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Neoaortoiliac Reconstructions Using Femoropopliteal Veins: MDCT Angiography Findings

¹ Department of Radiology, UT Southwestern Medical Center, Dallas, TX.
² Present address: Department of Radiology, UT Health Science Center at San Antonio, 7703 Floyd Curl Dr., San Antonio, TX 78229-3900.
³ Department of Vascular Surgery, UT Southwestern Medical Center, Dallas, TX.

Received November 18, 2007; accepted after revision February 11, 2008.

 
Address correspondence to J. E. Lopera (Lopera{at}uthscsa.edu).

Abstract

Top Abstract Introduction Operative Planning and Surgical... Results Conclusion References

 
OBJECTIVE. In this article, we discuss the neoaortoiliac system procedure, a surgical procedure that uses femoropopliteal vein segments for arterial reconstructions in patients with aortofemoral prosthetic graft infections.

CONCLUSION. CT angiography (CTA) is a powerful imaging tool that can be used in the follow-up of patients after this complex surgery. CTA accurately detects early and late complications that may develop after the neoaortoiliac system procedure.

Keywords: aortic bypass • infected aortic graft • MDCT angiography • neoaortoiliac system • superficial femoral vein • vascular imaging

Introduction

Top Abstract Introduction Operative Planning and Surgical... Results Conclusion References

 
Prosthetic graft infection continues to be a significant challenge to the vascular surgeon because of high mortality (10–36%), high limb amputation rates (10–45%), and high incidence of reinfection of any new prosthetic graft (10–15%) [1, 2]. Definitive treatment of graft infection requires removal of the infected graft material and revascularization of the affected extremities or viscera. The most common surgical approach is extraanatomic bypass with staged removal of the infected vascular prosthesis; in many cases aortic ligation is required, thus placing the patient at risk for aortic stump blowout [3]. An extraanatomic bypass with prosthetic material is at risk of reinfection and is associated also with poor patency rates. Thrombosis of these conduits often leads to major amputation [1, 3]. Other techniques that can be used in cases of prosthetic graft infection include in situ replacement with aortic allografts, autogenous veins and arteries, or antibiotic-coated synthetic prostheses. Aortic allografts are prone to reinfection, graft blowout, and late deterioration [3]. Antibiotic-coated prostheses appear to be promising in the treatment of low-grade infections but probably are not the ideal solution for infections with an aggressive organism [2]. Conservative measures include antibiotic administration and percutaneous drainage.

The neoaortoiliac system procedure is a complex surgical procedure that uses femoropopliteal vein segments for arterial reconstructions to treat aortofemoral prosthetic infections in patients in whom an extraanatomic bypass is not an option, patients with an already-infected extraanatomic bypass, and patients with infections of the lower abdomen or groins. The greater saphenous vein can also be used for the arterial reconstructions, but long-term patency is poor because of the small caliber of the veins and severe intimal hyperplasia [3, 4]. Despite its initial complexity, the neoaortoiliac system procedure has been shown to be a valuable alternative in treating cases of graft infections. Advantages of the neoaortoiliac system procedure include the native veins' natural resistance to infection, which is superior to any prosthetic material; excellent long-term patency; and acceptable lower extremity venous morbidity. Another promising indication is the use of the neoaortoiliac system for vascular reconstructions in young patients (< 55 years) with small aortas in whom the incidence of prosthetic graft failures is high with very high amputation rates [5].

Disadvantages of the neoaortoiliac system procedure include the extensive operative times (mean ± SD, 8 ± 2 hours), significant blood loss, difficulty in controlling body core temperature during such long operative times, and residual compromise of extremity venous drainage. The neoaortoiliac system procedure is not appropriate for very sick patients with severe medical comorbidities or severe sepsis and is not indicated for rapid control of active bleeding. The neoaortoiliac system procedure also requires adequate femoropopliteal vein segments and is contraindicated in patients with a history of deep venous thrombosis [3, 4].

Operative Planning and Surgical Technique

Top Abstract Introduction Operative Planning and Surgical... Results Conclusion References

 
Duplex sonography is used to evaluate the quality of the femoropopliteal veins. Recanalized veins are not used. Most duplicated systems (25% of patients) work well as arterial conduits [3]. Catheter angiography had an important role for preoperative planning to determine adequate sites for distal revascularization and was used routinely in the past [3]. In our institution, CT angiography (CTA) has completely replaced catheter angiography for the preoperative assessment of patients with prosthetic graft infections because it is less invasive, is less expensive, and is quicker than catheter angiography and gives anatomic definition of the vascular structures as well as the soft tissues. CTA allows precise localization of the extent of the graft infection, identifies the anatomy of previous operations, and helps determine the sites that will require future revascularization after graft removal [6].

