Outcomes after redo aortobifemoral bypass for aortoiliac occlusive disease

Abstract

Objective Patients presenting with occluded aortobifemoral bypass(ABF) grafts are managed with a variety of techniques. Redo ABF(rABF) procedures are infrequently performed due to concerns about procedural complexity and morbidity. The purpose of this analysis is to compare mid-term results of rABF to primary ABF(pABF) for aortoiliac occlusive disease(AIOD) to determine if there are significant differences in outcomes. Methods A retrospective review was performed of all patients undergoing ABF for occlusive disease between January 2002 and March 2012. A total of 19 patients underwent rABF and 194 received pABF during that time period. Data for an indication and comorbidity-matched case control cohort of 19 elective pABF patients were collected for comparison to the rABF group. Primary end-points included rate of major complications, as well as 30-day and all-cause mortality. Secondary end-points were amputation-free survival(AFS) and freedom from major adverse limb events(MALEs). Results rABF patients more frequently underwent prior extra-anatomic or lower extremity bypass operations compared to pABF(P=.02), however no difference was found in the incidence of in prior failed endovascular iliac intervention(P =.4). By design, indications for the rABF and pABF groups were the same: claudication, N=6/6(31.6%), P =1; critical limb ischemia, N=13/13(78.4%), P=1. Aortic access was more frequently via retroperitoneal exposure in the rABF group(N=13 vs. N=1;P<.0001) and a significantly higher proportion of the rABF patients required concomitant infrainguinal bypass or intra-procedural adjuncts such profundaplasty(N=14 vs. N=5; P=.01). rABF patients experienced greater blood loss (1097±983mL vs. 580±457mL;P=.02), received more intraoperative fluids(3400±1422mL vs. 2279±993mL;P=.01), and had longer overall procedure times(408±102 vs. 270±48 minutes; P<.0001). Length of stay(days±SD) was similar (pABF, 11.2±10.4 vs. rABF, 9.1±4.5;P=.7) and no 30-day or in-hospital deaths occurred in either group. Similar rates of major complications occurred in the 2 groups(pABF, N=6(31.6%) vs. rABF, N=4(21.1%); observed difference 9.5%, 95% confidence interval:-17.6%, 36.7%;P=.7). Two-year freedom from MALE(±standard error mean) was 82±9% vs. 78±10% for pABF and rABF patients(log-rank, P=.6). Two-year AFS was 90±9% vs. 89±8% between pABF and rABF patients(P=.5). Two-year survival was 91±9% and 90±9% for pABF and rABF patients(P=.8). Conclusions Patients undergoing rABF have higher procedural complexity compared to pABF as evidenced by greater operative time, blood loss and need for adjunctive procedures. However, similar perioperative morbidity, mortality and mid-term survival occurred in comparison to pABF patients. These results support a role for rABF in selected patients.

The Utility of Duplex Ultrasonography Surveillance in Identifying Failing Aortobifemoral Grafts

“…Performing aortobifemoral graft thrombectomy and revision with open surgery, often required in an emergent setting, is associated with considerable morbidity due to acute limb ischemia, operating in a re-do scarred groin, and increased chances of inadvertent nerve injury and bleeding due to technical misadventure . 7 Weaknesses of our study include the retrospective nature of the analysis and the arbitrary choice of a focal PSV > 350 cm/ sec and adjacent PSV ratio > 3.5 as being surrogates for failing grafts. Other authors have suggested similar and differing PSVs and ratios to suggest failing peripheral vein and prosthetic bypasses.…”

Management of noninfected prosthetic aortic bypass failures using femoral vein

“…Patients undergoing redo aortobifemoral bypass also experience higher volume of blood loss and have longer overall procedure times. 4 The 2-year amputation-free survival is estimated to be 89% 6 9% in these patients; however, half of the failures of the second aortofemoral bypass will result in major amputation.…”

“…2,3 Factors identified with failure of aortofemoral bypass include young age at initial bypass, continued smoking history, distal occlusive disease, and coronary artery disease. 4 The neoaortoiliac system (NAIS), a technique that is often used for treating infected aortofemoral bypasses, uses the femoropopliteal veins as conduits for aortic reconstruction. It can be performed in a single operation or as a staged procedure, with harvest of deep vein on one day and reconstruction of the aortoiliac system on the subsequent day.…”

“…5 The procedure has perioperative morbidity rates of 10% to 20%, including amputation, lower extremity venous hypertension complications, and wound infections, and a mortality rate of 10% to 20% when used for infected aortic grafts; however, NAIS has demonstrated an excellent 5-year primary assisted patency of >90%. 4 This technique has been used in noninfected situations, but its use as salvage for failed aortofemoral bypass grafts has not been previously described. 6 Our hypothesis was that the use of deep vein to treat noninfectious failures of aortofemoral bypass grafts is a viable option in patients who have had prosthetic graft failure procedures, offering an excellent limb salvage and patency that is better than repeated prosthetic bypass.…”

Contemporary outcomes of thoracofemoral bypass

“…These subjects can be managed with a variety of remedial procedures including thrombolysis, angioplasty/stenting, thrombectomy, extra-anatomic revascularization or redo aortic surgery. Although redo AFB can be performed safely in good risk patients 7,8 , some present with severe pararenal aortic neck calcification and/or thrombus that precludes the ability to safely construct a juxtarenal anastomosis [9][10][11] . Similarly, certain patients have severe native pararenal and/or mid-visceral aortic atherosclerotic disease that, due to clinical symptoms and/or anatomic proximity, mandates concurrent reno-mesenteric arterial reconstruction if in-line aortic repair is attempted [9][10][11] .…”