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Total infrarenal aortic occlusion
Total lnfrarenal Aortic Occlusion Robert E. Casali, MD, FACS, Little Rock, Arkansas Everett Tucker, MD, Little Rock, Arkansas Raymond C. Read, MD, FACS, Little Rock, Arkansas Bernard W. Thompson, MD, FACS, Little Rock, Arkansas
Atherosclerotic aortoiliac occlusive vascular disease (Leriche syndrome) is a common entity which causes ischemia of the lower extremities. Since the introduction by Oudot [1] in 1951 of aortic resection and homograft replacement, reconstructive procedures to restore distal blood flow by either endarterectomy or, later, with prosthetic grafts have become standardized. High total abdominal aortic occlusion extending to the level of the renal arteries is much less commonly encountered and presents different and challenging problems in its surgical management [2,3]. Control of the aorta to prevent excessive hemorrhage is essential; also, the kidneys and viscera must be protected from embolization during endarterectomy. Postoperative acute renal dysfunction, usually a fatal complication, has been the most serious one reported. It presumably results from atheromatous embolism occurring during cross clamping of the aorta or when the aortic thrombus is extracted
[41. A question to be considered is: Are these patients with total aortic occlusion different from the usual patient with Leriche syndrome, and are they at such high risk, that a safer extraanatomic bypass should be performed? The present report describes our experience treating patients with total infrarenal aortic occlusion and addresses this issue. Material and Methods
During the period 1960 to 1976,16 of 388 patients (4.1 per cent) operated on for atherosclerotic aortoiliac occlusive vascular disease had total infrarenal aortic occlusion. There were fourteen men and two women, aged forty to sixty-four years (average, 54 years). All had smoked at least one pack of cigarettes per day for at least twenty years. All From the Surgical Service, Veterans Administration Hospital, and the Defor Medical Science, Llttie Rock, Zsyf Swgery. ~~e=ity of m Reprint requests should be addressed to B. W. Thompson, MD, FACS. Surgical Service, Veterans Administration Hospital, 300 East Roosevelt Road, Little Rock, Arkansas 72208. Presented at the Twenty-Ninth Annual Meeting of the Southwestern Surgical Congress, Acapulco, Mexico, April 25-28. 1977.
vohlmo 134, Docembu
1977
had had claudication for at least one month, and in one woman (6 per cent) rest pain was present. Sexual impotence was present in 57 per cent of the males. Femoral pulses were absent bilaterally in all. Delineation of the responsible lesion and evaluation of the renal arteries was undertaken by abdominal aortic angiography, performed via the percutaneous transbrachial route. Seven patients (44 per cent) had myocardial disease as documented by a history of myocardial infarction, angina pectoris, or an abnormal electrocardiogram. Five (31 per cent) had a blood pressure greater than 150/90 mm Hg, and one (6 per cent) had diabetes mellitus. Arteriography demonstrated complete occlusion of the abdominal aorta at the level of the renal arteries in all patients. (Figure 1.) Operative
Technic
Preoperative hydration was obtained by infusing 3,000 ml of a balanced salt solution containing 15 mEq/l of potassium chloride 12 hours prior to surgery. The abdomen was opened using a xiphoid to symphysis pubis incision. The aorta was then exposed by incising the retroperitoneum and mobilizing the third portion of the duodenum. Gentle dissection of the aorta was begun just proximal to the inferior mesenteric artery and carried cephalad to the level of the renal arteries. Blunt aortic dissection was avoided. The renal arteries were dissected and encircled by vascular loops. The aorta was completely mobilized for a distance of 4 to 5 cm below the renal arteries. Prior to any vascular occlusion, mannitol25 g, furosemide 20 mg, and heparin sodium 120 ufkg were given. Activated coagulation times (ACT) were monitored every 20 minutes in an attempt to maintain prolongation of the coagulation time at more than 200 seconds throughout the operative procedure. The renal arteries were then occluded close to the aorta with noncrushing vascular clamps. The aorta was transected 3 to 4 cm below the renal arteries. Thrombectomy was performed using a curette, while the assistant’s hand occluded the aorta at the diaphragm. After removal of the thrombus, an infrarenal aortic clamp was placed, and the renal arteries and proximal aorta were released. (Figure 2.) The renal warm ischemia time varied from 5 to 12 minutes. A preclotted Dacron@ prosthesis was sutured end-to-end to the aorta proximally, and the distal aorta was oversewn. The distal ends of the graft were then approximated end-
809
Casali et al
Figure 1. Artehgram demonstfathg comph3te occtushm ot the abhmtnal aorta at the level of the renal arte-
ries.
