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

Purpose: Techniques for managing the distal anastomoses of aortofemoral and iliofemoral endovascular grafts are described. Methods: Over a 2 1/2-year period 46 endovascular grafts were successfully placed to treat severe iliac artery occlusive disease. Endovascular grafts were anchored proximally in the distal aorta or iliac arteries with Palmaz balloon-expandable stents. The distal anastomoses were performed with the u se of open, sutured anastomotic techniques. In contrast to stented distal a nastomoses, these techniques allowed us to (1) treat occlusive lesions exte nding from the distal aorta to below the inguinal ligament, (2) terminate e ndovascular grafts in the groin where stents are contraindicated, (3) vary the distal anastomotic site depending on the local pattern of disease, and (4) standardize the preinsertion length of the endovascular graft. Results: Two distal perianastomotic stenoses and one graft occlusion were d etected postoperatively in 11 bypass grafts that had distal anastomoses sew n endoluminally without an overlying patch angioplasty. Only one perianasto motic stenosis was found among 35 anastomoses performed with other techniqu es. There were no significant differences in primary and secondary patency between grafts originating in the distal aorta or iliac arteries. Conclusions: Hand-sewn distal anastomoses can simplify the insertion of end ovascular grafts used for the treatment of aortoiliac occlusive disease. Th ese anastomoses permit tailoring of the graft according to the patients' pa ttern of disease and eliminate the need to precisely measure the length of the graft preoperatively. In addition, because a distal stent is not requir ed, endovascular grafts can be safely terminated in the groin instead of th e external iliac artery where disease progression can lead to graft failure . Finally, endovascular distal anastomoses should be closed with a patch or the hood of a more distal bypass graft to prevent perianastomotic stenoses or occlusions in the postoperative period. (J Vasc Surg 2000;32:307-14.).