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Long term success of aortoiliac operation for arteriosclerotic obstructive disease
P J van den Akker1, R van Schilfgaarde, R Brand
1Department of Surgery, University Hospital Leiden, The Netherlands.
Insights
This study evaluated a surgical strategy for aortoiliac obstructive disease, finding favorable long-term survival rates. The approach prioritized endarterectomy over prostheses, leading to comparable outcomes despite higher rates of secondary operations for complications.
Area of Science:
- Vascular Surgery
- Cardiovascular Medicine
- Surgical Outcomes Research
Background:
- Aortoiliac obstructive disease significantly impacts patient mobility and survival.
- Treatment strategies vary, with a debate on the optimal approach for limited disease.
- University Hospital Leiden historically favored endarterectomy over prosthetic use for localized disease.
Purpose of the Study:
- To evaluate the long-term outcomes of a specific surgical strategy for aortoiliac obstructive disease.
- To compare the effectiveness of endarterectomy versus prosthetic reconstruction in different patient groups.
- To assess perioperative and late mortality, complications, and functional success rates.
Main Methods:
- Retrospective analysis of 747 patients with aortoiliac obstructive disease.
- Categorization of patients into moderate claudication, severe claudication, and critical ischemia groups.
- Comparison of outcomes between patients treated with thromboendarterectomy and those receiving prosthetic reconstructions.
Main Results:
- Overall survival rates compared favorably with other series.
- Perioperative mortality rates ranged from 1.6% to 3.1% across patient groups.
- Atherosclerotic heart disease was the leading cause of death; 21% of survivors required secondary operations for complications.
Conclusions:
- The University Hospital Leiden's surgical strategy for aortoiliac obstructive disease demonstrated favorable long-term survival.
- While endarterectomy was prioritized, prosthetic reconstructions were used when necessary.
- Functional failure rates increased over time, influenced by reobstruction and progression of distal disease.
Abstract:
The current retrospective study was performed on 747 patients with aortoiliac obstructive disease who underwent reconstructive operation. Unlike many other centers, the University Hospital Leiden has, throughout the years, maintained the strategy of avoiding the implantation of a prosthesis in patients with limited and localized obstructive disease that could readily be treated with an endarterectomy. When a prosthesis was used, it was anastomosed to the femoral artery if a more proximal anastomosis was not feasible. In the present study, the long term outcome of the strategy is evaluated. Three groups of patients were studied--245 patients with moderate claudication, 331 patients with severe claudication and 162 patients with critical ischemia at presentation. Thromboendarterectomies were used in 229 patients (30.7 per cent) and prosthetic reconstructions in 518 patients (69.3 per cent), of which 339 (45.5 per cent) were aortoiliac reconstructions. The perioperative mortality rates were 1.6, 3.0 and 3.1 per cent for the three groups, respectively. Atherosclerotic heart disease was the most common cause of perioperative (30.0 per cent) and late (30.8 per cent) death. Late complications of surgical treatment also contributed significantly to the causes of late deaths (12.1 per cent). Because over-all survival rates in the current series compared favorably with those in other series, the influence of reconstructive operation on late survival was compensated for by a beneficial effect in patients without such complications. Secondary operations for late complications, such as false aneurysms and aortoiliac reobstruction or for progressive obstructive disease, were necessary in 21 per cent of all 727 survivors of the first operation. Actuarial curves with various endpoints--mortality, secondary operation, patency of aortoiliac segments, functional failure, amputation, presence of mild, moderate and severe claudication--were calculated according to the standard method of life table construction. In terms of technical success rates, the results of our surgical technique strategy compared favorably with those reported in other series, in which most patients were treated with aortobifemoral prostheses. The chances of functional failure increased with time, amounting to about 23 per cent at 15 years postoperatively for each group of patients. Comparison of technical and functional success rates showed a significant disparity, which was explained by the effects of collateral blood flow in instances of aortoiliac reobstruction and of progressing femoropopliteal obstructions in instances of open aortoiliac vessels.