Infrarenal Iterative Aortic Surgery: Early and Late Morbi-Mortality Observed in 61 Patients

Article Outline

• Abstract
• Introduction
• Patients and Methods
• Results
  • Early Results
  • Late Results
• Discussion
• References
• Copyright

The aim of this study was to analyze the early and late results of iterative aortic surgery after bypass of infrarenal aorta. Results from Clermont-Ferrand and Saint-Etienne hospitals have been collected. Between January 1993 and December 2001, 61 patients (59 men and two women, mean age 65 years) underwent a partial or complete second aortic reconstruction through a direct approach. Three different indications that required redo surgery were detected. Twenty-three patients presented with an infection (37%), 17 with an occlusive pathology (28%), and 21 with an aneurysm (34%). Medical or endoluminal treatment could no longer be considered. Mean period of time for redo surgery was 101 months (range 1-294). Eighteen of the procedures were emergency surgeries. A polyester prosthesis was used in 45 cases, an arterial allograft in 15 cases, and autogenous venous material in one case. In 22 cases (36%) a visceral, renal, or infracrural revascularization was associated. Four patients died (6.5%): three with an infection and one with an occlusive pathology. Global morbidity rate was 64%. Twelve vascular surgical complications (19%) required redo surgery: seven limb ischemia, three hemorrhage, and two colic ischemia. The preoperative factors generating severe complications were a septic context, renal insufficiency, and American Society of Anesthesiologists grade 3 or 4. Follow-up concerned the 57 surviving patients with a 43-month mean period of time (range 4-105). Actuarial survival rate was 80.7% at 3 years and could be compared to that observed after infrarenal aortic first surgery. Primary and secondary global patency rates were, respectively, 66.4 ± 6.7% and 94.6 ± 3% at 3 years with no major amputation. In our series including 37% of septic patients and nearly 30% of patients operated on in emergency, aortic iterative surgery led to mortality and morbidity rates twice and four times as important as those resulting from infrarenal aortic initial surgery, respectively. In the long term, patient survival and limb salvage rates were quite similar to those obtained with de novo surgery.

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Introduction 

Aortic surgical restoration with replacement remains the “gold standard” surgery to treat infrarenal aortic aneurysm or aortoiliac occlusive disease.¹ Long-term results for restorations are very satisfying.² Nevertheless, they are impaired by the occurrence of some complications that may require redo surgery in order not to lose these benefits. These complications can be infectious, occlusive (stenosis or thrombosis), or characterized by aneurysm or false aneurysm occurrences. According to the cases, surgical treatment limited to the femoral anastomotic site or an endoluminal procedure can be sufficient to treat the complication. In some rare cases, it may be necessary to perform iterative aortic surgery, including new aortic clamping and total or partial replacement of the already in place prosthetics.

Since very few data can be found in the literature,³, ⁴, ⁵ the aim of our study was to evaluate early and long-term results of iterative aortic surgery using a retrospective analysis of the experience of two vascular surgery departments.

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Patients and Methods 

Between January 1993 and December 2001, 61 patients (59 men and two women, mean age 65 years, range 40-85) underwent a partial or complete second aortic reconstruction through a direct approach.

The pathology treated during the initial infrarenal aorta replacement was an aneurysm in 16 patients (26%) and an occlusive disease in 45 patients (74%). At the time of the initial surgery, seven aortoaortic tubes (12%), five bifurcated aortobi-iliac prostheses (8%), and 49 aortobifemoral prostheses (80%) were implanted.

The patients were divided into three groups according to the indication for redo surgery: 23 graft infections (38%), 17 occlusive lesions (28%), and 21 aneurysms (aortic aneurysms or false aneurysms) (Fig. 1, Fig. 2, Fig. 3) (34%). Table I shows the different indications for redo surgery according to the initial aortic pathology.

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• Fig. 1 

  Preoperative aortic tomodensitometry of a patient with graft infection, showing a periprosthetic collection associated with gaseous pictures, which indicates the infectious origin of the collection.

