1.

Aortoiliac Disease
 1. A 62-year-old woman presents for evaluation of her 5.6-cm
abdominal aortic aneurysm (AAA) shown in the coronal
computed tomograph. The patient strongly desires
endovascular repair. The most appropriate management of
this patient is:

A
Open infrarenal abdominal aortic aneurysm (AAA) repair

B
Open type IV thoracoabdominal repair

C
Endovascular repair with infrarenal device with 10-mm proximal neck indication

D
Endovascular repair with commercially available fenestrated device

E
Hybrid repair with open visceral debranching followed by endovascular relining of
the aorta
Answer 1

E
Hybrid repair with open visceral debranching followed by endovascular
relining of the aorta

HIDE
E
Discussion
The patient has a juxtarenal AAA with 7-mm proximal neck and could
undergo open repair. Any form of infrarenal endovascular repair is at
significant risk for further aneurysmal degeneration of her proximal neck
and development of a type IA endoleak. Bilateral renal artery snorkels
would allow additional seal zone in the pararenal segment and allow use
of off-the-shelf components in an urgent or emergent situation. However, it
likely would perform less well over time than renal fenestrations, because
of issues with gutter endoleaks and renal mobility with breathing. The
patient is a candidate for the commercially available zFen device and, given
her preference for endovascular repair, this is the best option for the
patient.

References
1. Oderich GS, Greenberg RK, Farber M, Lyden S, et al: Results of the
United States multicenter prospective study evaluating the Zenith
fenestrated endovascular graft for treatment of juxtarenal abdominal aortic
aneurysms. J Vasc Surg 2014 Dec;60(6):1420-8.e1-5. PMID: 25195145
 2. A 65-year-old man presents for consideration of repair of his
6.2-cm aortic aneurysm. He is otherwise healthy and has good
exercise tolerance. Selected axial, coronal, and sagittal cuts
of his preoperative computed tomography arteriogram are
shown. The recommended treatment for this patient is:

A
Open infrarenal abdominal aortic aneurysm (AAA) repair

B
Open type IV thoracoabdominal repair

C
Endovascular repair with infrarenal device with 10-mm proximal neck indication

D
Endovascular repair with commercially available fenestrated device

E
Hybrid repair with open visceral debranching followed by endovascular relining of
the aorta
Answer 2

B
Open type IV thoracoabdominal repair

Discussion
The patient has a type IV thoracoabdominal aneurysm with degeneration
of the paravisceral aorta. He has a high likelihood of further aneurysmal
degeneration if an open infrarenal repair is performed, which will
complicate subsequent repair of the paravisceral segment. He is not a
candidate for endovascular infrarenal repair, given his proximal neck. He
is not a candidate for the commercially available fenestrated device
secondary to this aneurysmal degeneration. Endovascular repair of type IV
thoracoabdominal aneurysms with 4-vessel snorkels or sandwich repairs
have been reported, but this is likely only being used because of the
absence of commercially available devices that allow for
branched/fenestrated repair in the United States. Open visceral
debranching with endovascular relining has been proposed as a way to
minimize visceral ischemia time and decrease the morbidity and mortality
of open thoracoabdominal repair. However, the open visceral debranching
procedure tends to take a relatively long time, carries associated morbidity
and mortality that are not insignificant, and makes the patient’s visceral
arteries depend on long prosthetic grafts. Therefore, open repair is
preferred in a patient who is a reasonable candidate for open repair.

References
1. Oderich GS, Greenberg RK, Farber M, Lyden S, et al: Results of the
United States multicenter prospective study evaluating the Zenith
fenestrated endovascular graft for treatment of juxtarenal abdominal aortic
aneurysms. J Vasc Surg 2014 Dec;60(6):1420-8.e1-5. PMID: 25195145
 3. A 60-year-old male smoker with hypertension presents with
an asymptomatic right popliteal artery aneurysm. What is the
prevalence of an associated abdominal aortic aneurysm?

A
5%
B
10%
C
25%
D
50%
E
85%
Answer 3

HIDE
D
50%

Discussion
An abdominal aortic aneurysm is present in approximately half (50%) of
patients with a popliteal aneurysm and 85% of patients with a femoral
aneurysm. Conversely, 10%-15% of patients with an abdominal aortic
aneurysm have a popliteal artery aneurysm.

References
1. Diwan A, Sarkar R, Stanley JC, et al: Incidence of femoral and popliteal
artery aneurysms in patients with abdominal aortic aneurysms. J Vasc Surg
2000 May;31(5):863-69. PMID: 10805875
 4. A 65-year-old male presents with an asymptomatic infrarenal
abdominal aortic aneurysm. Repair should be recommended
at what aortic diameter in order to maximize his long-term
survival?

A
4 cm
B
4.5 cm
C
5 cm
D
5.5 cm
E
6 cm
Answer 4

D
5.5 cm

Discussion
There are two large randomized trials evaluating the role of repairing small
aortic aneurysms: the Aneurysm Detection and Management (ADAM)
study and the UK small aneurysm trial. Both trials demonstrated a low
annual rupture risk for small aneurysms and concluded that the best
diameter at which to recommend repair remains 5.5 cm.

References
1. United Kingdom Small Aneurysm Trial Participants et al: Long-term
outcomes of immediate repair compared with surveillance of small
abdominal aortic aneurysms. N Engl J Med 2002 May 9;346(19):1445-
52. PMID: 12000814
2. Lederle FA, Wilson SE, Johnson GR, et al: Immediate repair compared
with surveillance of small abdominal aortic aneurysms. N Engl J Med 2002
May 9;346(19):1437-44. PMID: 12000813
 5. A 70-year-old man in otherwise good health presents with rest
pain in both his lower extremities. He had an endovascular
repair of an infrarenal aortic aneurysm several years ago with
no follow up. CT angiography obtained during his clinic visit is
shown (Figures). Operative mortality for late open conversion
is most closely related to:

A
Elective versus emergent operation
B
Presence of suprarenal fixation
C
Presence of a concurrent endoleak
D
Presence of graft occlusion
E
Need for supra-celiac cross-clamping
Answer 5
HIDE
A
A
Elective versus emergent operation

Discussion
Late open conversions are associated with significant mortality and
morbidity. Most conversions are done in an elective fashion. The 30-day
mortality for elective late open conversion (2.8%) is almost comparable to
that of primary elective open abdominal aortic aneurysm repair. Combined
30-day mortality rate for late elective and emergent open conversions is
approximately 16%, compared to emergent open conversions, which
carries a mortality rate that is 10 times higher compared to elective open
conversions. The most common indication for late open conversion is
endoleak (>60%). Most patients will need suprarenal surgical clamping—
with clamp locations reported literature to be at supraceliac (22%),
supramesenteric (1.3%), or suprarenal in (23%)—as compared to
infrarenal (36%).

References
1. Goudeketting SR, Fung Kon Jin PHP, Ünlü Ç, et al: Systematic review
and meta-analysis of elective and urgent late open conversion after failed
endovascular aneurysm repair. J Vasc Surg 2019 Aug;70(2):615-
628.e7. PMID: 30956006
 6. When compared with men, endovascular repair of abdominal
aortic aneurysms in women is associated with:

A
Higher mortality rates for elective endovascular repair
B
No difference in the threshold diameter of the aneurysm sac when considering
repair
C
Higher risk of rupture at a smaller diameter
D
Similar risk for post-operative cardiovascular complications
E
Exemption from current aneurysm screening guidelines if they are 65 years of age
or older and smoke
Answer 6

C
Higher risk of rupture at a smaller diameter

Discussion
Women are generally protected from development of abdominal aortic
aneurysms, with 3 to 4 times higher prevalence of aortic aneurysms in men
65 years of age and older. Women develop aneurysms later in age and
these are associated with aggressive growth and rupture. Current Society
for Vascular Surgery guidelines recommend screening in women who are
65 years and older with risk factors for developing aortic aneurysms that
include smoking and a family history of aortic aneurysms. There is a
stronger association in women between smoking and the development of
aneurysms. Generally, women should be considered for elective repair of
aortic aneurysms when the threshold diameter reaches 5.0–5.4 cm, rather
than waiting for growth to 5.5 cm, because these aneurysms tend to rupture
at smaller aortic diameters in women. Both men and women have
comparable mortality rates when considering elective endovascular repair,
with most morbidity resulting from access site complications. Women tend
to have suboptimal medical management of cardiovascular risk factors,
which may contribute to higher rates of postoperative complications.
Women have a higher rate of access site complications.

References
1. Lo RC, Schermerhorn ML: Abdominal aortic aneurysms in women. J
Vasc Surg 2016 Mar;63(3):839-44. PMID: 26747679
 7. A 55-year-old man with a 6-cm infrarenal abdominal aortic
aneurysm (AAA) is being counseled about repair. Compared
to open AAA repair, endovascular aneurysm repair (EVAR) is
associated with:

A
Higher rate of graft infections
B
Lower rate of late rupture
C
Lower rate of secondary interventions
D
No difference in late survival
E
Inferior late survival benefit
Answer 7

E
E
Inferior late survival benefit

Discussion
Follow-up results from EVAR-1 trial at 15 years suggests patients
undergoing endovascular repair have inferior late survival benefit
compared to open repair. Patients undergoing endovascular repair should
continue to have surveillance irrespective of the duration of the repair.
Although the patients undergoing endovascular repair have a higher risk
for secondary interventions, patients who undergo open repair are not
exempt from secondary interventions. Patients undergoing reinterventions
following endovascular repair have a continued risk for secondary
interventions at all-time points during follow up.

References
1. Patel R, Sweeting MJ, Powell JT, et al: Endovascular versus open repair
of abdominal aortic aneurysm in 15-years' follow-up of the UK
endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised
controlled trial. Lancet 2016 Nov 12;388(10058):2366-2374. PMID:
27743617
 8. A 58-year-old man in otherwise good health is referred to your
clinic with an aortic aneurysm. The patient is hemodynamically
stable with a large pulsatile abdominal mass. The CT
angiographic image is shown in the figure. The most
appropriate treatment for this patient is:

A
Endovascular repair of aortic aneurysm (EVAR)
B
Open aortic aneurysm repair
C
Fenestrated endovascular aneurysm repair
D
Endovascular repair with use of endoanchors
E
Chimney/snorkel endovascular aneurysm repair
Answer 8

B
Open aortic aneurysm repair

B
Discussion
This 58-year-old patient is relatively young and in good health with an
anatomy that is a contraindication for conventional endovascular aneurysm
repair. He has no suitable aortic neck for the conventional repair (15-mm
infrarenal aortic neck) or even for the use of endoanchor-assisted repair.
The lack of any infrarenal aortic neck would make an FDA-approved
fenestrated EVAR outside the Instructions for Use (IFU) for the device.
Furthermore, other complex endovascular aortic repairs will need
continued surveillance, which will increase the risk of renal insufficiency as
well as radiation-related secondary malignancies. Open repair of the aortic
aneurysm remains an appropriate choice for this patient. Suboptimal repair
with endovascular methods will be associated with device migration,
endoleaks, and the need for secondary interventions with eventual failure
of the endovascular repair. Patients who are younger than 65 years of age
have comparative mortality outcomes following open or endovascular
abdominal aortic aneurysm repair.

