LIMB-THREATENING ISCHEMIA DUE TO MULTILEVEL ARTERIAL OCCLUSIVE DISEASE - SIMULTANEOUS OR STAGED INFLOW OUTFLOW REVASCULARIZATION

Summary Background Data Limb-threatening ischemia due to severe multil evel arterial occlusive disease may require both inflow and outflow by pass to achieve limb salvage. Simultaneous inflow/outflow bypass has b een advocated because the cumulative risks of separate staged inflow/o utflow procedures can be avoided. However, the magnitude of complete r evascularization is substantial; thus, the morbidity and mortality of simultaneous inflow/outflow bypass may be excessive. Methods The medic al records of 450 patients undergoing lower extremity arterial reconst ruction between 1988 and 1994 were retrospectively reviewed, allowing identification of 54 patients who had undergone simultaneous aortoilia c and infrainguinal bypasses. This group consisted of 38 men and 26 wo men (mean age: 64.7 years), with significant cardiac disease in 24, sm oking history in 53, and diabetes mellitus in 15. indications for surg ery were limb-threatening ischemia in 48 (89%) and severe short-distan ce claudication in 6 (11%). inflow disease was corrected by direct aor toiliac reconstruction in 28, whereas other extra-anatomic bypasses we re constructed in 26. Outflow revascularization required infrainguinal bypass to the infragenicular arteries in 46 (below-knee popliteal: 21 , tibial: 25), a concomitant profundaplasty in 26, and a composite byp ass conduit in 14. Results Limb salvage was 97% at 30 days whereas mor bidity/mortality were 61% and 19%, respectively. However, the majority of complications and deaths occurred in patients undergoing aortic in flow plus complex outflow procedures (profundaplasty and/or composite bypass conduits), in which the morbidity/mortality rates were 84.2% an d 47.4%, respectively, compared with rates of 45.7% and 2.9% (p < 0.01 ) after all other inflow/outflow procedures. The increased difficulty of these complex procedures is reflected in the significantly greater blood loss and operative times (1853 mi and 10.0 hours) compared with similar values (1125 mt and 7.7 hours)(p < 0.01) for all other inflow/ outflow procedures. Conclusion Simultaneous inflow/outflow bypasses ar e effective and safe in patients with severe, multilevel arterial occl usive disease, except when a complex outflow procedure is needed in co njunction with direct aortoiliac reconstruction. In the latter setting , a staged procedure is recommended because it may be associated with less morbidity and mortality.