Professor of Surgery University of Alabama at Birmingham Birmingham, Alabama
Objectives: Historically the treatment of choice for aortoiliac occlusive disease, aortic endarterectomy (AE) is now rarely performed. However, in patients with severe multi-vessel atherosclerotic disease of the paravisceral aorta, and with severe disease limited to the infrarenal aortoiliac segment, AE provides an opportunity to restore in-line flow, either as a primary procedure or as a salvage procedure after prior endovascular attempts at revascularization have failed. We evaluated outcomes for patients at a single institution undergoing AE for disease involving multiple visceral vessels, or involving the infrarenal aorta and the iliac system.
Methods: We conducted a single institution retrospective review of 18 patients who underwent aortic endarterectomy over the time period 2017-2022.
Results: Thirteen patients underwent infrarenal aorto-bi- or uni-iliac endarterectomy (72%) (Table I). Five patients underwent AE and one or more visceral vessels (27%) (Images 1&2). Six infrarenal AE patients (46%) and one paravisceral patient (20%) had undergone prior interventions for critical limb ischemia; four (22%) underwent revision during AE including aortobifemoral bypass graft explant (n=1), and bilateral common iliac stent explant (n=3). There were no mortalities during the index hospitalization (0%). One infrarenal aorto-iliac AE patient developed right iliac thrombosis in the setting of suspended anticoagulation requiring reintervention; there were no other perioperative complications in this group. In the paravisceral group, one patient with pre-existing risk factors experienced pulmonary and gastrointestinal complications (20%). Median ICU length of stay was 3.5 days (n=18), median hospital length of stay was 7 days (n=17). Median postoperative ABIs were 1.05 on the right and 1.00 on the left (n=13), median improvement from pre-operative ABI was +0.57 on the right and +0.45 on the left (p= < 0.01 and p=0.018, respectively). Two patients in the paravisceral AE group who underwent aortic, celiac, and SMA endarterectomy were noted to have SMA stenosis on routine post-operative imaging at the distal endarterectomy endpoint successfully treated by stenting (40%), with one being symptomatic (20%). Median length of follow up was 19 months (n=17). Of patients with at least one year of follow up, primary patency was 83% (n=12).
Conclusions: In this series of 18 patients, AE in appropriately selected patients was associated with no mortalities, a low rate of perioperative morbidity, significant improvement in postoperative ABIs, and high rates of primary- or primary-assisted patency (SMA stenting) in patients undergoing paravisceral and infrarenal aorto-iliac interventions. AE should be considered a viable treatment for appropriate patients with severe multi-vessel paravisceral or aortoiliac occlusive disease.