The three main surgical steps of the neoaortoiliac system procedure are vein harvesting, removal of the infected prosthetic material, and arterial reconstruction. Usually a two-team approach is used to decrease operative times. After the femoropopliteal vein is harvested, multiple branches of the femoropopliteal vein are carefully ligated. Valvulotomy or valve excision is performed so the vein segment is used in a nonreversed direction; this facilitates anastomosis of the large proximal end of the vein to the terminal abdominal aorta [4]. The infected prosthetic material is then removed, and after aggressive débridement of septic material, the aortofemoral reconstruction is performed. Different combinations of anastomoses are created according to the previous vascular anatomy and surgical reconstructions and the caliber of the native arteries and femoropopliteal veins (Figs. 1A, 1B, 1C, 1D, 1E, and 1F). Figures 2, 3, 4, 5, 6, and 7 illustrate normal CTA images showing different combinations of neoaortoiliac systems.

View larger version (73K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —Diagrams show multiple possible combinations of anastomoses used in neoaortoiliac system procedure. Aortobifemoral or pantaloon anastomosis.

View larger version (75K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —Diagrams show multiple possible combinations of anastomoses used in neoaortoiliac system procedure. Aortofemoral anastomosis with contralateral end-to-side limb.

View larger version (72K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —Diagrams show multiple possible combinations of anastomoses used in neoaortoiliac system procedure. Aortoiliac anastomosis with contralateral end-to-side limb.

View larger version (74K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D —Diagrams show multiple possible combinations of anastomoses used in neoaortoiliac system procedure. Unilateral aortofemoral anastomosis with femorofemoral crossover.

View larger version (70K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1E —Diagrams show multiple possible combinations of anastomoses used in neoaortoiliac system procedure. Thoracoiliac anastomosis with iliofemoral crossover.

View larger version (73K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1F —Diagrams show multiple possible combinations of anastomoses used in neoaortoiliac system procedure. Unilateral iliac limb replacement of synthetic aortobifemoral graft.

View larger version (101K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2 —68-year-old man with history of neoaortoiliac system procedure for infected aortobifemoral graft and left nephrectomy. Volume-rendered semitransparent coronal projection shows proximal anastomosis with aorta (yellow arrow). Two limbs of superficial femoropopliteal veins (white arrows) extend into distal anastomoses with common femoral artery (arrowheads). Left kidney is absent. Note characteristic appearance of native veins in limbs of bypass.

View larger version (104K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3 —77-year-old man who underwent neoaortoiliac system procedure for infection of right aortofemoral and left aortoiliac grafts. Volume-rendered coronal image shows right aortofemoral neoaortoiliac system bypass (white arrows) with left aortoiliac limb (yellow arrow). Left kidney had severe hydronephrosis with delayed excretion of contrast material.

View larger version (83K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4 —60-year-old woman after neoaortoiliac system procedure for occluded and infected aortobifemoral graft. Volume-rendered coronal image shows unilateral left aortofemoral bypass with end-to-end anastomosis between left limb of neoaortoiliac system and aorta (arrow) and shows left-to-right femorofemoral crossover bypass.

View larger version (72K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5 —56-year-old man who underwent neoaortoiliac system procedure with right femoropopliteal bypass. Volume-rendered right anterior oblique image shows left aortofemoral neoaortoiliac system bypass with left-to-right femorofemoral crossover bypass. Note proximal end-to-side anastomosis with aorta (straight arrow). Patient also has patent right femoropopliteal bypass (curved arrows).

View larger version (86K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6 —57-year-old man who had history of infected aortobifemoral bypass graft with occlusion of left limb that required previous amputation. Volume-rendered coronal image shows unilateral right aortofemoral neoaortoiliac system or hemineoaortoiliac system.

View larger version (87K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7 —62-year-old woman who underwent neoaortoiliac system procedure for thrombosed and infected aortobifemoral graft. Volume-rendered coronal image shows neoaortoiliac system with right aortofemoral bypass (arrows). Left limb is anastomosed in end-to-side fashion to right limb of bypass (arrowheads).

Top Abstract Introduction Operative Planning and Surgical... Results Conclusion References

Venous Outcomes
During the period immediately after the neoaortoiliac system procedure, venous hypertension has been associated with compartment syndrome requiring fasciotomy in 17.8% of patients [7]. Using duplex scanning and venous function tests, functional obstruction is identified in 80–90% of patients and mild reflux in 11% [8, 9]. Extensive collaterals develop between the popliteal stump and the profunda femoris vein. Clinical problems are minimal even in patients in whom the greater saphenous vein is absent. Approximately 35% of patients experience transient mild to moderate lower extremity edema, which is usually treated with compression stockings [8]. Signs of chronic hypertension such as skin pigmentation, venous claudication, or venous ulceration are rare [7]. Chronic venous insufficiency is more common if concomitant femoropopliteal veins and great er saphenous vein harvests are performed [7]. During the early postoperative period, thrombus formation is common at the popliteal stumps, but because the vein is ligated, the thrombus cannot propagate proximally [4] (Figs. 8A and 8B).