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• Fig. 2 

  Preoperative aortoiliac arteriography of a patient belonging to the occlusive lesions group, showing a prosthetic left branch occlusion associated with a right branch postanastomotic stenosis and aortic atheroma above the aortoprosthetic terminolateral anastomosis.

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• Fig. 3 

  Preoperative aortoiliac arteriography of a patient belonging to the aneurysmal pathology group, showing a false aneurysm on the aortic anastomosis of an aortobifemoral bypass. Renal arteries are very close.

Table I. Indications for reoperation

Risk factors and previous medical history are summarized in Table II. Tobacco addiction and dyslipidemia were most frequently discovered. The American Society of Anesthesiology (ASA) score was ≥3 in >80% of the cases, which reveals the polypathology of the studied population. Two patients were in chronic preoperative dialysis.

Table II. Operative risk factors

HBP, high blood pressure; COPD, chronic obstructive pulmonary disease; ins, insufficiency.

The mean time before redo surgery was 101 months (8.5 years, range 1-294 months). Redo surgery was performed in emergency within the 24 hr following hospital entry in 18 cases (30%).

Among the 23 graft infections, 11 were treated with emergency surgery and 12 benefited from scheduled surgery. In occlusive pathology, with five emergency surgery cases, the distribution was modal, with a 30% emergency mean rate. For aneurysms, with only two emergency surgeries out of 21 cases, the scheduled surgery rate exceeded 90% of the cases.

Thirteen aortoaortic bypasses (21%), 15 aortobi-iliac bypasses (25%), and 33 aortobifemoral bypasses (54%) were carried out. In graft infections, only three aortoaortic bypasses were performed (13%) whereas 13 out of the 23 patients required an aortobifemoral bypass. Nonmaterial was implanted in 16 cases (15 allografts and one autologous vein). In occlusive lesions, only two aortoaortic bypasses were carried out (12%) whereas 12 out of 17 patients required aortobifemoral bypasses. In aneurysmal pathology, aortoaortic, aortobi-iliac, and aortobifemoral restorations were equally distributed.

In graft infection, only three aortoaortic bypasses were used (13%) whereas 13 out of the 23 patients required an aortobifemoral bypass. An additional arterial restoration associated with aortoiliac revascularization was indicated in 22 patients, whereas only eight patients benefited at the time of the initial surgery. Seven patients required several revascularizations including three visceral reconstructions (Table III).

Table III. Associated revascularizations

CT, celiac trunk; SMA, superior mesenteric artery; renal, renal artery; IMA, inferior mesenteric artery; IIA, internal iliac artery.

Transperitoneal access was used in 55 cases including 50 vertical medial laparatomies and five transverse laparatomies. Six retroperitoneal approaches were performed thanks to thoracophrenic lombotomies and a simple lombotomy.

Aortic clamping was infrarenal in 47 cases and suprarenal in 14 cases. Mean clamping duration was 57 min (range 14-110). In the initial surgery, the aortic implantation site was always infrarenal. In redo surgery, the new implantation was located on the lower thoracic aorta in two cases, on the celiac aorta in four cases, on the suprarenal aorta in two cases, and on the infrarenal aorta in 53 cases. In 45 cases, a polyester prosthesis was used. Among the infected cases, 15 received an arterial allograft and one had an aortobifemoral reconstruction with superficial femoral autologous vein.

