TREATMENT OF COMPLEX ABDOMINAL AORTIC-ANEURYSMS BY A COMBINATION OF ENDOLUMINAL AND EXTRALUMINAL AORTOFEMORAL GRAFTS

Purpose: The purpose of this study was to test the hypothesis that abdominal aortic aneurysms (AAA) whose morphology makes them unsuited for repair with an endoluminal tube graft can be treated by a combination of a transluminally placed aortofemoral graft and a femorofemoral crossover graft. In addition the technique involves either ligation or balloon occlusion of the contralateral common iliac and internal iliac arteries in such a manner that excludes the AAA from the circulation. Methods: We report the use of this technique in three male patients with 6.4 to 7.0 cm diameter AAA. Two had renal impairment and cardiac function too poor to permit open repair, and the third had an unfavorable abdomen caused by previous surgery and the presence of a permanent colostomy. Each patient had an individually tailored Dacron tube graft constructed on the basis of preoperative arteriograms and computed tomography scans. The grafts were delivered transluminally into the aorta through a sheath in the iliac arteries and anchored proximally with a stainless steel stent under radiographic control. The grafts were then anastomosed distally to the femoral artery. Results: Recovery was complicated by a midgraft stenosis corrected by percutaneous balloon dilation in one patient, an episode of pulmonary edema in the second and an unexplained pyrexia in the third. Follow-up with duplex scanning confirmed normal flow through the grafts and the presence of thrombus between the prosthetic graft and the aneurysmal sac. Conclusions: We conclude that transluminal placement of an aortofemoral graft combined with a femorofemoral crossover graft is feasible in patients who are unsuited to repair with an endoluminal tube graft. The outcome with this technique is not known and requires further careful evaluation.