliac arteries (see left arteriogram centerline). I placed a pair of JP drains, removed one that wasn’t draining much on POD #3, and the other about a week after discharge on POD#5. His WBC elevation which was never high promptly resolved. I kept him on oxacillin with consultation from ID, and waited. After 3 weeks, I repeated his CTA.
His right iliac centerline showed patent stent with diffuse plaque and calcium starting in mid infrarenal aorta.
His abscess had significantly resolved and his pain was gone. He was ambulating again.
The choices at this point were the following
Continue treatment of patient with supressing antibiotics for life
Resection of left iliac stent graft which is presumed to be infected
If resection chosen, the options for repair that I considered included:
NAIS (ref 1). Neoaortoiliac System graft using femoral vein
Rifampin soaked gelatin coated graft (ref 2)
Extra-anatomic bypass with axillofemoral bypass or femorofemoral bypass.
Aortoiliac endarterectomy and repair with bovine pericardial patch and graft
The choice of replacement is becoming clearer in that while rifampin soaked grafts offer immediacy and expedience, all grafts seem to be prone to reinfection at a higher rate than autologous material (ref 3). The NAIS bypass is a great option, but is hampered by the addition of several hours invested in harvest of the femoral veins. While it can be staged with mobilization done one day and harvest another, those added hours add complications. We often forget that the simple metric of procedure time is the most important determinant of complication rate. Any operation going over 2 hours risks wound infection for example simply from ambient colonization of the open wounds from the rain of dead skin from the surgeon’s face, aerosolized fecal flora from flatii (prohibited in my ORs). The microenvironment of the open wound is also room temperature and not 37, having an impact on organ function and hemostasis. The homograft is the original aortic graft -before Arthur Voorhees invented the cloth vascular graft as a resident at Columbia P&S (my medical school alma mater, ref 4), major hospitals had tissue banks of aortic homografts harvested from the recently deceased. Having homografts is now an outsourced function, but does require having proper refrigeration for the cyropreserved grafts and generally can’t be ordered with short notice.
Rifampin soaked grafts work well, especially wrapped in omental flap, in the short and medium term but suffer a reinfection rate that is higher than seen with autologous tissues, and prosthetic grafts without rifampin, such as PTFE for extraanatomic bypass, have the highest rates of reinfection (3), despite being the board answer decades ago.
Endarterectomy allows for use of native tissues for repair. The adventitia around plaque and stents, while thin, can support physiologic pressures, even when they have been occluded for years. And while practice of aortoiliac endarterectomy is a bit of a lost art, it has both a long history stretching back nearly a century and a modern track record with carotid and femoral endarterectomy. It is merely a matter of scale. Pinch and zoom in on a femoral endarterectomy at the bifurcation and you have the same case as with an aortic one.
The question is, is bovine pericardium more autologous than prosthetic? It is a decellularized sheet of collagen from a cow’s pericardium, used in heart valves and vascular patches, but only recently applied as a graft (ref 5-7). I have long used bovine pericardium as a patch with some caution, but the rule of thumb is are there well vascularized tissues around it? A layer of Scarpa’s fascia and fat in a groin wound are not sufficient to protect a bovine patch, but a sartorius flap is. For me, once the infected stent graft is out, knowing if the surrounding tissues bleeds well is an important one.
I chose to do aortoiliac endarterectomy. The patch and graft would be made with bovine pericardium, unless I found the left iliac segment to be devitalized and foul with anaerobic vapors, then, I would close and go NAIS or extra-anatomic. The key point is that choices have to be on the table and constantly rearranged during the conduct of the operation.
The patient was preoperatively vein mapped and had suitable deep femoral vein for bypass conduit, having robust duplicated systems that would impact the patient minimally. The patient was placed in a supine position and via a midline laparotomy, the infrarenal aorta and the common iliac arteries beyond the short iliac stents exposed. I chose this limited exposure as any further into the phlegmon on the left risk injury to ureter and vein. The aorta had a palpable demarcation between plaque and mildly diseased proximal segment, predicted by the CTA to be at the IMA. A longitudinal arteriotomy was created on the right side from mid aorta to mid right iliac, and the left side had a separate arteriotomy to release the stent. The plaque came out in a single specimen (image).