After hospital discharge, each patient's follow-up was performed at 1 and 3 months and then every 6 months. Follow-up included general and vascular clinical examination along with duplex scan. Blood numeration and formula, plasmatic ionogram, tomodensitometric examination, and aortoarteriography were performed only on selected patients presenting with an abnormality of systematic examinations. On May 1, 2002, a phone call with the general practioner, the angiologist, or the cardiologist enabled us to appraise the patient's status provided they had met within the previous 4 months. If needed, a private phone call with the patient was scheduled. Survival and patency were calculated according to the actuarial method and expressed with a 95% confidence interval. The results were compared with the log rank test. A patient who was lost to follow-up was considered as “alive or patent excluded” at the last consultation date. Patients were compared using the chi-squared test. Associations were considered statistically significant at p<0.05. Statistical analyses were performed with the SAS software (SAS System, Los Angeles, CA). Qualitative variables were presented as mean ± 2 standard deviations. Their comparison was done with analysis of variance. The definitions used to express the results (survival, patency) were those taken into consideration by the Ad Hoc Commitee of Society for Vascular Surgery/International Society of Cardiovascular Surgery.⁶

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Results 

Early Results 

Early results correspond to the data collected during the period extending to the thirtieth postoperative day and/or to the patient's hospital discharge day. We observed four postoperative deaths (6.5%). Three of these patients were operated on for infection; two of them presented with an aortoenteric fistula. The fourth death concerned a patient with occlusive lesions.

Taking into consideration the pathology that had induced redo surgery, the difference observed in the deaths was not significant. Death causes in graft infections were a hemorrhagic syndrome on the twelfth postoperative day resulting from coagulation disorders in a cirrhosis patient, a hemorrhagic syndrome on the eighteenth postoperative day resulting from the rupture of a homograft limb, and a coronary thrombosis that occurred on the thirty-fifth postoperative day. The death of the patient treated for occlusive lesions was due to a coronary thrombosis that occurred on the thirtieth postoperative day.

Global morbidity rate was 64%. Thirty-nine patients, including the four patients who died during the early postoperative period, experienced one or several postoperative complications. Only 22 patients did not suffer from any postoperative complications. Table IV gives the details about the number and the incidence of these lethal or nonlethal postoperative complications.

Table IV. Postoperative morbidity (total population n = 61)

Complications	n	%
Respiratory	12	19.7
Pneumopathy	11	18.0
Pulmonary embolism	1	1.6
Cardiac	4	6.5
Myocardial infarction	2	3.2
Acute pulmonary edema	2	3.2
Renal/ureteral	21	34.4
Acute renal ins	15	24.6
Acute renal ins requiring dialysis	3	4.9
Ureteral	3	4.9
Cerebrovascular	2	3.2
Transient ischemic accident	1	1.6
Cerebrovascular accident	1	1.7
Digestive	11	18.0
Hepatic ins	1	1.6
Pancreatitis	3	4.9
Cholecystitis	2	3.2
Colic ischemia	3	4.9
Occlusion	2	3.2
Hemorrhagic	15	24.6
Shock	2	3.2
DIVC/coagulopathy	3	4.9
Postoperative hemorrhage	5	8.2
Digestive hemorrhage	5	8.2
Infectious	19	31.1
Septic shock	2	3.2
Septicemia	13	21.3
Deep abscess	4	6.5
Vascular	13	21.3
Limb ischemia	10	16.4
Proximal venous ischemia	2	3.2
Type II heparin- induced thrombosis	1	1.6
Total	97

ins, insufficiency; DIVC, disseminated intravascular blood coagulation.

Ninety-seven complications occurred in 39 patients, i.e., 2.5 complications per patient for the patients presenting complications and 1.6 complications per patient for the global population.

The unifactorial analysis of risk factors and associated preoperative clinical history on the number of complications per patient (Table V) showed that only preoperative renal insufficiency (p = 0.023) and an ASA score ≥3 (p = 0.042) were significantly associated with an increase in the number of postoperative complications. Dyslipidemia and tobacco addiction could not be studied because of group imbalance since the cohort included only five nonsmoking patients and eight (patients) without dyslipidemia.

