Lars G. Svensson, MD, PhD, E. Stanley Crawford, MD, Kenneth R. Hess, MS, Joseph S. Coselli, MD, and Hazim J. Sail, MD, Houston, Texas

Transcription

1 Thoracoabdominal aortic aneurysms associated with celiac, superior mesenteric, and renal artery occlusive disease: Methods and analysis of results in 271 patients Lars G. Svensson, MD, PhD, E. Stanley Crawford, MD, Kenneth R. Hess, MS, Joseph S. Coselli, MD, and Hazim J. Sail, MD, Houston, Texas Two hundred seventy-one of 1509 patients who underwent thoracoabdominal aortic repairs had either celiac or superior mesenteric or renal artery occlusive disease. These latter patients were treated by endarterectomy or bypass between June 20, 1960 and Jan. 10, After 1987, the 30-day survival rate was 93% (79 of 85) compared with 90% (245 of 271) before Multivariate predictors of death were age, postoperative reoperation for bleeding, and cardiac complications (p < 0.05). Kenal complications (13% dialysis, 35 of 271) were associated with preoperative renal dysfunction, elevated preoperative serum creatinine level, urine clearance time of dye, extent of the aorta replaced, coagulopathy, and paraplegia or paraparesis (p < 0.05). The incidence of postoperative renal dysfunction was reduced by renal artery endarterectomy (20 < 0.05). On univariate analysis the risk of renal failure was reduced by renal artery perfusion with cold Kinger's lactate solution (p < 0.05). Gastrointestinal complications (9%, 25 of 271) were associated with a history of peptic ulcer disease on multivariate analysis (p < 0.05). The Kaplan-Meier 5-year survival rates for patients with and without occlusive disease were 53% and 60%, respectively, and at 10 years 37% and 30%, respectively (p = 0.08). We conclude that endarterectomy or bypass of occlusive visceral disease reduces the risk of renal failure after thoracoabdominal aortic aneurysm repairs, does not decrease early or late survival, and does not increase the risk of gastrointestinal complications. (J VASC SURG 1992;16: ) Sudden total occlusion of the visceral arteries can result in disastrous complications such as gangrene of the intestines or renal failure. Stenoses of the visceral arteries, with the concomitant risk of sudden total occlusion occurring, is seldom detected before becoming symptomatic, except as an incidental finding during arteriography of the abdominal aorta. Clearly, for those patients in whom symptoms are present and who can undergo operation, operative repair of the occlusive segment is usually warranted. Crawford et al.~ have previously reported that if occlusive disease (either total occlusion or stenosis) of the arteries was bypassed with tube grafts in patients From the Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX Presented at the Sixteenth Annual Meeting of the Southern Association for Vascular Surgery, St. Thomas, the Virgin Islands, Jan, 22-25, Reprint requests: Lars G. Svensson, MD, Methodist Hospital and Baylor College of Medicine, 6535 Fannin MS-B40S, Houston, TX ]6/ with symptomatic disease, and operation was limited to an abdominal procedure, the risks of operation were low, and a 5-year survival rate of 63% could be achieved. Excellent results for the surgical repair of symptomatic disease of the superior mesenteric and celiac arteries have also been published by several other authors. 2-1~ Nevertheless, opinion differs as to whether asymptomatic superior mesenteric plus celiac artery disease or renal artery occlusive disease should be repaired at the time of abdominal aortic operation. In patients undergoing infrarenal abdominal aortic operation, Connolly and Kwaan 16 have strongly argued in favor of prophylactic bypass or endarterectomy of the superior mesenteric artery and ccliac artery if occlusive disease is present, since, in their experience, the risk of early and late postoperative intestinal gangrene or symptoms was frequent if not treated. Thc viewpoint that asymptomatic occlusive disease should be repaired during infrarenal aortic operation has also been endorsed by other surgeons.l,s,12,a4, I~