The left iliac artery was destroyed by the infection but the tissues around it bled avidly and were not foul or infected. I avoided excess debridement here as the iliac vein was intimate with the phlegmon. There was a 3cm gap. Again, I thought briefly about taking femoral vein, but proceeded to make a graft from the bovine pericardium. This was sewn around the rod portion of a renal vein retractor from the OMNI set. The finished product resembled Voorhees’ graft. It was sewn into the orifice of the iliac from inside the aorta and end to end to the freshened iliac stump. Unfortunately, the omentum was atropic across the transverse colon, but the tissues around the resected artery and stent graft bled well, indicating good penetration of antibiotic. The retroperitoneum was closed after hemostasis obtained. Dr. Shashank Sharma, our chief resident headed to a vascular surgery fellowship at the renown Houston Methodist next year got to see what is unfortunately a rare occurrence -an aortoiliac endarterectomy, which through me puts him three degrees of separation from Cid Dos Santos (ref 8). Dr. D’Andre Williams, PGY-2 Vascular Surgery Resident, got important lessons on sewing the aorta. She’s part of a fortunate cohort that get exposed to open aortic surgery at our main campus which is unfortunately rare throughout the world.
The final graphic shows the operative end result.
The patient recovered well and was discharged within the week with another month of IV antibiotics planned.
Conclusion: The operation was started at 8 in the morning and was done by lunch time. For aortic cases, this is a crucial metric, as when the clock winds past the surgeon’s comfort, the patient suffers even more. Adding the femoral vein for a NAIS may have been the textbook thing to do, but we don’t do extra-anatomic bypasses that much either. I don’t believe that adding two more hours for retrieving the femoral vein would have enhanced the procedure, and would have served to add potential areas for complication. Technically, the aorta closes much as with a carotid or femoral endarterectomy, but the adventia is thin and really should be sewn with 5-0 or 6-0 Prolene. The larger needles such as the SH size creates unnecessary bleeding unless sewn with a line of felt which could become infected. Despite the thinness, it will hold pressure if it is not infected. Clamps that bend out of the “airspace” above the laparotomy, such as the Cherry Supraceliac Clamp and Wiley Hypogastric Clamp, prevent limiting the operative space with long clamps such as aortic Fogarty or DeBakey clamps, while being stronger than the Zenker.
A final comment for Staphyloccocus lugudensis. This is the second major vascular graft infection with this organism I encountered this year. The other was an infected aortic stent graft. Lugudensis means from Lyons. I do not know why that is, but it is so far not the nasty player that is S. aureus. I am sure it will share some plasmids, and become resistant one day, but in the earlier case in Abu Dhabi and now this, it is sensitive to penicillin, and came from the skin at the femoral puncture site, and for this we are fortunate. Major vascular infections are one of the few areas that still demand open surgical skills, and we foresake them at great peril. It’s critical to remember all the collective memory of surgery from the past, or we will become mere technicians fixing whatever comes out of the radiologist’s report with whatever knowledge obtained from a Zoom meeting for the latest, greatest device.
Gratefully, the patient gave his permission, as with all patient, for use of his case for educational purposes.
Chung J, Clagett GP. Neoaortoiliac System (NAIS) procedure for the treatment of the infected aortic graft. Semin Vasc Surg. 2011 Dec;24(4):220-6. doi: 10.1053/j.semvascsurg.2011.10.012. PMID: 22230677.
Oderich GS, Bower TC, Hofer J, Kalra M, Duncan AA, Wilson JW, Cha S, Gloviczki P. In situ rifampin-soaked grafts with omental coverage and antibiotic suppression are durable with low reinfection rates in patients with aortic graft enteric erosion or fistula. J Vasc Surg. 2011 Jan;53(1):99-106, 107.e1-7; discussion 106-7. doi: 10.1016/j.jvs.2010.08.018. PMID: 21184932.
Smith RB 3rd. Arthur B. Voorhees, Jr.: pioneer vascular surgeon. J Vasc Surg. 1993 Sep;18(3):341-8. PMID: 8377227.
Almási-Sperling V, Heger D, Meyer A, Lang W, Rother U. Treatment of aortic and peripheral prosthetic graft infections with bovine pericardium. J Vasc Surg. 2020 Feb;71(2):592-598. doi: 10.1016/j.jvs.2019.04.485. Epub 2019 Jul 18. PMID: 31327614.
Lutz B, Reeps C, Biro G, Knappich C, Zimmermann A, Eckstein HH. Bovine Pericardium as New Technical Option for In Situ Reconstruction of Aortic Graft Infection. Ann Vasc Surg. 2017 May;41:118-126. doi: 10.1016/j.avsg.2016.07.098. Epub 2016 Nov 27. PMID: 27903471.