Table V. Unifactorial analysis of risk factors and preoperative associated defects according to the number of complications per patient

In the same way, the influence of redo surgery indication on morbidity was examined. The results were as follows: in the infectious group there were 2.5 complications per patient, in the occlusive lesions group 1.2 complications per patient, and in the aneurysmal pathology group 0.9 complications per patient. Taking into consideration the treated pathology, this difference concerning the number of complications per patient was statistically significant (p = 0.013) in each of the three groups: Postoperative complications were statistically more frequent in the infectious pathology group compared to the occlusive lesions group and even more frequent in the aneurysmal group.

Morbidity univariate statistical analysis according to the kind of surgery (emergency or scheduled) did not show any significant differences (p = 0.145). Morbidity univariate statistical analysis according to the type of redo surgery (purely intra-abdominal intervention or femoral access) did not show significant differences either (p = 0.851).

Sixteen patients (26%) required a total of 25 redo surgeries due to postoperative complications. Vascular complications concerned 12 patients. Acute ischemia was observed nine times in seven patients and was the most frequent cause of redo surgery in the postoperative period.

Three hemorrhages were also observed: a wound of the hepatic artery caused by an intimal lesion due to clamping with a Fogarty probe leading to rupture 24 hr after operation, a rectus abdominis muscle hematoma requiring surgical drainage at day 2, and a homograft limb rupture on the twenty-first postoperative day. Two colic ischemia cases requiring a Hartmann's procedure were observed. The other redo surgeries were as follows:

No major amputation was performed during the postoperative period.

Late Results 

The follow-up concerned 57 surviving patients with a mean duration of 43 months (range 4-105). A patient was lost to follow-up but was alive and patent at 60-month follow-up. Fifteen late deaths were observed. Two patients died after late vascular complications, one at 4 months from limb ischemia related to nonrevascularized limb thrombosis. This patient was in the occlusive lesions group. One patient died of a secondary rupture of a homograft limb 12 months after placement. Initially, this patient presented with an aortoenteric fistula. The other death causes observed during the follow-up were not directly related to the performed surgery (Table VI). Actuarial survival was 80.7% ± 5.9 at 3 years (Fig. 4).

Table VI. Causes of late deaths

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• Fig. 4 

  Actuarial survival curve of the 61 patients. Actuarial survival was 80.7 ± 5.9% at 3 years. ^∗Number of patients surviving at the start of follow-up.

Most of the late complications were occlusive. Four patients had to undergo surgical or endovascular treatment for five distal infra-anastomotic stenoses: one patient was treated with bilateral profundaplasty at 8 months, two patients with surgical angioplasty of the femoral bifurcation at 13 and 22 months, one patient with endoluminal dilatation of the internal iliac artery, revascularizing the common femoral artery below an occlusion of the external iliac axis at 15 months. Twelve limb thromboses were observed in seven patients. These thromboses occurred between the second and the sixty-second follow-up months (mean 18 months). Eight times they were treated with thrombectomy, in association with vascular reconstruction in six cases (four profundaplasties, one below-knee femoropopliteal bypass, and one proximal restoration). Four patients with a limb occlusion were medically treated without any surgery since they had minor symptoms.

Actuarial primary patency was 66.2% ± 6.7 at 3 years (Fig. 5). We did not observe any significant differences between the three groups of patients (p = 0.083) using the log rank test. It was the same for the actuarial global patency, which was 92.6% ± 3.5 at 3 years (Fig. 6).

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• Fig. 5 

  Actuarial primary patency was 66.2 ± 6.7% at 3 years. ^∗Number of patients at risk at the start of follow-up.

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• Fig. 6 

  Actuarial global patency was 92.6 ± 3.5% at 3 years. ^∗Number of patients at risk at the start of follow-up.

Two patients presented with three outflow degradations. Fifty-five months after the redo surgery, one patient with subacute leg ischemia was treated with a femoroperoneal bypass. A patient presented with critical leg ischemia at 25 months after redo surgery. The treatment consisted of a reversed saphenous vein below-knee femoropopliteal bypass. The same patient presented with contralateral critical leg ischemia at the sixtieth postoperative month, which was treated with an above-knee femoropopliteal bypass. No major amputations was done during the follow-up.