References
1. Donas KP, Lee JT, Lachat M, et al: Collected World Experience About
the Performance of the Snorkel/Chimney Endovascular Technique in the
Treatment of Complex Aortic Pathologies the PERICLES Registry. Ann
Surgery 2015 Sep; 262(3):546-553. PMID: 26258324
2. Liang NL, Reitz KM, Makaroun MS, et al: Comparable perioperative
mortality outcomes in younger patients undergoing elective open and
endovascular abdominal aortic aneurysm repair. J Vasc Surg 2018 May;
67(5):1404-1409. PMID: 29097041
3. Chaikof EL, Dalman RL, Eskandari MK, et al: The Society for vascular
surgery practice guidelines on the care of patients with an abdominal aortic
aneurysm. J Vasc Surg 2018 Jan; 67(1)2-77. PMID: 29268916
 9. The anatomic factor that will limit fenestrated endovascular
repair of abdominal aortic aneurysms using currently available
FDA approved stent grafts is:

A
Infrarenal aortic neck ≥ 4 mm
B
Angle < 45 degrees relative to the long axis of the aneurysm
C
Angle < 45 degrees relative to the axis of the suprarenal aorta
D
Ipsilateral distal fixation site > 30 mm in length and 9-21 mm in diameter
E
Main renal artery measuring 7 mm with bifurcation less than 15 mm from the origin
Answer 9

E
E
Main renal artery measuring 7 mm with bifurcation less than 15 mm from
the origin

Discussion
The FDA has approved Zenith fenestrated endovascular grafts (Z-FEN) for
the treatment of aortic aneurysms involving the juxtarenal abdominal aorta.
The following anatomic factors are important for repair. Patients should
have an infrarenal aortic neck measuring ≥4 mm with diameters between
19-31 mm at the attachment site. They also should have an angulation or
curvature of <45 degrees relative to the long axis of the aneurysm as well
as the suprarenal aorta. Patients should have adequate femoral and iliac
artery access for the delivery of the device, with an ipsilateral iliac artery
fixation site of >30 mm in length measuring 9-21 mm in diameter and with
contralateral iliac artery fixation site of > 30 mm in length with 7-21 mm in
diameter when measured from outer wall to outer wall of the aneurysm.
Patients with multiple renal arteries as well as those with early branches
points or bifurcations compromising flow into more than a third of the renal
parenchyma is considered as a limitation of this technology.

References
1. Physician’s pocket reference
guide. https://www.cookmedical.com/data/resources/AI-D22611-EN-
F_M3_2016-01-27_111103.pdf. Accessed January 30, 2020
2. Oderich GS, Greenberg RK, Farber M, et al: Results of the United States
multicenter prospective study evaluating the Zenith fenestrated
endovascular graft for treatment of juxtarenal abdominal aortic aneurysms.
J Vasc Surg 2014 Dec;60(6):1420-8. PMID: 25195145
3. Oderich GS, Correa MP, Mendes BC. Technical aspects of repair of
juxtarenal abdominal aortic aneurysms using the Zenith fenestrated
endovascular stent graft. J Vasc Surg 2014 May;59(5):1456-1461. PMID:
24767275
 10. Compared to fenestrated endovascular repair, a
significant limitation of parallel stent graft repair
(chimney/snorkel stenting) is:

A
Need for at least 20 mm proximal seal zone
B
Higher risk of renal stent occlusions
C
Higher branch vessel reinterventions
D
Higher 30-day mortality
E
Persistent endoleaks and gutter leaks
Answer 10

HIDE
A
A
Need for at least 20 mm proximal seal zone

Discussion
Multi-center studies evaluating the chimney/snorkel stents with outcomes
reported using PERICLES registry represent the largest collection of
chimney/snorkel endovascular aneurysm repair (ChEVAR) procedures.
Study examined the use of this technique applied to the treatment of
complex juxtarenal and pararenal aortic pathologies. When systematic and
meta-analysis were compared to the outcomes from the PERICLES
registry, there was no difference in the degree of sac regression
postoperatively, the rate of primary patency of these chimney grafts, and
the relatively low incidence of type I endoleaks requiring intervention. The
majority of intraoperative endoleaks may resolve when assessed with
follow-up imaging studies. Registry also reports pooled 30-day mortality
after FEVAR (2.1%) from reported literature as comparable to those from
elective CHEVAR (3.7%). Close attention to technical details, device
selection, and careful planning to create a sufficient seal zone of at least
20 mm is necessary to achieve good outcomes.

References
1. Donas KP, Lee JT, Lachat M, et al: Collected World Experience About
the Performance of the Snorkel/Chimney Endovascular Technique in the
Treatment of Complex Aortic Pathologies the PERICLES Registry. Ann
Surgery 2015 Sep; 262(3):546-553. PMID: 26258324
 11. The most appropriate use of endoanchors as an
adjunctive technique to repair infrarenal aortic aneurysms is:

A
Prevention of type 1A endoleaks in patients with aortic neck thrombus
B
Prevention of type 1A endoleaks in patients with calcium-laden aortic neck
C
Prevention of type 1A endoleaks in the absence of hostile neck anatomy
D
Treatment of type 1 endoleaks in endografts with infrarenal, but not suprarenal,
aortic fixation
E
Treatment of intraoperative acute and delayed type 1A endoleaks
Answer 11

E
E
Treatment of intraoperative acute and delayed type 1A endoleaks

Discussion
Endoanchors are used to treat existing and acute type IA endoleaks as well
as endograft migration. Prophylactic use of endoanchors in patients with
hostile aortic neck anatomy appears promising. Initial results from the
ANCHOR registry indicate that at midterm follow up, primary use and
delayed secondary use of endoanchors with infrarenal and suprarenal
fixation stent grafts are equally effective in maintaining a low incidence of
type Ia endoleaks, aneurysm sac regression and need for secondary
interventions. Currently available anchors have a penetration of 4.5 mm
with a 3-mm diameter and their use in patients with thrombus or calcium-
laden aorta is questionable.

References
1. Jordan Jr WD, Mehta M, Varnagy D, et al: Results of the ANCHOR
prospective, multicenter registry of EndoAnchors for type Ia endoleaks and
endograft migration in patients with challenging anatomy. J Vasc Surg
2014 Oct;60(4):885-92. PMID: 25088739
2. Mehta M, et al: EndoAnchors Use With Infrarenal Versus Suprarenal
Stent Grafts—Results From ANCHOR Global Registry. J Vasc Surg
2017;66(4):e91. https://www.jvascsurg.org/article/S0741-5214(17)31810-
4/abstract. Accessed January 30, 2020
 12. A 78-year-old woman is referred for evaluation of a 5 cm
pararenal abdominal aortic aneurysm. Comorbidities include
coronary artery disease with a percutaneous coronary
intervention 6 months ago, chronic obstructive pulmonary
disease requiring bronchodilators, and chronic kidney disease
with a maximum serum creatinine level of 1.8 mg/dl. The
probability of mortality from an open repair is:

A
1%
B
5%
C
10%
D
15%
E
>30%
Answer 12

E
E
>30%

Discussion
Society for Vascular surgery practice guidelines dictate the use of the
Vascular Quality Initiative mortality risk calculator to identify patients at low,
medium, high, and prohibitive risk for aneurysm repair. The risk calculator
incorporates variables of type of repair, location of clamp for vascular
control, aneurysm size, age, gender, presence or absence of myocardial
disease, cerebrovascular disease, chronic obstructive pulmonary disease,
and underlying renal insufficiency. Each of these variables carry points,
based on which the probability of mortality from the proposed procedure is
predicted. This should help physicians make decisions using a risk/benefit
ratio of the repair as well as which patients can be safely subjected to repair
with acceptable risk compared to continued surveillance.

References
1. Chaikof EL, Dalman RL ,Eskandari MK, et al: The society for vascular
surgery practice guidelines on the care of patients with an abdominal aortic
aneurysm. J Vasc Surg 2018 Jan;67(1):2-77. PMID: 29268916
2. Eslami MH, Rybin D, Doros G, et al: Comparison of a vascular study
group of New England risk prediction model with established risk prediction
models of in-hospital mortality after elective abdominal aortic aneurysm
repair. J Vasc Surg 2015 Nov;62(5):1125-33. PMID: 26187291
 13. A 68-year-old woman undergoes uneventful open repair
of a DeBakey Type 2 thoracoabdominal aortic aneurysm. The
chances of developing a late aortic or graft-related problem is
approximately:

A
2%
B
5%
C
10%
D
30%
E
50%
Answer 13

C
C
10%

Discussion
Clouse et al looked at late outcomes over a 15-year period with a mean
follow up of 30 months. Of the 333 patients studied, 10.8% (33 patients)
developed events related either to aortic disease (7.9%) or to grafts (2.9%).
Four risk factors were independent predictors of late events: female gender
(odds ratio [OR] 2.3), partial aortic aneurysm resection (OR 4.2), expansion
of the remaining native aorta (OR 2.5), or initial aneurysm rupture (OR 4.8).
Aneurysm etiology (dissection or degenerative) and extent of disease had
no independent correlation.

References
1. Clouse WD, Marone LK, Davison JK, et al: Late aortic and graft-related
events after thoracoabdominal aneurysm repair. J Vasc Surg 2003
Mar;37(2):254-61. PMID: 12563193
 14. A 60-year-old man with a 4-cm thoracoabdominal aortic
aneurysm is being followed with annual CT scans. He
presents to the emergency department with a urinary tract
infection. The antibiotic shown to have an increased risk of
aneurysmal degeneration is:

A
Fluoroquinolones
B
Cephalosporins
C
Macrolides
D
Sulfonamides
E
Tetracyclines
Answer 14

A
A
Fluoroquinolones

Discussion
Fluoroquinolones should be avoided in patients with existing aneurysms
and dissection as well as those at risk for aneurysm formation, unless no
other treatment option is available. The FDA Adverse Event Reporting
System (FAERS) database review of multiple epidemiological studies
showed a possible association between fluoroquinolone use and increased
risk of aortic aneurysm or dissection. A study by Lemaire and associates
examined the effect of ciprofloxacin on aortic aneurysm and dissection
(AAD) development in mice. It showed ciprofloxacin increases
susceptibility to aortic dissection and rupture. They added that ciprofloxacin
should be used with caution in patients with aortic dilatation, as well as in
those at high risk for AAD.

References
1. Lee CC, Lee MG, Chen YS, et al: Risk of Aortic dissection and aortic
aneurysm in patients taking oral fluoroquinolone. JAMA Int Med 2015
Nov;175(11):1839-47. PMID: 26436523
2. Pasternak B, Inghammar M, Svanstrom H. Fluoroquinolone use and risk
of aortic aneurysm and dissection: nationwide cohort study. BMJ 2018
Mar;360:k678. PMID: 29519881
3. Lee CC, Lee MG, Hsieh R, et al: Oral fluoroquinolone and the risk of
aortic dissection. J Am Coll Cardiol 2018 Sep;72(12):1369-1378. PMID:
30213330
4. LeMaire SA, Zhang L, Luo W, et al: Effect of Ciprofloxacin on
Susceptibility to Aortic Dissection and Rupture in Mice. JAMA Surg. 2018
Sep;153(9):e181804. doi: 10.1001/jamasurg.2018.1804. PMID: 30046809
 15. A spinal drain was removed on postoperative day 3 after
open repair of a DeBakey type 2 thoracoabdominal aortic
aneurysm. The next morning the patient developed bilateral
lower extremity motor sensory deficit consistent with spinal
cord ischemia. Epidural hematoma was excluded and a new
spinal drain was inserted. The intervention least likely to
reverse spinal cord ischemia is to:

A
Increase mean blood pressure to above 90 mmHg
B
Place patient flat
C
Place patient on oxygen
D
Drain CSF to a pressure less than 15 mmHg
E
Keep hemoglobin above 12 mg/dl
Answer 15
HIDE
D
D
Drain CSF to a pressure less than 15 mmHg

Discussion
Estrera et al reported their use of the “COPS” protocol (cerebrospinal drain
status, oxygen delivery, patient status) for patients with delayed neurologic
deficit. The spinal drain was left for at least 7 days and pressure maintained
at less than 5 mmHg. Oxygen delivery was increased by supplementing
oxygen, increasing hemoglobin, and increasing cardiac index. BP was
maintained at a mean greater than 90 mmHg. Other groups have reported
the use of COPS in their practice for delayed neurologic deficits with
success.

