Chronic Abdominal Aortic Occlusion

Jung, In Mok; Lee, Tae Seung; Ha, Jongwon; Kim, Sang Joon

Abstract

Chronic abdominal aortic occlusion(CAO) is a rare entity and poses a particular management challenge. It shows a spectrum of clinical presentations due to chronic progression and suprarenal thrombus progression. Ongoing debate over the proximal thrombus propagation leading to renal and mesenteric artery occlusion results in controversy regarding the need of in-line aortic reconstruction with proximal thromboendarterectomy(TEA). To evaluate the management and surgical outcome of chronic abdominal aortic occlusion, a retrospective study of 24 patients surgically treated for angiographically documented CAO between September, 1986 and September, 1997 was conducted. Male to female ratio was 22:2 with a mean age of 56.8 years(range: 33~71 years). Mean follow-up period was 55.0 months. All patients presented with sympoms of vascular insufficiency of lower limbs including claudication in 10(41.7%), rest pain in 11(45.8%) and tissue loss in 3(12.5%). Impotence was present in 59.1% in men. Location of aortic occlusion was distributed in juxtarenal and above(11, 45.8%) and infrarenal(13, 54.2%). Associated visceral arterial involvement included 18 inferior mesenteric artery(IMA) occlusion, 8 renal artery(RA) stenosis and 1 superior mesenteric artery(SMA) occlusion. Infrainguinal arteries were involved in 11 patients(45.8%) including 9 superficial femoral artery obstruction. Aortobifemoral bypass(AoBF) grafts were implanted all but one case, which was treated with an axillobifemoral bypass(AxBF). In AoBF, proximal thrombectomy or thromboendarterectomy was performed and, in most cases, end to end anastomosis is favored in proximal anastomosis due to possibility of proximal thrombus propagation. Concomitant visceral revascularizations were performed in selected cases(2 renal, 2 IMA) with inflow procedures. The operative mortality rate was 4.2%(1/24) and the perioperative morbidity rate was 37.5%. AoBF inflow procedures yielded 1, 5-year primary patency rate of 95.5% and 89.1%, respectively. The one AxBF graft was occluded graft at 26 days after surgery. Two patients died and the 5-year survival rate for AoBF was 95.7%. There was no statistical change in renal function between pre- and postoperative periods. Follow-up renal dysfunction(serum creatinine levels>2.0 mg/dl) was documented in two patients, and one patient developed acute renal failure requiring dialysis. Aortobifemoral bypass following proximal thromboendarterectomy is the optimal treatment modality with high patency rate in chronic abdominal aortic occlusion. Visceral artery reconstruction in clinically significant stenosis and judicious attention for prevention of renal damage in pararenal thrombectomy under suprarenal clamping are helpful for better outcome in chronic abdominal aortic occlusion.