2 Volume 16 Number 3 September 1992 Visceral occlusive disease 379 In this study we have evaluated the results of thoracoabdominal aortic operations fijr either asymptomatic or symptomatic visceral disease. The results have also been compared with those patients without identified or treated visceral occlusive disease. PATIENTS AND METHODS Retrospective review of 1509 patients who were operated on by the senior author (E.S.C.) between June 20, 1960, and Jan. 10, 1991, revealed 14% (271) were treated for visceral occlusive disease. The number of patients with occlusive disease but who did not have a repair of the arteries could not be accurately determined in this retrospective analysis. Thus there may have been some patients in the "no occlusive disease" group (Table I) who did have some unidentified or not treated occlusive disease. For the purposes of this study visceral occlusive disease was defined as total occlusion or stenoses of the superior mesenteric, celiac, or renal arteries. The clinical profile of the patients and operative procedures performed are shown in detail in Appendixes A to I. The median age was 67 years and ranged from 20 years to 86 years. Of the 217 patients, 25 (9%) had symptoms, including abdominal angina assodated with meals, or bowel gangrene, weight loss, or chronic intestinal complaints, and 26 (10%) had a history of peptic ulcer disease. Ninety-two were women (34%), 15 (6%) had aortic dissection, 113 (42%) had a history of coronary artery disease, 16 (6%) had diabetes, 73 (27%) had a history" of renal dysfunction, and 24 (9%) had a preoperative serum creatinine level greater than 3 mg/dl. Evidence of chronic pulmonary disease was present in 119 (44%) of patients. Preoperative angiography was obtained routinely in both the anteroposterior and lateral views. The Crawford extent of thoracoabdominal aortic aneurysmal disease included 14 type I (proximal half of the descending aorta to abdominal aorta above the renal arteries), 101 type II (proximal half of the descending aorta to below the renal arteries), 70 type III (distal half of the descending thoracic aorta into the abdominal aorta), and 86 type IV (most of the abdominal aorta). The operative techniques of endarterectomy, reimplantation, or bypass of the visceral arteries have been reported previously by us.1 In most instances 8 mm tube grafts were used for the bypasses from the aorta to the visceral arteries in an antegrade direction. Bypasses to the right renal artery, however, were usually performed from the right iliac artery or right graft limb of a bifurcated aortic graft. Figs. 1 and 2 Table I. Comparison of 30-day survival, renal complications, gastrointestinal complications, and incidence of postoperative dialysis in patients with and without occlusive disease of the visceral arteries after undergoing thoracoabdominal aortic repairs Occlusive No occlusive disease disease Outcome N = 271 N = 1238 p value Survival 245 (90%) 1139 (92%) NS Renal 78 (29%) 191 (15%) < Gastrointestinal 25 (9%) 76 (6%) 0.07 Dialysis 35 (13%) 101 (8%) In-hospital 235 (87%) 1119 (90%) NS survival illustrate the operative technique in two patients who underwent repair. Thirty-seven patients (14%) had repair of all four major visceral vessels (both renal arteries, superior mesenteric and celiac artery), 21 (8%) had three repaired, 73 (27%) had two repaired, and 140 (52%) had one artery repaired. In 86 of the 271 patients (32%) either celiac and~or superior mesenteric artery repairs were performed; celiac artery repair with (43) or without (17) the superior mesenteric artery repair in 60 (22%); and superior mesenteric artery repair with (43) or without (26) celiac artery repair in 69 (25%) (Fig. 3). Renal artery repair of either renal artery was performed in 260 (96%) patients of whom 190 (70%) had renal artery endarterectomies. Renal artery perfusion with cold Ringer's lactate solution was used in 24 (9%) of patients, and atriofemoral" bypass was used in 28 (10%) of patients. In 54 patients (20%) the aortic cross-clamp time exceeded 1 hour, with the longest being 197 minutes. The reappearance time of dye in the urine after aortic unclamping exceeded 45 minutes in 36 patients (24%). No routine intraoperative studies were obtained; however, if a patient had an inadequate urine output, an urgent arteriogram was performed. Twenty-two preoperative variables, 16 operative variables, and 8 postoperative variables were evaluated with respect to the early 30-day mortality rate, the renal complication rate (defined as the need for dialysis or postoperative creatirfine greater than 3 mg/dl), and to the rate of gastrointestinal complications (Appendix A). The variables were first analyzed by univariate analysis (cross-tabulation with Pearson chi-squared tests) and then by logistic stepwise regression analysis with use of the BMDP (BMDP Statistical Software, Inc., Los Angeles, Calif.) statistical program. The p values obtained by

