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Pelvic blood flow after end-side aortofemoral bypass
ANNUAL
MEETING
ABSTRACTS
From the New England Society for Vascular Surgery The Eighteenth Annual Meeting of the New England Society for Vascular Surgery will be held on Sept. 26-27, 1991, in Quebec, Canada. The following are selected abstracts from that meeting published in the order of presentation at the meeting.
Axillofemoral risk patients
bypass: an acceptable
alternative
in high-
with critical lower extremity ischemia who usually do not need the more durable AEB.
Joseph R. Schneider, MD, PhD, Martha D. McDaniel, MD, Daniel B. Walsh, MD, Robert M. Zwolak, MD, PhD, and Jack L. Cronenwett, MD, Dartmouth-Hitchcock Medical Center, Hanover, N.H. Aortofemoral bypass (AFB) is the preferred method to provide lower extremity inflow, but axillofemoral bypass (AXB) is an alternative for high-risk patients. We compared our experience with these two operations from 7185 to 12/90. Thirty-three axillobifemoral and eight axillounifemoral grafts were done preferentially because of severe associated medical disease (n = 34), aortic graft sepsis (n = 2), or aortoduodenal fistula (n = 5). During the same interval, 107 patients received an AFB. PTFE was used for 39/41 AXB, and Dacron was used for 102/107 AFB. Nearly all AXB and AFB patients were heavy smokers, and the two groups had similar rates of hypertension and angina. However, other major risk factors were found more frequently in AXB patients. Limb-threatening ischemia was more common and femoral artery occlusive disease (SVS/ISCVS-angiographic outflow score) was more severe in AXB patients. Profunda anastomoses and concomitant infrainguinal bypass were more likely to be required in AXB patients. Life-table patient survival at 3 years was 39% for AXB versus 90% for AFB (p < 0.001). Primary patency at 3 years was 64% for AXB versus 85% for AEB (p = 0.052) and secondary patency was 69% for AXB versus 93% for AFB (p = 0.004). Limb salvage at 3 years was 82% for AXB versus 97% for AFB (p = 0.078). Of 23 AXB deaths during follow-up, 22 patients died with patent grafts. Hemodynamic performance of AXB and AFB were compared. Mean preoperative ankle-brachial index (ABI) was higher in AFB (0.50) than AXB (0.41,~ = 0.005), but postoperative ABI was much higher after AFB (0.84) than AXB (0.57,~ < 0.001). Even after adjustment for severity of outflow disease, postoperative ABI was much better after AFB than AXB. AXB was performed in older, higher risk patients with more severe ischemia than AFB. Hemodynamic performance was inferior and graft failure more common after AXB. However, AXB provided limb salvage in all but 1 of 23 patients who have died, and only one survivor has had amputation as a result of graft failure. AXB is an acceptable alternative to AFB in properly selected high-risk patients 428
Pelvic blood flow after end-side aortofemoral bypass Susan O’Connor, MD, Daniel B. Walsh, MD, Anne Musson, RVT, F. Elizabeth LaBombard, RVT, MaryAnne Waters, RVT, Joseph R. Schneider, MD, PhD, Robert M. Zwolak, MD, and Jack L. Cronenwett, MD, DartmouthHitchcock Medical Center, Hanover, N.H. We prefer end-end aortobifemoral bypass grafts (AFB), but selectively use end-side proximal anastomoses for patients with severe external iliac disease to avoid inadequate retrograde iliac blood flow and possible pelvic ischemia. Recently nine such patients with end-side AEB were studied with use of color duplex imaging to determine the source of pelvic blood flow in the first year after surgery. No patient exhibited clinical evidence of pelvic ischemia in the postoperative period. Despite the aortic end-side anastomosis, six of nine patients were found to have occluded distal aortas by duplex studies performed at a mean of 4.4 months after operation (range, 0.8 to 8.2 months). Of the six patients with occluded aortas, postoperative duplex examination demonstrated two with no common or external iliac blood flow; two with bilateral retrograde external iliac flow; and
two with unilateral retrograde external iliac flow. Among the three patients with patent distal aortas, two had no demonstrable external iliac blood flow, whereas the third had continued antegrade flow through one iliac limb and retrograde flow through the other. Extensive analysis of preoperative angiographic data failed to reveal accurate predictors of postoperative distal aortic patency or retrograde iliac blood flow. Despite the preoperative assumption that prograde common iliac blood flow was required to prevent pelvic ischemia, distal aortic patency was maintained in only three of nine patients. In the six patients without prograde iliac blood flow, no ischemic symptoms were present, including
two patients with complete absenceof antegrade aortic or retrograde iliac blood flow. It is possible that patency of the native aortoiliac system is only important in the immediate postoperative period before collateral circulation develops. However, our observations indicate that assumptions that underlie the decision to perform end-side aortic auastomoses are rarely borne out in the months after aortobifemoral bypass.
