Chronic visceral ischemia. Three decades of progress
Related Experiment Videos
C G Cunningham1, L M Reilly, J H Rapp
1Department of Surgery, University of California, San Francisco 94143.
Insights
Transaortic endarterectomy (TA TEA) and antegrade bypass (AB) offer durable symptom relief for chronic visceral ischemia. Both surgical techniques provide comparable long-term asymptomatic outcomes with acceptable risks for visceral atherosclerosis treatment.
Area of Science:
- Vascular Surgery
- Atherosclerosis
- Gastroenterology
Background:
- Symptomatic visceral atherosclerosis presents a significant surgical challenge due to its severity and complexity.
- Surgical management of chronic visceral ischemia has evolved with advancements in operative techniques and patient care.
- Reviewing cumulative experience is crucial for understanding the efficacy of different revascularization strategies.
Purpose of the Study:
- To compare the outcomes of transaortic endarterectomy (TA TEA) and antegrade bypass (AB) for visceral revascularization.
- To evaluate the long-term efficacy, morbidity, and mortality associated with these two preferred surgical techniques.
Main Methods:
- Retrospective review of 74 patients undergoing visceral revascularization over three decades.
- Primary reconstruction utilized either transaortic endarterectomy (TA TEA) (n=48) or antegrade bypass (AB) (n=26).
- Comparison of patient demographics, symptoms, risk factors, operative details, complications, and long-term outcomes.
Main Results:
- Both TA TEA and AB groups showed comparable long-term asymptomatic rates at 1 year (97.3% vs 95.8%) and 5 years (86.1% vs 86.5%).
- Perioperative mortality was similar between TA TEA (14.6%) and AB (7.7%), with an overall rate of 12.2%.
- TA TEA group had a higher incidence of multiple complications and all significant pulmonary complications.
Conclusions:
- Both transaortic endarterectomy and antegrade bypass are effective in providing durable symptom relief for chronic visceral ischemia.
- These techniques offer acceptable operative morbidity and mortality rates for complex vascular reconstructions.
- The choice of technique may depend on specific patient factors and associated atherosclerotic involvement.
Abstract:
Symptomatic visceral atherosclerosis is a major surgical challenge because of its life-threatening course and the complexity of its definitive operative treatment. Evolution in the operative approach to the visceral aorta and progress in the intraoperative management of patients undergoing complex vascular reconstructions prompted a review of the authors' cumulative experience in the surgical management of chronic visceral ischemia. Among all patients undergoing visceral revascularization at the University of California, San Francisco during the past three decades, 74 patients were identified whose primary reconstruction used transaortic endarterectomy (TA TEA) (n = 48) or antegrade bypass (AB) (n = 26), the authors' preferred revascularization techniques. The two treatment groups were comparable in gender distribution, age, presenting symptoms, and physical findings, although the amount of preoperative weight loss was greater in the AB group (35.8 +/- 19.5 versus 22.4 +/- 12.0, p = 0.003). The groups were also comparable in the prevalence of atherosclerosis risk factors, symptomatic vascular disease at other sites, and previous vascular operations. However associated renal artery atherosclerosis was slightly greater in the TA TEA group (58.3% versus 23.1%, p = 0.07) when compared to the AB group. Antegrade bypass was usually performed transabdominally (88.5%), while TA TEA was approached thoracoretroperitoneally (75.0%). Celiac revascularization was almost universal in both treatment groups, but the TA TEA group underwent significantly more frequent superior mesenteric artery (SMA) revascularization (93.8% versus 46.2%, p = 0.0001) and slightly more frequent inferior mesenteric repair (18.8% versus 3.8%, p = 0.07) than the AB group. In addition the frequency of combined renal and visceral repair (25.0% versus 0.0%, p = 0.01) as well as combined aortic, renal, and visceral repair (22.9% versus 3.8%, p = 0.03) was significantly greater in the TA TEA group. The obligatory interval of renal and visceral ischemia did not differ between the two approaches. The perioperative mortality rate was 12.2% and was the same for TA TEA (14.6%) and AB (7.7%). Overall the incidence of complications was the same with either operative approach, although patients in the TA TEA group tended to have multiple complications (17.1% versus 0.0, p = 0.03) and all significant pulmonary complications occurred in this group. Two patients were lost to follow-up. The cumulative percentage of patients who remained asymptomatic following AB or TA TEA was (respectively) 95.8% and 97.3% at 1 year and 86.5% and 86.1% at 5 years. Both of these operative approaches provide durable symptom relief with acceptable operative morbidity and mortality rates.(ABSTRACT TRUNCATED AT 400 WORDS)