|Year : 2018 | Volume
| Issue : 2 | Page : 74-79
Comparison of therapeutic effects between open surgery and endovascular therapy for juxtarenal aortic occlusion
Yongquan Gu1, Lixing Qi1, Alan Dardik2, Xixiang Gao1, Lianrui Guo1, Zhu Tong1, Jianming Guo1, Jian Zhang1, Zhonghao Wang1
1 Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
2 Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
|Date of Web Publication||26-Sep-2018|
Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing
Source of Support: None, Conflict of Interest: None
OBJECTIVE: To compare the effectiveness of surgical bypass and endovascular therapy for juxtarenal abdominal aortic occlusion.
METHODS: Data of 37 patients treated with open arterial bypass surgery or endovascular therapy for juxtarenal abdominal aortic occlusion in the last 10 years were retrospectively analyzed.
RESULTS: Of the 37 cases, 32 were male and five were female; the mean age was 58.5 years; the mean disease history was 8.2 months. Open surgery was performed in 18 cases and endovascular treatment was done in 19 cases. No significant differences in either technical success rate or perioperative symptom improvement rate were found between the open surgery and endovascular therapy groups. There w as much more blood loss, hospital stay time, and fewer hospitalization expenses in the open group than the endo group. In the open group, the mean follow-up time was 60.5 months and graft patency rate was 94.4%; in the endo group, the mean follow-up was 52.5 months but the patency rate was 82.4% (P = 0.009).
CONCLUSIONS: Both open surgery and endovascular treatment are effective for juxtarenal aortic occlusion. In comparison, open surgery has lower cost with better long-term eff icacy, while endovascular therapy has less invasiveness with faster postoperative recovery. O perative approach should be made according to the patient's clinical conditions.
Keywords: Arterial bypass, endovascular therapy, juxtarenal abdominal aortic occlusion, limb ischemia
|How to cite this article:|
Gu Y, Qi L, Dardik A, Gao X, Guo L, Tong Z, Guo J, Zhang J, Wang Z. Comparison of therapeutic effects between open surgery and endovascular therapy for juxtarenal aortic occlusion. Vasc Invest Ther 2018;1:74-9
|How to cite this URL:|
Gu Y, Qi L, Dardik A, Gao X, Guo L, Tong Z, Guo J, Zhang J, Wang Z. Comparison of therapeutic effects between open surgery and endovascular therapy for juxtarenal aortic occlusion. Vasc Invest Ther [serial online] 2018 [cited 2019 Jun 17];1:74-9. Available from: http://www.vitonline.org/text.asp?2018/1/2/74/242265
| Introduction|| |
Abdominal aortic occlusion frequently affects the bifurcation of the aorta. Complete occlusion of the infrarenal abdominal aortic and bilateral iliac arteries is rare but difficult to treat with many potential complications. Although open surgical bypass is the traditional therapy for aortoiliac occlusion, several recent reports of endovascular therapy suggest that endovascular approaches may provide reasonable durability with reduced perioperative complications. However, it is not clear whether these potential benefits of endovascular therapy are present when compared within the same series as open surgery. Accordingly, we hypothesized that open surgery provides long term durability whereas endovascular provides reduced perioperative complications.
| Methods|| |
This was a single-center retrospective cohort study that evaluated all cases of juxtarenal aortic occlusion (JAO) from January 2005 to December 2014. Electronic medical records were reviewed to obtain patient demographics, perioperative information, and associated outcomes.
For surgical bypass: Patients were included if they had: (1) normal heart function with EF >60% and no history of coronary heart disease, or heart failure; (2) no history of cerebrovascular disease; (3) age below 65 years. 15 patients were enrolled before December 2009, and three patients received laparoscopic aortoiliac graft bypass reconstruction in 2012 (according to the requirements of the patients). For endovascular treatment: Patients were included if they were: (1) not suitable for surgical bypass; or, (2) patients' insistence on endovascular treatment; or (3) failed previous surgical treatment.