3 380 ~ournal of VASCULAR SURGERY Svensson et al. Fig. 1A. Diagram and arteriogram of a patient with type III thoracoabdominal aortic aneurysm shows occlusive disease of superior mesenteric, celiac, and both renal arteries. univariate analysis should be interpreted with caution considering the large number of comparisons performed and the post hoc nature of the study. RESULTS The 30-day survival rate for the entire period of study was 90% (245 of 271), and after 1987 it was 93% (79 of 85). In-hospital survival was 87% (235 of 271). Gastrointestinal complications developed in 25 patients (9%) of whom two died. Renal complications developed in 78 of the 271 patients (29%), although this later improved to a rate of 19% (11 of 58) after Of the 78 patients who had renal complications, 35 (13% of the 271 patients) required postoperative dialysis. Twelve of the 271 patients (4%) had both renal and gastrointestinal complications, and 91 patients (34%) had either renal or gastrointestinal complications. For comparison, Table I shows the 30-day survival rate, renal complication rate, and gastrointestinal complication rate in 1238 patients who did not have documented occlusive disease of the visceral arteries. The risk of renal complications was significantly increased (p < ) but not for gastrointestinal complications (p = 0.066) in the patients who underwent repair of visceral occlusive disease. Table II shows the incidence of various postoperative complications in the 271 patients and their association with early death, renal complications, and gastrointestinal complications.

4 Volume 16 Number 3 September 1992 Visceral occlusive disease 381 Fig. lb. Endarterectomy of visceral arteries. On univariate analysis, the following variables were associated with an increased risk of death after operation: age greater than 75 years (p = ), diabetes (p = 0.031), preoperative creatinine greater than 3 mg/dl (p = 0.013), aortic cross-clamp time greater than 1 hour (p = ), the time for the appearance of dye in the urine after aortic unclamping greater than 45 minutes, pulmonary complications (p = 0.05), cardiac complications (p < ), reoperation for bleeding (iv = ), postoperative sepsis (p = 0.01), intraoperative coagulopathy (p = ), and renal complications (p = ). Renal complications were associated with preoperative renal dysfunctions (p < ), renal calculi (do = 0.024), preoperative serum creatinine level exceeding 3 mg/dl (p < ), urine dye reappearance time exceeding 45 minutes (p < ), and postoperative complications as shown in Table II. Of interest, renal artery perfusion with cold Ringer's lactate solution (p = 0.02I), renal artery endarterectomy (p = ), and if either renal artery was repaired (p = 0.05), was associated with a decreased risk of postoperative renal complications. Gastrointestinal complications were associated with evidence of chronic pulmonary disease (p = 0.034) and peptic ulcer disease (p = 0.001). On multivariate analysis by stepwise logistic regression analysis, the variables independently associated with 30-day deaths were increasing age (20 = , odds ratio 3.7 for 10-year increases of age), postoperative reoperation for bleeding compli- cations (p = , odds ratio 5.3), and cardiac complications (p < , odds ratio 17). Renal complications were independently- associated with preoperative renal dysfunction (p = 0.022, odds ratio 3.3), preoperative serum creatinine level (to = , odds ratio 2.4 for 1 mg/dl increase), extent replaced (p = 0.007, odds ratios 1.9, 2.6, and 8.4 for extent II, III, and IV versus extent I), renal artery endarterectomy (p = 0.014, odds ratio reduction by 0.34), the urine appearance time of dye (p < , odds ratio 2.1 for every 30-minute increase), coagulopathy (p = , odds ratio 8.5), and paraplegia/paraparesis (p = 0.03, odds ratio 3.0). Gastrointestinal complications were only associated with a histo~ 7 of peptic ulcer disease (p = , odds ratio 4.6). On the examination of the data according to preoperative symptoms or dysfunction, presence of occlusive disease, repair by either bypass or endarterectomy, and the postoperative outcome, the number of combinations and permutations of the results become large. Appendixes B, H, and I show the results according to the above variables. Since the numbers in each cell are often small, the data should be interpreted with caution. Some trends, however, appear to be apparent. The results shown in Appendix B would suggest that patients with untreatable preoperative renal dysfunction had a high complication rate (100%); untreated occlusive disease (N = 4) had a 75% renal failure rate; and treated occlusive disease had a good