References
1. Estrera AL, Sheinbaum R, Miller CC, et al: Cerebrospinal fluid drainage
during thoracic aortic repair: safety and current management. Ann Thorac
Surg 2009 Jul;88(1): 9-15; discussion 15. PMID: 19559180
2. Yanase Y, Kawaharada N, Maeda T, et al: Treatment of delayed
neurological deficits after surgical repair of thoracic aortic aneurysm. Ann
Thorac Cardiovasc Surg 2012; 18(3):271-4. PMID: 22791006
 16. The most common complication seen after open
thoracoabdominal aortic aneurysm (TAAA) repair is:

A
Cardiac
B
Stroke
C
Renal failure
D
Paralysis
E
Pulmonary
Answer 16

E
E
Pulmonary

Discussion
The most common complication seen after open TAAA repair is pulmonary
due to the high association between smoking and aneurysm formation.
Some degree of chronic obstructive pulmonary disease will be present in
30% to 40% of the patients. Based on the largest series for open TAAA
(3,309 patients) by Coselli et al, pulmonary complications were reported in
35.85% of the cohort. Extent 2 TAA had the highest incidence of pulmonary
complications at 42.7%, followed by Extent 1 (38%), Extent 3 (33.8%), and
Extent 4 at 23.9%. Tracheostomy was required in 8.5% of the cohort, with
extent 2 having the highest risk at 12.3%.

References
1. Coselli JS, LeMaire SA, Preventza O, et al: Outcomes of 3309
thoracoabdominal aortic aneurysm repairs. J Thorac Cardiovasc Surg
2016 May;151(5):1323-37. PMID: 26898979
 17. A 47-year-old man with Marfan’s syndrome presents with
an asymptomatic DeBakey type 2 thoracoabdominal aortic
aneurysm measuring 5.5 cm in maximum diameter. The best
repair option for this patient is:

A
Endografting with a four-vessel investigator-modified device
B
Abdominal debranching followed by aortic endografting
C
Open repair with the celiac and superior mesenteric arteries as one on-lay (Carrel)
patch and individual bypasses to both renal arteries
D
Open repair with the celiac, superior mesenteric, and right renal arteries as one on-
lay (Carrel) patch and a separate bypass to the left renal artery
E
Open repair with individual bypasses to the celiac, superior mesenteric, right renal,
and left renal arteries
Answer 17

E
E
Open repair with individual bypasses to the celiac, superior mesenteric,
right renal, and left renal arteries

Discussion
Patients with connective tissue disorder should be treated with open repair.
Endovascular repair at this point is reserved for emergency cases and
when anatomy is suitable to stabilize them for open repair. Open repair
requires individual bypasses to the visceral segments, rather than on-lay
(Carrel) patches, because of the high risk of aneurysmal degeneration of
the on-lay patch constructed from the abnormal aorta of patients with
Marfan’s syndrome. Anastomotic patch aneurysms are common in these
patients. Abdominal debranching in general was associated with significant
morbidity and mortality.

References
1. De Rango P, Estrera AL, Miller C 3rd, et al: Operative outcomes using a
side-branched thoracoabdominal aortic graft (STAG) for thoracoabdominal
aortic repair. Eur J Vasc Endovasc Surg 2001 Jan;41(1),41-47. PMID:
21147541
2. Afifi RO, Tanaka A, Yazji I, et al: Thoracoabdominal aortic aneurysm
repair in Marfan syndrome: how we do it. Ann Cardiothorac Surg 2017
Nov;6(6):709-11. PMID: 29270385
 18. A 77-year-old woman, who is a heavy smoker with
multiple comorbidities, is being evaluated for
fenestrated/branched endovascular repair of her 7.1-cm
thoracoabdominal aortic aneurysm (TAAA) (Figures). There is
a significant amount of thrombus. Aortic wall thrombus is
associated with increased:

A
Operative mortality
B
Cardiac complications
C
Limb loss
D
Solid organ infarction
E
Late mortality
Answer 18

HIDE
D
Solid organ infarction

Discussion
A recent single center study looked at not only the risks associated with
thrombus and endovascular TAAA treatment, but also examined the
thrombus burden. Severe aortic wall thrombus was associated with solid
organ infarction (24%), acute kidney injury (21%) that did not require
permanent dialysis, and delay in resuming oral intake by 3.4 days. Despite
these complications, the cohort of 212 patients had only one (0.5%) 30-day
mortality. The effect and burden of aortic wall thrombus has not been well
studied with open repair outcomes.

References
1. Ribeiro M, Oderich GS, Macedo T, et al: Assessment of aortic wall
thrombus predicts outcomes of endovascular repair of complex aortic
aneurysms using fenestrated and branched endografts. J Vasc Surg 2017
Nov;66(5):1321-33. PMID: 28596039
 19. In patients undergoing thoracoabdominal aortic
aneurysm (TAAA) repair, the complication that has the same
incidence regardless of age is:

A
Stroke
B
Spinal cord ischemia
C
Renal failure
D
Cardiac complication
E
Hospital length of stay
Answer 19

A
A
Stroke

Discussion
In a large series published by Coselli et al, the outcomes patients
undergoing TAAA repair were stratified and compared based on age.
Patients younger than 50 years were compared with those older than 50
years of age (445 vs. 2,901 patients, respectively). The comparison
showed the following results based on age: operative death = 3.1%
vs.8.2%; stroke = 1.3% vs. 2.55 (not significant); paraplegia = 1.1% vs.
3.2%), renal failure = 1.6% vs. 6.3%; cardiac complication = 11.2% vs.
28.3%; and length of hospital stay = 10 days vs. 12 days. The only
comparison that was not significantly different in the two age groups was
the risk of stroke. Despite these excellent results, the long-term survival
was 85%, 69%, and 52% at 5, 10, and 15 years.

References
1. Coselli JS, Amarasekara HS, Green SY, et al: Open repair of
thoracoabdominal aortic aneurysm in patients 50 years old and younger.
Ann Thorac Surg 2017 Jun;103(6):1849-57. PMID: 27938888
 20. The characteristic that is associated with increased risk
of aortic growth in patients with uncomplicated type B aortic
dissections is:

A
Age older than 70 years
B
Aortic diameter of greater than 40 mm
C
Aortic false lumen diameter of less than 20 mm
D
Entry tear less than 10 mm
E
Elliptical formation of false lumen
Answer 20

HIDE
B
Aortic diameter of greater than 40 mm

Discussion
Patients with uncomplicated type B aortic dissections can be managed
medically with anti-impulse control. These patients need to be followed
closely with imaging studies to monitor aortic diameter because they are at
high risk for developing aortic aneursyms with risk of rupture in future. It is
important to know which factors predict rapid aortic growth in patients with
type B aortic dissections. A study by Van Bogerijen et al showed the factors
listed in Outline 1 to be associated with a high risk for developing rapid
aortic growth in such patients.

References
1. van Bogerijen GH, Tolenaar JL, Rampoldi V, et al: Predictors of aortic
growth in uncomplicated type B aortic dissection. J Vasc Surg 2014
Apr;59(4):1134-43. PMID: 24661897
2. Reutersberg B, Trenner M, Haller B, et al: The incidence of delayed
complications in acute type B aortic dissections is underestimated. J Vasc
Surg 2018 Aug;68(2):356-63. PMID: 29615351
 21. A 72-year-old man presents with crushing chest pain. A
CT angiogram shows acute type B aortic dissection with one
true lumen and 2 false lumens. The presence of multiple false
lumens places this patient at an increased risk for:

A
Death
B
Aneurysmal dilatation
C
Re-dissection
D
Organ ischemia
E
Limb ischemia
Answer 21

HIDE
A
A
Death

Discussion
Traditionally, management of acute type B aortic dissection included
conservative management with strict blood pressure control. Recent
literature supports endovascular repair (TEVAR) is the preferred treatment
modality. Many of these recommendations are based on data for patients
with double-barreled aortic lumen (a single true lumen, and a single false
lumen). The presence of more than one false lumen, also known as multi-
barreled aortic lumen, is an entity that is relatively less frequently
described. Sueyoshi et al compared the outcomes of aortic dissections with
double-barreled anatomy with outcomes related to multi-barreled anatomy
and showed that the mortality rate for patients with multi-barreled aortic
dissections was significantly higher than that with double-barreled aortic
lumens (45% vs 17%).

References
1. Sueyoshi E, Nagayama H, Hayashida T, et al: Comparison of outcome
in aortic dissection with single false lumen versus multiple false lumens:
CT assessment. Radiology 2013 May;267(2):368-75. PMID: 23297333
 22. A 72-year-old man underwent endovascular repair of
acute type B aortic dissection with placement of a thoracic
endograft. Two days later, he complains of severe chest pain.
He undergoes CT angiography (Figure). This finding is
associated with:

A
>10% oversizing of endograft
B
Multiple endografts
C
Proximal endograft stent configuration
D
Proximal landing zone diameter less than 40 mm
E
Choice of endograft
Answer 22

A
>10% oversizing of endograft

Discussion
Thoracic endovascular aortic repair (TEVAR) is being increasingly used for
the treatment of acute and chronic type B aortic dissections. One of the
most challenging complications of this procedure is retrograde type A
dissection. Although the incidence of this complication is low (1.6%), it is
associated with high mortality, ranging from 7% to 50%. Several factors
have been associated with retrograde type A dissections. Canaud et al
have shown that an oversized endograft is significantly associated with this
complication. Each percentage increase in endograft oversizing above 9%
resulted in a relative increased risk of retrograde type A dissection by 14%.
Tjaden et al, in reporting the outcomes from the Gore Global Registry,
showed that a proximal landing zone diameter of more than 40 mm was
associated with increased risk of retrograde type A dissection (18% vs 2%).
Other risk factors for retrograde dissection include peri-procedural
hypertension, proximal deployment zones, and underlying aortopathy at
the proposed seal zone.

References
1. Canaud L, Ozdemir BA, Patterson BO, et al: Retrograde aortic dissection
after thoracic endovascular aortic repair. Ann Surg 2014 Aug;260(2):389-
95. PMID: 24441822
2. Tjaden BL Jr, Sandhu H, Miller C, et al: Outcomes from the Gore Global
Registry for Endovascular Aortic Treatment in patients undergoing thoracic
endovascular aortic repair for type B dissection. J Vasc Surg 2018
Nov;68(5):1314-32. PMID: 29941315
 23. The use of thoracic endovascular aortic repair (TEVAR)
to treat type B aortic dissections is associated with the
following effect on aortic diameter:

A
TEVAR stops progression of aortic lumen growth completely
B
Thoracic aortic diameter becomes normal, but abdominal aortic diameter continues
to grow
C
Thoracic aortic diameter continues to grow, and abdominal aortic diameter is
unchanged
D
Both thoracic and abdominal aortic diameters continue to grow
E
No data exist to support growth or regression of a false lumen
Answer 23

D
D
Both thoracic and abdominal aortic diameters continue to grow

Discussion
TEVAR has become the treatment of choice for complicated thoracic aortic
dissections. In the short term, TEVAR has been shown to be effective to
prevent development of thoracic aortic aneurysms. The success of TEVAR
for complicated thoracic aortic dissections has led many to believe that the
same results could be obtained in patients with uncomplicated type B aortic
dissections. As patients with uncomplicated type B dissections do not have
symptoms of malperfusion, the aim of TEVAR in such cases is to prevent
aneurysmal degeneration. A recent systemic review and meta-analysis by
Famularo et al has shown that the thoracic aorta continues to grow in 6%
to 84% of patients who undergo TEVAR for aortic dissection. In addition,
the abdominal aorta continues to grow in 10% to 54% of such patients.
These results caution against treating all type B aortic dissections with
TEVAR.