Belkorissat RA, Sadoul C, Bouziane Z, Saba C, Salomon C, Malikov S, Settembre N. Tubular Reconstruction with Bovine Pericardium Xenografts to Treat Native Aortic Infections. Ann Vasc Surg. 2020 Apr;64:27-32. doi: 10.1016/j.avsg.2019.10.104. Epub 2020 Jan 10. PMID: 31931127.
Barker WF. A history of endarterectomy. Perspectives in Vascular and Endovascular Therapy. 1991;4(1)1-12. doi:10.1177/153100359100400102
The patient is a man over 70 years of age who came to the hospital with severe pain of his right foot and leg with walking short distances and at night while recumbent. He had a history of hypertension, diabetes, and coronary artery disease, and several years ago had his left common iliac artery stented. On examination, he had no lesions of his foot, and his pulses were only palpable (barely) in the femoral arteries only. He did have strong monophasic signals in the anterior tibial arteries bilaterally.
Initial vascular lab testing showed only mildly depressed ankle brachial (above), with dampened waveforms consistent with inflow and femoropopliteal disease on the right. He underwent arteriography by our vascular medicine specialist and cardiologist Dr. Faisal Hasan, and it showed bilateral common iliac stenoses, a severely calcified and nearly occlusive plaque in the right common femoral artery, and a long segment occlusion in the superficial femoral artery with diffuse calcified plaque extending into the popliteal artery. There was diseased but patent 3 vessel tibial runoff.
To Act As A Unit are the Cleveland Clinic’s words and it shows the Clinic’s roots as an US Army field hospital on the vasty fields of World War I France a little over a century ago, and we take it seriously. It may come as a surprise to some that a cardiologist referred me this patient after mutually deciding that the common femoral disease and the TASC D SFA occlusive disease, but we both decided that a surgical approach was the best one. The question then is how much more flow?
I ordered a CTA (CT angiogram) particularly for endarterectomies as I find it imperative to know the actual end point of plaque. Arteriography only hints at it, and while a 5mm lumen may look large and patent, it may be a channel in a 10mm wide plaque that when a stent terminates within it, breaks and becomes biologically active as intimal hyperplasia at best or embolizes at worst. CTA shown below revealed the plaque where contrast angio showed only the lumena of the vessels.
The 3D reconstruction function also allowed me to see and plan the operative approach and predict the lack of saphenous vein confirmed on duplex ultrasound.
For the students reading this, ischemic rest pain is often simpler to treat because it requires only a little more blood flow. There is a neurologic ischemia component that is not well studied, particularly in diabetics, as ischemia may result in anesthesia in someone who has underlying diabetic neuropathy, but that is not an indication for revascularization while rest pain is, and someone should investigate this. This little more blood flow in the form of treating inflow disease only may be sufficient in relieving rest pain while avoiding interventions on the superficial femoral, popliteal and tibial arteries which have limited longevity.
The common femoral artery on the other hand is the throttle of inflow and as a principle, inflow can be considered as the infrarenal aorta to profunda femoral artery, and repairing the common femoral necessitates an operation. There is no durable or laudable endovascular procedure for occlusive disease of the common femoral artery, a feature shared with the subclavian artery at the thoracic outlet and the celiac axis at the median arcuate ligament. All three are externally compressed by hard structures and revascularization must be ever mindful of the inguinal ligament, the thoracic outlet, and median arcuate ligament. The only exception to the “you must operate” rule of the CFA is calcified atherosclerotic disease in high risk individuals, and I make careful exception here with rotational atherectomy devices.
Claudication is another thing entirely. Claudication limits lifestyle and can be corrected by changing lifestyle -either with more exercise or limiting exercise. The thing is, when a patient has reached a certain age, that lifestyle may be walking slowly from chair to commode, and if that activity is limited, no amount of haranguing may be able to induce that person to embark on an ambitious exercise program. Sometimes, you have to be realistic about telling a frail old man to go for a 60 minute walk. But if that person has difficulty getting to the bathroom because of leg cramps, then either they have to get assistance or more bloodflow, and ironically, a little more blood flow represented by improving inflow, may not be enough.
That was what I was thinking when I was planning this operation. Improve the inflow with stents to the common iliacs and a right CFA endarterectomy, but use the opportunity of surgical exposure to extend the endarterectomy to the distal external iliac and through the entire SFA.
