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Management and outcome of chronic atherosclerotic infrarenal aortic occlusion
J Ligush1, E Criado, S J Burnham
1Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill 27599-7212, USA.
Insights
Aorta-based bypass procedures for infrarenal aortic occlusion (IRAO) show superior outcomes compared to axillobifemoral bypass. Descending thoracic aorta is a viable inflow source, while nonoperative management increases mortality and limb loss risk.
Area of Science:
- Vascular Surgery
- Atherosclerotic Disease Management
- Reconstructive Procedures
Background:
- Chronic atherosclerotic infrarenal aortic occlusion (IRAO) presents significant management challenges.
- Patient demographics included a mean age of 57, with 47 of 48 patients being heavy smokers.
- Common symptoms were claudication (81%), rest pain (25%), and tissue loss (15%), with high incidence of impotence (73%).
Purpose of the Study:
- To evaluate the management strategies and clinical outcomes for patients with chronic atherosclerotic infrarenal aortic occlusion (IRAO).
- To compare the effectiveness of different surgical inflow procedures and nonoperative management.
- To assess long-term patency rates and patient survival following treatment for IRAO.
Main Methods:
- A retrospective review of 48 patients with angiographically documented IRAO treated between 1980 and 1994.
- Surgical interventions included thoracobifemoral bypass (TBF), aortobifemoral/iliac bypass (ABFI), and axillobifemoral bypass (AXBF).
- Eight patients were managed nonoperatively; inflow sources varied based on prior surgery or aortic condition.
Main Results:
- Overall operative mortality was 5%, with no significant difference between TBF and ABFI groups.
- Five-year patency rates were 71% for TBF and 79% for ABFI, significantly higher than AXBF (44% at 2 years).
- Nonoperative management resulted in higher mortality and limb loss; AXBF showed inferior outcomes compared to aorta-based procedures.
Conclusions:
- Aorta-based inflow procedures (TBF, ABFI) are superior to AXBF for IRAO regarding hemodynamics and patency.
- The descending thoracic aorta is a suitable inflow alternative for IRAO treatment.
- Nonoperative management of IRAO is associated with poor outcomes, including increased mortality and limb loss.
Purpose:
To evaluate the management and outcome of chronic atherosclerotic infrarenal aortic occlusion (IRAO), a review of 48 patients who were treated for angiographically documented IRAO between January 1980 and December 1994 was undertaken. Mean follow-up was 45 months. Mean age was 57 years (range, 33 to 88 years). Forty-seven patients were heavy smokers. Symptoms included claudication in 81%, rest pain in 25%, and tissue loss in 15%. Impotence was documented in 73% of men. Associated arterial disease included inferior mesenteric artery occlusion in 31 patients, renal artery stenosis or occlusion in 12, superior mesenteric artery stenosis in two, and celiac artery stenosis in one.
Methods:
Forty inflow procedures were performed, including 17 thoracobifemoral bypass (TBF) procedures, 15 aortobifemoral/iliac bypass (ABFI) procedures, and eight axillobifemoral bypass (AXBF) procedures. Eight patients were managed without surgery. The thoracic aorta was chosen as the inflow source in 17 patients because of previous abdominal aortic surgery in eight, poor status of the abdominal aorta in eight, and horseshoe kidney in one.
Results:
The overall operative mortality rate was 5%, and the perioperative morbidity rate was 18%. There was no statistical difference in perioperative mortality and morbidity rates among the operative groups. The five-year survival rate (life-table) for all IRAO patients was 67%. TBF and ABFI revascularization procedures yielded 5-year patency rates of 71% and 79%, respectively (p < 0.05). All eight patients who underwent AXBF died or had occluded grafts at 3 years after surgery. Two-year patency rates (life-table) for TBF, ABFI, and AXBF were 92%, 92%, and 44%, respectively. The AXBF patency rate was significantly inferior to those of TBF and ABFI (p < 0.05). Changes in ankle-brachial indexes after TBF or ABFI were similar, but were significantly greater than changes after AXBF (p < 0.05). Three patients in the nonoperative group died, and two underwent major amputation. Acute renal failure did not occur in our study population. Follow-up creatinine levels > 2.0 mg/dl were documented in three operative patients and in one nonoperative patient, and none required dialysis.
Conclusions:
In patients who have IRAO, aorta-based inflow procedures are superior to AXBF both in hemodynamic outcome and in patency rates. Treatment of IRAO with TBF or ABFI yields similar long-term results; the descending thoracic aorta represents an excellent inflow alternative to the abdominal aorta. Clinically significant renal impairment is rarely associated with IRAO. Nonoperative management of IRAO is associated with an increased mortality rate and a high rate of limb loss.