For surgical bypass: Patients were excluded if they: (1) had poor general health; or (2) who refused surgical bypass. For endovascular treatment: Patients were excluded if they: (1) had renal insufficiency, (2) refused endovascular treatment; or (3) had a contrast agent allergy.
The diabetic patients received routine oral or insulin injection treatment, and hypertension patients received regular angiotensin-converting enzyme inhibitors or calcium channel blockers. The patients of both groups all were prescribed aspirin and a statin after the procedure.
Open surgery and endovascular procedures
Patients always underwent open surgical bypass under general anesthesia, including abdominal aorta-unilateral/bilateral femoral artery bypass, with sequential distal bypass or local artery endarterectomy, and patch repair, as indicated.
According to the patient's physical condition or lesion characteristics, patients underwent an endovascular treatment with local anesthesia or general anesthesia. Antegrade (via the left subclavian artery) or retrograde (femoral) access was chosen and patients received an intravenous heparin bolus dose (50–70 U/kg) after introduction of the sheath; then a diagnostic angiogram was performed. In case the target lesion was successfully traversed with a hydrophilic coated guidewire, a bare stent or covered stent was deployed. The procedure was considered as successful when there was a residual stenosis of <30%.
We defined short-term results as clinically related events that appeared between the day of the procedure and the day of discharge. All patients were followed by surveillance using computed tomographic angiography (CTA) or duplex ultrasonography in accordance with the following schedule: before discharge, 3rd month, 6th month, and 12th month, and subsequently annually, after the procedure.
Procedure-related and primary endpoint data collection
Procedure-related and in-hospital data were collected including technical success, operative time, volume of blood loss, hospital stay and cost, and perioperative complications. The endpoints for treatment outcomes included primary patency, limb salvage rate, ankle-brachial index (ABI), and ulcer healing.
Statistical analysis was performed by an independent statistician using SPSS statistical software package version 13.0 (SPSS Inc., Chicago, IL, USA). Comparison of the clinical results between two groups was calculated using the Chi-square test. Time-to-event endpoint analyses were performed using the Kaplan–Meier method. P values <0.05 were considered statistically significant.
| Results|| |
Thirty-seven patients with 73 limbs suffering from juxtarenal abdominal aortic occlusion received surgical bypass or endovascular treatment. There were 32 male and 5 female patients; the male-to-female ratio was 6.4:1. The mean age was 57.6 (range, 45–68) years. The average duration of disease was 8.2 months (range, 3 months–2 years). The patients had histories of varying degrees of smoking, and none had history of diabetes. One patient previously had an above-knee amputation secondary to a prior history of right lower-limb gangrene. Forty eight limbs had intermittent claudication. The average walking distance was 80 (range, 20–200) m. Fifteen limbs had rest pain. Six limbs had a foot ulcer, and four limbs had toe gangrene. Twelve patients had proximal disease with hip discomfort and impotence. The average preoperative ABI was 0.28 (range, 0.00–0.59). There was no significant difference in age, sex, symptom distribution, comorbid diseases, and especially renal function between the two groups [Table 1].
All 37 patients were diagnosed with infrarenal abdominal aortic and bilateral iliac artery occlusion with either CTA, magnetic resonance angiography, or digital subtraction angiography. Bilateral superficial femoral artery occlusion was found in 10 patients, and unilateral occlusion of the superficial femoral artery was found in two patients. Five patients had renal artery stenosis.
In the surgical bypass group, 15 patients underwent open surgery bypass under general anesthesia, in which eight patients underwent abdominal aorta-bilateral femoral artery bypass, five patients required abdominal aorta-bilateral femoral artery-bilateral popliteal artery bypass, one patient required abdominal aorta-bilateral femoral artery bypass and bilateral femoral artery thrombectomy and left deep femoral artery angioplasty with saphenous vein patch, and the patient with one leg underwent abdominal aorta-left femoral artery bypass. Three patients required laparoscopic abdominal aorta-bilateral femoral artery bypass under general anesthesia. The mean distance from the proximal edge of the occlusion to the nearest renal artery was 3.5 mm, and 34 of 36 renal arteries were flush.
