Factors Contributing to Recurrent Lower Limb Ischemia Following Bypass Surgery for Aortoiliac Occlusive Disease, and their Management

Fifty-eight patients have been treated for recurrent lower limb ischemia following bypass surgery for aortoiliac occlusive disease over a three-year period. Based on clinical case notes, angiograms, operative notes and histologic examination of endarterectomy specimens, 32 patients (55.2%) were found to have progressive atherosclerotic occlusion involving the inflow (seven patients) or outflow (25 patients) tracts. Seven patients (12.0%) had problems related to graft angulation or mural thrombus fragmentation and, in four patients, anastomotic fibroplasia was demonstrated. Fifteen patients (25.9%) had not had their disease bypassed by the primary operation and required reoperation within one year. It is suggested that the use of juxtarenal end-to-end proximal anastomosis, extending to the groins distally in most cases, and good graft to host size match may be important considerations. Management entailed major aortic reconstructions in 28 patients, and local groin procedures or crossover grafts in 30 patients. There was one postoperative death (1.7%). Two patients had amputations (3.4%) although all grafts were functioning at the time the patients were discharged from the hospital. Major complications were more frequent following aortic reconstruction, and operations of this magnitude may, possibly, be confined to patients with aortic inflow obstruction, infection involving the graft body or redundancy of the graft body causing sufficient angulation to cause obstruction.