to-side to the external iliac arteries in twelve patients. When the external iliac arteries contained atheromatous plaques (4 patients), the graft limbs were sutured to the common femoral arteries, and in three patients, profundaplasty was also performed. If at the end of the procedure, the activated clotting time was prolonged, protamine sulfate was given in 20 mg increments for hemostasis. Results
Table I shows the long-term patient survival and graft patency rates. There was one myocardial infarction and four renal complications. Table II indicates the renal complications. Earlier in the study when renal protection was not used, three of six patients (50 per cent) sustained kidney complications; presumably, these were due to atheromatous embolism during extraction of the clot. One patient developed anuria intraoperatively. An attempt in the immediate postoperative period to salvage the kidneys was unsuccessful; thrombi were removed from the larger branches of the renal arteries, but adequate renal function never returned. Two patients had unilateral loss of one kidney, which was not diagnosed early because they did not develop renal failure. Four of the thirteen long-term survivors died, three suddenly, possibly from myocardial infarction, three, nine, and ten years after the operative procedure. The other late death occurred secondary to chronic renal failure. They were asymptomatic with open grafts when last evaluated. One patient had thrombosis of one limb of the graft nine months after operation and underwent successful revision. There
were no permanent graft occlusions, and none resulted in amputation. Comments
The most common symptom in patients with chronic total occlusion of the infrarenal aorta is claudication; ischemic ulceration and impending tissue loss are rare. All of our patients presented with intermittent claudication of the lower extremity. It has been demonstrated in experimentally produced atherosclerosis [5-71, that arteries distal to an occlusion of the aorta are “protected” from atherosclerotic disease. This phenomenon may be present in patients with total occlusion of the aorta, in that occlusive disease is uncommon distal to the origins of the hypogastric arteries. This concept coupled with the frequent use of profundaplasty make operative arteriograms to assess “runoff’ unnecessary. The preoperative aortogram delineates the extent of the disease as well as the number and involvement of renal arteries. Frequently, the distal arterial tree is also visualized. Rarely, in patients presenting with more advanced disease, such as ischemic ulcers or impending tissue loss, the groins should be explored first and the adequacy of the “runoff’ ascertained. Protection of the kidneys from atheromatous emboli occurring during manipulation and extraction of the aortic thrombus is an essential feature [2,3,8-101. Earlier in our experience, we as well as others [8] had renal complications secondary to this phenomenon. Thurlbeck and Castleman [4] were the first to describe atherosclerotic emboli in patients with ruptured abdominal aneurysms. Renal failure
The American Journal ol Surgery 810
infrarenai
FIgwe
Aortic Occlusion
2. Operative procedure followed on patients with lnfrarenal aortlc occlusion.
secondary to multiple emboli has been permanent, chronic dialysis being necessary to support the patients. To avoid this devastating complication, vascular clamps are applied to the renal arteries in juxtaposition to the aorta during extraction of the thrombus. This technic was used successfully in our last ten patients. The warm ischemic time of the kidneys has been less than 15 minutes. It is well known that kidneys tolerate this without sequelae. If reconstruction of the renal arteries is not required, a suprarenal aortic clamp is not placed, because this is difficult, and effective tamponade can be accomplished with the assistant’s hand. Preoperative and intraoperative volume expansion is an important feature [II]. Hemorrhage may be brisk during flushing of the aorta after the thrombus has been removed; however, with volume expansion, hypotension is less likely to occur. Dehydration and hypotension are hazardous to the kidney, and ischemia is tolerated best during diuresis. The addition of mannitol, an osmotic diuretic, further increases the glomerular filtration rate [12,13]. Furosemide, a loop diuretic, has also been proposed to prevent renal failure [14,15]. Therefore, volume expansion along with osmotic and loop diuretics given prior to renal injury provide an optimal situation to protect against acute tubular necrosis. We routinely use systemic heparin in the doses
vohlmo 134, December 1977
mentioned previously to avoid clotting in the distal vessels, although others [9] have not. At the end of the procedure, protamine sulfate is given intravenously in small doses, using the activated coagulation time to monitor the total dose. This technic has been
TABLE I
Long-Term Patient Burvival, Gralt Patency Rate, ODerative and Late Complications Operative
Late*
4 0 0 1 0
0 1 0 3 4
Renal Thrombosed graft Amputation Myocardiai infarction Deaths l
Complications occurring more than thirty days postoperative-
iY.
