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Aortofemoral graft occlusion: strategy and timing of reoperation
L S Erdoes1, V M Bernhard, S S Berman
1Department of Surgery, University of Arizona Health Sciences Center, Tucson 85724, USA.
Insights
Secondary revascularization after aortofemoral graft occlusion often requires repeat surgery. While thrombolytic therapy can restore inflow, outflow obstruction frequently necessitates further surgical intervention for successful limb salvage.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
Background:
- Aortofemoral graft limb occlusion presents a significant challenge in vascular reconstruction.
- Restoring patency is crucial for limb salvage in patients with severe ischemia or rest pain.
Purpose of the Study:
- To evaluate secondary revascularization strategies following unilateral aortofemoral graft limb occlusion.
- To determine the optimal procedural approach for restoring and maintaining graft patency.
Main Methods:
- Retrospective review of 46 patients undergoing 64 procedures over 8.5 years.
- Analysis of surgical thrombectomy, transcatheter thrombolytic therapy, and outflow procedures like profundaplasty.
- Assessment of graft patency, complications, mortality, and limb salvage rates.
Main Results:
- Outflow obstruction was the primary cause of graft thrombosis (78.2%).
- Catheter-directed thrombolysis was successful in 13/14 cases, but 9 required subsequent surgical repair for residual stenosis.
- Overall cumulative patency was 68%, with 5% operative mortality and 85% limb salvage.
Conclusions:
- Secondary revascularization for aortofemoral graft occlusion often involves complex, multi-step interventions.
- While thrombolysis can be effective for inflow, addressing outflow obstruction is critical for long-term success.
- A combination of endovascular and surgical techniques may be necessary for optimal outcomes.
Abstract:
The authors' experience with 46 patients treated over 8.5 years was reviewed to determine the optimal secondary revascularization procedure after occlusion of a unilateral aortobifemoral graft limb. A total of 64 procedures was performed on these patients to restore and maintain graft patency. Repetitive operations for reocclusion were needed in 14 patients (30%). Transcatheter thrombolytic therapy was used in 14 patients, four as sole therapy and 10 in conjunction with operation. The mean time from aortofemoral grafting to presentation with graft limb occlusion was 59.4 months. Rest pain or severe ischemia was present in 85%, and severe claudication in the remainder. Some 78% had urgent operation after diagnostic angiography and catheter-directed thrombolytic therapy was attempted in 22%. The etiology of graft thrombosis was outflow obstruction in 78.2% of cases. Inflow was obtained by surgical thrombectomy in 35 and by lytic therapy in 13. Extra-anatomic inflow was used in 11 and intra-abdominal thrombectomy or redo aortofemoral grafting in five. Outflow procedures, mainly profundaplasty, were performed in all but five cases (four urokinase and one surgical). Infrainguinal bypass was needed in 10 cases in addition to the groin reconstruction. Catheter-directed thrombolysis was successful in 13 of 14 instances; however, in nine of these residual stenosis was disclosed in the outflow requiring surgical repair. Ultimately, 12 of 14 cases treated with thrombolysis required surgical intervention. Cumulative patency for all procedures was 68%. Complications were seen in 14% of cases. Operative mortality was 5%, and limb salvage was obtained in 85%.(ABSTRACT TRUNCATED AT 250 WORDS)