In the endovascular therapy group, 19 patients underwent endovascular treatment, which was completed under general anesthesia in nine cases and local anesthesia in 10 cases. Single bare stents were employed in the abdominal aorta in nine cases. Stent graft was used in nine cases including a single stent graft in four cases and kissing stent grafts in five cases. Of 38 renal arteries, 30 were protected by balloon angioplasty synchronously with the aortic angioplasty.
In the open group, the technical success rate was 100%, and the mortality rate was 0%. Symptoms were completely relieved in the 23 limbs with intermittent claudication. For the seven limbs with rest pain, symptoms were partially relieved in five limbs and totally relieved in two limbs. Foot ulcers healed in one limb and became smaller in two limbs. Amputation was performed simultaneously in the two limbs with toe gangrene, and the wounds healed within 2 weeks after the operation. Hip discomfort was alleviated in three cases and was relieved in one case and did not change in one case. Impotence relieved in two cases and did no change in the other two cases. The average ABI of the 35 limbs significantly improved from 0.36 to 0.94 after the operation (P< 0.01). The average blood loss was 670 ml (400–1500 ml). Length of hospital stay was 21 days. The average cost of hospitalization was 83,000 RenMinBi (RMB).
In the endovascular group, the technical success rate was 94.7% (18/19), and the total recanalization rate was 89.5% (17/19), with no mortality. Endovascular treatment failed in one case with residual claudication in one limb and rest pain in the other; t he patient then underwent arterial bypass. Another patient underwent arterial recanalization in one limb and femofemoral arterial bypass in the other limb. The symptoms were completely relieved in the 24 limbs with intermittent claudication, with patients reporting a walking distance >1 km. For the seven limbs with rest pain, five limbs were partially relieved of pain, and the other two limbs were completely relieved. Ulcers healed in one limb and became smaller in the other two limbs. Toe gangrene did not change in the two limbs. Hip discomfort was alleviated in three cases, was significantly relieved in one case, and had no relief in the other two cases. Impotence was relieved in one case and did not change in the other two. The average ABI value of the 36 limbs was significantly improved from 0.39 to 0.96 after the operation (P< 0.01). Complications of the endovascular group included: Renal artery embolization occurred in one case and was treated by stent implantation since catheter suction thrombectomy and thrombolytic therapy was not effective. One case who received bare stent implantation after catheter directed thrombolysis for 3 days before the recanalization suffered from blue toe syndrome; thrombectomy was performed during the operation, but no clot was found; the patient received vasodilator drugs and low-molecular-weight heparin anticoagulant therapy, and the toe necrosis ulcer got healed after one month later. The average blood loss was 210 ml (range, 100–500 ml). Length of stay was 12 days. The average cost of hospitalization was 136,000 RMB.
There was no significant difference in efficacy, technical success rate, and mortality between the two groups (P > 0.05). All renal arteries remained patent, and there were no significant changes in postoperative creatinine in either of the groups. Endovascular treatment was significantly better than surgical bypass in reducing blood loss and length of stay (P< 0.001). However, the cost of endovascular treatment was significantly higher than open treatment (P< 0.001) [Table 2].
|Table 2: Perioperative and short-term results of two groups open and endovascular treatment groups|
Click here to view
All the patients treated with open repair were followed up for an average of 60.5 months (range, 38–108). Two patients died. One patient died of an unrelated aortic arch aneurysm rupture 2 months later, but the abdominal aortic graft was patent. The other patient died of graft infection, which lead to multiple-organ failure. The graft patency rate was 94.4% (16/18) without symptoms. Both of the two toe ulcers got healed by the time of discharge. Hip discomfort and impotence changed little.
Seventeen patients treated with an endovascular approach were followed up for an average of 52.5 months (range, 9–108). The follow-up rate was 94.4%. Fourteen patients were asymptomatic, and symptoms recurred in three patients. The patency rate was 82.4% (14/17). Stents were occluded in one case and were restenosed in two cases. Three patients received repeated endovascular treatment and the symptoms were relieved. The ulcers in two limbs were healed at discharge. One gangrenous toe was amputated after the endovascular treatment, and another gangrenous toe autoamputated. All wounds healed quickly. Hip discomfort and impotence changed little.