TABLE II
Renal ComDiications
occiuded Bilateral infarctions Unilateral infarctions Acute tubular necrosis Chronic dialysis l
Nonoccluded
0 0 1’ 0
intraoperative myocardiai infarction.
811
Casali et al
routinely used by us in other aortic surgery. Postoperative hematomas have only rarely been encountered. Since the distal arterial tree is virtually free of disease, restoration of pedal pulses is usually accomplished. The long-term patency rate of these grafts has been reported to be in excess of 80 per cent [8], and in our experience with these thirteen patients, with one exception, no long-term graft failure has occurred. The reported operative mortality varies from 4 to 10 per cent. Most of the deaths occurred earlier, before the currently recommended technics for performing vascular surgery were used. Presently, operative deaths are related to myocardial infarctions or cerebral vascular accidents. Since atherosclerosis is generally a diffuse process, such complications will be difficult to reduce. Extraanatomic bypassing offers a lesser procedure with, theoretically, reduced operative mortality [16-181. However, one of the largest series of elective axillobilateral femoral grafts reports an immediate mortality of 5 per cent [18]. These were high risk patients with associated systemic illnesses and may not be comparable. The major objection to axillobilateral-femoral grafting is that the aortic thrombus remains, thus allowing propagation of the clot [2,8,19,20]. Infarction of the kidneys and visceral organs has been reported to occur in as high as 50 per cent of unoperated patients [8]. Since claudication, and not rest pain or gangrene, is the most common presenting symptom, the main threat to the patient is propagation of the clot, not loss of limb. The long-term patency rate of axillobilateral-femoral grafts may equal aortoiliac or aortofemoral grafts, but frequent reoperations have been necessary because of graft thrombosis. For these reasons we strongly favor a direct approach in patients with total aortic thrombosis.
Summary
Our experience from 1960 to 1976 with total infrarenal aortic thrombosis (Leriche syndrome) was reviewed. Sixteen heavy smokers (14 men and 2 women) with an average age of fifty-four years underwent thrombectomy with aortoiliac (12 patients) or aortofemoral (4) Dacron bypasses. The last ten patients were hydrated for 12 hours preoperatively with 3,000 ml of Ringer’s solution containing supplemental potassium. Mannitol (25 g), furosemide (20 mg), and heparin (120 u/kg) were given intraoperatively. Thrombectomy was accomplished by transection of the aorta, with proximal manual con-
trol of the aorta after the renal arteries were occluded. With this technic there were no deaths or renal complications, whereas previously, three of the six patients developed renal complications and one died. Ninety-two per cent of the grafts have remained open. We recommend that the direct transabdominal approach be continued rather than the extraanatomic bypass (axillobilateral-femoral), since further propagation of the aortic thrombosis may then lead to infarction of the kidneys or other viscera. References 1. Oudot J: La greffe vasculaire dans les thromboses du carrefour aot-tique. Presse Med 59: 234, 195 1. 2. Bergan JJ. Trippel OH: Management of juxtarenal aortic occlusions. Arch Surg 87: 230, 1963. 3. Chavez CM, Conn JH, Fair WR, Gee HL: Surgical treatment of high aortoiliac occlusion. Surgery 65: 757, 1989. 4. Thurlbeck WM, Castleman B: Atheromatous emboli to the kidneys after aortic surgery. N Engl J Med 257: 442, 1957. 5. Synder DD, Campbell GS: Effect of aortic constriction on exoerirnental atherosclerosis In rabbits. Proc Sot Drp B/o/ h&d i-I9: 563, 1958. 6. Mestel AL, Spain DM, Turner HA: Atheroma absence distal to subtotal aorta occlusion. Arch Patho/ 78: 186, 1964. 7. Kakos GS, Hagen PO, Oldham HN Jr, et al: The influence of segmental hypotension on experimental atherosclerosis. Surgery 72: 479, 1972. 