Totally laparoscopic bypass surgery for aortoiliac occlusive disease in China

Background Totally laparoscopic aortic surgery is still in its infancy in China.One of the factors preventing adoption of this technique is its steep learning curve.The objective of this study was to evaluate the feasibility and safety of laparoscopic surgery for aortoiliac occlusive disease （AIOD）.Methods From November 2008 to November 2012,12 patients were treated for severe AIOD with a totally laparoscopic bypass surgery at our university hospital.The demographic data,operative data,postoperative recovery data,morbidity and mortality were analyzed and compared with those of conventional open approach.Results Twelve totally laparoscopic aortic surgery procedures,including two iliofemoral bypasses （IFB）,three unilateral aortofemoral bypasses （UAFB）,and seven aortobifemoral bypasses （ABFB）,were performed.Conversion to open procedures was required in three patients.The mean operation time was 518 （range,325-840） minutes,mean blood loss was 962 （range,400-2500） ml,and mean aortic anastomosis time was 75 （range,40-150） minutes.Compared with conventional open approach for aortofemoral bypasses performed concomitantly during this period,laparoscopic patients required fewer narcotics and a shorter in-hospital stay and earlier recovery.Postoperative complications developed in four patients,including a single patient with transient left hydronephrosis,ischemic colonic fistula and pneumonia,residual aortic stenosis proximal to the anastomotic site,and asymptomatic partial left renal infarction.All patients recovered and were discharged on postoperative Days 7-14 except one patient that died of respiratory failure on Day 46.All grafts were patent with follow-up imaging performed by Duplex examination,with a mean follow-up time of 10.7 （range,2-61） months.Conclusion Totally laparoscopic bypass surgery is a feasible and safe procedure forAIOD,but attention needs to be paid to improve laparoscopic skills of vascular surgery in order to minimize morbidity during the learning curve of this advanced procedure.

Long-term results of extensive aortoiliac occlusive disease (EAIOD) treated by endovascular therapy and risk factors for loss of primary patency

Background::Although endovascular therapy has been widely used for focal aortoiliac occlusive disease(AIOD),its performance for extensive AIOD(EAIOD)is not fully evaluated.We aimed to demonstrate the long-term results of EAIOD treated by endovascular therapy and to identify the potential risk factors for the loss of primary patency.Methods::Between January 2008 and June 2018,patients with a clinical diagnosis of the 2007 TransAtlantic Inter-Society Consensus II(TASC II)C and D AIOD lesions who underwent endovascular treatment in our institution were enrolled.Demographic,diagnosis,procedure characteristics,and follow-up information were reviewed.Univariate analysis was used to identify the correlation between the variables and the primary patency.A multivariate logistic regression model was used to identify the independent risk factors associated with primary patency.Five-and 10-year primary and secondary patency,as well as survival rates,were calculated by Kaplan-Meier analysis.Results::A total of 148 patients underwent endovascular treatment in our center.Of these,39.2%were classified as having TASC II C lesions and 60.8%as having TASC II D lesions.The technical success rate was 88.5%.The mean follow-up time was 79.2±29.2 months.Primary and secondary patency was 82.1%and 89.4%at 5 years,and 74.8%and 83.1%at 10 years,respectively.The 5-year survival rate was 84.2%.Compared with patients without loss of primary patency,patients with this condition showed significant differences in age,TASC II classification,infrainguinal lesions,critical limb ischemia(CLI),and smoking.Multivariate logistic regression analysis showed age<61 years(adjusted odds ratio[aOR]:6.47;95%CI:1.47-28.36;P=0.01),CLI(aOR:7.81;95%CI:1.92-31.89;P=0.04),and smoking(aOR:10.15;95%CI:2.79-36.90;P<0.01)were independent risk factors for the loss of primary patency.Conclusions::Endovascular therapy was an effective treatment for EAIOD with encouraging patency and survival rate.Age<61 years,CLI,and smoking were independent risk factors for the loss of primary patency.

Acute Aortic Occlusion in a Critically Ill Adult Presenting to the Emergency Department

Acute Aortic Occlusion (AAO) is a rare, life-threatening event so far described mainly in small-scale series. The most common causes of AAO are large saddle emboli to the aortic bifurcation, in-situ thrombosis of an atherosclerotic aorta, and occlusion of previous surgical reconstruction. We present the case of a 52-year-old female with rheumatic heart disease, ischemic cardiomyopathy with restricted left ventricular function, atrial fibrillation, and previous cardio-embolic stroke, who was brought to the Emergency Department (ED) with sudden-onset dyspnea and lower backache radiating to both the legs. On arrival at the ED, the patient was electively intubated and mechanically ventilated in view of hypoxia and altered mental status, attributed to respiratory failure secondary to acute cardiogenic pulmonary oedema. The secondary survey revealed absence of bilateral femoral and popliteal artery pulsations. A computed tomography (CT) aortogram showed a complete lumen occlusion thrombus in the infra-renal region of the abdominal aorta at the level of L3-L4 lumbar vertebrae. An emergency embolectomy was performed successfully, following which the patient was started on heparin infusion and managed in the Intensive Care Unit (ICU). In the ICU, she suffered a torsade-cardiac arrest, with return of spontaneous circulation (ROSC) following rapid defibrillation. She was extubated on Day 3. Three weeks later, she was discharged from the hospital. At the time of discharge, she had developed ischemic lumbosacral radiculoplexus neuropathy, for which neuro-rehabilitation was advised. In our case report, we would like to highlight the following key points: 1) The importance of a detailed secondary survey in the Emergency Department (ED). 2) An inter-disciplinary approach to a complex syndrome that ensures the highest probability of a good outcome. .