Neoaortoiliac System For Severe Aortoiliac Disease
Gina Biagetti, MD, Alexander Fairman, MD, Julia Glaser, MD, Grace Wang, MD, Venkat Kalapatapu, MD.
University of Pennsylvania, Philadelphia, PA, USA.
DEMOGRAPHICS: In this case, a young patient in their fifties who was a known smoker presented with a chronic infrarenal aortic occlusion and rest pain.
HISTORY: The patient's aortic occlusion had previously been refractory to multiple surgical therapies, to include an aortobifemoral bypass, thoracobifemoral bypass, and a right axillary-biprofunda bypass, all of which had failed. The patient had severe rest pain and was beginning to develop a heel wound; previously, they had refused offers for palliative amputation and instead sought a second opinion.
PLAN: After extensive discussion of the options, risks, and potential benefits the patient elected to undergo creation of a neoaortoiliac system (NAIS) using deep femoral vein for an open bypass of their aorta to the iliac bifurcations with a proximal anastomosis end-to-end infrarenally, and distally to the right iliac bifurcation and the left external iliac artery. They required a jump graft from the left external iliac to the left profunda using 6mm ringed PTFE as well as fasciotomies postoperatively day 1 for a thrombosed left limb, and have required no further interventions since. The patient's ankle-branchial indices (ABIs) increased from preoperative values of 0.16/0.27 (R/L) to 0.63/0.59 two months postoperatively. They are now six months post-procedure with stable ABIs and have been ambulating with a walker at home
DISCUSSION: The gold standard for reconstruction of long-segment infrainguinal reconstruction is surgical bypass with vein. However, for suprainguinal lesions endovascular therapy or surgical reconstruction with prosthetic is the most common approach. Creation of a neo-aortoiliac system has been well described as a method for managing infected aortic grafts; however due to the complexity of the procedure it is not typically utilized as a primary option in non-infected pathologies. This patient already had multiple different attempts at restoring flow to the lower extremities via prosthetic graft, and all had failed. Autologous vein is associated with higher patency rates and NAIS offered an additional option in continuing to pursue limb salvage in a young, active patient. In patients that can tolerate the prolonged operative time and high-risk nature of the procedure, NAIS provides a novel option for restoring in-line flow with autologous conduit for aortoiliac occlusive disease.
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