My fondness of remote endarterectomy is well known from my many blog posts on it (link). It is a modern update on a very old procedure -the ring endarterectomy, done since the middle of the last century when bypass grafts were unavailable. The occlusive plaque is removed, and an end-point reached and cut with a scissor like device (available from LeMaitre). It is the ultimate hybrid operation (below) requiring open and endovascular skills. I tell prospective trainees to judge training programs by how facile are the surgeons and how many are the procedures with and involving a hybrid approach, because any program can have few (getting fewer) old surgeons doing only open surgery and a lot of young surgeons doing only endovascular procedures, but a rare few will do a lot of hybrid procedures.
I chose to add femoral EndoRE. This would bring the extra blood flow needed to kickstart any walking program, barring cardiopulmonary limitations.
The patient was brought to our hybrid operating theatre and prepped from nipples to toes. The right common femoral artery was exposed for endarterectomy, and accessed then with a sheath along with a left femoral sheath for kissing balloon angioplasty and stenting of the common iliac artery stenoses (below).
Afterword, the CFA was opened and endarterectomized, and the SFA was remote endarterectomized (below).
The endpoint was chosen in the above knee popliteal artery to avoid having to stent the dissected end point plaque well into the popliteal artery. If I wanted to go all the way to the below knee popliteal artery, I would have to open it to manage the plaque and artery at the so-called trifurcation, typically with a patch angioplasty. The plaque came out in one piece (below):
The terminus of the plaque in the POP where it was cut has to be managed with a stent, unless you open and complete the endarterectomy and patch the artery. I was able to cross the dissection (no small feat) and plaque a stent. The artery was widely patent and even the small branches off the previously occluded SFA were now reopened.
His pulse volume recording done after intervention reflects the improved flows (below).
His rest pain resolved, but more gratifyingly, he has regained the confidence to walk and exercise, which he now does without limitation up to 45 minutes a day. In two month followup, we performed a duplex which showed his right SFA to be basically normal (below), including an intimal stripe and media. This is not an anomaly. When I took a punch out of restored artery to perform an anastomosis (from this case link), I sent it. Previously it had been an artery that was obstructed for nearly a decade, but after EndoRE, had become an elastic, compliant vessel. The pathology returned as “normal artery.”
When these fail, they typically do so a random points on the endarterectomized vessel and on the stent. While stent grafting may have better outcomes with regard to restenosis, doing so covers collateral vessels and PTFE grafts behave poorly by embolizing while clotting off, and PTFE stent grafts are no different. Data from over a decade ago suggests that EndoRE of the SFA while inferior in patency to vein grafts, are equivalent to PTFE [reference 1] and superior to endovascular revascularization [reference 2] in terms of primary patency. When they occlude, they achieve a “soft landing” without the furious acute ischemia and embolization seen with PTFE bypasses.
I think these handful of cases I performed here in the UAE represent the first in the region. The main difference here is that the arteries tend to be smaller by about 20%, and in one instance, the smallest Vollmer ring was too large for the vessel in a case where I abandoned the SFA revascularization -the profunda and inflow revascularization proved sufficient in reversing rest pain. The intriguing property of endarterectomy is something that we all try to do with surgery but rarely achieve -a restoration to an earlier time. I believe this patient’s right femoral artery is now back to a youthful state.
An oldie but a goodie from my first blog, “The Pipes Are Calling” on Medscape. This case came to mind when I recently diagnosed a pheochromacytoma from my clinic -middle aged man with difficult to control hypertension and unilateral renal artery stenosis. One of the most critical lessons learned from medical school, the Columbia University College of Physicians and Surgeons, was to be a complete physician, to be curious and engaged in the well being of your patient even outside the narrow focus of your specialty. This I learned especially from people like Drs. Harold Neu and Mark Hardy.
W. Michael Park, MD, Surgery, Vascular, 05:24PM Jun 23, 2010
The patient is a middle aged man who developed rest pain of his left leg after CABG for 3VCAD/MI. Workup revealed an occluded left iliac arterial system with diffuse atherosclerosis of his aorta and iliac arteries. He had a long history of bilateral calf claudication and his right SFA was occluded and his left SFA was diffusely diseased. CTA was performed and showed the described anatomy
And a “2.2cm peripherally enhancing mass” probably representing a lymph node with central necrosis, adjacent to the aorta.
I proceeded with aorto-right iliac and left femoral bypass, planning on later leg revascularization as needed after establishing inflow. During the retroperitoneal dissection over the aorta, I ran into this purplish mass and on manipulation, the patient’s blood pressure shot to 210mmHg. As my brain processed, my resident who had just finished reading his chapter on endocrine, said, “this could be a pheochromocytoma.”