8. Starrett RW, Stoney RJ: Juxtarenal aortic OCClusiOn.Surgery 76: 890, 1974. 9. Liddicbat JE, Bekassy SM, Dang MH. DeBakey ME: Complete occlusion of the infrarenal abdominal aorta: management of results in 64 patients. Surgery 77: 487, 1975. 10. Hobson RW, Rich NM, Fedde CW: Surgical management of high aortoiliac occlusion, Am Surg 41: 271, 1975. 11. Thompson JE, Vollman RW, et al: Prevention of hypotension and renal complications of aortic sugery using balanced salt solution: thirteen year experience with 670 cases. Ann Surg 167: 767, 1968. 12. Barry KG, Cohen A, Knochel JP, et al: Mannitol Infusion. II. The prevention of acute functional renal failure during resection of an aneurysm of the abdominal aorta. N Engl J Med 264: 967, 1961. 13. Stone AM, Stahl WM: Effect of ethacrynic acid and furosemlde on renal function in hypovolemia. Ann Surg 174: 1, 1971. 14. Gennari FJ, Kassirer JP: Osmotic diuresis. N Engl J Med 291: 714.1974. 15. Cantarovich F, Fernandez J, Locatelli A, et al: Furosemide in high doses in the treatment of acute renal failure. Postgrad MedJ47: 13, 1971. 16. Frantz SL, Kaplltt MI, Bell AR Jr, et al: Ascending aorta-bilateral femoral artery bypass for the totally occluded infrarenal abdominal aorta. Surgery 75: 471, 1974. 17. Nunn DB, Kamal MA: Bypass grafting from thoracic aorta to femoral arteries for high aortoiliac occlusive disease. Surgery 72: 749, 1972. 18. LoGerfo FW, Johnson WC, Corson JD, et al: A comparison of the late patency rates of axillo-bilateral femoral and axlllounilateral femoral grafts. Surgery 81: 33, 1977. 19. Gomes MMR, Bernatz PE: Aorta-Iliac occlusive disease. Extensive cephalad to origin of renal arteries with surgical considerations and results. Arch Surg 101: 161, 1970. 20. Johnson JK: Ascending thrombosls of abdominal aorta as fatal complication of Leriche’s syndrome. Arch Surg 89: 863, 1954.
The American Journal ol Surgery 812
Atherosclerotic aortoiliac occlusive vascular disease (Leriche syndrome) is a common entity which causes ischemia of the lower extremities. Since the introduction by Oudot [1] in 1951 of aortic resection and homograft replacement, reconstructive procedures to restore distal blood flow by either endarterectomy or, later, with prosthetic grafts have become standardized. High total abdominal aortic occlusion extending to the level of the renal arteries is much less commonly encountered and presents different and challenging problems in its surgical management [2,3]. Control of the aorta to prevent excessive hemorrhage is essential; also, the kidneys and viscera must be protected from embolization during endarterectomy. Postoperative acute renal dysfunction, usually a fatal complication, has been the most serious one reported. It presumably results from atheromatous embolism occurring during cross clamping of the aorta or when the aortic thrombus is extracted
[41. A question to be considered is: Are these patients with total aortic occlusion different from the usual patient with Leriche syndrome, and are they at such high risk, that a safer extraanatomic bypass should be performed? The present report describes our experience treating patients with total infrarenal aortic occlusion and addresses this issue. Material and Methods
During the period 1960 to 1976,16 of 388 patients (4.1 per cent) operated on for atherosclerotic aortoiliac occlusive vascular disease had total infrarenal aortic occlusion. There were fourteen men and two women, aged forty to sixty-four years (average, 54 years). All had smoked at least one pack of cigarettes per day for at least twenty years. All From the Surgical Service, Veterans Administration Hospital, and the Defor Medical Science, Llttie Rock, Zsyf Swgery. ~~e=ity of m Reprint requests should be addressed to B. W. Thompson, MD, FACS. Surgical Service, Veterans Administration Hospital, 300 East Roosevelt Road, Little Rock, Arkansas 72208. Presented at the Twenty-Ninth Annual Meeting of the Southwestern Surgical Congress, Acapulco, Mexico, April 25-28. 1977.
