1. Aortic revascularization: diagnostic and therapeutic aspects
Coordinator: Asis. Univ. Dr. Russu Eliza
First author:
Fanfaret Ioan - Serban

2. Background:
Patients with critical ischemia require urgent referral to a vascular surgeon who, in addition to correcting risk factors, will revascularize the leg.
Intermittent claudication is a marker for widespread atherosclerosis.
The minority of patients with intermittent claudication will benefit from intervention, whereas the majority of patients with critical ischemia require angioplasty or bypass surgery.
Copyright: Arterial and Venous Disease Richard Donnelly

3. Why do patients get chronic lower limb ischaemia?
The majority of cases will be due to atherosclerosis (if present in the legs, it will also have affected the coronary and cerebral arteries).
Other risk factors: diabetes, familial hyperlipidaemia and smoking.
Less frequent causes: arterial embolism, thrombosis of limb aneurysms and arterial dissection.
Copyright: Arterial and Venous Disease Richard Donnelly

4. Normal
Asymptomatic
Intermittent
claudication
Rest pain
Critical limb
ischaemia
Leg muscle pain
on exercise relieved
by rest
Ulceration
gangrene
ABPI - 1.1
ABPI – 0.7
ABPI - 0.2
Risk factor modification
Angioplasty or surgery
As the ABPI drops with progressively worsening PVD so the claudication distance reduces, and eventually perfusion to the foot is so compromised that the patient complains of rest pain.
Rest pain is pain in the foot at night, often relieved by hanging the leg out of bed.
If not improved by vascular intervention, the circulation may continue to deteriorate, resulting in ulceration or gangrene.
Copyright: Arterial and Venous Disease Richard Donnelly

5. Objective:
To asses all patients admitted for either intermittent claudication or critical ischemia of the lower limbs to Surgery Clinic No.1 from Tg.Mures, as symptoms for aortic obstructive disease, between January 2009 and December

6. Material and methods:
We included 177 cases in our study, evaluating them for:
gender,
age,
blood pressure,
blood glucose level,
body mass index,
smoking habit,
claudication index,
type of surgical procedure performed,
early graft patency.

7. Results:
The average age was 60 years with values ranging from 36 to 80 years.

8. Body mass index (BMI) of the patients:
Patients presented a mean value of the body mass index (BMI) of 26.3 corresponding to the overweight pre- obese category after the WHO classification.
Copyright: Adapted from WHO, 1995, WHO, 2000 and WHO 2004.
Classification
BMI(kg/m2)
Underweight
<18.50
Severe thinness
<16.00
Moderate thinness
Mild thinness
Normal range
Overweight
≥25.00
Pre-obese
Obese
≥30.00
 Obese class I
 Obese class II
 Obese class III
≥40.00

10. Blood Pressure Category
The average blood pressure was mmHg,
With values ranging from 120 to 240 mmHg for systolic blood pressure and from 70 to 100 mmHg for diastolic blood pressure.
Copyright: Readings_UCM_301764_Article.jsp
Blood Pressure Category
Systolic mm Hg (upper #)
Diastolic mm Hg (lower #)
Normal  
less than 120
and
less than 80
Prehypertension
120 – 139 or
80 – 89
High Blood Pressure (Hypertension) Stage 1
140 – 159
90 – 99
High Blood Pressure (Hypertension) Stage 2
160 or higher
100 or higher
Hypertensive Crisis (Emergency care needed)
Higher than 180
Higher than 110

11. Blood glucose levels ranged from 77 mg/dl to 495 mg/dl with the average value being 132.7 mg/dl.
Blood glucose level is most strongly correlated with arterial blood pressure (r=0.281), body mass index (BMI),(r=0.224).
American Diabetes Association recommends a blood glucose value between mg/dl.

12. “If not for your lungs do it for your feet!”
Social behavior:
“If not for your lungs do it for your feet!”

13. Based on Leriche-Fontaine classification:
Copyright:

14. According to TASC classification the most aortobifemoral bypasses were performed for type D lesions, which are beyond the endoluminal approach.

15. Type of surgical procedures performed:
Aortobifemoral bypass
Other procedures: Aortoiliac endarterectomy
Iliofemoral bypass
Femorofemoral bypass
Axillofemoral bypass

16. Copyright: Atlas of Vascular Surgery: Basic Techniques and Exposures Rutherford

17. Copyright: Atlas of Vascular Surgery: Basic Techniques and Exposures Rutherford

18. Copyright: Atlas of Vascular Surgery: Basic Techniques and Exposures Rutherford

19. The aortobifemoral bypass is performed typically with both the anastomosis in a T-L manner, through a median laparotomy of which length decreased over the years from 15 cm to almost 6 cm during the last 2 years.
All the patient were heparinated during the procedure, none of them needing protamine to reverse the anticoagulation.
Blood transfusion was used in 35 cases, generally for prevention of miocardic ischemia in elder patients with prior cardiac impairment, rather then due to blood loss.

20. 170 Dacron prosthesis were used and 7 ePTFE(GoreTex), of which a number of 25 were precoagulated and 30 were silver-coated, used especially during the last 2 years.
Special Atrium tunnelers were used in all patients, to minimize the trauma associated with tunneling the femoral components.

21. Most frequent postoperative complications were:
Thrombosis- 20 cases, which required reintervention
Infection-15 cases, requiring graft excision and later extra-anatomical grafting.
We registered one death due to acute miocardiac infarction.

22. Early graft patency Operative indication Five years patency
Ten years patemcy
Claudication
CLI
Regarding the limb
91 (90-94)
87 (80-88)
86 (85-92)
81 (78-83)
Regarding the patient
85 (85-89)
80 (72-82)
79 (70-85)
72 (61-76)

23. 5 years patency for the 25 cases operated in 2009 was as follows: 20 grafts performed excellent, 5 needed thrombembolectomy, after that having no further complications.
For the remaining years establishing the patency is difficult, as the 5 year period has not passed yet, but we registered an increased number of graft infections, as late complications, especially in diabetic patients.

24. Discussion There is an increasing number of cases every year.
TASC clasiffication has to become widely used in both medical and surgical observational sheets, for the better standardization of large observational studies regarding peripheral arterial disease.
Preoperative evaluation of the patient should also include lipid profile and glycated hemoglobin.
Better postoperative surveillance could also be a goal for establishing corectly the secondary patency of these grafts.

25. Conclusions:
The majority of the patients were men, with elevated BMI, high blood pressure and blood glucose levels, smokers with an advanced index of claudication.
The most frequent surgical procedure performed in Aortoiliac occlusive disease was: Aortobifemoral Bypass and the most common postoperative complication was thrombosis.
The median time of the procedure also decreased from almost 4 hours to aproximately 2 hours and 30 minutes.

26. Most of the patients seek medical help when found in an advanced stage of critical ischaemia.
Risk factors need to be corrected otherwise the condition and the outcome will not improve and it could lead to later complications.

27. Bibliography American Diabetes Association: http://www.diabetes.org/
American Heart Association:
World Health Organization:
ABC of Arterial and Venous Disease Richard Donnelly
Guide to Lab & Diagnostic Tests
Vascular Surgery - Principles and International Practice, 2nd Edition
Atlas of Vascular Surgery: Basic Techniques and Exposures Rutherford

28. Thank you for your attention!