That tumor was out quicker than you could say “snit.” Frozen section, and later final pathology returned paraganglionoma.
The patient recovered well and graciously gave permission, as all my patients here do, to allow this to be discussed. He noted that hypertension kept him out of Vietnam. Records showed an uneventful CABG.
Applying the retrospectocsope, I will now be far more wary of midline retroperitoneal lesions that are highly vascularizad.
Leriche Syndrome -one of those disease names that adds to our work in a way that an ICD codes and even the “aortoiliac occlusive disease” fails to describe. When I hear someone described as having Leriche Syndrome, I think about a sad, chain smoking man, unmanned, complaining of legs that cramp up at fifty feet, pulseless.
The CT scan will occasionally show an aorta ringed by calcium in the usual places that are targetrs for clamping below and above the level of the renal arteries. Even without the circumferential calcium, a bulky posterior plaque presages the inability to safely clamp the aorta. Woe to the surgeon who blithely clamps a calcified lesion and finds that the rocky fragments have broken the aorta underneath the clamp! The first way to deal with this is to look for ways not to clamp the aorta, by planning an endovascular procedure, but circumstances may necessitate the need to control the aorta despite the unclampability.
The traditional methods of avoiding clamping the calcifed peri-renal aorta are extra-anatomic bypasses including femorofemoral bypass and axillo-femoral bypass. I propose these following options for the consideration when the patient needs a more durable solution while avoiding a heavily diseased aorta.
Not Clamping I:
EndoABF does work to avoid clamping -these are common femoral endarterectomies supplemented by stenting of the aortoiliac segment, including in those with appropriate anatomy, a bifurcated aortic stent graft. This is often not possible to treat both sides, but one side is usually more accessible. Often, people will compromise and perform an AUI-FEM-FEM, but I have found the fem-fem bypass to be the weak link, as you are drawing flow for the lower half of the body through a diseased external iliac artery. The orientation of the proximal anastomosis is unfavorable and in the instance of highly laminar or organized flow, the bypass is vulnerable to competitive flow on the target leg, leading to thrombosis.
The femorofemoral bypass is the option of patients whose options have largely run out. It is made worse when fed by an axillofemoral bypass. Sometimes, you have no choice, but in the more elective circumstance, you do.
Not Clamping II:
The second method is performing a aorto-uni-iliac stent graft into a conduit sewn end to end to the common iliac aftery, oversewing the distal iliac bifurcation.
The conduit is 12mm in diameter, the key is to deliver the stent graft across the anastomosis, sealing it. The conduit is then sewn to the side of a fem-fem bypass in the pelvis, maintaining antegrade flow to both legs. The other option is to sew the conduit to a 14×7 bifurcated graft. Illustrated above is this 12mm conduit sewn end to end to the diseased common iliac artery with wire access into the aorta and a aorto-uni-iliac device. Typically, a small AUI converter (Cook, Medtronic) can be used, but the aorta is often too small even for a 24mm device, and an iliac limb with a generous sized docking segment (Gore) ending in a 12mm diameter fits nicely. Below is a CTA from such a case, where the stent graft is deployed across the anastomosis, sealing it off from anastomotic leaks (exoleaks).
Not Clamping III:
Often, the infrarenal aorta is soft anteriorly and affected only by posterior plaque at the level of the renal arteries. While a clamp is still not entirely safe (I prefer clamping transversely in the same orientation as the plaque with a DeBakey sidewinder clamp), a balloon is possible. I do this by nicking the aorta -simple application of a finger is sufficient to stop the bleeding if you have ever poked the ascending aorta to place cardioplegia line.
A Foley catheter is inserted and inflated. The Foley’s are more durable and resist puncture better than a large Fogarty. This is usually sufficient for control, although supraceliac control prior to doing this step is advised. The aorta can be endarterectomized and sewn to the graft quite easily with this non-clamp.
This has worked well, Although pictured above with an end-to end anastomosis planned, it works just as well end-to-side. I actually prefer end to side whenever possible because it preserves the occluded native vessels for future intervention in line.
The Non-Thoraco-Bi-Femoral Bypass
The typical board answer for the non-clampable aorta is taking the inflow from the thoracic aorta or from the axillary artery -neither of which are good options. The first because the patient is positioned in right lateral decubitus and tunneling is not trivial. The second because of long term durability. The supraceliac aorta, technically it is the thoracic aorta, is often spared from severe plaque and clampable. Retropancreatic tunelling is straightforward, and a 12 or 14mm straight graft can be tunelled in this fashion from the lesser sac to the infrarenal retroperitoneum. It then sewn to the supraceliac aorta and then anastomosed to a 12x6mm or 14x7mm bifurcated aorto-bifemoral bypass, of which limbs are tunneled to the groins.
