Reoperative abdominal arterial surgery--a ten-year experience

The safety and durability of elective reconstructive procedures of the abdominal aorta and its major branches are universally accepted; however, late complications continue to threaten limbs and lives of a minority of patients. The strategy of managing such revascularization failures has received inadequate attention. Between February 1971 and July 1981, 76 patients underwent 83 remedial, transabdominal revascularization procedures because of failed reconstructions. Group I consisted of 34 patients with occlusive complications (0% remedial operative mortality rate); group II, 21 patients with prosthetic sepsis including graft-enteric fistula (14% operative mortality); group III, 11 patients with aneurysmal degeneration (36% operative mortality); and group IV, 10 patients with visceral ischemia (0% operative mortality). The remedial operative mortality rate for the combined groups was 7.9%. Limb preservation was the rule in group I (91%); however, 29% of limbs at risk in group II ultimately required major amputation (15% early, 14% late). All patients in group II without an established graft-enteric fistula were saved; however, three of ten with active hemorrhage died of the sequelae of hypovolemic shock. Progressive arteriosclerotic morbidity and massive intraoperative bleeding accounted for the high mortality rate in group III. Favorable results were obtained in reoperation for recurrent visceral ischemia (renal ischemia in five, mesenteric ischemia in five). On the basis of this experience, an aggressive surgical approach seems justified. First, complete bifemoral revascularization performed at the time of original operation should reduce the need for reoperation. Second, elective, transabdominal remedial arterial surgery can be done with acceptable morbidity and mortality rates. Third, graft-enteric erosions and periprosthetic sepsis must be treated aggressively to avoid life-threatening sepsis and hemorrhage. Finally, anatomic revascularization can be performed successfully after a suitable period following removal of an infected retroperitoneal prosthesis.