Three false aneurysms were observed in two patients. One patient presented with an iliac anastomotic false aneurysm treated with a covered stent. After the treatment of an aortoenteric fistula with an aortobifemoral homograft replacement, one patient presented with bilateral femoral anastomotic false aneurysms at 53 and 65 months. The treatment consisted of an exclusion and bypass between the homograft and the deep femoral artery on both sides. In one of the two cases, surgical treatment was performed emergently and the superficial femoral vein was used for the bypass. In the other case, a homograft was used.

Two urological complications were observed. Five months after the implantation of an aortobifemoral homograft, one patient presented with a fatal hemorrhagic shock due to a fistula between the homograft and the left ureter. Forty-eight months after the treatment of an aortic false aneurysm with a polyester tube, a patient presented with ureterohydronephrosis by ureteral compression due to an iliac false aneurysm. The treatment consisted of placing a ureteral probe and exclusion of the iliac anastomotic false aneurysm with a covered stent.

Two visceral ischemia cases were observed. Two months after hospital discharge, a patient presented with a colic ischemia. He had previously undergone an aortoaortic restoration to treat an aortic false aneurysm. A left hemicolectomy with a terminal iliac colostomy was performed.

One patient presented with thrombosis of an associated renal revascularization 59 months after the aortic restoration. This patient presented with renal function deterioration in association with severe high blood pressure. Thrombosis of a lower pole accessory renal artery with a right partial renal infarction was detected. Hypertension was controlled with converting enzyme inhibitors.

Two infectious complications were observed. Two months after the treatment of an aortoenteric fistula with an aortoaortic polyester tube, a patient presented with an ongoing septic evolution and a perigraft abscess. An iterative closure of the aortoenteric fistula with an aortoaortic homograft implantation was performed. Two months after the treatment of an aortoenteric fistula with an aortobi-iliac homograft, a patient presented with an ongoing septic evolution with a reccurring aortoenteric fistula and hemorrhagic shock. Infrarenal aortic ligature associated with an axillobifemoral bypass was performed.

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Discussion 

In our series including 37% of septic patients and 30% of patients operated on emergently, iterative aortic surgery was plagued with a significant morbi-mortality. The observed mortality amounts to 6.5%; this rate is twice as high as the one observed with the initial infrarenal aortic surgery.

Anidjar et al.⁷ reported a mortality rate <3% after 385 aortic restorations performed for occlusive lesions; in aneurysm treatment, the mortality rate was 2.6% in the ARCHIV group study concerning 383 patients, and it reached 3.9% in the French University Association for Surgical Research (AURC) multicentric study concerning 780 cases.⁸, ⁹ In the United States, the recently reported rate for a multicentric study was 3.3%.¹⁰

The results we observed for aortic iterative surgery are similar to those mentioned in the literature. In 1994, Kraus et al.³ reported an 8% mortality rate in a series of 36 patients who underwent a redo surgery with a new proximal aortic anastomosis. Fulenwider et al.,⁴ in a series of 76 patients, 11 with no aortic prosthesis, showed a similar mortality rate of 7.9%. Similarly in 1991, the Haiart et al. study⁵ concerning 50 patients included six patients who had first undergone an endarterectomy; the early mortality rate was 8%. However, these results must be qualified since, in our series, 18 patients were operated on in emergency. In the Anidjar et al. series,⁷ emergency revascularizations were not taken into consideration, which was also the case in the AURC and the ARCHIV group studies.⁸, ⁹ Infection cases were not accounted for in these studies, which concerned elective aortic surgery. In our study, 23 patients presented with an infectious pathology and three deaths out of four occurred in this group (13%). Kieffer et al.¹¹ reported a 20.1% mortality rate in a series of 179 infections involving an aortic anastomotic site and treated with in situ allograft replacement. The significant mortality rate observed in the group of patients presenting with an infection was related to the emergency surgery frequency, to the seriousness of hemorrhagic complications resulting from aortoenteric fistulae, to the deterioration of the physical state resulting from sepsis, and to the frequent occurrence of severe medical or surgical postoperative complications. When excluding patients of the septic group, we observed a 2.6% mortality rate, which corresponds to the relatively low results that are usually observed after elective aortic surgery. In our study, the observed mortality rate was particularly high, four times as significant as the one observed after elective aortic surgery.⁷, ⁸, ⁹ However, the respiratory complication rate (19.7%) and cardiac complication rate (6.5%) were similar to those usually observed with elective surgery. Renal complications were frequent, which has to be related to the great number of renal restorations performed in our population (15 renal arteries revascularized in 61 patients). Nearly half of these restorations were performed at the same time as visceral artery restorations, which, despite last year's technical advances, could not have been treated with endoluminal techniques. Infrarenal clamping also had to be performed in 14 patients.