MEETING
ABSTRACTS
From the New England Society for Vascular Surgery The Eighteenth Annual Meeting of the New England Society for Vascular Surgery will be held on Sept. 26-27, 1991, in Quebec, Canada. The following are selected abstracts from that meeting published in the order of presentation at the meeting.
Axillofemoral risk patients
bypass: an acceptable
alternative
in high-
with critical lower extremity ischemia who usually do not need the more durable AEB.
Joseph R. Schneider, MD, PhD, Martha D. McDaniel, MD, Daniel B. Walsh, MD, Robert M. Zwolak, MD, PhD, and Jack L. Cronenwett, MD, Dartmouth-Hitchcock Medical Center, Hanover, N.H. Aortofemoral bypass (AFB) is the preferred method to provide lower extremity inflow, but axillofemoral bypass (AXB) is an alternative for high-risk patients. We compared our experience with these two operations from 7185 to 12/90. Thirty-three axillobifemoral and eight axillounifemoral grafts were done preferentially because of severe associated medical disease (n = 34), aortic graft sepsis (n = 2), or aortoduodenal fistula (n = 5). During the same interval, 107 patients received an AFB. PTFE was used for 39/41 AXB, and Dacron was used for 102/107 AFB. Nearly all AXB and AFB patients were heavy smokers, and the two groups had similar rates of hypertension and angina. However, other major risk factors were found more frequently in AXB patients. Limb-threatening ischemia was more common and femoral artery occlusive disease (SVS/ISCVS-angiographic outflow score) was more severe in AXB patients. Profunda anastomoses and concomitant infrainguinal bypass were more likely to be required in AXB patients. Life-table patient survival at 3 years was 39% for AXB versus 90% for AFB (p < 0.001). Primary patency at 3 years was 64% for AXB versus 85% for AEB (p = 0.052) and secondary patency was 69% for AXB versus 93% for AFB (p = 0.004). Limb salvage at 3 years was 82% for AXB versus 97% for AFB (p = 0.078). Of 23 AXB deaths during follow-up, 22 patients died with patent grafts. Hemodynamic performance of AXB and AFB were compared. Mean preoperative ankle-brachial index (ABI) was higher in AFB (0.50) than AXB (0.41,~ = 0.005), but postoperative ABI was much higher after AFB (0.84) than AXB (0.57,~ < 0.001). Even after adjustment for severity of outflow disease, postoperative ABI was much better after AFB than AXB. AXB was performed in older, higher risk patients with more severe ischemia than AFB. Hemodynamic performance was inferior and graft failure more common after AXB. However, AXB provided limb salvage in all but 1 of 23 patients who have died, and only one survivor has had amputation as a result of graft failure. AXB is an acceptable alternative to AFB in properly selected high-risk patients 428
Pelvic blood flow after end-side aortofemoral bypass Susan O’Connor, MD, Daniel B. Walsh, MD, Anne Musson, RVT, F. Elizabeth LaBombard, RVT, MaryAnne Waters, RVT, Joseph R. Schneider, MD, PhD, Robert M. Zwolak, MD, and Jack L. Cronenwett, MD, DartmouthHitchcock Medical Center, Hanover, N.H. We prefer end-end aortobifemoral bypass grafts (AFB), but selectively use end-side proximal anastomoses for patients with severe external iliac disease to avoid inadequate retrograde iliac blood flow and possible pelvic ischemia. Recently nine such patients with end-side AEB were studied with use of color duplex imaging to determine the source of pelvic blood flow in the first year after surgery. No patient exhibited clinical evidence of pelvic ischemia in the postoperative period. Despite the aortic end-side anastomosis, six of nine patients were found to have occluded distal aortas by duplex studies performed at a mean of 4.4 months after operation (range, 0.8 to 8.2 months). Of the six patients with occluded aortas, postoperative duplex examination demonstrated two with no common or external iliac blood flow; two with bilateral retrograde external iliac flow; and
two with unilateral retrograde external iliac flow. Among the three patients with patent distal aortas, two had no demonstrable external iliac blood flow, whereas the third had continued antegrade flow through one iliac limb and retrograde flow through the other. Extensive analysis of preoperative angiographic data failed to reveal accurate predictors of postoperative distal aortic patency or retrograde iliac blood flow. Despite the preoperative assumption that prograde common iliac blood flow was required to prevent pelvic ischemia, distal aortic patency was maintained in only three of nine patients. In the six patients without prograde iliac blood flow, no ischemic symptoms were present, including
two patients with complete absenceof antegrade aortic or retrograde iliac blood flow. It is possible that patency of the native aortoiliac system is only important in the immediate postoperative period before collateral circulation develops. However, our observations indicate that assumptions that underlie the decision to perform end-side aortic auastomoses are rarely borne out in the months after aortobifemoral bypass.