The role of omentopexy in the prevention of femoral anastomotic aneurysm
Courbier, R.; Ferdani, M.; Jausseran, J.M.; Bergeron, P.; Reggi, M.
Journal of Cardiovascular Surgery 33(2): 149-153
1992
ISSN/ISBN: 0021-9509 PMID: 1572869 Document Number: 391365
In our experience the incidence of anastomotic aneurysms (AA) after prosthetic bypass varied from 0.3 to 0.7% depending on location; it was 5 times higher at aortobifemoral anastomoses (77/3146; 2.44%) than aortic anastomosis (8/2173; 0.37%) (p < 0.005). In the inguinal region the incidence of femoral AA (FAA) is the same as elsewhere when the prosthesis is placed in front of the inguinal ligament (axillo-femoral anastomoses, 1/200; 0.5%; femoro-femoral anastomoses 1/270; 0.37%). However when the prosthesis is placed behind the ligament, the incidence of FAA rises to 2.44% (77/3746). In our opinion, this difference is due to adherence between the prosthesis and the ligament during hip movement. When the hip is in extension, tension is placed on the prosthesis and the adjacent arterial junction causing the wall of the artery to tear. The sutures almost always remain intact. In an effort to avoid this problem, we have developed a technique that consists of enlarging the passage of the prosthesis by partial section of the inguinal ligament and then wrapping the prosthesis with a free non pedunculated segment of omentum from above the femoral anastomosis down to the healthy segment of the femoral artery which, being elastic, can stretch. The omentum acts as sheath that reinforces the anastomosis. To evaluate this technique we assessed our patients operated upon for aortobifemoral (or aortofemoroiliac) bypass into two groups. Group A included 115 patients operated on by the same surgeon using the new technique (October 1981 and December 1984). There were 111 men and 4 women (mean age: 59.7 years). Mean follow-up was 7.36 years. these patients were assessed by clinical examination, Doppler ultrasound imaging and, in suspicious cases by angiography. Only 74 patients could be retrospectively re-examined since 34 died without FAA and 7 were lost to follow-up. In 68 patients the prosthesis was patient with a normal diameter. There was 1 stenosis and 5 cases of thrombosis of one graft limb requiring revision with 1 amputation. Two patients (follow-ups: 8.2 and 8.6 years) developed dilatation (one and a half time the diameter of the prosthesis) at the distal anastomosis and continue under surveillance. No AA, inguinal hernia or rejection of the free omental graft observed. In 11 patients who underwent secondary surgery, histology revealed fibrosis but no necrosis of the graft. Group B operated upon before implementation of this technique (January 1965 to October 1981) incluided 2173 patients in whom 2173 aortic, 600 iliac and 3746 femoral anastomoses were performed. There were 2092 men and 81 women (mean age: 58.1 years). Aortic AA occurred in 8 of these patients, iliac AA in 4 and femoral AA in 77. The peak incidence occurred in the first 6 months (6 cases) perhaps due to latent infection and during the fourth year (16 cases). Although our technique does not eliminate the risk of anastomotic aneurysm between the artery and the prosthesis in the inguinal region, it lowers its incidence to the same level as that seen in other locations.