vohlmo 134, Docembu
1977
had had claudication for at least one month, and in one woman (6 per cent) rest pain was present. Sexual impotence was present in 57 per cent of the males. Femoral pulses were absent bilaterally in all. Delineation of the responsible lesion and evaluation of the renal arteries was undertaken by abdominal aortic angiography, performed via the percutaneous transbrachial route. Seven patients (44 per cent) had myocardial disease as documented by a history of myocardial infarction, angina pectoris, or an abnormal electrocardiogram. Five (31 per cent) had a blood pressure greater than 150/90 mm Hg, and one (6 per cent) had diabetes mellitus. Arteriography demonstrated complete occlusion of the abdominal aorta at the level of the renal arteries in all patients. (Figure 1.) Operative
Technic
Preoperative hydration was obtained by infusing 3,000 ml of a balanced salt solution containing 15 mEq/l of potassium chloride 12 hours prior to surgery. The abdomen was opened using a xiphoid to symphysis pubis incision. The aorta was then exposed by incising the retroperitoneum and mobilizing the third portion of the duodenum. Gentle dissection of the aorta was begun just proximal to the inferior mesenteric artery and carried cephalad to the level of the renal arteries. Blunt aortic dissection was avoided. The renal arteries were dissected and encircled by vascular loops. The aorta was completely mobilized for a distance of 4 to 5 cm below the renal arteries. Prior to any vascular occlusion, mannitol25 g, furosemide 20 mg, and heparin sodium 120 ufkg were given. Activated coagulation times (ACT) were monitored every 20 minutes in an attempt to maintain prolongation of the coagulation time at more than 200 seconds throughout the operative procedure. The renal arteries were then occluded close to the aorta with noncrushing vascular clamps. The aorta was transected 3 to 4 cm below the renal arteries. Thrombectomy was performed using a curette, while the assistant’s hand occluded the aorta at the diaphragm. After removal of the thrombus, an infrarenal aortic clamp was placed, and the renal arteries and proximal aorta were released. (Figure 2.) The renal warm ischemia time varied from 5 to 12 minutes. A preclotted Dacron@ prosthesis was sutured end-to-end to the aorta proximally, and the distal aorta was oversewn. The distal ends of the graft were then approximated end-
809
Casali et al
Figure 1. Artehgram demonstfathg comph3te occtushm ot the abhmtnal aorta at the level of the renal arte-
ries.
to-side to the external iliac arteries in twelve patients. When the external iliac arteries contained atheromatous plaques (4 patients), the graft limbs were sutured to the common femoral arteries, and in three patients, profundaplasty was also performed. If at the end of the procedure, the activated clotting time was prolonged, protamine sulfate was given in 20 mg increments for hemostasis. Results
Table I shows the long-term patient survival and graft patency rates. There was one myocardial infarction and four renal complications. Table II indicates the renal complications. Earlier in the study when renal protection was not used, three of six patients (50 per cent) sustained kidney complications; presumably, these were due to atheromatous embolism during extraction of the clot. One patient developed anuria intraoperatively. An attempt in the immediate postoperative period to salvage the kidneys was unsuccessful; thrombi were removed from the larger branches of the renal arteries, but adequate renal function never returned. Two patients had unilateral loss of one kidney, which was not diagnosed early because they did not develop renal failure. Four of the thirteen long-term survivors died, three suddenly, possibly from myocardial infarction, three, nine, and ten years after the operative procedure. The other late death occurred secondary to chronic renal failure. They were asymptomatic with open grafts when last evaluated. One patient had thrombosis of one limb of the graft nine months after operation and underwent successful revision. There
were no permanent graft occlusions, and none resulted in amputation. Comments
The most common symptom in patients with chronic total occlusion of the infrarenal aorta is claudication; ischemic ulceration and impending tissue loss are rare. All of our patients presented with intermittent claudication of the lower extremity. It has been demonstrated in experimentally produced atherosclerosis [5-71, that arteries distal to an occlusion of the aorta are “protected” from atherosclerotic disease. This phenomenon may be present in patients with total occlusion of the aorta, in that occlusive disease is uncommon distal to the origins of the hypogastric arteries. This concept coupled with the frequent use of profundaplasty make operative arteriograms to assess “runoff’ unnecessary. The preoperative aortogram delineates the extent of the disease as well as the number and involvement of renal arteries. Frequently, the distal arterial tree is also visualized. Rarely, in patients presenting with more advanced disease, such as ischemic ulcers or impending tissue loss, the groins should be explored first and the adequacy of the “runoff’ ascertained. Protection of the kidneys from atheromatous emboli occurring during manipulation and extraction of the aortic thrombus is an essential feature [2,3,8-101. Earlier in our experience, we as well as others [8] had renal complications secondary to this phenomenon. Thurlbeck and Castleman [4] were the first to describe atherosclerotic emboli in patients with ruptured abdominal aneurysms. Renal failure