References
1. Famularo M, Meyermann K, Lombardi JV. Aneurysmal degeneration of
type B aortic dissections after thoracic endovascular aortic repair: A
systematic review. J Vasc Surg 2017 Sep;66(3):924-30. PMID: 28736120
 24. A 45-year-old man presents with acute onset of crushing
pain in chest that does not resolve over the next 48 hours with
optimal medical therapy. His CT angiography findings are
shown in the Figure. In addition to anti-impulse therapy, the
best treatment for this patient is:

A
Thoracic endovascular aortic repair (TEVAR)
B
TEVAR with coverage of left subclavian artery
C
Left carotid subclavian bypass and TEVAR
D
Continued medical management
E
Open thoracic aortic repair
Answer 24

C
C
Left carotid subclavian bypass and TEVAR

Discussion
A young man presenting with acute thoracic aortic dissection with multiple
lumens should be treated with TEVAR in addition to medical therapy.
TEVAR requires a 2 cm proximal landing zone when treating an aortic
dissection. The location of an entry tear in the aorta in this case is adjacent
to the origin of left subclavian artery and necessitates the placement of an
endograft in zone 2, which will cover the origin of left subclavian artery. A
retrospective study performed by Bradshaw et al showed that the risk of
30-day stroke in patients undergoing zone 2 TEVAR without left subclavian
artery revascularization was 14.3%. The risk of stroke was 1.9% for
patients who underwent left subclavian artery revascularization followed by
TEVAR. The incidence of spinal cord ischemia was not different between
these two treatment groups. In elective situations, revascularization of the
left subclavian artery is recommended before TEVAR. In emergency
situations, revascularization of the left subclavian artery must be decided
on a case-by-case basis.

References
1. Bradshaw RJ, Ahanchi SS, Powell O, Larion S, et al: Left subclavian
artery revascularization in Zone 2 thoracic endovascular aortic repair is
associated with lower stroke risk across all aortic diseases. J Vasc Surg
May 2017;65(5):1270-79. PMID: 28216353
2. Teixeira PG, Woo K, Beck AW, et al: Association of left subclavian artery
coverage without revascularization and spinal cord ischemia in patients
undergoing thoracic endovascular aortic repair: A Vascular Quality
Initiative® analysis. Vascular 2017 Dec;25(6):587-97. PMID: 29022855
 25. The characteristic that is associated with the growth of
false lumen in patients with uncomplicated type B aortic
dissection is:

A
Male gender
B
Number of vessels originating from false lumen
C
Smoking
D
Shorter length of dissection
E
Number of patent false lumens
Answer 25

HIDE
B
Number of vessels originating from false lumen

Discussion
Patients with uncomplicated type B aortic dissections are commonly
treated with best medical therapy, with in-hospital mortality rates of 1% to
10%. Between 20% and 50% of such patients will require subsequent
invasive treatments due to complications, including aneurysmal
degeneration of the diseased aortic segments. TEVAR has suggested as
the treatment of choice to prevent complications in patients with
uncomplicated type B aortic dissections. The Investigation of Stent Grafts
in Aortic Dissection (INSTEAD) trial did not show short-term benefits of
TEVAR, but long-term outcomes favored TEVAR. The Acute Dissection
Stent Grafting or Best Medical Treatment (ADSORB) trial showed benefits
of TEVAR in aortic remodeling at 1- year follow up. Several studies have
tried to identify the patients who are at high risk for growth in the false aortic
lumen. Kamman et al analyzed the patients in ADSORB trial and showed
that the number of vessels originating from false lumen at baseline and the
increased length of the dissected aorta were associated with the continued
growth of false lumen.

References
1. Nienaber CA, Rousseau H, Eggebrecht H, et al: Randomized
comparison of strategies for type B aortic dissection: the INvestigation of
STEnt Grafts in Aortic Dissection (INSTEAD) trial. Circulation 2009
Dec;120(25):2519–28. PMID: 19996018
2. Brunkwall J, Kasprzak P, Verhoeven E, et al: Endovascular repair of
acute uncomplicated aortic type B dissection promotes aortic remodelling:
1-year results of the ADSORB Trial. Eur J Vasc Endovasc Surg 2014 Sep;
48(3):285–91. PMID: 24962744
3. Kamman AV, Brunkwall J, Verhoeven EL, et al: Predictors of aortic
growth in uncomplicated type B aortic dissection from the Acute Dissection
Stent Grafting or Best Medical Treatment (ADSORB) database. J Vasc
Surg 2017 Apr;65(4):964-71. PMID: 27876516
 26. A 78-year-old man underwent endovascular repair of his
abdominal aortic aneurysm 12 years ago. Approximately 1
month ago, he began developing fever, chills, and general
malaise. On clinical examination, he is awake and
normotensive with a low-grade fever. His computed
tomography scan is shown in the Figure. The best treatment
option for this patient is:

A
Intravenous antibiotics for 6 weeks
B
Recanalize the left iliac limb, perform thrombolysis, and place an iliac stent
C
Undergo percutaneous access and drainage of the abscess in the aortic sac with
intravenous antibiotics tailored to culture results
D
Proceed with an esophagogastroduodenoscopy
E
Explant the infected graft with revascularization
Answer 26

E
E
Explant the infected graft with revascularization

Discussion
This patient has an abscess in his aortic sac with a thrombosed left
common iliac limb in the setting of constitutional symptoms affirming
infectious process, and possibly even an aortoenteric fistula. The principles
of management in this situation include removal of all infected prosthetics,
repair the bowel if there is an aortoenteric fistula, and in situ
revascularization with a rifampin-soaked dacron graft, a cryopreserved
allograft, or an autogenous deep vein graft. Esophagogastroduodenoscopy
is frequently non-diagnostic, as the most common site of a fistula is the
fourth portion of the duodenum. Additionally, insufflating the upper
gastrointestinal tract during esophagogastroduodenoscopy can result in
uncontrolled hemorrhage. Intravenous antibiotics are tailored to the
organisms identified on preoperative and intraoperative cultures, although
antibiotic therapy is not viable as the only therapy option. Percutaneous
drainage and recanalization of iliac limb are also not definitive treatments
to address the problem.

References
1. Smeds MR, Duncan AA, Harlander-Locke MP, et al: Treatment and
outcomes of aortic endograft infection. J Vasc Surg 2016 Feb;63(2):332-
40. PMID: 26804214
2. Fatima J, Duncan AA, de Grandis E et al: Treatment strategies and
outcomes in patients with infected aortic endografts. J Vasc Surg 2013
Aug;58(2):371-9. PMID: 23756338
3. Oderich GS, Bower TC, Hofer J, et al: In situ rifampin-soaked grafts with
omental coverage and antibiotic suppression are durable with low
reinfection rates in patients with aortic graft enteric erosion or fistula. J Vasc
Surg 2011 Jan;53(1):99-106, 107.e1-7; discussion 106-7. PMID:
21184932
 27. A 75-year-old man with a history of treated coronary
artery disease underwent an endovascular aortic aneurysm
repair (EVAR) 10 years ago for a 5.0-cm infrarenal abdominal
aortic aneurysm. He developed a type II endoleak 7 years
later, for which he underwent inferior mesenteric artery
embolization for an aortic sac enlargement to 5.8 cm. The
patient underwent a transcaval embolization 2 years after that
for a sac enlargement to 6.3 cm. He presents with aortic sac
enlargement to 7.0 cm, persistent type II endoleak, and
impending type 1a endoleak with a decrease of the proximal
seal to 8 mm (Figure). The optimal treatment strategy to
adequately address this EVAR complication is:

A
Observation, with a CT scan in 6 months to
assess growth of abdominal aortic aneurysm
B
Placement of an aortic cuff with endoanchors to
reinforce the proximal seal
C
Trans-lumbar embolization with additional coils
and glue
D
EVAR conversion with explant of aortic
endograft and in situ repair using a dacron graft
E
EVAR conversion with explant of the aortic
endograft and in situ repair using a femoral vein
Answer 27
D
D
EVAR conversion with explant of aortic endograft and in situ repair using
a dacron graft

Discussion
This patient has persistent type II endoleak with pressurization of the aortic
sac despite multiple prior attempts at endovascular remediations. Given
the growth in aortic sac size, the proximal seal is now compromised. Any
therapy at this point should address both problems. Although endoanchors
and aortic cuff may address and prevent type Ia endoleak, this will be
temporary until the type II endoleak is also addressed adequately. After
multiple failed endovascular remediations, it is best to convert to open
repair with an EVAR conversion. This will require supraceliac control and
clamp, explant of the endograft, suture ligation of back-bleeding lumbars,
and in situ aorto-iliac repair. Given the absence of infectious etiology,
dacron graft is an adequate choice and there is no indication for use of
femoral vein harvest for a neo-aorto-iliac (NAIS) reconstruction, which will
unnecessarily prolong the procedure and add morbidity.

References
1. Kelso RL, Lyden SP, Butler B, et al: Late conversion of aortic stent grafts.
J Vasc Surg 2009 Mar;49(3):589-95. PMID: 19135829
2. Mohapatra A, Robinson D, Malak O, et al: Increasing use of open
conversion for late complications after endovascular aortic aneurysm
repair. J Vasc Surg 2019 Jun;69(6):1766-75. PMID: 30583895
 28. A 77-year-old man with a history of prior myocardial
infarction and partial right colectomy underwent an open type
IV thoracoabdominal aortic aneurysm repair. On
postoperative day 2, he develops hypotension with increasing
white blood cell count, pressor requirements, and worsening
lactic acidosis. The most appropriate management of this
patient is:

A
CT with intravenous contrast to assess colon viability
B
Large-volume resuscitation intravenous antibiotics and monitoring for improvement
C
Flexible sigmoidoscopy with emergent colectomy and primary anastomosis
D
Flexible sigmoidoscopy with emergent colectomy and end colostomy
E
Flexible sigmoidoscopy and return to the operating room for reimplantation of the
inferior mesenteric artery (IMA)
Answer 28

D
D
Flexible sigmoidoscopy with emergent colectomy and end colostomy

Discussion
Ischemic colitis after open AAA repair is rare, with an incidence of 1% to
5%. It is associated with a high mortality if not addressed expeditiously. If
caught in an early phase, the complications can be transient and can be
managed medically. In the setting of transmural ischemia, however, there
is massive fluid, protein, and electrolyte loss through the gangrenous
mucosa, resulting in severe acidosis and hypovolemic shock, as in this
patient. Although a CT scan may be performed to look for signs of colon
ischemia, it may not be the modality of choice in an emergent setting. A
flexible sigmoidoscopy is the mainstay of making this diagnosis. If ischemic
colitis is noted, the patient should be returned immediately to the operating
room and colectomy and end colostomy should be performed. In the setting
of an emergent take-back and resultant high mortality, a primary colon
anastomosis may not be prudent.