5 382 Svensson et al lournal of VASCULAR SURGERY Fig. m. Postoperative repair and arteriogram. result (18% renal failure) if no preoperative dysfunction was present. However, the incidence of renal failure increased to 52% in patients with preoperative renal failure. Appendix C shows the results according to method of repair. On superficial examination the results may suggest that endarterectomy is preferable, since the results are better with endarterectomy (renal failure rate 25% (44 of 179)) versus bypass (renal failure rate 39% (27 of 70)). It should be noted, however, that bypasses were usually reserved for total occlusions or for arteries that had distal stenoses, thus the risks would be expected to be higher with bypasses. Furthermore, in the 11 patients who had endarterectomies combined with bypass, renal failure developed in one (9%). Appendix D further supports the point that endarterectomy has a lower risk if it can be performed, even if combined with bypass. Appendix E summarizes the data according to preoperative renal function and shows that renal failure was more common in patients with preoperative dysfunction (p < o.oool). The relationship of mesenteric (celiac or superior mesenteric) occlusive disease to symptoms, treatment of the arteries, and results are shown in Appendix F. There was no statistically significant difference in outcome. The relationship of symptoms to occlusive disease and treatment are shown in Appendix G. The numbers are small, and few conclusions can be made. No difference occurred in the incidence of gastrointestinal complications according to whether arteries were treated (13%, 11 of 86) versus no treatment of occlusive disease (10%, 3 of 30). As

6 Volume 16 Number 3 September 1992 Visceral occlusive disease 383 Fig. 2. A, Patient with type III thoracoabdominal aneurysm and occlusive disease of superior mesenteric and renal arteries. B, Operative repair and bypasses to superior mesenteric and renal arteries. would be expected, patients with occlusive disease documented before operation more frequently had treatment of the arteries. Appendixes H and I show the results by treatment method. As with renal artery repairs, endarterectomy has a better result (11% gastrointestinal complication rate) than if a bypass has to be performed (25% complication rate); however, the numbers are small. The patients with preoperative gastrointestinal symptoms did well (4% complication rate), with the only patient in whom complications developed being a patient who had both endarterectomy and bypass performed. The Kaplan-Meier estimation of the long-term survival at 5 years for the 1238 patients without treated occlusive disease was 60% versus 53% in those 271 patients treated for occlusive disease (2 = 0.08). No patients required reoperation for recurrent occlusive disease of the superior nqesenteric or celiac arteries. One patient, however, required balloon angioplasty ofa stenosed superior mesenteric artery, and another patient needed a bypass 1:o the left renal artery. The causes of early and late deaths are shown in Table III. DISCUSSION In this study the 30-day survival rate over the entire time period was 90%, which compares favorably with the survival rate of 92% in the patients without visceral occlusive disease operated on during the same time interval (Table I). These data should, TOTAL - 86 PATIENTS Fig. 3. Venn alia.gram of patients who had celiac and/or superior mesentenc artery repairs. however, be interpreted with some reservation, since this was not a prospective study. More recently in our experience the 30-day survival rate has improved to 97% in patients undergoing thoracoabdominal aortic operations. 17a8 We did not find that the risk of gastrointestinal complications was significantly increased in the present study by the repair of the superior mesenteric or celiac arteries (Table I). The incidence of renal complications, however, was increased (29% versus 15%, p < ) in these patients compared with those who did not undergo

