A thirty-year survey of the reconstructive surgical treatment of aortoiliac occlusive disease

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With the view of assessing functional durability and the factors that influence or determine it, we reviewed the clinical course of 1748 reconstructive operations performed between Jan. 1, 1954, and Dec. 31, 1983 in the treatment of 1647 patients with aortoiliac occlusive disease (AIOD). Disabling intermittent claudication (in 65.6%), ischemic rest pain and/or pregangrene (in 20.7%), and ischemic gangrene (in 13.7%) were the operative indications. Patency proven by angiography was the criterion of success. Follow-up was continuous and endless and 94% successful over a period of 30 years. Twenty-five percent of the patients were followed up for 11 to 30 years. The incidence of severe degree of occlusive involvement increased significantly from the first (9.3%) to the third (17.1%) decade of observation, whereas the perioperative mortality rate improved markedly from the first (7.4%) to the third (2.5%) decade. The aortobifemoral bypass (AF 2B) procedure remained the most popular type of repair (with a perioperative patency rate of 91.4%) throughout, but both it and unilateral reconstructions lost some ground to remote (extra-anatomic) bypasses in the third decade. Atherosclerotic heart disease remained the most common cause of perioperative (50%) and late (60.2%) death. Among the early postoperative local complications graft thrombosis improved markedly from the first (8.3%) to the third (3.2%) decade. Graft infection remained rare (1.6% to 0.8%). The incidence of the most common late wound complication, anastomotic aneurysm at the common femoral level, remained relatively constant (5.7% per anastomosis), but it responded very well to surgical correction. The partial or complete secondary repair of all late complications (26.0%) improved the cumulative late patency rate in the AF 2B procedures by 2% to 12% during 20 years of observation. The perioperative (97.3%), 5-year (76.6%), 10-year (76.6%), 15-year (72.5%), and 20-year (67.5%) cumulative patency rates of AF 2B operations were highly satisfactory. The postoperative late survival rate of patients with AIOD declined rapidly (59% at 5, 33% at 10, 14% at 15 years). The cause of late death in 60.2% of the cases was atherosclerotic heart disease.