References
1. Moghadamyeghaneh Z, Sgroi MD, Chen SL, et al: Risk factors and
outcomes of postoperative ischemic colitis in contemporary open and
endovascular abdominal aortic aneurysm repair. J Vasc Surg 2016
Apr;63(4):866-72. PMID: 26747680
 29. A 59-year-old man presents to the emergency
department with abdominal and lower back pain for the past 2
weeks. He denies fevers, chills, or chest pain. CT scans are
as shown in Figures. Laboratory values show a white blood
cell count of 12,000, erythrocyte sedimentation rate at 46, and
C-reactive protein at 60. Blood cultures were positive for E
coli. Antibiotics were initiated. The best treatment strategy is:

A
Percutaneous biopsy of the periaortic
inflammation
B
Open repair with replacement of the aorta with
in-situ rifampin-soaked dacron graft
C
Endovascular aortic aneurysm repair
D
Ligation of the aorta with axillary-femoral-
femoral bypass
E
Antibiotic therapy for 6 weeks with follow-up CT
scan
Answer 29
B
B
Open repair with replacement of the aorta with in-situ rifampin-soaked
dacron graft

Discussion
Aortic aneurysms related to aortitis represent a subset of abdominal aortic
aneurysms. Both infectious and non-infectious aortitis must be considered
in the differential diagnosis. Clues to the presence of an infectious aortitis
include the presence of constitutional symptoms, such as fever and chills,
a recent history of infection, and saccular aortic morphology. Rarely there
may be air around the aorta. If the diagnosis of infectious aortitis is
suspected, antibiotics should be initiated immediately. Because of the high
risk of aortic degeneration and rupture, antibiotics alone will not usually
suffice and surgical intervention is recommended. Despite aggressive
therapy, mortality associated with infectious aortitis remains significant for
infectious aortitis. In contrast, the primary treatment of noninfectious aortitis
due to large-vessel vasculitis is immunosuppressive therapy. Despite
glucocorticoid therapy, the relapse rate for both giant cell arteritis and
Takayasu’s arteritis is high, up to 50% or greater. When surgical
intervention is considered, open aortic reconstructive surgery is generally
the standard for treatment of aortic aneurysms associated with aortitis,
although endovascular techniques have recently been employed with early
reported successes. Both treatments led to regression of periaortic
inflammation. Secondary intervention may be required in 22% of patients
after endovascular aneurysm repair (EVAR). Resolution of the periaortic
fibrosis is observed less often after EVAR. In this patient, all immunologic
work up was negative, so the aortitis was concerning for a possible
infectious etiology. Additionally, given the patient’s young age, an open
repair with in-situ repair of the aorta offers the most definitive and durable
repair.

References
1. Gornik HL, Ceager MA. Aortitis. Circulation 2008 Jun;117(23):3039–51. PMID: 18541754
2. Rasmussen TE, Hallett JW. Inflammatory Aortic Aneurysms. A clinical review with new
perspectives in pathogenesis. Ann Surg 1997 Feb; 225(2): 155-64. PMID: 9065292
3. Paravastu SC, Ghosh J, Murray D, et al: A systematic review of open versus endovascular repair
of inflammatory abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2009 Sep; 38(3):291-
97. PMID: 19541509
 30. A 78-year-old man underwent an emergent endovascular
aortic repair (EVAR) for ruptured abdominal aortic aneurysm
(AAA). He had aggressive resuscitation with a large
transfusion requirement. A few hours postoperatively, he
decompensated with hypotension, high peak inspiratory
pressures with hypercarbia, anuria, and worsening acidosis.
Bladder pressure is noted to be 30 mmHg. The most
appropriate management of this patient is:

A
Neuromuscular blockade with sedation and analgesia
B
Conservative use of crystalloids with use of blood products for resuscitation
C
Use of vasopressors to support an abdominal perfusion pressure ≥60 mmHg
D
Renal replacement therapy to decrease fluid overload
E
Emergent laparotomy with evacuation of hematoma and temporary abdominal
closure
Answer 30
HIDE
E
E
Emergent laparotomy with evacuation of hematoma and temporary
abdominal closure

Discussion
Endovascular repair of ruptured AAA is the treatment of choice for patients
with acceptable anatomy. However, 10% to 20% of patients develop
abdominal compartment syndrome. The grading of intra-abdominal
pressures is outlined in Table 1. Patients with Grade I or II intraabdominal
hypertension may develop oliguria, elevated end-inspiratory pressures,
and hypoperfusion due to decreasing cardiac output. With progression of
the intraabdominal compartment syndrome, high peak inspiratory
pressures causing hypercarbia, impaired venous return, marked oliguria to
anuria unresponsive to fluid challenge, altered levels of consciousness,
and respiratory failure may ensure. At or above an intra-abdominal
pressures of 25 mmHg, extensive bowel necrosis may ensure. For
decompression, a full midline laparotomy should be utilized once
abdominal compartment syndrome is diagnosed. Immediately upon
decompression, hypotension may be exacerbated due to the venous return
of a large acid load.

References
1. Veith FJ, Lachat M, Mayer D, et al: Collected world and single center experience with endovascular
treatment of ruptured abdominal aortic aneurysms. Ann Surg 2009 Nov;250(5):818–24. PMID: 198092962.
2. Mehta M, Darling RC III, Roddy SP, et al: Factors associated with abdominal compartment syndrome
complicating endovascular repair of ruptured abdominal aortic aneurysms. J Vasc Surg 2005
Dec;42(6):1047–51. PMID: 163761903
3. Rasmussen TE, Hallett JW Jr., Noel AA, et al: Early abdominal closure with mesh reduces multiple organ
failure after ruptured abdominal aortic aneurysm repair: guidelines from a 10-year case-control study. J Vasc
Surg 2002 Feb;35(2):246–52. PMID: 11854721
4. Cheatham ML, Malbrain MLNG, Kirkpatrick A, et al: Results from the international conference of experts
on intra-abdominal hypertension and abdominal compartment syndrome. II. Recommendations. Intensive
Care Med 2007 Jun;33(6):951–962. PMID: 17377769
 31. A 55-year-old man with a history of polysubstance abuse
presents with a contained rupture of a juxta-renal abdominal
aortic aneurysm. He has tachycardia to 109, a white blood cell
count of 14,000 cells/mm3, and Hgb of 11mg/dl. The CT scan
is shown. He has a known history of viral hepatitis. The best
treatment strategy for this patient is:

A
Debranching of visceral and renal arteries from uninvolved aorta with excision and
debridement of infected aorta and restoration of blood flow to the lower extremities
B
Fenestrated endograft repair of the aneurysm
C
Debranching of visceral and renal arteries with thoracic endovascular aortic repair
(TEVAR) across the aneurysmal segment
D
Intravenous antibiotics and observation
E
Steroids and observation
Answer 31

HIDEA
A
Debranching of visceral and renal arteries from uninvolved aorta with
excision and debridement of infected aorta and restoration of blood flow to
the lower extremities

Discussion
This is a patient with a history of intravenous drug abuse and a mycotic
aneurysm involving the visceral aorta. There is an emerging body of
literature to indicate that fenestrated endovascular repair is an option in
some patients with mycotic aneurysms, but this approach is probably most
appropriate for elective repair in patients who are unfit for open surgery.
Because this patient is young and hemodynamically stable, definitive
treatment involves visceral and renal debranching with bypasses from
uninvolved aorta, followed by excision of all infected tissue, debridement of
the infected field, and revascularization of lower extremities. Lower
extremity revascularization can be accomplished with an in-situ repair or
by an ax-fem-fem bypass with oversewing of the aortic stump. There is no
role for steroid therapy in an infectious mycotic aneurysm, nor is there a
role for antibiotic therapy alone in a contained rupture of a mycotic
aneurysm.

References
1. Sorelius K, Wanhalnen A, Furebring M, et al: Nationwide study of the
treatment of mycotic abdominal aortic aneurysms comparing open and
endovascular repair. Circulation 2016 Dec;134(23):1822-32. PMID:
27799273
2. Sule JA, Dharmaraj RB. Surgeon modified fenestrated endovascular
abdominal aortic repair (F-EVAR) for subacute multifocal mycotic
abdominal and iliac artery saccular aneurysms. EJVES Short Reports 2016
May;32:7-11. PMID: 28856307
 32. A 61-year-old man presented to the emergency
department with abdominal pain. His CT scan is shown in the
video. Vital signs include a blood pressure of 100/65 mmHg
and heart rate of 110 beats per minute. The best treatment
option for this patient is:

1.32.1.item.mp4
Please use this link to download the video

https://up-load.io/4kf05oz08hm7

A
Endovascular aortic aneurysm repair (EVAR)
B
Endovascular aortic aneurysm repair (EVAR) with inferior vena cava stent graft
C
Open aortic aneurysm repair with ligation of the inferior vena cava
D
Open aortic aneurysm repair with primary repair of the inferior vena cava
E
Open repair of the inferior vena cava followed by aortic aneurysm repair
Answer 32
HIDE
D
D
Open aortic aneurysm repair with primary repair of the inferior vena cava

Discussion
Aortocaval fistula is a rare complication of an abdominal aortic aneurysm
(AAA) in which the AAA erodes into the wall of the inferior vena cava (IVC),
resulting in the formation of a fistula. A primary/spontaneous ACF occurs
in 1% of AAA cases and 6% of ruptured AAA cases. Although endovascular
option is a reasonable approach in an infrarenal aortic aneurysm, the fistula
tends to allow decompression of any endoleak into the low-pressure
venous system. This results in a high risk of a persistent endoleak with
EVAR, which would allow the aortocaval fistula to persist. In patients with
juxtarenal aortic aneurysm, open aortic repair remains the mainstay to
avoid the obligatory delay in obtaining a fenestrated device.

References
1. Brightwell RE, Pegna V, Boyne N. Aortocaval fistula: current
management strategies. ANZ J Surg 2013 Jan;83(1-2):31-5. PMID:
23072669
2. Schmidt R, Bruns C, Walter M, et al: Aorto-caval fistula--an uncommon
complication of infrarenal aortic aneurysms. Thorac Cardiovasc Surg 1994
Aug;42(4):208-11. PMID: 7825158
3. Orion KC, Beaulieu RJ, Black JH 3rd. Aortocaval fistula: is endovascular
repair the preferred solution? Ann Vasc Surg 2016 Feb;31:221-28. PMID:
26597238
 33. A 76-year-old man presents to the emergency
department with massive hemoptysis. His past medical history
includes a prior open repair of aortic coarctation several years
ago. An urgent CT scan demonstrated a 5.5-cm saccular
aneurysm of the descending thoracic aorta arising 2 cm from
the left subclavian artery with intrapulmonary hematoma. The
best approach in the management of this patient is:

A
Thoracoscopic lung resection for bronchiectasis
B
Bronchial artery embolization followed by open thoracic aortic repair
C
Open thoracic aortic aneurysm repair
D
Bronchoscopy followed by thoracic endovascular stent graft repair (TEVAR)
E
Thoracic endovascular stent graft repair (TEVAR)
Answer 33

HIDE
E
E
Thoracic endovascular stent graft repair (TEVAR)

Discussion
Aorto-bronchial fistula (ABF) is a life-threatening condition. It can be difficult
to diagnose, but should be considered in a patient with hemoptysis who
has a prior history of open or endovascular thoracic aortic repair. Primary
aorto-bronchial fistula is an even rarer diagnosis. Open surgical repair of
ABFs has long been the primary treatment approach, but open repair is
associated with high morbidity and mortality (15-41%). In most centers
currently TEVAR is considered the preferred approach to manage this
condition to decrease risk of mortality and morbidity. Multiple case series
describing the use of TEVAR as definitive management of ABF have shown
reduced mortality rates compared to conventional open repair.
Preoperative bronchoscopy should be avoided because it could provoke
further bleeding, which may be fatal.