This worked very well recently, allowing a middle aged patient with severe medical problems, occluded aorta and iliac arteries, with critical limb ischemia, survive with minimal blood loss and home under 5 days. It delivers excellent flow to both legs in an antegrade fashion. Dr. Lew Schwartz gave me a list of references showing that this is not novel, but represents a rediscovery as the papers were published in the 80’s [reference], and buttresses the principle that innovations in open vascular surgery are exceedingly rare, largely because we have been preceeded by smart people.
Conclusion: All of these come about through application of some common sense and surgical principles. The most important this is that the aorta is the best inflow source and reconstructing it with the normal forward flow of down each leg and not reversing directions as in a fem-fem bypass gives each of these options a hemodynamic advantage.
References for Supraceliac Aorta to Lower Extremity Bypass
Surgery [Surgery] 1987 Mar; Vol. 101 (3), pp. 323-8.
The principles of salvage are in rescuing valuable undamaged goods in the setting of catastrophe. This guided me when a patient was flown in from an outside institution to our ICU with a saline soaked OR towel in his right groin -he had had an aorto-bifemoral bypass for aorto-iliac occlusive disease a year prior, but had never properly healed his right groin wound which continued to drain despite VAC therapy and wound care. On revealing his groin, this is what I saw:
A CT scan was sent with the patient but has been lost to time, and it showed a patent aorto-bifemoral bypass send flow around an occluded distal aorta and iliac arteries. The graft did not have a telltale haze around it nor a dark halo of fluid which signaled to me that it was likely well incorporated and only sick in the exposed part. The patient was not septic, but had grown MRSA from the wound which was granulating from the extensive wound care that had been delivered.
I felt that it would be possible to move his anastomosis point more proximally on the external iliac in a sterile field (figure above), and then close, then endarterectomize the occluded external iliac artery after removing the distal graft, then after vein patching, cover the repair with a sartorius muscle flap. It would salvage the remaining graft and avoid a much larger, more intense operation which was plan B. To prepare for that, I had his deep femoral veins mapped.
The patient was prepped and draped, the groin was excluded by placing a lap pad soaked in peroxide/betadine/saline solution (recipe for “brown bubbly” liter saline, a bottle of peroxide, a bottle of betadine), and covering with an adesive drape. The rest of the abdomen was then draped with a second large adhesive drape. A retroperitoneal (transplant-type) right lower quadrant incision was made (below) and the external iliac artery and graft were exposed. As predicted on CT, the graft was well incorporated.
The external iliac artery was opened and focally endarterectomized of occlusive plaque (image below). The adventitia had good quality despite the longstanding occlusion.
The graft was mobilized and transected and anastomosed end to side to this segment of artery (below). Dissecting was made difficult by how well incorporated it was.
The wound was irrigated (with brown bubbly) and closed, dressed, and sealed over with the adhesive drape. The groin wound was then revealed and the graft pulled out (below).
Remote endarterectomy using a Vollmer ring was used -in this case I didn’t use fluoroscopy given the short distance to the terminus of the plaque which i had mobilized in the pelvis.
The plaque came out easily and was not infected appearing. It is shown below ex vivo.
A segment of saphenous vein was harvested from the patient medially and the arteriotomy was patched. The sartorius muscle was mobilized and applied as a flap over this. The wound was irrigated with brown bubbly and packed open with the intention of VAC application.
The patient healed very rapidly and remains infection free. I had used this approach on several occasions in the past and twice more recently. It truly is salvage as it preserves the uninfected graft while never exposing it to the infection in the process of operating. It avoids having to remove the whole graft which then damages the left side -I have seen other surgeons take this approach elsewhere taking a all-or-nothing approach to graft infection to considerable morbidity to the patient. It avoids having to harvest deep femoral vein -another large operation to which the body responds truculently. The patient recently came by for his 4 year followup, still smoking, but legs preserved.
Followup At 4 Years
The patient came back in followup -it has been 4 years since his infection was repaired. He was complaining of short distance claudication. His wound healed well and remains closed. CTA shows along with his short segment SFA occlusion which we will treat, a widely patent R. EIA (below).
