key: cord-275833-c3zamfix
authors: McElligott, Helen; Toale, Conor; Moloney, Michael A.; Kavanagh, Eamon G.
title: Hybrid-CERAB (Covered Endovascular Reconstruction of the Aortic Bifurcation) Procedure is preferable to Aorto-Bi-Femoral Bypass for Limb-threatening Aortoiliac Occlusive Disease during the COVID-19 Crisis.
date: 2020-09-02
journal: J Vasc Surg Cases Innov Tech
DOI: 10.1016/j.jvscit.2020.08.019
sha: 
doc_id: 275833
cord_uid: c3zamfix

The COVID-19 pandemic is disrupting the provision of acute vascular surgery across the globe. Limited evidence regarding the impact of nosocomial infection on patient outcomes, as well as concerns regarding critical care capacity, will likely impact upon surgical decision making. Endovascular therapy offers a way by which peri-operative risk can be reduced for vascular patients, while also reducing the impact of acute surgery on intensive care unit capacity. This case reports the management of a patient with complex aorto-iliac occlusive disease via a hybrid endovascular approach in light of the above constraints, with a successful outcome.

The COVID-19 pandemic has significantly impacted the provision of emergency surgery. Early 3 data has highlighted the risks of morbidity and mortality in the event of SARS-Cov2 infection in 4 the post-operative period 1 . Furthermore, critical care bed and overall hospital capacity will likely 5 continue to impact upon vascular surgery services. Minimally invasive techniques offer a way of 6 mitigating against these constraints while providing quality care with acceptable outcomes for 7 patients 2, 3 . We report a case of a patient with acute-on-chronic TASC-II (Trans-Atlantic Inter-8 Society Consensus II) D aorto-iliac occlusive disease managed by covered endovascular 9 reconstruction of the aortic bifurcation (CERAB) as an alternative to open surgery in the era of 10 COVID-19. The patient provided written informed consent for their case details to be published. 11 12 Case Report 13 14 A 57-year-old gentleman presented to a tertiary level care unit with a 3-week history of left foot 15 and calf pain at rest and a 4-day history of forefoot paraesthesia. The patient denied right sided 16 symptoms. A history of hypertension, hyperlipidaemia and obesity was noted. The patient was an 17 active smoker. He was taking rivaroxaban for a recently diagnosed left below-knee deep venous 18 thrombosis, based on a duplex scan reporting an isolated tibial vein that failed to compress 19 normally. This in retrospect was likely an incorrect diagnosis which lead to delayed referral. On 20 examination, the left foot was pale, with a sensory deficit noted over the lateral foot. There was 21 no tissue loss or ulceration, no motor deficit, and he had minimal calf tenderness. Lower limb 22 pulses, including femoral pulses, were absent. A diagnosis of limb threatening acute on chronic 23 J o u r n a l P r e -p r o o f 5 lower limb ischemia was made, and unfractionated heparin infusion commenced. Left sided toe 1 waveforms were absent, while ankle-brachial pressure indices (ABPI) and toe-brachial indices 2 on the right were 0.64 and 0.81 respectively. Computed-tomography angiography (CTA) 3 revealed extensive mural thrombus in the infrarenal aorta with greater than 50% stenosis ( Figure  4 1). Aneurysmal dilatation of the right common iliac measuring up to 2.9 cm was observed, with 5 extensive thrombus occluding more than 80% of the lumen proximally. There was complete distance. Open surgery with aorto-femoral bypass remains the gold standard for the management 1 of TASC-II D aortoiliac occlusive disease 4 . Patency rates of 75-80% at 10 years have yet to be 2 matched by endovascular techniques 5, 6 . However, several studies have reported successful 3 endovascular management of extensive aortoiliac disease in selected patients 7 . Endovascular 4 management carries a lower risk of peri-operative morbidity, at the expense of a higher re-5 intervention rate and lower primary patency 8 . Technical success rates of 95.1% have been 6 recorded, with major complication rates of 1.9% and a short median hospital length of stay 7 observed 9 . Loss of primary patency after endovascular repair can often be managed by 8 percutaneous techniques, with subsequent secondary patency rates of 80% to 98% reported in the 9 literature 7 . While these studies demonstrate the safety and efficacy of an endovascular approach 10 in severe disease, in this age group an open approach to TASC II D disease would normally be 11 favoured in our institution given the higher long-term rates of primary patency 7 .This case 12 highlights the importance of proficiency in endovascular techniques in order to provide an 13 individualised approach to patient care. 14 15

The coronavirus pandemic has impacted on the management of vascular disease. Early data has 16 highlighted the impact of SARS-Cov2 infection on post-operative outcomes, with mortality rates 17 as high as 40% in COVID-19-positive patients undergoing vascular surgery reported 10 . The 18

Vascular Society for Great Britain and Ireland has emphasised the importance of reducing 19 inpatient length of stay and critical care bed dependency in a letter to members 11 . Endovascular 20 techniques are highlighted as a way by which this may be achieved in order to deliver acute care 21 to patients requiring surgery while recognising of the above complexities 11 . In a recent The COVD-19 pandemic has impacted significantly on the delivery of acute-care vascular 6 surgery. Concerns regarding post-operative mortality in the event of SARS-Cov2 infection, 7 critical care bed capacity and inpatient length of stay will undoubtedly lead to a re-imagining of 8 the role of endovascular therapy in the management of complex aorto-iliac occlusive disease. 9

This case demonstrates the management of a TASC-II D lesion with a hybrid endovascular 10 approach, negating the need for a critical care bed and resulting in a successful outcome. 11 J o u r n a l P r e -p r o o f

Clinical characteristics and outcomes 2 of patients undergoing surgeries during the incubation period of COVID-19 infection

percutaneous treatment of TransAtlantic Inter-Society Consensus class C and D aorto-iliac

Journal of vascular surgery

Global vascular 8 guidelines on the management of chronic limb-threatening ischemia

Consensus for the Management of Peripheral Arterial Disease (TASC II)

Clinical and anatomical considerations for surgery in aortoiliac disease and 14 results of surgical treatment

Minimally Invasive Management of Severe Aortoiliac

Acute limb 8 ischemia in patients with COVID-19 pneumonia

COVID-19 virus and vascular surgery

COVID-19 virus and vascular surgery

The global impact of COVID-19 on 15 vascular surgical services

3-D reconstruction of lower limb CT Angiography demonstrating abdominal aorta thrombosis, Right common iliac aneurysmal degeneration and left common iliac artery occlusion, left external iliac occlusion and re-canalisation of the left common femoral artery via the left inferior epigastric artery

Intra-operative Digital Subtraction Angiogram showing (A) a diagnostic angiogram demonstrating a right common iliac artery aneurysm and occlusion of the left common iliac artery, and (B) the completion angiogram post-endovascular recanalization