View larger version (53K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A —65-year-old man who underwent neoaortoiliac system procedure for infected aortobifemoral graft. Axial CT image after administration of IV contrast material shows popliteal veins distended with clots at stumps (arrows) after superficial femoropopliteal vein harvesting.

View larger version (54K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B —65-year-old man who underwent neoaortoiliac system procedure for infected aortobifemoral graft. Axial CT image obtained at more superior level than A, at area of vein harvesting, shows that superficial femoropopliteal veins are absent.

Image interpretation included axial images and 3D reconstructions using volume-rendering techniques and maximum intensity projections. All acquired image data were sent to a 3D workstation (Vitrea workstation, Vital Images) and evaluated predominately using planar reformations and volume-rendering techniques. Volume-rendered 3D images can over- or underestimate the degree of stenosis, so vessel analysis software is commonly used to further assess the degree of stenosis [6]. In many cases, patients present clinically with recurrent claudication; in those cases, a bilateral runoff protocol is added to the CTA protocol to evaluate the distal circulation. Reviewing the specific type of surgery each patient has undergone is important for adequate interpretation of CTA because most of the stenotic complications occur at anastomotic sites.

Complications—The incidence of major complications can be as high as 49%; these complications can include major amputations, compartment syndrome requiring fasciotomy, lower extremity paresis or paralysis, wound infections, and death [3, 4, 9, 10]. Neoaortoiliac system limb thrombosis can occur early in the postoperative period and usually occurs because of technical factors (Figs. 9A and 9B). Acute limb thrombosis can be associated with distal embolization, and the CTA protocol should include evaluation of the distal circulation (Figs. 10A, 10B, and 10C). Intimal hyperplasia at the anastomotic sites is not rare and requires surgical or endovascular reintervention [2] (Figs. 11A, 11B, 11C, 11D, 12A, 12B, 12C, 13A, 13B, 13C, and 13D). Other problems related to the use to native veins include retained valves (Fig. 14), small-caliber veins, and kinks. Development of aneurysmal degeneration of the native veins is rare (Fig. 15). Reinfection is uncommon because of the natural resistance of native veins to infection. However, patients with aggressive infections with gram-negative organisms, especially Pseudomonas aeruginosa, are at risk for anastomotic disruption with reinfection and bleeding [3].

View larger version (69K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A —48-year-old woman with severe aortoiliac disease and bilateral lower extremity claudication. Volume-rendered coronal projection before neoaortoiliac system procedure shows severe aortoiliac disease with diffuse stenosis of both iliac systems (arrows) with patent right femoropopliteal bypass (arrowheads). Left distal superior femoral artery and popliteal arteries are occluded. Patient underwent neoaortoiliac system procedure, but it was complicated by thrombosis of left limb of neoaortoiliac system. Leg amputation was performed 1 week after procedure.

View larger version (71K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B —48-year-old woman with severe aortoiliac disease and bilateral lower extremity claudication. Volume-rendered coronal image shows patent right limb of neoaortoiliac system and occluded left limb with proximal stump (arrow). Note also thrombosis of right femoropopliteal bypass.

View larger version (188K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A —60-year-old woman who underwent neoaortoiliac system procedure for infected aortobifemoral graft placed 1 year earlier presenting with acute ischemia of right leg lower extremity. Axial CT image shows partial thrombosis of right limb of neoaortoiliac system (arrow).

View larger version (75K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B —60-year-old woman who underwent neoaortoiliac system procedure for infected aortobifemoral graft placed 1 year earlier presenting with acute ischemia of right leg lower extremity. Volume-rendered right anterior oblique projection shows right limb stenosis (arrow); thrombus is not shown in 3D reconstruction.

View larger version (45K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10C —60-year-old woman who underwent neoaortoiliac system procedure for infected aortobifemoral graft placed 1 year earlier presenting with acute ischemia of right leg lower extremity. Volume-rendered posterior view of lower legs shows abrupt cutoff of right anterior and posterior tibial arteries related to distal embolization (arrowheads). Patient was treated with anticoagulation therapy and symptoms resolved thereafter.

View larger version (67K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11A —58-year-old woman who underwent neoaortoiliac system procedure 3 years before presenting with bilateral lower extremity claudication. Duplex sonogram shows tapering of abdominal aorta at proximal anastomosis of neoaortoiliac system (arrow). Note high velocities of 3.92 m/s at area of stenosis.

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11B —58-year-old woman who underwent neoaortoiliac system procedure 3 years before presenting with bilateral lower extremity claudication. Axial image shows severe decrease in caliber at area of stenosis (arrow).