7 384 Svensson et al. ~ournal of "VASCULAR SURGERY Table II. Incidence of postoperative complications and the association of the variables with early death, renal complications and gastrointestinal complications on univariate analysis in the 271 patients Incidence Gastrointestinal Complication No. (%) Death p value Renal p value p value Pulmonary 99 (37) Cardiac 36 (I3) < 0.000I Reoperation 32 (12) Sepsis 25 (9) Coagulopathy 14 (5) Paraptegia/P 41 (15) Gastrointestinal 25 (9) Renal 78 (29) Paraplegia~P, Paraplegia/paraparesis. Table III. Causes of early (N = 26) and late deaths (N = 63) Early Late Total Cardiac I Pulmonary Renal Sepsis Hemorrhage 4 4 Stroke Pulmona~ embolus Rupture Other Aortointestinal fistula 4 4 Unknown 3 3 Cancer 2 2 Gastrointestinal hemorrhage 2 2 repairs of the visceral arteries for occlusive disease. Nevertheless, in those patients with occlusive visceral disease, if renal artery endarterectomies were performed (p = ) or ifa repair was performed for either renal artery (p = 0.05), the incidence of renal complications was reduced. Furthermore, on stepwise logistic regression analysis with adjustment for the influence of the other variables, renal artery endartectomy was also significantly associated with a lower risk of renal failure. Thus in our opinion this justifies the performance of either a renal artery endarterectomy or bypass of occlusive disease of the renal arteries at the time of thoracoabdominal aortic operation, even ifasymptomatic. This study does not, however, address whether asymptomatic renal, celiac, or superior mesenteric artery occlusive disease should be treated in patients who are not undergoing thoracoabdominal aortic repairs, namely infrarenal abdominal aortic operation. Our approach to occlusive disease of the superior mesenteric and/or the celiac artery has been to perform endarterectomies for ostial stenoses at the time of the thoracoabdominal aortic repair. Thus although 60 patients had celiac artery repairs, this was usually combined with superior mesenteric artery repair (N = 43), or the patient had a celiac artery ostial stenosis that could easily be treated by endarterectomy (N = 17). If, however, only one vessel was totally occluded, particularly if the celiac artery was occluded, and the patient was asymptomatic, then no attempt was usually made to bypass the occlusion of the artery. If, however, both arteries are occluded, then by preference a bypass is done to the distally patent superior mesenteric artery and usually also to the celiac artery, especially in symptomatic patients. If the aortic graft has to be extended to below the inferior mesenteric artery origin, an attempt is made to always reimplant it, since it is usually the source of collateral blood flow to a proximally obstructed superior mesenteric artery or celiac artery. At the same time, the superior mesenteric and celiac arteries are also bypassed or endarterectomized because the long-term results appear to be better with complete revascularization. 1,s,ll This approach appears to have been satisfactory on the basis of our results. Nevertheless, even with repair of both major arteries and reimplantation of the inferior mesenteric artery, postoperative bowel ischemia may occur. Indeed, this occurred in one symptomatic patient who was surviving on her inferior mesenteric artery, and then after operation bowel ischemia, liver failure, and the surprisingly unusual postoperative complication of pancreatitis after thoracoabdominal aortic operation developed, ultimately resulting in her death. Nevertheless, despite the high incidence of stress ulceration in experimental animals after aortic cross-clamping, 19 gastrointestinal complications after similar th0racoabdominal aortic operations in humans are surprisingly uncommon) 8 A similar discrepancy in the sensitivity of the bowel to ischemic injury between animals and humans has been noted by Bergan et al.6 The reason for this is unclear but may be related to

