A contemporary experience of open aortic reconstruction in patients with chronic atherosclerotic occlusion of the abdominal aorta.

OBJECTIVE: To examine and report surgical results from a contemporary experience of open abdominal aortic reconstruction in patients with chronic atherosclerotic abdominal aortic occlusion (CAAAO).

METHODS: Between January 1999 through May 2010, 54 patients with CAAAO were identified and retrospectively reviewed. CAAAOs were categorized into infrarenal aortic occlusions (IRAOs) and juxtarenal aortic occlusions (JRAOs) based on superior extension of thrombus and requirement for supra-renal aortic clamping to repair. Morbidity, mortality, hospital stay, and operative variables were assessed. The χ2 or Fisher test and the Wilcoxon rank sum test were used to compare demographic and operative variables between two aortic occlusion groups (IRAO and JRAO). Univariate and multivariate analyses were performed to assess factors associated with surgical outcomes and hospital stay. The Kaplan-Meier method was used to calculate survival and patency rates.

RESULTS: Fifty patients underwent aortic reconstructions with aorto-bifemoral or iliac bypass, and three underwent a remote axillo-femoral bypass procedure. There were 35 (64.8%) males, and 19 (35.2%) females. Median age was 51.9 years (range, 32-72 years). Of the two CAAAO groups, there were 20 IRAOs and 33 JRAOs. Aorto-renal thromboendartectomy was performed in 26 (49.1%) patients; 26 (75.8%) among JRAOs versus 1 (5%) of IRAOs (P<.01). Proximal aortic clamps were required in 28 (85%) of JRAOs and 3 (15%) of IRAOs (P<.01). Thirty-day and in-hospital mortality was zero. Median length of hospital stay was 7 days (range, 4 to 66 days), and median intensive care unit length of stay was 3 days (range, 1-22 days). Complications included cardiopulmonary dysfunction in four (8%), postoperative renal insufficiency in 10 (18.9%), and other postoperative complications in 15 (28.3%). All 10 with renal insufficiency recovered renal function to baseline creatinine or a creatinine value<1.1 mg/dL. Mean increases in right and left ankle-brachial indicess were 0.54±0.25 and 0.59±0.22, respectively. On univariate analysis, coronary artery disease and African American race were predictors of postoperative complications (P=.048). Age was significantly associated with total complications. Patients with postoperative complications and/or renal insufficiency were older than those without such complications (P=.02) Independent predictors of prolonged hospital stay were intraoperative blood replacement (P=.003), postoperative complications (P<.01), and postoperative renal insufficiency (P<.01). Prolonged intensive care unit stay was predicted by JRAO (P=.04), postoperative complications (P=.02), and postoperative renal insufficiency (P=.013). Survival at 3, 5, and 7 years were 86.6%, 76.5% and 50.9%, respectively. The reduced survival rates were predicted by previous myocardial infarction and existing coronary artery disease (P<.01).

CONCLUSION: Abdominal aortic reconstruction is a safe method for treating CAAAO with low associated morbidity and mortality. Aorto-renal thromboendartectomy with supra-renal aortic clamping and aortic replacement remains an effective treatment for those with significant pararenal aortic disease, and can be performed without significant renal impairment.