Spinal cord ischemia following elective aortoiliac reconstruction

Spinal cord ischemia following abdominal aortic procedures is a rare complication. It occurs most commonly after operations for ruptured abdominal aortic aneurysms but has also been reported secondary to operations for aortoiliac occlusive disease. A 67-year-old man suffered spinal cord infarction following a routine, uncomplicated aortofemoral bypass. Although generally considered a rare and unpredictable complication of aortoiliac reconstruction, measures are discussed which might have prevented its occurrence in this case, and may further reduce its incidence in the future.     

Pelvic hemodynamics after aortoiliac reconstruction

Changes in blood flow to the pelvis were monitored by measurement of penile blood pressures before and after 38 aortoiliac vascular reconstructions. An increase in penile pressure was noted in 14 patients (37%), a decrease was seen in eight patients (21%), and no change occurred in 16 patients (46%). These changes could have been predicted by matching arteriograms to the surgical procedure performed. Preoperative impotence was present in 27 patients (17%). In this group a postoperative increase in penile pressure was associated with restoration of erectile capability in eight of 11 patients. Only one of 10 patients with an unchanged penile pressure regained sexual potency. In contrast, none of the eight patients whose penile pressures decreased had recurrence of erectile capability. Six of these patients had end-to-end aortobifemoral grafts, and concurrent external iliac disease prevented retrograde flow to the internal iliac vessels.     

Spinal cord ischemia following surgery for aortoiliac occlusive disease

A 70-year-old man had aortobifemoral bypass for severe aortoiliac occlusive disease. He developed spinal cord ischemia with anterior spinal artery syndrome. He had minimal recovery of muscle function, multiple postoperative complications, and 11 months postoperatively he died. Spinal cord ischemia is a rare and unpredictable complication of abdominal aortic surgery. It most often has occurred following surgery for aneurysm but can also occur after apparently routine surgery for occlusive disease.     

Pelvic hemodynamics before and after aortoiliac vascular reconstruction: the significance of penile blood pressure

The relationship between penile pressure and hypogastric arterial insufficiency, as well as the changes in the penile brachial pressure index and male sexual function after aortoiliac vascular reconstruction, were investigated in 47 patients with arteriosclerosis obliterans and in 6 patients with Buerger's disease. When the penile brachial pressure index was greater than 0.7, a value compatible with normal sexual function, there was enough arterial circulation to keep at least one hypogastric artery patent. In cases where there was insufficiency of both hypogastric arteries, the index increased significantly after the inflow was restored, even if it was unilateral, following arterial reconstruction. Reconstruction of the blood flow to the femoral artery tended to increase the index even without restoration of hypogastric flow, especially when the inferior mesenteric artery was occluded. In cases of high aortic occlusion, restoration of blood to the femoral artery alone led to a greatly significant increase in the index. These facts indicate that branches of the femoral artery and the inferior mesenteric artery play an important role in the collateral circulation of pelvic hemodynamics when the hypogastric artery is occluded.     

Pelvic hemodynamics before and after aortoiliac vascular reconstruction: The significance of penile blood pressure

The relationship between penile pressure and hypogastric arterial insufficiency, as well as the changes in the penile brachial pressure index and male sexual function after aortoiliac vascular reconstruction, were investigated in 47 patients with arteriosclerosis obliterans and in 6 patients with Buerger’s disease. When the penile brachial pressure index was greater than 0.7, a value compatible with normal sexual function, there was enough arterial circulation to keep at least one hypogastric artery patent. In cases where there was insufficiency of both hypogastric arteries the index increased significantly after the inflow was restored, even if it was unilateral, following arterial reconstruction. Reconstruction of the blood flow to the femoral artery tended to increase the index even without restoration of hypogastric flow, especially when the inferior mesenteric artery was occluded. In cases of high aortic occlusion, restoration of blood to the femoral artery alone led to a greatly significant increase in the index. These facts indicate that branches of the femoral artery and the inferior mesenteric artery play an important role in the collateral circulation of pelvic hemodynamics when the hypogastric artery is occluded. A part of this work was presented at the 27th Congress of the Japanese College of Angiology held in Kofu, Japan on October 30th, 1986     