The American Journal ol Surgery 810
infrarenai
FIgwe
Aortic Occlusion
2. Operative procedure followed on patients with lnfrarenal aortlc occlusion.
secondary to multiple emboli has been permanent, chronic dialysis being necessary to support the patients. To avoid this devastating complication, vascular clamps are applied to the renal arteries in juxtaposition to the aorta during extraction of the thrombus. This technic was used successfully in our last ten patients. The warm ischemic time of the kidneys has been less than 15 minutes. It is well known that kidneys tolerate this without sequelae. If reconstruction of the renal arteries is not required, a suprarenal aortic clamp is not placed, because this is difficult, and effective tamponade can be accomplished with the assistant’s hand. Preoperative and intraoperative volume expansion is an important feature [II]. Hemorrhage may be brisk during flushing of the aorta after the thrombus has been removed; however, with volume expansion, hypotension is less likely to occur. Dehydration and hypotension are hazardous to the kidney, and ischemia is tolerated best during diuresis. The addition of mannitol, an osmotic diuretic, further increases the glomerular filtration rate [12,13]. Furosemide, a loop diuretic, has also been proposed to prevent renal failure [14,15]. Therefore, volume expansion along with osmotic and loop diuretics given prior to renal injury provide an optimal situation to protect against acute tubular necrosis. We routinely use systemic heparin in the doses
vohlmo 134, December 1977
mentioned previously to avoid clotting in the distal vessels, although others [9] have not. At the end of the procedure, protamine sulfate is given intravenously in small doses, using the activated coagulation time to monitor the total dose. This technic has been
TABLE I
Long-Term Patient Burvival, Gralt Patency Rate, ODerative and Late Complications Operative
Late*
4 0 0 1 0
0 1 0 3 4
Renal Thrombosed graft Amputation Myocardiai infarction Deaths l
Complications occurring more than thirty days postoperative-
iY.
TABLE II
Renal ComDiications
occiuded Bilateral infarctions Unilateral infarctions Acute tubular necrosis Chronic dialysis l
Nonoccluded
0 0 1’ 0
intraoperative myocardiai infarction.
811
Casali et al
routinely used by us in other aortic surgery. Postoperative hematomas have only rarely been encountered. Since the distal arterial tree is virtually free of disease, restoration of pedal pulses is usually accomplished. The long-term patency rate of these grafts has been reported to be in excess of 80 per cent [8], and in our experience with these thirteen patients, with one exception, no long-term graft failure has occurred. The reported operative mortality varies from 4 to 10 per cent. Most of the deaths occurred earlier, before the currently recommended technics for performing vascular surgery were used. Presently, operative deaths are related to myocardial infarctions or cerebral vascular accidents. Since atherosclerosis is generally a diffuse process, such complications will be difficult to reduce. Extraanatomic bypassing offers a lesser procedure with, theoretically, reduced operative mortality [16-181. However, one of the largest series of elective axillobilateral femoral grafts reports an immediate mortality of 5 per cent [18]. These were high risk patients with associated systemic illnesses and may not be comparable. The major objection to axillobilateral-femoral grafting is that the aortic thrombus remains, thus allowing propagation of the clot [2,8,19,20]. Infarction of the kidneys and visceral organs has been reported to occur in as high as 50 per cent of unoperated patients [8]. Since claudication, and not rest pain or gangrene, is the most common presenting symptom, the main threat to the patient is propagation of the clot, not loss of limb. The long-term patency rate of axillobilateral-femoral grafts may equal aortoiliac or aortofemoral grafts, but frequent reoperations have been necessary because of graft thrombosis. For these reasons we strongly favor a direct approach in patients with total aortic thrombosis.
