Alternative techniques for management of distal anastomoses of aortofemoral and iliofemoral endovascular grafts

Purpose: Techniques for managing the distal anastomoses of aortofemoral and iliofemoral endovascular grafts are described. Methods: Over a 2 1/2 -year period 46 endovascular grafts were successfully placed to treat severe iliac artery occlusive disease. Endovascular grafts were anchored proximally in the distal aorta or iliac arteries with Palmaz balloon-expandable stents. The distal anastomoses were performed with the use of open, sutured anastomotic techniques. In contrast to stented distal anastomoses, these techiques allowed us to (1) treat occlusive lesions extending from the distal aorta to below the inguinal ligament, (2) terminate endovascular grafts in the groin where stents are contraindicated, (3) vary the distal anastomotic site depending on the local pattern of disease, and (4) standardize the preinsertion length of the endovascular graft. Results: Two distal perianastomotic stenoses and one graft occlusion were detected postoperatively in 11 bypass grafts that had distal anastomoses sewn endoluminally without an overlying patch angioplasty. Only one perianastomotic stenosis was found among 35 anastomoses performed with other techniques. There were no significant differences in primary and secondary patency between grafts originating in the distal aorta or iliac arteries. Conclusions: Hand-sewn distal anastomoses can simplify the insertion of endovascular grafts used for the treatment of aortoiliac occlusive disease. These anastomoses permit tailoring of the graft according to the patients' pattern of disease and eliminate the need to precisely measure the length of the graft preoperatively. In addition, because a distal stent is not required, endovascular grafts can be safely terminated in the groin instead of the external iliac artery where disease progression can lead to graft failure. Finally, endovascular distal anastomoses should be closed with a patch or the hood of a more distal bypass graft to prevent perianastomotic stenoses or occlusions in the postoperative period.