References
1. Bailey CJ, Force S, Milner R, et al: Thoracic endovascular repair as a
safe management strategy for aortobronchial fistulas. J Vasc Surg 2011
May;53(5):1202–9. PMID: 21367565
2. Quintana AL, Aguilar EM, Heredero, AF, et al: Aortobronchial fistula after
aortic coartactation. J Thorac Cardiovasc Surg 2006 Jan; 131(1):240-
43. PMID: 16399325
3. Léobon D, Roux A, Mugniot H, et al: Endovascular treatment of thoracic
aortic fistulas. Ann Thorac Surg 2002 Jul;74(1):247-49. PMID: 12118773
 34. A 65-year-old man underwent endovascular aneurysm
repair (EVAR) 3 years ago using a modular aortic bifurcated
device for 5.7-cm infrarenal abdominal aortic aneurysm. On
imaging for abdominal pain in the emergency department, his
aneurysm measures 7 cm in size with the findings shown.
Increased risk of type 2 endoleak after EVAR is associated
with:

A
Age less than 60 years
B
Preoperative aortic diameter < 6 cm
C
Occlusion of the inferior mesenteric artery prior to EVAR
D
Absence of type 2 endoleak at completion arteriography during EVAR
E
Hypogastric coil embolization and distal endograft extension
Answer 34
HIDE
E
E
Hypogastric coil embolization and distal endograft extension

Discussion
Persistent type II endoleaks develop in approximately 5% to 25% of the
patients after EVAR. Lo et al demonstrated in a large study of 2,367
patients who underwent EVAR, that persistent type II endoleaks are
associated with hypogastric coil embolization, distal graft extension, the
absence of chronic obstructive pulmonary disease, age 80 years and older,
and graft type. Risk of reintervention after persistent type 2 endoleaks is
between 15- and 19-fold higher than patients without endoleak and
freedom from reintervention is 67% to 76% at long-term follow up.2,5 Risk
of rupture is in the range of 1.5% to 3% with type 2 endoleaks. Patients
with systemic inflammatory disease are at high risk for postoperative
complications, type II endoleak, sac expansion, and additional
interventions after EVAR.

References
1. Lo RC, Buck DB, Herrmann J, et al: Risk factors and consequences of persistent
type II endoleaks. J Vasc Surg 2016 Apr;63(4):895-901. PMID: 26796291
2. Abularrage CJ, Crawford RS, Conrad MF, et al: Preoperative variables predict
persistent type 2 endoleak after endovascular aneurysm repair. J Vasc Surg 2010
Jul;52(1):19-24. PMID: 20478685
3. Timaran CH, Ohki T, Rhee SJ, et al: Predicting aneurysm enlargement in patients
with persistent type II endoleaks. J Vasc Surg 2004 Jun;39(6):1157-62. PMID:
15192552
4. Jones JE, Atkins MD, Brewster DC, et al: Persistent type 2 endoleak after
endovascular repair of abdominal aortic aneurysm is associated with adverse late
outcomes. J Vasc Surg 2007 Jul;46(1):1-8. PMID: 17543489
5. Sarac TP, Gibbons C, Vargas L, et al: Long-term follow-up of type II endoleak
embolization reveals the need for close surveillance. J Vasc Surg 2012 Jan;55(1):33-
40. PMID: 22056249
6. Shalaby SY, Foster TR, Hall MR, et al: Systemic inflammatory disease and its
association with type II endoleak and late interventions after endovascular aneurysm
repair. JAMA Surg 2016 Feb;151(2):147-53. PMID: 26501863
 35. A 53-year-old patient with prominent varicose veins is
referred for a bilateral venous insufficiency duplex study. Deep
and superficial venous thrombosis is ruled out with the patient
in a reverse Trendelenburg position. The patient is then
examined for valvular reflux in the standing position. The
technologist reports to you that the patient became dizzy and
nauseous almost immediately during this part of the test while
Valsalva maneuvers were performed. At that point, the patient
was placed in a supine position with the legs elevated. What
should you advise in terms of test completion?

A
After the patient recovers, the reflux examination should be performed in a steep
reverse Trendelenburg position
B
The patient should be rescheduled for another day with orders to walk as much as
possible before the test
C
After the patient recovers, ask the technologist to continue with the test by asking
the patient to just bear down minimally
D
The technologist should be directed to map the varicose veins and perforator
location on the skin to help determine treatment options
E
The technologist should be directed to continue the examination with the patient in
a flat, supine position using distal augmentation maneuvers
Answer 35

A
A
After the patient recovers, the reflux examination should be performed in
a steep reverse Trendelenburg position

Discussion
Performing Valsalva maneuvers can trigger a severe vasovagal response
in any patient, and the chances of this happening are significant when there
is dilation of the veins in the lower extremities due to valvular insufficiency.
The patient must be allowed to recover, while being monitored by the
technologist with support from other medical staff if needed. Standing is the
optimal position; however, reverse Trendelenburg is acceptable by IAC if
the patient’s condition precludes standing for this test. Changes to the pre-
examination orders and rescheduling does not provide efficient or effective
completion of the examination (choice B). Minimally bearing down or simply
holding one’s breath will not generate the needed reverse flow velocities of
30 cm/sec that is required. Reverse flow velocities less than this speed may
produce physiologic reflux in the presence of competent valves (choice C).
The origin of varicosities, not the presence of these structures, is the
required information to guide treatment options. Likewise, if an incompetent
axial vein is documented and treated, perforators may regain normal
function.

References
1. Salles Cuhna S, Neuhardt DL. Chapter 20: Venous valvular insufficiency
testing. In: Kupinski AM, ed. The Vascular System. Philadelphia, PA:
Lippincott, Williams & Wilkins, an imprint of Wolters Kluwer; 2013: 275-290.
2. Society of Diagnostic Medical Sonography. Scope of Practice and
Clinical Standards for the Diagnostic Medical Sonographer. Society of
Diagnostic Medical Sonography website.
https://www.sdms.org/docs/default-source/Resources/scope-of-practice-
and-clinical-standards.pdf?sfvrsn=8 . Published April 13, 2015.
 36. During endovascular repair of an abdominal aortic
aneurysm, the patient becomes hypotensive and there is
extravasation of contrast from the aorta immediately below the
level of the renal arteries. A fenestrated graft is not available.
During planned endovascular repair of abdominal aortic
aneurysms, conversion to open repair is associated with:

A
No increase in the risk of complications or death
B
Increased mortality
C
Increased need for future secondary interventions
D
Increase in graft aortic patency
E
Increase in the risk of graft infection
Answer 36
B
B
Increased mortality

Discussion
Emergent conversion from an endovascular to an open procedure is
uncommon, but associated with significant increase in both morbidity and
mortality. Factors that predict the need for acute conversion include
increased aneurysm diameter, young age, female gender, and nonwhite
race.

References
1. Ultee KHJ, Soden PA, Zettervall SL, et al: Conversion from endovascular
to open abdominal aortic aneurysm repair. J Vasc Surg 2016 Jul;64(1):76-
82. PMID: 27345505
 37. Which of the following is the single biggest risk factor for
the development of spinal cord ischemia after endovascular
thoracic aortic surgery?

A
Length of aortic coverage
B
Presence of a chronic type B aortic dissection
C
Multiple pairs of patent intercostal arteries
D
Dominant left vertebral artery
E
Presence of aortic atherosclerotic disease.
Answer 37
A
A
Length of aortic coverage

Discussion
Multiple series have evaluated risk factors for spinal cord ischemia
after thoracic aortic surgery, both open and endovascular. The
single biggest risk factor continues to be the length of aortic
coverage necessary. Prior endograft, preoperative hemoglobin,
and intraoperative hypotension have also been identified as
important risk factors.

References
1. Bisdas T, Panuccio G, Sugimoto M, et al: Risk factors for spinal
cord ischemia after endovascular repair of thoracoabdominal
aortic aneurysms. J Vasc Surg 2015 Jun; 61(6):1408-16. PMID:
25827967
 38. A 21-year-old woman presents to the clinic with remote
history of fever with the recent onset of severe hypertension,
debilitating lower extremity claudication, and possible
ischemic rest pain in both legs. She has no previous surgical
history. Femoral and pedal pulses are non-palpable.
Computed tomography with arterial phase imaging shows
severe, focal stenosis of the aorta from just distal to the origins
of the renal arteries to an area 3 cm proximal to the aortic
bifurcation. There is also a severe stenosis of the left renal
artery. The best option for further management is:

A
Balloon angioplasty of the focal stenosis without stent placement.
B
Steroid therapy and observation alone
C
Steroid therapy, followed by endarterectomy of the infrarenal aorta
D
Steroid therapy, followed by supraceliac clamping and placement of an interposition
graft from the infrarenal aorta to the bilateral common iliac arteries
E
Steroid therapy, followed by bypass from thoracic aorta to the aortic bifurcation and
to the left renal artery
Answer 38
HIDE
B
B
Steroid therapy and observation alone

Discussion
Steroid therapy should be initiated in patients presenting with systemic
signs of Takayasu’s disease. Surgery be considered for clinically significant
symptoms. The operative approach for the lesions associated with
Takayasu’s disease is different than that for atherosclerotic lesions. Inflow
of a bypass should originate for a disease-free segment. For mid-aortic
syndrome, this should often be the distal thoracic aorta. Bypass of diseased
renal arteries is indicated to treat renovascular hypertension in this young
patient. The donor artery for the renal artery bypass should be uninvolved
aorta or the aortic bypass graft since other aortic branches (such as the
celiac artery) can develop stenoses from Takayasu’s arteries in the future,
making splenorenal bypass or ilio-renal bypass unfavorable options.

References
1. Rigberg DA, Quinones-Baldrich WJ. Takayasu’s Disease: Nonspecific
Aortoarteritis. In: Loftus I, Hinchliffe R, eds. Vascular Surgery, 6th edition,
Elsevier Saunders, Philadelphia 2005.
 39. An active 75-year-old man presents after a CT scan
(Figure) incidentally identified a 2.9-cm left common iliac
artery aneurysm. Based on current literature, repair of this
aneurysm should be considered when the diameter reaches:

A
2.5 cm
B
3.5 cm
C
4.5 cm
D
5.0 cm
E
No threshold
Answer 39

B
B
3.5 cm

Discussion
Although level 1 evidence regarding the growth rate and rupture
risk of common iliac artery aneurysm (CIAA) is sparse,
retrospective reviews of the natural history of this entity have
suggested that rupture very rarely occurs below 3.8 cm to 4 cm in
diameter. Elective repair in asymptomatic patients is encouraged
at 3.5 cm.

References
1. Dix FP, Titi M, Al-Khaffaf. The isolated internal iliac artery
aneurysm – a review. Eur J Vasc Endovasc Surg 2005
Aug;30(2):119-29. PMID: 15939637
2. Laine MT, Björck M, Beiles CB, et al: Few internal iliac artery
aneurysms rupture under 4 cm. J Vasc Surg 2017 Jan;65(1):76-
81. PMID: 28010870
 40. A patient presents with syncope and acute left lower
quadrant abdominal pain. He is resuscitated in the emergency
department and a non-contrast CT scan is performed. He is
hemodynamically stable and is taken to the hybrid operating
room for endovascular repair. If coil embolization is attempted,
occlusion of the posterior division of the internal iliac artery is
necessary to reduce the risk of back bleeding from the:

A
Obturator artery
B
Middle rectal artery
C
Superior gluteal artery
D
Inferior pudendal artery
E
Middle sacral artery
Answer 40
HIDE
C
C
Superior gluteal artery

Discussion
To prevent ongoing expansion of an internal iliac artery aneurysm, all inflow
and outflow vessels must be occluded, especially in the case of rupture.
The posterior division of the internal iliac artery gives rise to the superior
gluteal artery and should be embolized to avoid retrograde filling.

References
1. Ryer EJ, Garvin RP, Webb TP, et al: Comparison of outcomes with coils
versus vascular plug embolization of the internal iliac artery for
endovascular aortoiliac artery aneurysm repair. J Vasc Surg 2012
Nov;56(5):1239-45. PMID: 22727840
 41. A patient presents to clinic one month following
successful endovascular repair of a left internal iliac artery
aneurysm by embolization and diverting inflow with a covered
stent across the origin. He has palpable distal pulses and no
abdominal pain. The imaging studies demonstrate thrombosis
of the residual aneurysm sac. He notes that he has been
suffering from mild cramping in his left buttock after he walks
about one block. You advise him that buttock claudication
happens in about 20% of patients after this procedure and the
time interval postoperatively in which it typically resolves is:

A
3 months
B
6 months
C
2 years
D
5 years
E
Never
Answer 41
B
B
6 months

Discussion
Case series examining postoperative outcomes following ipsilateral
internal iliac artery coil embolization have reported buttock claudication
rates ranging from 12% to 22%. With ongoing medical therapy and walking
regimen, symptoms resolve in most patients by 6 months.

