Durability of endarterectomy and antegrade grafts in the treatment of chronic visceral ischemia

Abstract

Several techniques have been used to revascularize the visceral circulation. Although initially successful, these repairs often have a significant rate of late occlusion. To determine the durability of transaortic endarterectomy (TEA) and antegrade aortovisceral grafting, we reviewed the last 67 consecutive patients operated on at the University of California, San Francisco for chronic visceral ischemia. The patients were principally middle-aged (mean, 59 years) women (76%) with atherosclerotic disease involving at least two major visceral arteries. Forty-seven patients underwent TEA; 22 patients had associated renal endarterectomy, and 15 patients had simultaneous aortic reconstructions. Twenty patients had an aortovisceral antegrade bypass placed as their only reconstruction. Two of these had concomitant aortic reconstructions. There were five perioperative deaths. Of the 62 patients available for follow-up, 60 patients who had a total of 111 major visceral branch repairs have been followed up for 6 months to 14 years (mean, 4.4 years). Four patients (7%) have had recurrent visceral ischemia. Two patients had recurrent symptoms and have been asymptomatic for nearly 5 and 6 years, respectively, after successful reoperations. Two patients had intestinal infarction and died as a result. Thirty-four patients have had follow-up aortography that showed 58 widely patent reconstructions, two asymptomatic single-vessel stenoses, and one asymptomatic occlusion. TEA and antegrade visceral bypass provided long-term relief of symptoms and prevented visceral gangrene in 56 of 60 patients (93%). The prolonged patency of these reconstructions is attributed to the following: They originate from undiseased or endarterectomized aorta, they provide optimal, nonturbulent flow, and they avoid the inherent technical pitfalls of retrograde grafting.

ACC/AHA 2005 Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic): A Collaborative Report from the American Association for Vascular Surgery/Society for Vascular Surgery,⁎Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients

“…Surgical treatment of chronic intestinal ischemia is accomplished by endarterectomy or bypass grafting, with the majority of surgeons preferring the latter approach (836,(851)(852)(853)(854)(855)(856)(857)(858). The overall operative mortality and durability of revascularization in chronic cases described by multiple contemporary reports are listed in Table 42.…”

ACC/AHA 2005 Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic): Executive Summary A Collaborative Report From the American Association for Vascular Surgery/Society for Vascular Surgery,⁎⁎AAVS/SVS when Guideline initiated, now merged into SVSSociety for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guideline

“…Surgical treatment of chronic intestinal ischemia is accomplished by endarterectomy or bypass grafting, with the majority of surgeons preferring the latter approach (239,(251)(252)(253)(254)(255)(256)(257)(258). In chronic cases, the overall operative mortality and durability of revascularization described by multiple contemporary reports are listed in Table 42 in the full-text guidelines.…”

Percutaneous transluminal angioplasty in the treatment of chronic mesenteric ischemia: results and 3 years of follow-up in 23 patients

“…The technical success rate is 100%, and the immediate clinical success rate is 96% (range Å 82-100%). Nevertheless, the surgical mortality rate is 9% (range Å 0-17%), and the morbidity rate is 25% (range Å 13-33%) [2,[15][16][17][18][19][20][21][22][23][24][25].…”

“…The primary longterm clinical success is equal to that of surgery (50-100%, mean Å 84% for follow-up periods of 24-69 months) [2,[15][16][17][18][19][20][21][22][23][24][25]. Moreover, in two surgical series with 93% and 70% primary long-term clinical success, respectively, the results improved with a second intervention and secondary clinical success reached 97% and 100%, respectively [22,24]. In our experience, repetition of PTA allowed us to achieve the secondary clinical success in 100% of patients.…”