Juxtarenal Aortic Occlusion

Abstract

The authors' experience with 113 aortic occlusions in 103 patients during a 26-year period (1965 to 1991) is reviewed. The authors found three distinct patterns of presentation: group I (n = 26) presented with acute aortic occlusion, group II (n = 66) presented with chronic aortic occlusion, and group III (n = 21) presented with complete occlusion of an aortic graft. Perioperative mortality rates were 31%, 9%, and 4.7% for each respective group and achieved statistical significance when comparing group I with group II (p = 0.009) and group I with group III (p = 0.015). Group I presented with profound metabolic insults due to acute ischemia and fared poorly. Group II presented with chronic claudication and did well long-term. Group III presented with acute ischemia but did well because of established collateral circulation. The treatment and expected outcome of aortic occlusion depends on the cause.

Surgical treatment of chronic aortoiliac occlusion

“…All of our patients had CAIO secondary to atherosclerotic aortoiliac occlusive disease, but other causes of CAIO such as embolism, dissection and aortitis have also been described. 1,15,16 We did not see any cases of SRO, but Tapper et al 9 have described an interesting series of 66 patients with CAIO, in which 10 patients (15%) had SRO, with a mortality rate of 9%.…”

“…1,8,9 Currently, a diagnosis of CAIO is still an absolute indication for surgical treatment in patients with aortoiliac occlusive disease, because the endovascular technique still suffers from limitations that impede adequate treatment of these patients, although there are already some recent studies that have reported promising results. 11,12 On the other hand, as endovascular techniques are being more and more widely adopted for treatment of patients with aortoiliac occlusive disease, open surgery has come to be reserved for patients with more severe forms of occlusive disease, such as CAIO.…”

“…In other reports the proportion of patients with critical ischemia appears to be lower, with the majority of patients presenting with intermittent claudication of the lower limbs. 1,6,7,9 This difference may be the result of delayed clinical diagnosis or late referral of these patients for vascular treatments, with the result that the disease is more advanced when they are operated on.…”

“…This classical and wellknown technique has been employed successfully and described by other authors. 1,[6][7][8][9] Our preference was to conduct aorto-bifemoral reconstruction in all of the patients treated with DAB. Some authors use an aortoiliac bypass, with the advantage that this approach avoids the inguinal exposure to conduct femoral anastomoses, thereby reducing the risk of complications such as infections of the surgical wound.…”

“…5 Over the years, several publications have reported good results after treatment of patients with CAIO using DAB, with mortality rates of less than 5%, 1,[6][7][8] although other authors have described worse results, with mortality of up to 23%. 9 Alternative techniques such as the extra-anatomic bypass (EAD), using either the axillary artery or the thoracic aorta as graft donors, have been proposed by some authors, 6,10 but the risks and complications of not directly treating the segment of the aorta that has thrombosis (primarily, the possibility of proximal propagation of the thrombus) mean that these procedures are less attractive and reserved for cases in which the patient does not offer clinical conditions to conduct the direct procedure.…”