Ureteral complications we had to deal with were linked to cicatricial fibrosis due to previous aortic restoration. Ureter identification during iterative aortic surgery is the main technical risk during the iterative tunnelization of limbs. In our recent experience, preoperative ureter spotting is facilitated by a temporary placement of JJ ureteral probes. These probes are placed the day before surgery and are removed as soon as possible during the postoperative period, usually at 72 hr. Another technique consists of dissection at the closest limb of the first prosthesis. Then, the limb is removed downstream after attaching it to the new limb. The disadvantage of this technique is that it makes ureter identification difficult, which may induce a ureteral lateral wound, as observed in our series.

Ischemic complications are also frequent and most often require redo surgery; in most cases, they show the severity of the atheromatous lesions in our population. They also reveal the importance of the technical difficulties inherent in iterative vascular accesses, which are at the origin of a great deal of locoregional complications.

The morbi-mortality rate observed during iterative aortic surgery must be seen in perspective with the benefits of this type of revascularization. According to the indication, the pros and cons are different.

In the case of infection, there are few therapeutic options: Aortic ligation associated with axillofemoral revascularization involves a high rate of reinfection and thrombosis.¹², ¹³, ¹⁴, ¹⁵ In situ restorations can use reconstructions with autologous venous material,¹⁶, ¹⁷ but they are long and difficult. Antibiotic- or antiseptic-impregnated prostheses are often prone to reinfection.

Cryopreserved arterial allografts show satisfying long-term results and, in case of infection, are the gold standard for in situ restorations.¹¹, ¹⁸, ¹⁹

The aneurysmal evolution of an artery-grafted aorta is possible.²⁰ Similarly, according to Van den Akker et al.,²¹ a proximal anastomotic false aneurysm occurs in 7.7% of cases.

Many authors have proposed treating these lesions with endoprostheses, which gives satisfaying immediate results.²², ²³ Long-term result evaluation is still under way.²⁴, ²⁵ However, an endoprosthesis cannot be placed when the morphological prerequisites are not present or when an infection is suspected.

Bifemoral or aortobi-iliac restorations afford excellent long-term patency rates, but occlusive complications may occur. Should both limbs and/or supra-anastomotic aortic stenotic lesions occur, an iterative proximal restoration can be considered, all the more since the long-term patency of direct restorations is better than extra-anatomic restoration patency.²⁶

At 3 years, the actuarial survival rate was 80.7% and can be compared with the rate observed after infrarenal elective aortic first surgery.², ²⁷ In our study, late death causes were the same as the ones usually observed after aortic prosthetic surgery: Both cardiovascular pathology and cancers are the main death causes in the follow-up.²

At 3 years, primary and global actuarial patency rates were 66.4% ± 7 and 94.3 ± 3%, respectively, which can be compared with those observed after aortic first surgery.²⁸ No major amputations were observed during the follow-up.

These satisfying long-term results enable us to consider iterative aortic surgery as a good therapeutic option in the treatment of complications that can occur in patients who have already undergone an aortic replacement.

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