Limb-threatening ischemia due to multilevel arterial occlusive disease. Simultaneous or staged inflow/outflow revascularization.

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SUMMARY BACKGROUND DATA: Limb-threatening ischemia due to severe multilevel arterial occlusive disease may require both inflow and outflow bypass to achieve limb salvage. Simultaneous inflow/outflow bypass has been advocated because the cumulative risks of separate staged inflow/outflow procedures can be avoided. However, the magnitude of complete revascularization is substantial; thus, the morbidity and mortality of simultaneous inflow/outflow bypass may be excessive. METHODS: The medical records of 450 patients undergoing lower extremity arterial reconstruction between 1988 and 1994 were retrospectively reviewed, allowing identification of 54 patients who had undergone simultaneous aortoiliac and infrainguinal bypasses. This group consisted of 38 men and 26 women (mean age: 64.7 years), with significant cardiac disease in 24, smoking history in 53, and diabetes mellitus in 15. Indications for surgery were limb-threatening ischemia in 48 (89%) and severe short-distance claudication in 6 (11%). Inflow disease was corrected by direct aortoiliac reconstruction in 28, whereas other extra-anatomic bypasses were constructed in 26. Outflow revascularization required infrainguinal bypass to the infragenicular arteries in 46 (below-knee popliteal: 21; tibial: 25), a concomitant profundaplasty in 26, and a composite bypass conduit in 14. RESULTS: Limb salvage was 97% at 30 days whereas morbidity/mortality were 61% and 19%, respectively. However, the majority of complications and deaths occurred in patients undergoing aortic inflow plus complex outflow procedures (profundaplasty and/or composite bypass conduits), in which the morbidity/mortality rates were 84.2% and 47.4%, respectively, compared with rates of 45.7% and 2.9% (p < 0.01) after all other inflow/outflow procedures. The increased difficulty of these complex procedures is reflected in the significantly greater blood loss and operative times (1853 mL and 10.0 hours) compared with similar values (1125 mL and 7.7 hours)(p < 0.01) for all other inflow/outflow procedures. CONCLUSION: Simultaneous inflow/outflow bypasses are effective and safe in patients with severe, multilevel arterial occlusive disease, except when a complex outflow procedure is needed in conjunction with direct aortoiliac reconstruction. In the latter setting, a staged procedure is recommended because it may be associated with less morbidity and mortality.

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