SUPRACELIAC AORTIC CROSS-CLAMPING - DETERMINANTS OF OUTCOME IN ELECTIVE ABDOMINAL AORTIC RECONSTRUCTION

Purpose: A 7-year experience in which 43 patients underwent supracelia c aortic cross-clamping (SC-AXC) during elective abdominal aortic reco nstruction was reviewed. Methods: Operation was performed for abdomina l aortic aneurysm (AAA) in 29 (68%) patients, aortoiliac occlusive dis ease in seven (16%), proximal anastomotic AAA in three (7%), ''shaggy' ' aorta syndrome in three (7%), and in situ grafting of a previously l igated aorta in one (2%) patient. The indications for supraceliac cont rol included pararenal AAA origin (25), pararenal aortic atheroscleros is (18), inflammatory AAA (2), and a short infrarenal aortic stump (1) . Vital organ ischemic complications (VOICs) were defined as any major ischemic complication involving the liver, kidneys, bowel, or spinal cord. Results: The incidence of VOICs was significantly increased when concomitant renal or visceral revascularization (CRVR) was required ( p = 0.002) and correlated with an increasing SC-AXC time (p = 0.015). In patients undergoing CRVR (n = 16) the perioperative mortality rate was 25%; VOICs developed in six patients and included renal failure (3 ), mesenteric/colonic ischemia (3), hepatic ischemia with coagulopathy (2), and spinal cord ischemia (1). In contrast, in those not requirin g CRVR (n = 27), SC-AXC was well tolerated. There were no VOICs and no deaths; morbidity rate was 33%. Conclusions: The incidence of VOICs a ssociated with the use of SC-AXC is primarily related to the level of preoperative renal or mesenteric insufficiency, the severity of parare nal aortic atherosclerosis, the extent of the operative procedure, and the duration of proximal aortic cross-clamping. In complex abdominal aortic reconstruction in which infrarenal aortic control is either not possible or deemed hazardous, SC-AXC is a safe and valuable technique for achieving proximal control.