8 Volume 16 Number 3 September 1992 Visceral occlusive disease 385 species differences in the tolerance of reperfusion injuries and the generation of oxygen derived free radicals in the gastrointestinal tract, 19,2 as has been documented in the heart. 21 In a previous study we reported the variables influencing the development of renal complications after 1525 descending thoracic aortic or thoracoabdominal aortic repairs. 22 The significant variables were similar to this study, including the protective effect of performing renal artery endarterectomy for occlusive disease. In the previous study, despite a larger sample size, we were unable to show that the routine use of cold Ringer's lactate solution to perfuse the kidneys reduced the risk of postoperative renal complications. 22 In this study, however, we have shown that in patients with occlusive disease the additional use of cold perfusion of the renal arteries with cold (4 C) Ringer's solution appears to protect the kidneys from ischemia during operations. We usually do this by injecting 120 ml of solution into each renal artery, and then we keep the left kidney cold by placing it in a cooling jacket. Alternatively, 1.5 L of cold solution can be administered and the temperature monitored by a thermistor needle in the left kidney as described previously. 22 In conclusion, this study supports the principle that occlusive disease of the renal arteries should be treated by endarterectomy or bypass at the time of thoracoabdominal aortic operation and that superior mesenteric or celiac artery repairs can be performed without an increased risk of death or postoperative gastrointestinal complications. REFERENCES 1. Crawford ES, Morris GC, Myhre HO, Roehm JOF. Celiac axis, superior mesentetic artery and inferior mesenteric artery occlusion: surgical considerations. Surgery 1977;82: Morris GC, DeBakey ME. Abdominal angina, diagnosis and surgical treatment, lama 1961;176: McCollum CH, Graham JM, DeBakcy ME. Chronic mesenteric arterial insufficiency: results of revascularization in 33 cases. South Med J 1976;69: Shaw RS, Maynard EP. Acute and chronic thrombosis of mesenteric arteries associated with malabsorption: report of two cases successfially treated by thromboendarterectomy. N Engl J Med/958;258: Hollier LH, Bernatz PE, Pairolero PC, Payne WS, Osmundson PA. Surgical management of chronic intestinal ischemia: a reappraisal. Surgery 1981;90: Bergan JJ, Dean RH, Conn J Jr, Yao JST. Revascuiarization in treatment of mesenteric infarction. Ann Surg 1975;182: Hertzer NR, Beven EG, Humphries AW. Chronic intestinal ischemia. Surg Gynecol Obstet 1977;145: Rogers DM, Thompson JE, Garret WV, Talkington CM, Parman RD. Mesenteric vascular problems. Ann Surg 1982; 195: Bole), SJ, Sprayregan S, Siegelman SS, et al. Initial results from an aggressive roentgenological and surgical approach to acute mesenteric ischemia. Surgery 1977;82: Stoney RJ, Ehrenfeld WK, Wylie EJ. Revascularization methods in chronic visceral ischemia caused by atherosclerosis. Ann Surg 1977;186: Geelkerken RH, Van Bockd JH, De Roos WK, Hermans j, Terpstta JL. Chronic mesenteric vascular syndrome. Results of reconstructive surgery. Arch Surg 1991;126: Rheudasil JM, Stewart MT, Schetlack IV, Smith RB, Salam AA, Perdue GD. Surgical treatment of chronic mesenteric arterial insmcfidency. J VAsc SURG 1988;8: Stanton PE, Hollier PA, Seidel TW, Rosenthai D, Clark M, Lamis PA. Chronic intestinal ischemia: diagnosis and therapy. VASC SURG 1986;4: Rapp JH, Reilly LM, Qvarfordt PG, Goldstone ), Ehrenfeld WK, Stoney RJ. Durability of endarterectomy and antegrade grafts in the treatment of chronic visceral ischemia. J VAsc SURG 1986;3: Van Dongen JAM. Renal and intestinal artery occlusive disease. World J Surg 1988;12: Conolly JE, KwaanHM. Prophylactic revascutarization of the gut. Ann Surg 1979;190: Crawford ES, Svensson LG, Hess KR, et al. A prospective randomized study of CSF drainage to prevent paraplegia meter high-risk surgery of the thoracoabdominal aorta, l VAsc Sur~G 1991;13: Svensson LG, Hess KR, Coselli JS, Sail HJ, Crawford ES. A prospective study of respiratory failure after high-risk surgery on the thoracoabdominal aorta. J VAsc St;l~c 1991;14: Svensson LG, Ritter CV, Oosthuizen MMJ, et al. Prevention of gastric mucosal lesions following aortic cross-clamping. Br 1 Surg 1987;74: Bourchier RG, Gloviczki P, Larson MV, et al The mechanism and prevention ofintravascular fluid loss after occlusion of the supraceliac aorta in dogs. J VASC SUinG 1991;13: McCord JM. Oxygen-derived free radicals in postischemic tissue injury. N Engl J Med 1985;312: Svensson LG, Coselli IS, Sail HJ, Hess KR, Crawford ES. Appraisal of adjuncts to prevent acute renal failure after surgery on the thoracic or thoracoabdominal aorta. J VAse SURG 1889;10: Submitted Jan. 29, 1992; accepted April 10, (Appendixes begin on page 386.)

