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

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Objective: Great vessel reconstruction for arterial occlusive disease has been shown to be a durable procedure. The purpose of this report is the examination of the influence of cause and risk factors on outcomes for the identification of patients who may be better treated with endovascular techniques or other surgical approaches.Methods: Data for patients who underwent aortic-origin great vessel reconstruction between 1988 and 1998 were reviewed. The data were analyzed with Fisher 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 arms (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 cause 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 states (ie, thrombophilia; n = 6) had an increased perioperative stroke rate (33% vs 4% for patients without hypercoagulable states; P < .05) and an increased 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 vs 79% for patients with atherosclerosis obliterans and 92% for patients with 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 increased perioperative stroke and stroke/death rates, respectively. Patients with RA have an increased incidence rate of late major infection, which directly contributes to an increased rate of stroke or death. Patients with thrombophilia have an increased rate of late graft thrombosis. These patient conditions should be approached cautiously, and some patients may benefit from endovascular therapy.