Ureteral complications and aortoiliac reconstruction

A 33-year experience with 58 ureteral complications in 50 of 3580 patients undergoing aortoiliac reconstruction was analyzed. Ureteral obstruction was treated before or in conjunction with aneurysm repair in six patients with aneurysmal disease. The remaining 44 patients had 46 ureteral complications after aortic reconstruction; complications included hydronephrosis (42), ureteral leak (3), and ureteral necrosis (1). A high incidence of associated graft complications was noted. Graft thrombosis developed in one of the six patients undergoing prior or simultaneous ureteral procedures, and graft infection developed in another. Thirty-six graft complications developed in 24 (55%) of the 44 patients with postoperative ureteral complications. The complications included 19 anastomotic aneurysms, eight graft limb thromboses, six graft infections, and three aortoenteric fistulas. Twenty-nine of the 44 patients with postoperative ureteral complications underwent ureteral or graft operations or both. These included five patients having ureteral operations alone, seven with a ureteral procedure and subsequent graft operation, eight requiring simultaneous ureteral and graft procedures, and nine undergoing a graft operation with ureteral observation. Six of these 29 patients (21%) died after operation, all from graft complications including aortoenteric fistulas (three), ruptured anastomotic aneurysms (two), and graft infection (one). Graft complications affected 55% of 44 patients with postoperative ureteral complications, compared to 12% of 3536 patients without ureteral complications (p less than 0.0001). Patients with postoperative ureteral complications were 4.4 times as likely to have graft complications compared to those without ureteral complications (p less than 0.0001). These data suggest that such urologic complications may be markers for recognition of or harbingers for graft complications.     

骶骨肿瘤切除ISOLA重建骨盆环稳定

目的探讨骶骨肿瘤切除术后应用ISOLA重建骨盆环稳定的疗效。方法手术治疗32例骶骨肿瘤患者。肿瘤切除后均应用ISOLA行腰骶部内固定植骨融合,其中24例行前后联合入路,结扎双侧髂内动脉;8例行单纯后路肿瘤切除植骨融合内固定。结果术后经过6个月～5年的随访,术后感染去除内固定1例,因肿瘤复发死亡3例,再手术3例,失访5例,余患者术后症状均明显改善,植骨融合好,骨盆环稳定,内固定物无松动,未发现断钉断棒现象。结论骶骨肿瘤切除术后应用ISOLA重建下腰椎及骨盆环稳定,疗效满意。     

动脉硬化性主髂动脉闭塞症血管重建的术式选择

目的分析解剖位和非解剖位术式对动脉硬化性主髂动脉闭塞的手术疗效、围手术期死亡和主要并发症的影响。方法对动脉硬化性主髂动脉闭塞症行主髂动脉重建术的382例患者的30d围手术期疗效、死亡和并发症的危险因素采用Logistic回归进行分析。结果共126名患者纳入分析。Logistic逐步回归显示手术有效率的影响因素有溃疡坏死（OR0．13，95％CI0．33～0．36，P=0．005）、是否同期远端血管重建（OR11．29，95％CI1．25～102．53，P=0．012）；围手术期主要并发症为13．5％，危险因素有年龄（OR37．13，95％CI3．29～48．53，P=0．003）、肾功能异常（OR5．71，95％CI1．25～25．02，P=0．024）、Goldman心脏风险（OR26．83，95％CI4．85～49．54，P=0．001）、术式选择（OR0．03，95％CI0．002～0．34，P=0．005）；围手术期死亡的危险因素有年龄（OR65．56，95％CI4．88～87．64，P=0．002）、Goldman心脏风险（OR23．86，95％CI3．90～45．99，P=0．032）、术式选择（OR0．02，95％CI0．001—0．262，P：0．005）。结论年龄70岁以上、中度以上Goldman心脏风险、肾功能异常是围手术期死亡和主要并发症的危险因素，对于这些高危患者需考虑采用解剖外术式以降低手术风险。     

Optimal methods of aortoiliac reconstruction.

Alternate methods of aortic reconstruction for aortoiliac occlusive disease were reviewed in one author's (R.C.D.) personal series of 582 patients (1,105 limbs) during the 15 year period from 1963 to 1977. To illustrate certain trends, separate analysis was done for periods 1963 to 1969 (interval I) and 1970 to 1977 (interval II). During the earlier period, endarterectomy was performed in 72% of patients, with unilateral operations carried out in 15% of patients. Operative mortality was 5.1% and early failure occurred in 4% of patients. In contrast, in interval II graft procedures were done in 89% of patients, with mortality of only 2% and early failure in less than 1% of patients. Unilateral procedures were utilized infrequently (4%). Our analysis suggests that aortoiliac endarterectomy is still the procedure of choice for a small group (approximately 10%) with localized disease. For more extensive disease, aortofemoral grafts appear to be the procedure of choice. Patency of such grafts in the most recent interval was 91% at 5 years. Superior long-term function of aortofemoral grafts appears to be associated with use of a knitted Dacron prosthesis, end-to-end proximal anastomosis, and distal anastomosis which ensures patency of the profunda femoris outflow. The incidence of infection (0.3%) and false aneurysm formation (1.4%) was extremely low. In view of the low mortality rate and superior long-term success of direct reconstructions, extraterritorial grafts are felt to be rarely indicated.     