The average time of follow-up of the two groups was >50 months. The long-term patency rate was significantly higher in patients treated with an open approach (94.4% vs. 82.4%, P = 0.009) [Figure 1]. There were no differences in event-free survival between the two groups (P = 0.269).
|Figure 1: Event-free survival of open and endovascular treatment. Group A, Open. Group B, endo|
Click here to view
| Discussion|| |
JAO is typically due to atherosclerosis. The initial onset of JAO is generally slow, but it can progress rapidly. JAO is unusual, with an incidence of about 7%–8% of aortoiliac artery occlusions., The symptoms include not only intermittent claudication, rest pain, ulcers, and even gangrene, but also other characteristic symptoms caused by internal iliac artery ischemia, such as hip discomfort, sexual dysfunction, and even impotence.,, Since the proximal extent of the lesion is near the renal artery, it is difficult to treat and has many complications. Trans-Atlantic InterSocietal Consensus (TASC) Classification D lesions are recommended to be treated by open surgery, such as abdominal aorta-iliac/femoral artery bypass which is a classic procedure with excellent long-term efficacy. However, open surgeries have the shortcoming of a large traumatic procedure, and accordingly many complications. It is reported that  the incidence of complications and perioperative mortality within 30 days is 61% and 6.1% respectively in the cases requiring a suprarenal aortic clamp, while the incidence and mortality is 37% and 2.9% respectively in cases with only infrarenal aortic occlusion. Although descending thoracic aorta-femoral bypass by clamping the side wall of aorta can significantly reduce complications and achieve satisfied efficacy,,, the mortality rate of 4% is still high and it is not suitable for elderly and infirm patients. We used a new method  to avoid clamping the blocking suprarenal aorta. First, gently compress the aorta just below the renal artery with a clamp and gauze; incise the infrarenal aorta and remove the plaque and thrombus inside; then, clamp the infrarenal aorta and perform the proximal anastomos is. All the 15 patients who underwent open surgery received the same good results.
Laparoscopic bypass ,,, not only has a good long-term effect as open surgery but also has the advantages of laparoscopic technique, such as small incisions and early recovery. However, the procedure is complex and requires a higher degree and learning curve of surgical technique It is reported that it takes 20–30 cases to master the basic technique. Three patients in the open group received laparoscopic bypass and achieved satisfactory results which cannot be compared with directly to open surgery bypass due to the small sample size.
Several authors have reported endovascular treatment of aortoiliac artery occlusion.,, However, there are only a few reports on endovascular treatment of JAO. Nineteen patients underwent this procedure; one case failed and required a bypass. The other 18 patients all have achieved satisfactory results, and its long-term effects are acceptable. This suggests that endovascular treatment is a feasible method of JAO.
The technical success rate of the two groups was 100% and 94.7% (P = 0.324), respectively. The total recanalization rate of patients treated with endovascular treatments was 89.5%. Although surgical bypass has larger operative trauma, more blood loss (P< 0.001), and longer length of stay (P< 0.001), the cost is much lower (P< 0.001) and the long-term patency rate was significantly higher (94.4% vs. 82.4%, P = 0.009) compared with endovascular treatment. These results suggest that open surgery may be a more cost-effective option for most patients that are fit for the procedure, but that patients who are not reasonable candidates of open surgery may still benefit from endovascular treatment, although it is more expensive.
To prevent complications, protection of the renal arteries is one of the most important technical aspects of the procedure. We placed balloons in the renal arteries via an upper-limb approach prior to balloon angioplasty to avoid embolism caused by aortic thrombus or plaque. The embolic protection balloon in the renal artery was carefully retracted after wards to sweep away potential emboli. Another complication is blue toe syndrome, which can be effectively protected by placement of a covered graft. No patient suffered from blue toe syndrome after the use of stent graft.
| Conclusions|| |
Both surgical bypass and endovascular treatment are effective treatments for JAO. Open surgery has a high success rate, low cost, and good short- and long-term effect; endovascular treatment has less operative trauma, rapid postoperative recovery, and shorter length of stay.
