Schultz R D, Sterpetti A V, Feldhaus R J
Surgery. 1986 Oct;100(4):635-45.
We reviewed our experience with reoperations for recurrent obstruction occurring after aortoiliac or aortofemoral reconstruction. Patients who underwent successful transfemoral thrombectomy of the aortofemoral graft or femorofemoral crossover graft were excluded from the study. A more proximal source of inflow to revascularize the ischemic limbs was required in the remaining 35 patients. Bilateral reconstruction was performed in 22 patients. Operative indication was rest pain or necrosis in 36 limbs and severe claudication in 21 limbs. Preoperative ankle/brachial pressure index (API) ranged from 0.05 to 0.61. Thirteen patients (21 limbs, group I) underwent transabdominal reoperation. Since the transabdominal approach was considered hazardous because of multiple previous operations, the remaining patients underwent retroperitoneal descending thoracic aorta-femoral artery bypass (15 patients, 25 limbs; group II) or axillofemoral bypass graft (7 patients, 11 limbs; group III). No statistically significant difference was present between the three groups in regard to the operative indication, API, and angiographically determined outflow (analysis of variance, p greater than 0.2). Axillofemoral bypass was preferred in patients with severe chronic pulmonary disease. Postoperative deaths (2 of 35 patients) and morbidity (6 of 35 patients) had a similar incidence in the three groups (p greater than 0.2). Follow-up ranged from 3 to 120 months (mean 37 months). The 5-year actuarial patency rate was 80.5% for group I and 80.2% for group II. In group III it was statistically lower (32.9%, p less than 0.05). Serial measurement showed a significant decrease of API in group III compared with group I and group II. We conclude that retroperitoneal descending thoracic aorta-femoral artery bypass is a valid alternative to transabdominal reoperation when exposure or availability of the abdominal aorta poses a specific hazard and is preferable to axillofemoral bypass in terms of long-term patency and hemodynamic results.
我们回顾了主动脉髂动脉或主动脉股动脉重建术后复发性梗阻再次手术的经验。成功进行主动脉股动脉移植物或股股交叉移植物经股动脉血栓切除术的患者被排除在研究之外。其余35例患者需要更靠近近端的血流来源以恢复缺血肢体的血运重建。22例患者进行了双侧重建。手术指征为36条肢体出现静息痛或坏死，21条肢体出现严重间歇性跛行。术前踝/肱压力指数（API）范围为0.05至0.61。13例患者（21条肢体，I组）接受了经腹再次手术。由于既往多次手术，经腹入路被认为具有危险性，其余患者接受了腹膜后降主动脉-股动脉旁路移植术（15例患者，25条肢体；II组）或腋股旁路移植术（7例患者，11条肢体；III组）。三组在手术指征、API和血管造影确定的流出道方面无统计学显著差异（方差分析，p大于0.2）。严重慢性肺部疾病患者首选腋股旁路移植术。三组术后死亡率（35例患者中的2例）和发病率（35例患者中的6例）相似（p大于0.2）。随访时间为3至120个月（平均37个月）。I组5年实际通畅率为80.5%，II组为80.2%。III组在统计学上较低（32.9%，p小于0.05）。系列测量显示，与I组和II组相比，III组的API显著下降。我们得出结论，当腹主动脉的暴露或可及性存在特定危险时，腹膜后降主动脉-股动脉旁路移植术是经腹再次手术的有效替代方法，并且就长期通畅率和血流动力学结果而言，优于腋股旁路移植术。
