William P. Robinson, Rupal Patel, Jesse Columbo, Francesco A. Aiello, Andres Schanzer, Donald T. Baril, Elias J. Arous, Louis M. Messina
Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, MA.
OBJECTIVES: Published series of acute infrarenal aortic occlusion (AAO) predate the widespread application of endovascular therapy in the last decade. We aimed to examine the modern management and outcomes of AAO, including the impact of endovascular therapy.
METHODS: We reviewed consecutive patients with AAO at a tertiary referral center from 2004-2012. Outcomes were stratified according to etiology and procedure performed.
RESULTS: AAO in 30 patients was due to in situ thrombosis (IST) in 21 (70%) and embolism in 9 (30%) patients. Neurologic deficit was present in 15 (50%) patients, including 6 with paresis secondary to spinal ischemia. Patients with embolism were older (78±7 vs. 66±12 years, p=0.01) and had higher rates of atrial fibrillation (89% vs. 25%, p=0.001) and CHF(67% vs. 5%, p=0.0003) in comparison to those with IST. Twenty-nine patients underwent procedures: transfemoral embolectomy (n=6), aortoiliac thrombectomy (n=2), axillobifemoral bypass (n=10), aortobifemoral bypass (n=6) and endovascular therapy including thrombolysis, angioplasty ± stenting (n=5). Endovascular therapy was used for both embolism and IST. Mortality did not vary significantly according to etiology (embolism: 44% vs. IST: 24%) but varied widely according to procedure (transfemoral embolectomy: 50%, aortoiliac thrombectomy: 100%, axillobifemoral bypass: 30%, aortobifemoral bypass: 0%, and endovascular therapy: 20%, p=0.05). Major morbidity (57%), length of stay (7±7days), and discharge to a rehabilitation facility (52%) did not vary by etiology or procedure. Among in-hospital survivors, long-term amputation-free survival was 90% at a mean follow-up of 455±488 days.
CONCLUSIONS: Endovascular therapy is increasingly utilized in the modern management of AAO in comparison to historical controls but has not improved outcomes. AAO remains a heterogeneous condition managed via a variety of endovascular and surgical procedures. The modern management of AAO is associated with significant morbidity and mortality, but reasonable prognosis can be expected for survivors.
AUTHOR DISCLOSURES: F. A. Aiello: Nothing to disclose; E. J. Arous: Nothing to disclose; D. T. Baril: Nothing to disclose; J. Columbo: Nothing to disclose; L. M. Messina: Nothing to disclose; R. Patel: Nothing to disclose; W. P. Robinson: Nothing to disclose; A. Schanzer: Nothing to disclose.
Posted March 2013