References
1. Papazglou KO, Sfyroeras G, Zambas N, et al: Outcomes of
endovascular aneurysm repair with selective internal iliac artery coverage
without coil embolization. J Vasc Surg 2012 Aug;56(2):298-303. PMID:
22572010
2. Stokmans RA, Willigendael EM, Teijink JAW, et al: Challenging the
evidence for pre-emptive coil embolization of the internal iliac artery during
endovascular aneurysm repair. Eur J Vasc Endovasc Surg 2013
Mar;45(3):220-26. PMID: 23305786
 42. A 62-year-old man is undergoing an open repair of an
abdominal aortic aneurysm with concurrent aneurysmal
degeneration of the right common iliac artery. After completing
the proximal aortic anastomosis, the right common iliac artery
aneurysm is opened and a short-segment, high-grade
stenosis of the right internal iliac artery is observed. The left
internal iliac artery is occluded at its origin. To decrease the
risk of pelvic ischemia, the best distal reconstruction technique
would be:

A
Distal anastomosis at the right iliac artery bifurcation
B
Distal anastomosis at the right external iliac artery with ligation at the origin of the
right internal iliac artery
C
Ligation of the common iliac artery and distal anastomosis at the right common
femoral artery
D
Distal anastomosis at the right external iliac artery with an additional graft to a
healthy segment of the internal iliac artery
E
Endarterectomy of the right internal iliac artery with patch angioplasty and distal
anastomosis of the graft at the right iliac bifurcation
Answer 42
D
D
Distal anastomosis at the right external iliac artery with an additional graft
to a healthy segment of the internal iliac artery

Discussion
Maintenance of at least unilateral internal iliac artery perfusion is vital to
decrease the risk of pelvic ischemia with the clinical consequences of
vasculogenic impotence, intractable buttock claudication, colon or rectal
ischemia, gluteal necrosis, and spinal cord ischemia. During open aortoiliac
aneurysm repair, distal anastomosis at the iliac bifurcation is preferable in
conjunction with aortic and common iliac artery aneurysmorraphy. In this
case, however, the high-grade stenosis occurs at the origin of the lone
patent internal iliac artery. Effective maintenance of both lower extremity
and pelvic perfusion should be maintained by distal graft anastomosis to
the external iliac artery or common femoral artery in conjunction with a jump
graft to the ipsilateral downstream healthy internal iliac artery.

References
1. Krupski WC, Selzman CH, Florida R, et al: Contemporary management
of isolated iliac aneurysms. J Vasc Surg 1998 Jul;28(1):1-11. PMID:
9685125
2. Huang Y, Gloviczki P, Duncan AA, et al: Common iliac artery aneurysm:
expansion rate and results of open surgical and endovascular repair. J
Vasc Surg 2008 Jun;47(6):1203-10. PMID: 18514838
 43. A 68-year-old woman underwent endovascular aneurysm
repair (EVAR) with left iliac limb extension into the external
iliac artery and the right iliac limb seal in the right common iliac
artery (Figures). The inferior mesenteric artery was chronically
occluded. On postoperative day 1, she had low-grade
tachycardia, nausea, mild abdominal pain, and a white blood
cell count of 18,000 cells/dL. The most appropriate
management of this patient would be:

A
Anti-emetic therapy and initiation of clear liquid
diet
B
Beta-blockade and CT angiography of the chest
C
Fluid resuscitation and observation
D
Non-contrast CT scan of the abdomen and pelvis
E
Flexible sigmoidoscopy and initiate broad-
spectrum antibiotics
Answer 43
HIDE
E
E
Flexible sigmoidoscopy and initiate broad-spectrum antibiotics

Discussion
In the setting of an occluded inferior mesenteric artery, covering the origin
of the left internal iliac artery can significantly alter perfusion of the sigmoid
colon. This patient is demonstrating early signs of systemic inflammation
attributable to colon ischemia. Maintenance of nothing per oral (NPO)
status, fluid resuscitation, and broad-spectrum antibiotics are important
initial interventions to protect against bacterial translocation, but flexible
sigmoidoscopy is necessary to determine the depth of ischemic injury.
Although only a fraction of these patients will progress to full-thickness
injury requiring colon resection, delays in diagnosis are associated with
worse outcomes, even mortality. For this reason, the suspicion of colon
ischemia post-EVAR mandates urgent flexible sigmoidoscopy.

References
1. Karch LA, Hodgson KJ, Mattos MA, et al: Adverse consequences of
internal iliac artery occlusion during endovascular repair of abdominal
aortic aneurysms. J Vasc Surg 2000 Oct; 32(4):676-83. PMID: 11013030
2. Angiletta D, Marinazzo D, Guido G, et al: Spinal cord, bowel, and buttock
ischemia after endovascular aneurysm repair. Ann Vasc Surg 2011
Oct;25(7):980.e15-9. PMID: 21621970
 44. A 75-year-old man presents with short distance
claudication (<25 feet) for 1 week and new onset burning pain
across the right foot metatarsal region with absent pedal
pulses. A CT arteriogram demonstrated an isolated right
common iliac artery aneurysm with mural thrombus and
occlusion of the common femoral and popliteal arteries. In
addition to embolectomy of the right lower extremity, the
operative surgeon should also consider:

A
Placement of lytic catheter into the right common iliac artery aneurysm
B
Four-compartment fasciotomy of the right lower leg
C
Endovascular aneurysm repair of right iliac artery aneurysm
D
Femoral to below knee bypass with reversed saphenous vein graft
E
Left to right femoral to femoral artery bypass with ligation of the right external iliac
artery
Answer 44
HIDE
C
C
Endovascular aneurysm repair of right iliac artery aneurysm

Discussion
Although rare, common iliac artery aneurysms may be a source of distal
embolization and should be considered in the scenario of acute onset
claudication and ischemic rest pain. When planning revascularization, both
the emboli and the source need to be treated. Therefore, following open
embolectomy of the right common and popliteal arteries, this patient should
be treated with an endovascular aneurysm repair of the right common iliac
artery aneurysm in order to exclude the aneurysm and prevent repeat
embolization.

References
1. Ferreira J, Canedo A, Brandão D, et al: Isolated iliac artery aneurysms:
six-year experience. Interact Cardiovasc Thorac Surg 2010 Feb;10(2):245-
48. PMID: 19910361
2. Bacharach JM, Slovut DP. State of the art: management of iliac artery
aneurysmal disease. Catheter Cardiovasc Interv 2008 Apr;71(5):708-
14. PMID: 18360870
3. Nachbur BH, Inderbitzi RG, Bär W. Isolated iliac aneurysms. Eur J Vasc
Surg 1991 Aug; 5(4):375-81. PMID: 1915902
RESET RESPONSE
 45. Approximately 5 years after standard endovascular
aneurysm repair (EVAR) placement, a 68-year-old man
presents with aneurysm sac enlargement (< 5 mm) and a type
1B endoleak (Figure). The current Instructions for use
requirements for the FDA-approved iliac branch
endoprosthesis device include anatomic requirements of:

A
Minimal internal iliac artery diameter of 6.5 mm
B
Aneurysmal degeneration at the origin of the internal iliac artery
C
Less than 45-degree angulation at the origin of the internal iliac artery
D
Distal seal zone in the internal iliac artery of at least 15 mm in length
E
Patency of posterior division of the ipsilateral internal iliac artery
Answer 45
HIDE
A
A
Minimal internal iliac artery diameter of 6.5 mm

Discussion
Iliac branch endoprostheses have been designed to maintain pelvic
perfusion while treating a common iliac artery aneurysm. Current
indications for use include a minimum common iliac artery diameter of 17
mm, external iliac artery treatment diameter ranging from 6.5 mm to 25 mm
with seal zone of 10 mm, and internal iliac artery treatment diameter
ranging from 6.5 mm to 13.5 mm with seal zone of 10 mm

References
1. Schneider DB, Matsumura JS, Lee JT, et al: Prospective, multicenter
study of endovascular repair of aortoiliac and iliac aneurysms using the
Gore Iliac Branch Endoprsthesis. J Vasc Surg 2017 Sep;66(3):775-
85. PMID: 28559174
 46. A 32-year-old man arrives in shock following a motorcycle
collision. Radiographic evaluation reveals a splenic laceration
and pelvic ring fracture. The CT angiogram shows a blunt
grade III aortic injury and semi-elective thoracic endovascular
aortic repair (TEVAR) is being planned. The utility of intra-
procedural intravascular ultrasound (IVUS) in determining the
proper endograft size for a thoracic endovascular aortic repair
(TEVAR) in a young trauma can be explained by:

A
Initial CT angiography may oversize the aortic diameter in hyperdynamic physiology
B
Aortic elasticity and compliance are directly related to age
C
IVUS may account for the changes in aortic diameter during resuscitation
D
Angiography is better than IVUS for measuring the aortic diameter
E
Variation in aortic diameter during the cardiac cycle is minor in hypovolemic shock
Answer 46
HIDE
C
C
IVUS may account for the changes in aortic diameter during resuscitation

Discussion
The utility of intravascular ultrasound (IVUS) in determining the proper graft
size for a thoracic endovascular aortic repair TEVAR in a young trauma
patient is that the initial CT angiography may result in an undersized aortic
diameter. The aortic size is affected by the hemodynamic status of the
trauma patient in shock with multiple injuries. There are reports of
discrepancies of up to 40% between the initial CT angiography and
repeated CT angiography after resuscitation. Compliance and elasticity are
inversely related to age. Given that an early CT angiography can undersize
the true diameter, IVUS may be useful in determining an accurate proximal
aortic diameter with greater accuracy than angiography.

References
1. Azizzadeh A, Valdes J, Miller CC, et al: The utility of intravascular
ultrasound compared to angiography in the diagnosis of blunt traumatic
aortic injury. J Vasc Surg 2011 Mar; 53(3):608-14. PMID: 21129901
2. Shi Y, Tsai PI, Wall MJ, et al: Intravascular ultrasound enhanced aortic
sizing for endovascular treatment of blunt aortic injury. J Trauma Acute
Care Surg 2015 Nov;79(5):817-21. PMID: 26496107
RESET RESPONSE
 47. A 24-year-old helmeted motorcyclist suffered a high-
impact collision. He arrived hemodynamically stable with a
normal neurologic examination. A CT angiogram (Figures)
shows an aortic injury along with a left pneumothorax, lung
contusion, splenic laceration, and multiple rib fractures. The
most appropriate management of the blunt aortic injury is:

A
No intervention is necessary; recommend follow up imaging in 1 week
B
Repair at discretion of the trauma team
C
Stabilization of concomitant injuries, anti-impulse control, semi-elective repair
D
The blunt aortic injury takes first priority and should be immediately repaired
E
Semi-elective open repair of the blunt aortic injury
Answer 47
HIDE
C

C
Stabilization of concomitant injuries, anti-impulse control, semi-elective
repair

Discussion
The figures show a moderate blunt aortic injury, with sufficient proximal
landing zone below the left subclavian artery. In the Society for Vascular
Surgery (SVS) grading system, grade III (pseudoaneurysm) is depicted
with a large intimal flap. In Seattle, during a 3-year period, 87 patients were
treated, of which 63% were classified as having moderate injuries,
representing the most common pattern of injury. None of the patients
required reintervention. A blunt thoracic aortic injury with external contour
abnormality or intimal tears >10 mm that are clinically stable without active
extravasation or large hematoma >15mm can be treated semi-electively.
Impulse control and stabilization of the concomitant injuries takes priority
over an immediate repair.

