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Is thrombosis of the infrarenal abdominal aortic aneurysm an acceptable alternative?
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Extra-anatomic bypass for infrarenal aortic aneurysms in debilitated patients had a high operative mortality (31%) and significant morbidity, including graft thrombosis and ischemic complications.
Area of Science:
- Vascular Surgery
- Aortic Aneurysm Management
- Surgical Risk Stratification
Background:
- Infrarenal aortic aneurysms pose significant risks, especially for patients deemed too debilitated for standard surgical repair.
- Extra-anatomic bypass with aortic aneurysm thrombosis is an alternative approach for high-risk individuals.
Purpose of the Study:
- To evaluate the efficacy and safety of axillobifemoral bypass with bilateral iliac artery occlusion for infrarenal aortic aneurysms in severely debilitated patients.
Main Methods:
- Retrospective analysis of 13 patients (mean age 75) undergoing axillobifemoral bypass for infrarenal aortic aneurysms (mean size 6.3 cm) between 1980 and 1984.
- Assessment of preoperative risk factors including cardiac, pulmonary, renal, and nutritional status.
- Management included embolization of runoff vessels to achieve aneurysm thrombosis.
Main Results:
- High operative mortality rate of 31%, with deaths attributed to multisystem organ failure and coagulopathy.
- Significant morbidity in survivors: graft thrombosis (3 patients), ischemic colitis (2 patients), ischemic neuropathy (1 patient), and amputations (1 patient).
- Aneurysm thrombosis was not consistently achieved in all patients.
Conclusions:
- Axillobifemoral bypass for infrarenal aortic aneurysms in debilitated patients is associated with unacceptably high operative mortality and morbidity.
- This approach is not recommended due to poor outcomes compared to conventional graft replacement.
Abstract:
Aortic aneurysm thrombosis with extra-anatomic bypass has been proposed for persons with infrarenal aortic aneurysms who are "too debilitated" to undergo standard aortic reconstruction. Thirteen patients (mean age, 75 years) were selected between January 1980 and June 1984 for axillobifemoral bypass with bilateral iliac artery occlusion to manage their infrarenal aortic aneurysms (mean size, 6.3 cm; range, 4.9 to 7.5 cm). Preoperative risk factors were cardiac (angina, compensated congestive heart failure, and significant preoperative arrhythmias), 100% of patients; pulmonary (symptomatic chronic obstructive pulmonary disease with a 1-second forced expiratory volume less than 50% of the predicted value), 46% of patients; renal (creatinine value greater than or equal to 2.0 mg/dl or creatinine clearance less than 20 ml/min), 46% of patients; or nutritional (albumin less than or equal to 3.5 gm/dl or body weight less than 90% of ideal), 46%. Ninety-two percent of the patients had two risk factors whereas 46% had three or more risk factors. The operative mortality rate was 31%; three patients died of multisystem organ failure and another died of thrombin-induced consumptive coagulopathy and hemorrhage. (Our operative mortality rate for conventional graft replacement of abdominal aortic aneurysms is less than 3%.) Morbidity in persons surviving at least 1 month included thrombosis of the extra-anatomic bypass graft requiring thrombectomy (three patients), ischemic colitis (two patients), ischemic neuropathy (one patient), and patients), ischemic colitis (two patients), ischemic neuropathy (one patient), and bilateral above-knee amputations (one patient). Thrombosis of the aneurysm was not achieved in two patients despite use of fluoroscopically controlled embolization of runoff vessels.(ABSTRACT TRUNCATED AT 250 WORDS)