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

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

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

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

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 2013.

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.

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

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 16.00 - 16.99 Mild thinness 17.00 - 18.49 Normal range 18.50 - 24.99 Overweight ≥25.00 Pre-obese 25.00 - 29.99 Obese ≥30.00  Obese class I 30.00 - 34.99  Obese class II 35.00 - 39.99  Obese class III ≥40.00

Blood Pressure Category The average blood pressure was 140-90 mmHg, With values ranging from 120 to 240 mmHg for systolic blood pressure and from 70 to 100 mmHg for diastolic blood pressure. Copyright: http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/AboutHighBloodPressure/Understanding-Blood-Pressure- 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

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 70-100 mg/dl.

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

Based on Leriche-Fontaine classification: Copyright: http://synapse.koreamed.org/ArticleImage/0068KJR/kjr-6-256-i004-l.jpg

According to TASC classification the most aortobifemoral bypasses were performed for type D lesions, which are beyond the endoluminal approach. http://www.revespcardiol.org/imatges/255/255v60n09/grande/255v60n09-13114115fig07.jpg

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

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

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

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

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.

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.

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.

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)

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.

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.

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.

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.

Bibliography American Diabetes Association: http://www.diabetes.org/ American Heart Association: http://www.heart.org/ World Health Organization: http://www.who.int/en/ 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

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