References
1. Azizzadeh A, Keyhani K, Miller CC, et al: Blunt traumatic aortic injury:
initial experience with endovascular repair. J Vasc Surg 2009 Jun; 49(6):
1403-8. PMID: 19497498
 48. Accurate measurements are of critical importance in
planning thoracic endovascular aortic repair (TEVAR). When
selecting the endograft, centerline measurements to
determine the optimal graft length are subject to:

A
Underestimation of the length, because the graft often takes the outer wall
curvature
B
Underestimation of the length, because the graft often takes the inner wall
curvature
C
Overestimation of the length, because the graft often takes the inner wall curvature
D
Overestimation of the length, because the graft often takes the outer wall curvature
E
The graft will tend to locate in the center of the aorta and length is easily
determined
Answer 48
HIDE
A
A
Underestimation of the length, because the graft often takes the outer wall
curvature

Discussion
The thoracic stent is often positioned along the outer curvature of the aortic
wall because of natural tortuosity and the aneurysm cavity. The tendency
of the endograft to locate against the greater outer curvature of the aortic
wall should be considered when planning the aortic coverage. A centerline
measurement when used to calculate endograft length may fall short of the
intended distal landing zone. When using strict centerline measurements,
the graft length can therefore be underestimated. These factors should be
taken into consideration during planning and sizing for TEVAR.

References
1. Iwakoshi S, Ichihashi S, Inoue T, et al: Measuring the greater curvature
length of virtual stent graft can provide accurate prediction of stent graft
position for thoracic endovascular aortic repair. J Vasc Surg 2019
Apr;69(4):1021-27. PMID: 30528412
 49. A 65-year-old man is undergoing elective thoracic
endovascular aortic repair (TEVAR). The lesion location
requires coverage of the left subclavian artery to obtain an
adequate proximal landing zone. The patient has a history of
a coronary bypass grafting using the left internal mammary
artery to left anterior descending artery. The most appropriate
management is:

A
Cover the left subclavian artery without revascularization
B
Cover the left subclavian artery and perform a coil embolization to
prevent endoleak
C
Perform a carotid subclavian transposition prior to TEVAR
D
Perform the TEVAR and revascularize the left subclavian artery only if
symptoms develop
E
Perform a carotid subclavian bypass followed by staged TEVAR
Answer 49
E
E
Perform a carotid subclavian bypass followed by staged TEVAR

Discussion
Up to 40% of patients undergoing TEVAR display pathology that extends
near the left subclavian artery (LSA). The Society of Vascular Surgery
pursued development of clinical practice guidelines for the management of
the left subclavian artery with TEVAR. There are some situations where the
left subclavian may be covered, such as life-threatening acute aortic
conditions. For elective procedures in which coverage compromises
perfusion to the brain, heart, or spinal cord, routine preoperative LSA
revascularization is strongly recommended. A classic example of a
compelling indication for revascularization of the LSA is the presence of a
coronary artery bypass graft using an internal mammary artery graft
emanating from the left subclavian artery. In such a patient, a bypass is
mandated over a transposition to avoid cross-clamping the subclavian
artery proximal to the internal mammary graft. Another compelling
indication for preemptive left subclavian artery revascularization is the
presence of a dominant left vertebral artery with an occluded or diminutive
right vertebral artery.

References
1. Matsumura JS, Lee WA, Mitchell RS, et al: The society for vascular
surgery practice guidelines: management of the left subclavian artery with
thoracic endovascular aortic repair. J Vasc Surg 2009 Nov;50(5):1155-
58. PMID: 19878791
2. Morasch MD. Technique for subclavian to carotid transportation, tips,
and tricks. J Vasc Surg 2009 Jan;49(1):251-54. PMID: 19174263
 50. A 27-year-old woman involved in a high-speed motor
vehicle crash suffered a traumatic brain injury with
intraparenchymal hemorrhage (IPH) and underwent thoracic
endovascular aortic repair (TEVAR) for a grade 3 blunt aortic
injury the following morning. The left subclavian artery was
partially covered. Six months later she presents with bilateral
lower extremity weakness, numbness, and pain. Based on CT
angiography findings (Figure), the most appropriate
management is:

A
Immediate systemic anticoagulation and
CT angiography surveillance
B
Magnetic resonance imaging and
neurology consultation
C
Cerebrospinal fluid (CSF) drainage,
intensive care unit admission, and serial
examination
D
Emergent angioplasty and distal extension
of thoracic stent
E
Angiography of the left subclavian artery
and revascularization
Answer 50
D
D
Emergent angioplasty and distal extension of thoracic stent

Discussion
Endovascular treatment of thoracic aortic disease may be associated with
neurologic complications. Paraplegia or paraparesis developed in 15
(2.5%) of 606 patients enrolled in the European Collaborators on
Stent/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) registry.
The role of flow into the left subclavian artery and occlusion was associated
with almost fourfold increase in the incidence of paraplegia. In this case,
the CT shows a stent graft with mural thrombus and a nearly occlusive
intraluminal stenosis of the distal portion of the stent within the descending
thoracic aorta. Caudal to the stenosis the aorta enhances normally.
Because the left subclavian was not completely covered, it is not likely to
be the source of spinal cord ischemia in the setting of these CT findings.
Although cerebrospinal fluid drainage and neurologic consultation may be
appropriate, the aortic coarctation requires urgent intervention.
Anticoagulation alone would be inadequate to restore compromised spinal
cord perfusion.

References
1. Buth J, Harris PL, Hobo R, et al: Neurologic complications associated
with endovascular repair of thoracic aortic pathology: incidence and risk
factors. A study from the european collaborators on stent/graft rechniques
for aortic aneurysm repair (EUROSTAR) registry. J Vasc Surg 2007
Dec;46(6):1103-10; discussion 1110-11. PMID: 18154984
 51. Most patients with traumatic thoracic aortic rupture die at
the scene or in the emergency department. A predictor of
death from blunt aortic injury is:

A
External aortic contour abnormality
B
Pseudoaneurysm width measurement
C
Size of periaortic hematoma
D
Large intimal flaps with intramural hematoma
E
Aortic diameter
Answer 51

HIDE
C
Size of periaortic hematoma

Discussion
Characteristics of aortic injury that predict death may persuade optimal
timing and best mode of therapy. In a multivariate logistic regression,
systolic blood pressure <90 mmHg was significantly associated with death
from traumatic rupture. A retrospective review of various orthogonal
measurements to the aortic flow channel showed that large intimal flaps,
pseudoaneurysm width, and external contour were not significantly
correlated with death. Hematoma at the level of the aortic arch on
computed tomography (CT) scan significantly correlated with death from
blunt aortic injury with an average of 20.3 mm in those who died versus 7.7
mm in those that did not (P<.001). A patient with an aortic pseudoaneurysm
associated with a hematoma >15 mm was significantly more likely to die.
This measurement may help to predict which injuries need urgent instead
of semi-elective repair.

References
1. Starnes BW, Lundgren RS, Gunn M, et al: A new classification scheme
for treating blunt aortic injury. J Vasc Surg 2012 Jan;55(1):47-54. PMID:
22130426
 52. A 25-year-old unresponsive woman arrives by
emergency medical services with a pelvic ring disruption,
traumatic brain injury, splenic laceration, rib and scapular
fractures, and a left pneumothorax. Based on the initial axial
CT angiography aortic morphology (Figure), the most
appropriate management is:

A
Treat the aortic injury as first priority
B
Follow up CT scan in one month
C
Immediate repair with full dose heparinization
D
Treat urgently when other injuries have stabilized
E
Re-image before discharge
Answer 52

D
D
Treat urgently when other injuries have stabilized

Discussion
Patients with blunt thoracic aortic injury have numerous concomitant
injuries that may confuse the prioritization of treatment to prevent death. A
decrease in aortic related mortality is likely attributed to endovascular
repair and a better understanding of CT angiography characteristics. A
practical grading system of mild, moderate, and severe findings may guide
priorities and optimal of treatment. In this case, no active extravasation is
noted. In addition to the large intimal irregularity, an external contour
abnormality of the aortic wall constitutes a pseudoaneurysm that should be
treated early when the other life-threatening conditions become stable. The
safety of systemic heparinization in the setting of a traumatic brain injury or
a solid organ laceration is controversial. A lower dose of heparin is an
acceptable alternative in these patients.

References
1. Quiroga E, Starnes BW, Tran NT, Singh N. Implementation and results
of a practical grading system for blunt thoracic aortic injury. J Vasc Surg
70(4):1082-1088.
 53. A hemodynamically stable 50-year-old construction
worker fell 40 feet and suffered a small intimal tear to the
descending thoracic aorta several centimeters below the left
subclavian artery. The most common natural history of grade
I and II blunt thoracic aortic (minimal) injuries is:

A
Repeat imaging is often stable and a majority will have no interval change
B
Risk of injury progression is high, and patients should be treated with
pharmacotherapy
C
Complete injury resolution is very rare
D
When injury progression is noted, it occurs relatively late in surveillance imaging
E
This is unknown as trauma patients do not return for follow-up examination
Answer 53
HIDE
A
A
Repeat imaging is often stable and a majority will have no interval change

Discussion
A growing body of literature on nonoperative management in blunt thoracic
aortic injury (BTAI) has emerged since the 2011 publication of the Society
for Vascular Surgery (SVS) practice guidelines. Injury progression in grade
I and II BTAI is rare (5% to 7%) and when injury progression was noted, it
occurred relatively early. In one 10-year retrospective review of 49 patients
and a subsequent metanalyses of 146 patients, injury resolution ranged
from 40% to 55%. Pharmacotherapy remains a cornerstone of medical
management in traumatic aortic injury.

References
1. Osgood MJ, Heck JM, Rellinger EJ, et al: Natural history of grade I-II
blunt, traumatic aortic injury. J Vasc Surg 2014 Feb;59(2):334-41. PMID:
24342065
 54. A 62-year-old woman presents with persistent fever,
malaise, and severe back and abdominal pain. CT of the
abdomen and pelvis demonstrated thickening of the infrarenal
abdominal aorta with aneurysmal degeneration to 6 cm.
Laboratory evaluation demonstrated an elevated erythrocyte
sedimentation rate (ESR). A temporal artery biopsy for giant-
cell arteritis (GCA) is performed. The most appropriate
management of this patient is:

A
Corticosteroids only if the temporal artery biopsy is positive for GCA
B
Corticosteroids based on the presumptive diagnosis of GCA, even if the biopsy is
negative
C
Observation alone with serial imaging of the aorta
D
Resection and interposition grafting of the infrarenal aorta
E
Resection and ligation of the infrarenal aorta with extra-anatomic bypass
Answer 54
HIDE
D
D
Resection and interposition grafting of the infrarenal aorta

Discussion
Giant cell arteritis has a variable presentation and a significant portion of
patients may not have the classic symptoms of headache and jaw
claudication associated with involvement of the temporal artery. Vascular
symptoms do not comprise the most common presentations of GCA.
Although definitive diagnosis of GCA requires a biopsy, temporal artery
biopsy is associated with false negatives and other large vessel
involvement may not be amenable to tissue sampling. Therefore, most
clinicians treat patients with high suspicion with empiric corticosteroids.
Serial testing for inflammatory markers and serial imaging is required to
follow the course of the disease while being treated. Surgical intervention
for complications of GCA are not the mainstay of therapy for GCA. Rather,
surgery is typically reserved for those failing medical therapy. In some
cases, there may be aneurysmal degeneration of the involved arteries,
which would be an indication for surgical intervention, especially in a patient
who is symptomatic with abdominal or back pain. Whether open or
endovascular repair is preferred is unknown because of the rarity of the
disease. Endovascular repair is appealing because of the peri-aortic
inflammatory changes that are encountered during open surgery, but the
tolerance of the aorta to endovascular manipulation and ballooning is not
known.

References
1. Janssen SP, Comans EH, Voskuyl AE, et al: Giant cell arteritis:
Heterogeneity in clinical presentation and imaging results. J Vasc Surg
2008 (Oct);48(4):1025-31. PMID: 18639414