Functional Assessment at the Buttock Level of the Effect of Aortobifemoral Bypass Surgery

Abstract

Little is known about the prevalence of proximal (hip, buttock, lower back) claudication after aortobifemoral bypass (AF2B) grafting and its hemodynamic effects at the buttock level. Forty-eight patients performed a treadmill test before and within 6 months after AF2B. The San Diego Claudication Questionnaire and the chest-corrected decrease from rest of transcutaneous oxygen pressure on buttocks were used to study exercise-induced proximal claudication and regional pelvic blood flow impairment. A decrease from rest of transcutaneous oxygen pressure value <-15 mm Hg was used to indicate regional blood flow impairment (RBFI). Patients had the following characteristics: 39 were men and 9 were women, 60 +/- 9 years, lowest ankle-to-brachial index (ABI) of 0.55 +/- 0.18 and maximal walking distance (MWD) on treadmill of 188 +/- 192 m at inclusion. ABI and MWD were significantly improved after surgery at 0.83 +/- 0.19 and 518 +/- 359 m (P < 0.0001). Unilateral or bilateral RBFI at the buttocks was found in 39 versus 29 patients before and after AF2B, respectively. Proximal claudication with underlying RBFI on one or both sides on treadmill were observed in 29 patients before AF2B, and in 9 of 26 (41%) versus 6 of 22 (23%) patients in end-to-end versus end-to-side proximal aorto-graft anastomosis of the AF2B, respectively (P < 0.05). A significant increase in MWD and ABI, but little improvement of proximal perfusion is observed after surgery, a finding that is expected from the absence of hypogastric artery revascularization. The prevalence of proximal claudication and proximal blood flow impairment is higher in case of end-to-end when compared with end-to-side proximal aorto-graft anastomosis, confirming the role of collaterals such as lumbar arteries in the buttock circulation during exercise in patients suffering from peripheral arterial disease. Proximal claudication on treadmill early after surgery affects almost one third of the patients and must not be underestimated among patients receiving AF2B. Attempts at hypogastric artery revascularization, if possible, might be preferable to decrease the risk of proximal claudication after AF2B.