Aortic-origin reconstruction of the great vessels: Risk factors of early and late complications

Objective: Great vessel reconstruction for arterial occlusive disease has b een shown to be a durable procedure. The purpose of this report is the exam ination of the influence of cause and risk factors on outcomes for the iden tification of patients who may be better treated with endovascular techniqu es or other surgical approaches. Methods: Data for patients who underwent aortic-origin great vessel reconst ruction between 1988 and 1998 were reviewed. The data were analyzed with Fi sher exact test, life-table analysis, and log-rank test. Results: Ninety-two vessels underwent revascularization in 58 patients (15 men, 43 women; mean age, 54 years; age range, 20 to 82 years). Etiology was atherosclerosis obliterans (n = 40; 69%), Takayasu's arteritis (n = 13; 22 %), radiation arteritis (RA; n = 4; 7%), and mediastinal fibrosis (n = 1; 2 %). The symptoms were cerebrovascular (n = 25), upper extremity (n = 8), or both (n = 23), and two patients were asymptomatic. The bypass grafting was performed with single-limb synthetic grafts (n = 23) or grafts plus side a rms (n = 28). Seven patients underwent innominate endarterectomy. The mean follow-up period was 45 months (range, 0 to 126 months). The perioperative stroke (n = 4; 7%) and death (n = 2; 3%) rates were not related to the caus e of disease. The patients with creatinine levels of 2 or more (n = 4) had a combined perioperative stroke/death rate of 50% (vs 7% for patients with healthy creatinine levels; P <.05). The patients with hypercoagulable state s (ie, thrombophilia; n = 6) had an increased perioperative stroke rate (33 % vs 4% for patients without hypercoagulable states; P < .05) and an increa sed late thrombosis rate. The primary and secondary graft patency rates at 5 years were 80% +/- 7% and 91% +/- 5%, respectively. Patients with RA had a greater risk of stroke or death at 3 years (33% free of stroke or death v s 79% for patients with atherosclerosis obliterans and 92% for patients wit h Takayasu's arteritis; P = .02) and an increased major late infection rate (50% vs 2% for all others; P = .01). Conclusion: Patients with thrombophilia and renal insufficiency have increa sed perioperative stroke and stroke/death rates, respectively. Patients wit h RA have an increased incidence rate of late major infection, which direct ly contributes to an increased rate of stroke or death. Patients with throm bophilia have an increased rate of late graft thrombosis. These patient con ditions should be approached cautiously, and some patients may benefit from endovascular therapy.