Descending thoracic aorta as an inflow source for late occlusive failures following aortoiliac reconstruction

From November 1984 to March 1990, 10 descending thoracic aorta-to-femoral artery bypass procedures were performed after failure of one or several aortoiliofemoral reconstructions. All patients were men, mean age 60 years. Indications included noninfected false aneurysm of an infrarenal end-to-side aortoprosthetic anastomosis in one case; one occlusion of an axillofemoral bypass; degradation of an aortobifemoral prosthetic graft; two occlusions of aortofemoral bypass; and five occlusions of aortobiiliac or aortobifemoral bypasses. Eight bifurcated grafts, one aortoprosthetic tube graft, and one aortopopliteal tube graft were inserted. One patient died 23 days postoperatively of multiple organ failure. Three patients underwent a successful secondary lower limb reconstruction procedure (prosthetic limb thrombectomy, embolectomy, femoral bifurcation angioplasty in one case each). Mean survival time was 14 months (range 3–48 months). Two patients were lost to follow-up, and one died of myocardial infarction six months postoperatively with a patent bypass. Graft thrombosis occurred in two patients. One was treated by thrombectomy at five months, the other was treated by in-situ thrombolysis at 15 months. Both of these patients had patent grafts at 12 and 21 months, respectively. The four other patients had patent grafts at 48 months. Primary patency was 55.5% (5/9 survivors) and secondary patency was 100% (9/9). This is a relatively simple method for constructing an extraanatomic aortofemoral or aortobifemoral bypass in late failures of aortoiliofemoral reconstructive surgery without having to re-enter the abdomen.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.     

Ischaemic colitis following aortoiliac surgery

Ischaemic colitis following aortoiliac surgery is a feared complication. Its frequency varies from 7% after repair of ruptured abdominal aortic aneurysm (AAA) to 0.6% after bypass for aortoiliac occlusive disease (AOD). In order to analyse predisposing factors and outcome of ischaemic colitis, the authors reviewed their clinical experience from 1988 to 1998. It concerns 28 cases (16 ruptured AAA, 7 elective AAA, 5 OAD) of clinically evident colonic ischaemia. This means an incidence of 7% after repair of ruptured AAA, 0.6% after elective AAA repair, and 0.8% after bypass for AOD. Transmural necrosis (grade 3) was observed in 21 patients, grade 2 ischaemia in 5 patients, and grade 1 ischaemia in 2 patients. Fifteen patients with grade 3 ischaemia underwent colectomy (Hartmann's procedure) with a mortality rate of 66%. All non operated grade 3 patients died. Overall, 16 of the 28 patients died at hospital (57% mortality rate). None of the patients with mild (grade 2 or 1) colonic ischaemia died. Profound hypovolaemic shock and inflammatory AAA were the only significant predisposing factors leading to colonic ischaemia. Associated colon revascularization could not avoid the evolution to colon necrosis in four patients. Reimplantation of a patent inferior mesenteric artery or an internal iliac artery was performed in only 4.8% of all aortoiliac reconstructions, and did not influence the development of ischaemic colitis. The authors conclude that a more liberal use of postoperative sigmoidoscopy could allow detecting colonic ischaemia at an earlier stage and reduce ensuing mortality. A reinforced effort to restore or preserve colonic vascularization could lower the incidence of colonic ischaemia following aortoiliac surgery.     

Preservation of erectile function after aortoiliac reconstruction

Men with aortoiliac atherosclerosis exhibit organic erectile dysfunction caused by inadequate blood flow and/or psychological factors. After aortoiliac reconstruction, organic erectile dysfunction may be due primarily to surgical interruption of autonomic nerve fibers. To avoid this, dissection principles preserving genital autonomic plexi were developed. The results of these dissections were compared with those of conventional bypasses. Thirty nondiabetic men (age range, 43 to 67 years) were studied. A history of erectile capacity was elicited preoperatively and evaluated postoperatively in follow-up interviews every six months. Normal postoperative erectile function was not affected by nerve-sparing dissections. Each of the 11 patients requiring conventional dissections was both preoperatively and postoperatively impotent. Four of the 19 patients who underwent nerve-sparing dissection were preoperatively and postoperatively impotent. Seven of these 19 patients maintained preoperative potency after nerve-sparing dissection. The potency of the remaining eight patients was either completely restored or improved after nerve-sparing dissection. This report emphasizes the importantance of a preoperative determination of a complex interplay of physical and psychological factors in erectile dysfunction.     