The choice of open or endovascular approach to treat juxtarenal aortic occlusion should be tailored to the individual patient, considering the risks and potential benefit for each unique patient. Fit patients with good life expectancy should still be considered for open surgery. Patients with high operative risk but willing to be treated could be considered for endovascular therapy. Patients with poor long term outcome may still benefit from conservative treatment.
Xuanwu Hospital Talent training Plan
Financial support and sponsorship
This work is supported by the Beijing Municipal Administration of Hospitals Clinical Technology Innovation Program [Grant No. XMLX201610], the Beijing Municipal Administration of Hospitals Climbing Talent Training Program [Grant No. DFL20150801], the Beijing Outstanding Talents Project [Grant No. 2016000020124G108], and the Beijing Municipal Science and Technology commission Clinical features Applied Research Project [Grant No. Z141107002514063] Xuanwu Hospital “Talent training Plan” Beijing Municipal Hospital Scientific Research cultivation Program PX2018035. National key R and D Program 2017YFC1104100.
Conflicts of interest
There are no conflicts of interest.
| References|| |
McCarthy WJ, Mesh CL, McMillan WD, Flinn WR, Pearce WH, Yao JS, et al.
Descending thoracic aorta-to-femoral artery bypass: Ten years' experience with a durable procedure. J Vasc Surg 1993;17:336-47.
Mwipatayi BP, Thomas S, Wong J, Temple SE, Vijayan V, Jackson M, et al.
Acomparison of covered vs. bare expandable stents for the treatment of aortoiliac occlusive disease. J Vasc Surg 2011;54:1561-70.
Koksal C, Kocamaz O, Aksoy E, Cakalagaoglu C, Kara I, Yanartas M, et al.
Thoracic aortobifemoral bypass in treatment of juxtarenal leriche syndrome (midterm results). Ann Vasc Surg 2012;26:1085-92.
Landry G, Lau I, Liem T, Mitchell E, Moneta G. Open abdominal aortic aneurysm repair in the endovascular era: Effect of clamp site on outcomes. Arch Surg 2009;144:811-6.
Sapienza P, Mingoli A, Feldhaus RJ, Napoli F, Marsan A, Franceschini M, et al.
Descending thoracic aorta-to-femoral artery bypass grafts. Am J Surg 1997;174:662-6.
Dion YM, Gracia CR. A new technique for laparoscopic aortobifemoral grafting in occlusive aortoiliac disease. J Vasc Surg 1997;26:685-92.
Barbera L, Mumme A, Metin S, Zumtobel V, Kemen M. Operative results and outcome of twenty-four totally laparoscopic vascular procedures for aortoiliac occlusive disease. J Vasc Surg 1998;28:136-42.
Guo LR, Gu YQ, Qi LX, Tong Z, Wu X, Guo JM, et al.
Totally laparoscopic bypass surgery for aortoiliac occlusive disease in China. Chin Med J (Engl) 2013;126:3069-72.
Diethrich EB, Santiago O, Gustafson G, Heuser RR. Preliminary observations on the use of the palmaz stent in the distal portion of the abdominal aorta. Am Heart J 1993;125:490-501.
Bosch JL, Hunink MG. Meta-analysis of the results of percutaneous transluminal angioplasty and stent placement for aortoiliac occlusive disease. Radiology 1997;204:87-96.
Nyman U, Uher P, Lindh M. Primary stenting in complete aortic occlusion. AJR Am J Roentgenol 2000;172:501-3.
Otahbachi M, Kumar A, Cevik C, Suarez A. Successful endovascular stenting of total juxtarenal aortic occlusion performed through brachial and femoral access. J Card Surg 2009;24:315-6.
[Table 1], [Table 2]