The remote endarterectomy of the external iliac artery remains patent. Compare this to the preop CTA which I found and wasn’t available when I posted this case originally:
The chronically occluded EIA can be readily seen. The artery shown in the current CTA is that recanalized artery.
The patient is an 70 year old man referred for evaluation of claudication that occurred at under a block of walking. He reported no rest pain or tissue loss. He smoked heavily up to a pack a day, with congestive heart failure with an ejection fraction of 40%, prior history of myocardial infarction treated with PTCA, and pacemaker, and moderate dyspnea on exertion.
On examination, patient had a flaccid abdomen through which the AAA could be palpated, and he had no palpable femoral artery pulse bilaterally, nor anything below. He had a cardiac murmur and moderate bilateral edema. Preoperative risk evaluation placed him in the high risk category because of his heart failure, coronary artery disease, and his mild to moderate pulmonary disease.
CTA (pictured above and below) showed a 5.1cm infrarenal AAA with an hourglass shaped neck with moderate atherosclerosis in the neck, an occluded left common iliac artery with external iliac artery reconstitution via internal iliac artery collaterals, and a right external iliac artery occlusion with common femoral artery reconstitution. There was calcified right common femoral artery plaque.
Treatment options included open surgical aortobifemoral bypass with exclusion of the AAA, total endovascular repair with some form of endo-conduit revascularization of the occluded segments of iliac artery, or a hybrid repair.
Open aortic repair in patients with heart failure and moderate COPD can be performed safely (ref 1). Dr. Hollier et al, in the golden age of open repair, reported a 5.7% mortality rate operating on 106 patients with severe category of heart, lung, kidney, or liver disease.
Typically, the hybrid repair involves sewing in a conduit to deliver the main body of a bifurcated or unibody stent graft when endovascular access is not possible. Despite techniques to stay minimally invasive -largely by staying retroperitoneal, this is not a benign procedure (ref 2). Nzara et al reviewed 15,082 patients from the NSQIP database breaking out 1% of patients who had conduit or direct puncture access.
Matched analyses of comorbidities revealed that patients requiring [conduit or direct access] had higher perioperative mortality (6.8% vs. 2.3%, P = 0.008), cardiac (4.8% vs. 1%, P = 0.004), pulmonary (8.8% vs. 3.4%, P = 0.006), and bleeding complications (10.2% vs. 4.6%, P = 0.016).
Despite these risks, I have performed AUI-FEM-FEM with good results with the modification of deploying the terminus of the stent graft across an end to end anastomosis of the conduit graft to the iliac artery (below), resulting in seal and avoiding the problems of bleeding from the usually heavily diseased artery
The iliac limbs of some stent graft systems will have proximal flares and can be used in a telescoping manner to create an aorto-uni-iliac (AUI) configuration in occlusive disease. The Cook RENU converter has a 22mm tall sealing zone designed for deployment inside another stent graft and would conform poorly to this kind of neck as a primary AUI endograft which this was not designed to act as. The Endurant II AUI converter has a suprarenal stent which I preferred to avoid in this patient as the juxtarenal neck likely was aneurysmal and might require future interventions
I chose to perform a right sided common femoral cutdown and from that exposure, perform an iliofemoral remote endarterectomy of the right external iliac to common femoral artery. This in my experience is a well tolerated and highly durable procedure (personal data). Kavanagh et al (ref 3) presented their experience with iliofemoral EndoRE and shared their techniques. This would create the lumenal diameter necessary to pass an 18F sheath to deliver an endograft. I chose the Gore Excluder which would achieve seal in the hourglass shaped neck and allow for future visceral segment intervention if necessary without having a suprarenal stent in the way. I planned on managing the left common iliac artery via a percutaneous recanalization.
The patient’s right common femoral artery was exposed in the usual manner. Wire access across the occluded external iliac artery was achieved from a puncture of the common femoral artery. Remote endarterectomy (EndoRE) was performed over a wire from the common femoral artery to the external iliac artery origin (pictures below).
The 18F sheath went up with minimal resistance, and the EVAR was performed in the usual manner. The left common iliac artery occlusion was managed percutaneously from a left brachial access. The stent graft on the left was terminated above the iliac bifurcation and a self expanding stent was used to extend across the iliac bifurcation which had a persistent stenosis after recanalization.
The patient recovered well and was sent home several days postprocedure. He returned a month later with healed wounds and palpable peripheral pulses. He no longer had claudication and CTA showed the aneurysm sac to have no endoleak (figures below).