View larger version (104K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11C —58-year-old woman who underwent neoaortoiliac system procedure 3 years before presenting with bilateral lower extremity claudication. Volume-rendered oblique projection shows severe stenosis of proximal anastomosis with infrarenal aorta (arrow).

View larger version (91K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11D —58-year-old woman who underwent neoaortoiliac system procedure 3 years before presenting with bilateral lower extremity claudication. Volume-rendered coronal image shows tube graft composed of synthetic polyester (Dacron, DuPont) extending from descending thoracic aorta into distal body of vein graft (arrows) and bypassing stenosis of proximal anastomosis of neoaortoiliac system.

View larger version (105K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12A —87-year-old woman who had undergone neoaortoiliac system procedure 5 months earlier presenting with severe left lower extremity claudication. Axial CT image (A) and volume-rendered coronal image (B) show severe stenosis of left limb of graft at end-to-side proximal anastomosis (arrows). Patient underwent right-to-left femoral crossover bypass graft with greater saphenous vein.

View larger version (106K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12B —87-year-old woman who had undergone neoaortoiliac system procedure 5 months earlier presenting with severe left lower extremity claudication. Axial CT image (A) and volume-rendered coronal image (B) show severe stenosis of left limb of graft at end-to-side proximal anastomosis (arrows). Patient underwent right-to-left femoral crossover bypass graft with greater saphenous vein.

View larger version (107K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12C —87-year-old woman who had undergone neoaortoiliac system procedure 5 months earlier presenting with severe left lower extremity claudication. Volume-rendered coronal image after surgical revision shows that left limb is now occluded. Severe stenosis is seen in midportion of femorofemoral bypass (arrow). Additional revision with angioplasty and stent placement was later performed.

View larger version (90K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13A —53-year-old woman who had undergone neoaortoiliac system procedure due to aortoiliac occlusive disease 1 year earlier presenting with limiting right leg claudication. Routine sonography shows very high velocities in right limb of neoaortoiliac system. Axial (A) and volume-rendered coronal (B) images show two high-grade stenoses in right limb of neoaortoiliac system (arrows). Native aorta (arrowhead, A) is occluded. Patient was treated with angioplasty of right limb stenosis, which resulted in vessel rupture; stent-graft was then placed.

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13B —53-year-old woman who had undergone neoaortoiliac system procedure due to aortoiliac occlusive disease 1 year earlier presenting with limiting right leg claudication. Routine sonography shows very high velocities in right limb of neoaortoiliac system. Axial (A) and volume-rendered coronal (B) images show two high-grade stenoses in right limb of neoaortoiliac system (arrows). Native aorta (arrowhead, A) is occluded. Patient was treated with angioplasty of right limb stenosis, which resulted in vessel rupture; stent-graft was then placed.

View larger version (85K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13C —53-year-old woman who had undergone neoaortoiliac system procedure due to aortoiliac occlusive disease 1 year earlier presenting with limiting right leg claudication. Routine sonography shows very high velocities in right limb of neoaortoiliac system. Volume-rendered coronal image after endovascular treatment shows metallic stent (arrows). Only surface of stent is visualized in 3D reconstruction.

View larger version (136K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13D —53-year-old woman who had undergone neoaortoiliac system procedure due to aortoiliac occlusive disease 1 year earlier presenting with limiting right leg claudication. Routine sonography shows very high velocities in right limb of neoaortoiliac system. Maximal-intensity-projection reconstruction image with vessel analysis shows that metallic stent is widely patent.

View larger version (76K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14 —65-year-old woman who had undergone neoaortoiliac system procedure for infected aortobifemoral graft presenting with left leg claudication. Volume-rendered oblique image shows severe stenosis of left distal limb of neoaortoiliac system (arrow) and mild to moderate stenosis in distal right limb (arrowhead). Retrograde filling of native right iliac system (I) is present. Right superficial femoral artery is occluded in short segment. Patient underwent patch angioplasty with greater saphenous vein. Lesion was produced by neointimal hyperplasia related to retained valve cusp.

View larger version (93K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 15 —Neoaortoiliac system procedure was performed 6 years earlier in 45-year-old man for severe aortoiliac disease. Volume-rendered coronal projection shows diffuse aneurysmal dilatation of right aortofemoral bypass (arrows). Right-to-left femorofemoral bypass has normal caliber.

Top Abstract Introduction Operative Planning and Surgical... Results Conclusion References

Acknowledgments
 
We would like to express our gratitude to Glen Katz for his excellent artistic work with the illustrations in Figures 1A, 1B, 1C, 1D, 1E, and 1F.

References

Top Abstract Introduction Operative Planning and Surgical... Results Conclusion References

 

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