REOPERATION FOR RECURRENT CHRONIC VISCERAL ISCHEMIA

Purpose: Recurrent visceral ischemia after a failed visceral revascula rization occurs in up to one third of patients, yet no comprehensive r eport has described the management of this problem. The purpose of thi s study was to examine the presentation, surgical management, and outc ome of patients with recurrent visceral ischemia. Methods: Between 195 9 and 1997, 109 patients underwent primary visceral revascularization at the University of California, San Francisco. Nineteen patients (17. 4%) had recurrent visceral ischemia (12 chronic visceral ischemia, sev en acute visceral ischemia). Fourteen additional patients with recurre nt chronic visceral ischemia were referred after failed primary revasc ularization (two patients underwent multiple operations before referra l). Thirty visceral reoperations were performed for recurrent visceral ischemia in 24 patients (10 patients with recurrence at University of California, San Francisco, 14 referred patients). Symptom-free and ov erall survival rates were determined by life table analysis. Results: Of seven patients (6.4%) who had recurrent acute visceral ischemia, si x (85.7%) died of bowel infarction. Twelve patients (11%) had recurren t chronic visceral ischemia. Patients with recurrent chronic visceral ischemia received their diagnoses earlier and lost less weight than at their initial presentation (p = 0.004 and 0.001, respectively). Recur rent ischemia was associated with younger age, greater weight loss, an d modification of surgical technique at the time of initial operation (p = 0.5, 0.009, and 0.02, respectively). For 20 (90.9%) of the 22 fir st reoperations, antegrade aortovisceral bypass (n = 10) or transaorti c visceral endarterectomy (n = 10) was used. Multiple techniques (four antegrade bypass, two retrograde bypass, one endarterectomy, one anas tomotic revision) were used in the eight second or third reoperations. Postoperative mortality and complication rates were 6.7% and 33.3%, r espectively. Symptoms recurred in six of 22 patients (27.3%) after the first reoperation, three of whom were cured or improved after additio nal reoperations. The life table symptom-free survival rate after reop eration was 77.3% and 62.8% at 1 and 5 years, respectively. The life t able overall survival rate after reoperation was 74.6% at 5 years. Con clusions: Recurrent visceral ischemia is not uncommon after primary vi sceral revascularization. These results show that reoperation for recu rrent chronic visceral ischemia can be accomplished safely and effecti vely with established revascularization techniques. Furthermore, after repeat visceral revascularization patients achieve durable relief of symptoms and have life expectancy rates comparable with those of patie nts who undergo primary visceral revascularization.