AORTOILIAC AND AORTOFEMORAL RECONSTRUCTION OF OBSTRUCTIVE DISEASE

This retrospective study evaluates our strategy to limit prosthetic reconstructions for aortoiliac obstructive disease to the diseased segments in 518 patients. There were 363 (70%) reconstructions without femoral anastomotic sites (FEM-0), 107 (21%) reconstructions with one femoral anastomotic site (FEM-1), and 48 (9%) aortobifemoral reconstructions (FEM-2). The ischemic symptoms and the extent of obstructions were significantly more severe in the FEM-1 and FEM-2 groups than in the FEM-0 group. Early operative results were comparable in all three groups. The difference in outcome became apparent when the long-term results were considered. Long-term follow-up continued for up to 20 years after the operation. Primary and secondary patency rates were significantly higher in the FEM-0 group (9% and 4% recurrent obstructions per 5 years, respectively) than in the FEM-1 and FEM-2 groups (both 14% and 10%, respectively), which was explained by patient selection. Late additional surgery was performed after aortoiliac procedures in most cases for recurrent aortoiliac obstruction and after aortofemoral procedures in most cases for false aneurysms. The risk of late additional operations during long-term follow-up were significantly lower in the FEM-0 group than in the FEM-1 and FEM-2 groups. These results support our strategy to tailor prosthetic reconstructive surgery to the individual status of the aortoiliac arteries

LONG-TERM SUCCESS OF AORTOILIAC OPERATION FOR ARTERIOSCLEROTIC OBSTRUCTIVE DISEASE

The current retrospective study was performed on 747 patients with aortoiliac obstructive disease who under-went reconstructive operation. Unlike many other centers, the University Hospital Leiden has, throughout the years, maintained the strategy of avoiding the implantation of a prosthesis in patients with limited and localized obstructive disease that could readily be treated with an endarterectomy. When a prosthesis was used, it was anastomosed to the femoral artery if a more proximal anastomosis was not feasible. In the present study, the long term outcome of the strategy is evaluated.Three groups of patients were studied-245 patients with moderate claudication, 331 patients with severe claudication and 162 patients with critical ischemia at presentation. Thromboendarterectomies were used in 229 patients (30.7 per cent) and prosthetic reconstructions in 518 patients (69.3 per cent), of which 339 (45.5 per cent) were aortobiiliac reconstructions. The perioperative mortality rates were 1.6, 3.0 and 3.1 per cent for the three groups, respectively. Atherosclerotic heart disease was the most common cause of perioperative (30.0 per cent) and late (30.8 per cent) death. Late complications of surgical treatment also contributed significantly to the causes of late deaths (12.1 per cent).Because over-all survival rates in the current series compared favorably with those in other series, the influence of reconstructive operation on late survival was compensated for by a beneficial effect in patients without such complications. Secondary operations for late complications, such as false aneurysms and aortoiliac reobstruction or for progressive obstructive disease, were necessary in 21 per cent of all 727 survivors of the first operation.Actuarial curves with various endpoints-mortality, secondary operation, patency of aortoiliac segments, functional failure, amputation, presence of mild, moderate and severe claudication-were calculated according to the standard method of life table construction. In terms of technical success rates, the results of our surgical technique strategy compared favorably with those reported in other series, in which most patients were treated with aortobifemoral prostheses. The chances of functional failure increased with time, amounting to about 23 per cent at 15 years postoperatively for each group of patients. Comparison of technical and functional success rates showed a significant disparity, which was explained by the effects of collateral blood flow in instances of aortoiliac reobstruction and of progressing femoropopliteal obstructions in instances of open aortoiliac vessels.</p