Summary
Our experience from 1960 to 1976 with total infrarenal aortic thrombosis (Leriche syndrome) was reviewed. Sixteen heavy smokers (14 men and 2 women) with an average age of fifty-four years underwent thrombectomy with aortoiliac (12 patients) or aortofemoral (4) Dacron bypasses. The last ten patients were hydrated for 12 hours preoperatively with 3,000 ml of Ringer’s solution containing supplemental potassium. Mannitol (25 g), furosemide (20 mg), and heparin (120 u/kg) were given intraoperatively. Thrombectomy was accomplished by transection of the aorta, with proximal manual con-
trol of the aorta after the renal arteries were occluded. With this technic there were no deaths or renal complications, whereas previously, three of the six patients developed renal complications and one died. Ninety-two per cent of the grafts have remained open. We recommend that the direct transabdominal approach be continued rather than the extraanatomic bypass (axillobilateral-femoral), since further propagation of the aortic thrombosis may then lead to infarction of the kidneys or other viscera. References 1. Oudot J: La greffe vasculaire dans les thromboses du carrefour aot-tique. Presse Med 59: 234, 195 1. 2. Bergan JJ. Trippel OH: Management of juxtarenal aortic occlusions. Arch Surg 87: 230, 1963. 3. Chavez CM, Conn JH, Fair WR, Gee HL: Surgical treatment of high aortoiliac occlusion. Surgery 65: 757, 1989. 4. Thurlbeck WM, Castleman B: Atheromatous emboli to the kidneys after aortic surgery. N Engl J Med 257: 442, 1957. 5. Synder DD, Campbell GS: Effect of aortic constriction on exoerirnental atherosclerosis In rabbits. Proc Sot Drp B/o/ h&d i-I9: 563, 1958. 6. Mestel AL, Spain DM, Turner HA: Atheroma absence distal to subtotal aorta occlusion. Arch Patho/ 78: 186, 1964. 7. Kakos GS, Hagen PO, Oldham HN Jr, et al: The influence of segmental hypotension on experimental atherosclerosis. Surgery 72: 479, 1972. 8. Starrett RW, Stoney RJ: Juxtarenal aortic OCClusiOn.Surgery 76: 890, 1974. 9. Liddicbat JE, Bekassy SM, Dang MH. DeBakey ME: Complete occlusion of the infrarenal abdominal aorta: management of results in 64 patients. Surgery 77: 487, 1975. 10. Hobson RW, Rich NM, Fedde CW: Surgical management of high aortoiliac occlusion, Am Surg 41: 271, 1975. 11. Thompson JE, Vollman RW, et al: Prevention of hypotension and renal complications of aortic sugery using balanced salt solution: thirteen year experience with 670 cases. Ann Surg 167: 767, 1968. 12. Barry KG, Cohen A, Knochel JP, et al: Mannitol Infusion. II. The prevention of acute functional renal failure during resection of an aneurysm of the abdominal aorta. N Engl J Med 264: 967, 1961. 13. Stone AM, Stahl WM: Effect of ethacrynic acid and furosemlde on renal function in hypovolemia. Ann Surg 174: 1, 1971. 14. Gennari FJ, Kassirer JP: Osmotic diuresis. N Engl J Med 291: 714.1974. 15. Cantarovich F, Fernandez J, Locatelli A, et al: Furosemide in high doses in the treatment of acute renal failure. Postgrad MedJ47: 13, 1971. 16. Frantz SL, Kaplltt MI, Bell AR Jr, et al: Ascending aorta-bilateral femoral artery bypass for the totally occluded infrarenal abdominal aorta. Surgery 75: 471, 1974. 17. Nunn DB, Kamal MA: Bypass grafting from thoracic aorta to femoral arteries for high aortoiliac occlusive disease. Surgery 72: 749, 1972. 18. LoGerfo FW, Johnson WC, Corson JD, et al: A comparison of the late patency rates of axillo-bilateral femoral and axlllounilateral femoral grafts. Surgery 81: 33, 1977. 19. Gomes MMR, Bernatz PE: Aorta-Iliac occlusive disease. Extensive cephalad to origin of renal arteries with surgical considerations and results. Arch Surg 101: 161, 1970. 20. Johnson JK: Ascending thrombosls of abdominal aorta as fatal complication of Leriche’s syndrome. Arch Surg 89: 863, 1954.
The American Journal ol Surgery 812