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When a surgical approach is more favorable

Open AccessPublished:June 26, 2021DOI:https://doi.org/10.1016/j.jvscit.2021.04.028

      Keywords

      We are grateful to Pham MA et al. for sharing such an interesting case of a patient with a rare congenital anomaly of the common iliac arteries affected by an abdominal aortic aneurysm
      • Pham Minh-Anh
      • PhD M.D.
      • Thanh-Phong Le M.D.
      Preservation of internal iliac artery flow during endovascular aortic aneurysm repair in a patient with bilateral absence of common iliac artery.
      . In our opinion, this setting is challenging for a vascular surgeon and it highlights some interesting aspects we would like to discuss.
      Why did the authors decide to treat an abdominal aortic aneurysm with a maximum transverse diameter of less than 55 mm? The authors wrote that a 65-years old man was transferred to the vascular surgery department for management of an infrarenal AAA. His medical history included hypertension and a colectomy combined with protective ileostomy to treat a colonic perforation. Since it was not possible to assess the subject as a high-risk patient, why not opting for an open repair? The abdomen was hostile for median transperitoneal access to the aorta, but what about performing a left lombotomy retroperitoneal access? Reaching the right iliac artery and its bifurcation with this access is usually arduous. Nevertheless, it would have been feasible to clamp external and hypogastric iliac arteries by a balloon catheter. Thus, an extensive dissection would have been avoidable, and the patient’s congenital anatomy would have simplified the access to the right iliac bifurcation.
      In the authors’ comments, a surgical option was accepted but then discarded for the presence of a hostile abdomen and because an “endovascular repair could also be a suitable alternative”. Since the gold standard treatment for an abdominal aortic aneurysm is still open surgery, it is reasonable to suggest an OSR first strategy in younger, fit patients with a long life expectancy.
      • Wanhaineen A.
      • Verzini F.
      • Van Herzeele I.
      • Allaire E.
      • Bown M.
      • Cohnert T.
      • et al.
      Editor’s Choice e European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms.
      The endovascular planning devised by the authors, the left iliac branch deployment in the right short limb of the aortic main body, would have been a brilliant yet remarkable choice for a high-risk patient. However, it entails the occlusion of the right internal artery: this is an extremely critical point for a dramatic colic ischemia in a young patient already devoid of the inferior mesenteric artery.
      In our view, the best long-term option for this patient would have been a bifurcated surgical graft on hypogastric arteries with reimplantation of the external iliac arteries on the prosthetic branches.

      References

        • Pham Minh-Anh
        • PhD M.D.
        • Thanh-Phong Le M.D.
        Preservation of internal iliac artery flow during endovascular aortic aneurysm repair in a patient with bilateral absence of common iliac artery.
        J. Vasc. Surg. Cases Innov. Tech. 2021 Mar; 7: 108-112
        • Wanhaineen A.
        • Verzini F.
        • Van Herzeele I.
        • Allaire E.
        • Bown M.
        • Cohnert T.
        • et al.
        Editor’s Choice e European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms.
        Eur. J. Vasc. Endovasc. Surg. 2019; 57 (8e93)