Pelvic reconstruction techniques

Partial resection of the pelvis or sacrum is an uncommon procedure, typically performed in the setting of tumors, severe infections, or trauma. The resultant defects, depending on the size and location, may cause significant postoperative morbidity or functional impairment. It is therefore essential that the surgeon be aware of all reconstructive options available and implement the most appropriate option for each individual patient. The purpose of this article is to review the functional consequences of the various pelvic resections and discuss the options available for reconstruction.     

腹膜后途径行主髂动脉重建的体会

目的总结腹膜后途径行主髂动脉重建的经验体会。方法28例患者在全身麻醉或硬膜外麻醉下接受了腹膜后途径主、髂动脉重建术,其中右侧8例,左侧20例。术式包括腹主动脉瘤切除加人工血管置换;腹主动脉内膜剥脱加补片成形;降主-腹主动脉人工血管转流;腹膜后肿物切除加髂总-股动脉人工血管转流;髂动脉瘤切除加腹主-髂外动脉人工血管转流;腹主-右髂总动脉异物取出;髂总动脉内膜剥脱;腹主-股动脉人工血管转流;髂总动脉．股动脉人工血管转流;髂总．股．胭动脉人工血管转流。术毕腹膜后腔放置胶管引流24例。结果28例患者手术全部成功,围手术期无死亡,术毕重建血管动脉搏动良好。术中出血150—400ml(平均240m1);术中2例患者输血;术后腹膜后腔引流量为50—170ml(平均85m1);术后平均28h拔除胃管。术后除心功能不全、应激性溃疡及腹膜后血肿各1例外,其余患者均未出现明显心、脑、肾、呼吸及消化系统并发症。22例患者随访3个月至2．5年。1例患者术后2年死于急性心梗,1例髂-股-腘动脉转流的患者术后10个月股-腘动脉段转流血管闭塞,1例患者术后近1．5年时虽患肢情况良好,但突发脑出血,其余患者均正常生活。结论腹膜后途径在充分显露主髂动脉的基础上,保证了腹膜腔的完整性,大大降低对胃肠道以及呼吸系统的影响,减少了术后肠麻痹以及呼吸系统并发症,避免了术后肠黏连、机械性肠梗阻的发生,是一种较为简便安全的主髂动脉手术途径。     

Intestinal retractor for transperitoneal laparoscopic aortoiliac reconstruction

BACKGROUND: We set out to design a bowel retractor for use during laparoscopic transperitoneal reconstruction of the infrarenal aorta and of both iliac axes. METHODS: This study was performed on five cadavers. After the insertion of four trocars, a pneumoperitoneum was created, and the bowels were gathered to the right flank. On each cadaver, the following four measurements were made: the distance between the Treitz angle and the aortic bifurcation (L1), the distance between the aortic bifurcation and the right internal inguinal ring (L2), the angles between L1 and L2 in the axial plane (A1), and the angles between them in the sagittal (A2) plane. These measurements enabled us to create a bowel retractor. The device was composed of a malleable metallic rod with a 2.5-mm diameter that was fixed to the operating table and whose intraabdominal section was designed to follow the outline of the mesenteric root in addition, a 25 x 12 cm polypropylene net was slipped around the rod. The infrarenal aorta and both iliac axes were then dissected. Secondarily, the bowel retractor was used in eight patients (seven men and one woman; mean age, 56 years; range 44-76) during laparoscopic aortoiliac reconstruction for occlusive (n = 6) or aneurysmal (n = 2) disease. RESULTS: The statistical analysis of the measurements performed on cadavers showed a significant correlation between body height and L1 (r = 0.8769; p < 0.05) and L2 (r = 0. 9706; p < 0.01) distances. It was then possible to design the shape of two metallic rods (one small and one large) so that they would be adaptable to the height of the patients (<1.65 m and >1.65 m). During our clinical experience, all laparoscopic procedures were completed in a mean operative and clamping time of 266 min (range, 215-360) and 54 min (range, 18-90), respectively. Mean postoperative hospital stay was 6 days (range, 3-13). CONCLUSION: Our experimental study allowed us to develop a bowel retractor that can make it easier to perform laparoscopic transperitoneal aortoiliac reconstruction in humans.