I have previously posted on using EndoRE (remote endarterectomy) for both occlusive disease and as an adjunct in EVAR. Iliofemoral EndoRE has excellent patency in the short and midterm, and in my experience has superior patency compared to the femoropopliteal segment where EndoRE is traditionally used. This case illustrates both scenarios. While the common iliac artery occlusions can be expected to have acceptable patencies with percutaneous interventions, the external iliac lesions typically fail when managed percutaneously especially when the stents are extended across the inguinal ligament. The external iliac artery is quite mobile and biologically, in my opinon, behaves much as the popliteal artery and not like the common iliac. Also, the common femoral arterial plaque is contiguous with the external iliac plaque, making in my mind, imperative to clear out all the plaque rather than what can just be seen through a groin exposure.
On microscopy, the external iliac artery is restored to a normal patent artery -I have sent arterial biopsies several months after endarterectomy and the artery felt and sewed like a normal artery and had normal structure on pathology. This implies that the external iliac can be restored to a near normal status and patients that are turned down for living related donor transplantation of kidneys can become excellent recipients. In this case, this hybrid approach effectively treated his claudication but also sealed off his moderate sized AAA while not precluding future visceral segment surgery or intervention with a large suprarenal stent.
The patient is a woman in her 60’s who self referred for complaint of abdominal pain, weight loss, and rest pain of the lower extremities. She is a 40 pack year smoker and had severe COPD, hypertension, congestive heart failure with mitral regurgitation, chronic kidney disease stage IV, and ischemic rest pain of the legs. She had a 30 pound weight loss due to severe postprandial abdominal pain. She had bloody stools. Her kidney function was worsening, and dialysis was being planned for likely renal failure but she was against dialysis. She had consulted several regional centers but was felt to be too high risk for surgery and with her refusal of dialysis, would be a high risk for renal failure and death with intervention. Physical examination revealed weakened upper extremity pulses, and nonpalpable lower extremity pulses and a tender abdomen. In clinic, she developed hypoxia and dyspnea and was admitted directly to the ICU.
CTA (above) revealed severely calcified atherosclerotic plaque of her visceral segment aorta occluding flow to her mesenteric and renal arteries and to her leg. The right kidney was atrophic. The left kidney had a prior stent which looked crushed. The infrarenal aorta was severely diseased but patent and there were patent aortic and bilateral iliac stents.
Echocardiography revealed a normal ejection fraction of 60%, diastolic failure, +2 to+3 mitral regurgitation, and pulmonary artery hypertension. She did respond to diuresis and stabilized in the ICU. Intervention was planned.
Options that I considered were an extranatomic bypass to her legs and revascularization from below. I have come across reports of axillo-mesenteric bypass, and I have performed ascending and descending thoracic aorta to distal bypass for severe disease, but concluded, as did the outside centers, that she was a formidable operative risk. Also, there was a high likelihood of great vessel occlusive disease. Looking at her CTA, I felt that she needed just a little improvement in flow -not perfect but good enough. The analogy is like drilling an airline through a cave-in. Also, her left kidney gave a clue -it was normal sized and survived the stress test of a contrast bolus for the CTA without dying. A discussion with the patient green lighted an attempt -she understood the cost of failure but did not wish to linger with this abdominal pain.
Access for intervention was via the left brachial artery. Aortography showed the severe stenosis at the origin of the SMA and the nearly occlusive plaque in the visceral segment aorta.
The plaque was typical of the coral reef type, and had an eccentric channel that allowed passage of a Glidewire. Access into the left renal artery was achieved. Its stent was patent but proximally and distally there were stenoses; this was treated with a balloon expandable stent. The path to it was opened with a balloon expandable stent to 8 mm from femoral access. This was the improvement the renal needed. A large nitinol stent was placed from this access in the infrarenal aorta when severe disease above the iliac stents was encountered. The SMA was then accessed and treated with a bare metal stent.
Her creatinine improved, as did her intestinal angina. She was discharged home. She later returned a month after the procedure with complaints of nausea and vomiting and right lower quadrant abdominal pain and was discovered to have an ischemic stricture of her small bowel. This was removed laparoscopically and she recovered well. She recovered her lost weight and now a year and a half later, remains patent and symptom free.
Discussion: Dr. Jack Wiley includes in the preface to his atlas of vascular surgery the words of Dr. Joao Cid Dos Santos, the pioneer of endarterectomy techniques, “Vascular surgery is the surgery of ruins.” And in that context, good enough is sufficient.