9 386 Svensson et al. Journal of VASCULAR SURGERY Appendix A. Evaluation of variables Age (yr) Variable Group No. Deaths (%) p Value Renal (%) p Value GI (%) p Value < (4%) (37 /6) (18%) (3%) 23 (25%) 8 (9%) (11%) 36 (27%) 10 (8%) > (37%) 9 (47%) 2 (10%) Sex Female 92 7 (8%) (22%) (6%) 0.27 Male (11%) 58 (32%) 19 (11%) Dissection No (9%) (29%) (9%) 0.72 Yes 15 2 (13%) 4 (27%) 1 (7%) Aortitis No (10%) (29%) (10%) 0.28 Yes 11 0 (0%) 3 (27%) 0 (0%) Concurrent proximal aneurysm No (9%) (28%) (9%) 0.40 Yes 23 3 (13%) 9 (39%) 1 (4%) Hypertension No 39 1 (3%) (20%) (8%) 0.72 Yes (11%) 70 (30%) 22 (1.0%) CPD No (9%) (30%) (6%) Yes (11%) 33 (28%) 16 (13%) ASHD No (9%) (29%) (10%) 0.54 Yes (11%0) 33 (29%) 9 (8%) DM No (9%) (29%) (9%) 0.17 Yes 16 4 (25%) 5 (31%) 3 (19%) Preoperative renal dysfimction No (10%) (19%) < (8%) 0.12 Yes 73 7 (10%) 40 (55%) 10 (14%) Cerebrovascular disease No (9%) (27%) (8%) 0.35 Yes 66 8 (12%) 22 (33%) 8 (12%) Gallstones No (10%) (29%) (10%) 0.16 Yes 18 2 (11%) 5 (28%) 0 (0%) Gout No (10%) (28%) (9%) 0.50 Yes 14 1 (7%) 6 (43%) 2 (14%) Peptic ulcer No (10%) (29%) (7%) Yes 26 1 (4%) 8 (31%) 7 (27 /6) Previous descending No (10%) (28%) (9%) 0.23 Yes 10 0 (0%) 4 (40%) 2 (20%) Previous AAA No (9%) (28%) (9%) 0.89 Yes 57 7 (12%) 18 (32%) 5 (9%) Previous CABG No (10%) (30%) (10%) 0.30 Yes 27 2 (7%) 4 (15%) 1 (4%) Previous CSI No (10%) (29%) (9%) 0.72 Yes 22 2 (9%) 7 (32%) 3 (14%) Previous GI Op No (9%) (30%) (9%) 0.61 Yes 25 3 (12%) 5 (20%) 3 (12%) Preoperative creatinine -< (5%) (16%) < (5%) (20%) 19 (37%) 7 (14%) (12%) 13 (38%) 5 (15%) Operative period Extent Bifurcation graft Clamp time (rain) > (12%) 20 (83%) 3 (12%) < (7%) (30%) (11%) (13%) 21 (30%) 1 (1%) (11%) 25 (35%) 9 (13%) > (7%) 11 (19%) 7 (12%) I 14 2 (14%) (29%) (7%) 0.64 II (11%) 21 (21%) 9 (9%) ui 70 7 (10%) 21 (30%) 9 (13%) IV 86 6 (7%) 32 (37%) 6 (7%) No (9%) (28%) (8%) 0,094 Yes 44 5 (11%) 15 (34%) 7 (16%) < (11%) (37%) (16%) (6%) 22 (23%) 12 (13%) (6%) 28 (28%) 5 (5%) > (22%) 19 (35%) 5 (9%) Renal ischemie time (rain) _< (10%) 0,86 14 (29%) (12%) (10%) 28 (26%) 11 (10 /6) (9%) 22 (32%) 4 (6%) > (6%) 11 (31%) 4 (11%) G/, Gastrointestinal complications; CPD, chronic pulmonary disease; ASHD, atherosclerotic heart disease; DM, diabetes mellitus; AAA, abdominal aortic aneurysm; CABG, coronary artery bypass graft; CSA, carotid, subclavian or innominate artery operation; GI op, gastrointestinal operation; Extent I-IV, Crawford thoracoabdominal aneurysm extent; VV, visceral vessels; SMA, superior mesenteric artery.

10 Volume 16 Number 3 September 1992 Visceral occlusive disease 387 Appendix A-con(d Variable Group No. Deaths (%) p Value Renal (%) p Value GI (%) p Value Urine reappearance time (rnin) < (3%) (10%) < (3%) (6%) 15 (18%) 8 (10%) (7%) 16 (39%) 5 (12%) > (19%) 28 (49%) 5 (9%) Renal perfusion No (9%) (31%) (10%) 0.37 Yes 24 2 (17%) 2 (8%) i (4%) Atriofemoral bypass No (9%) (29%) (10%) 0.27 Yes 28 4 (14%) 7 (25%) 1 (4%) No. W treated (9%) (27%) (7%) (11%) 27 (37%) 8 (11%) (10%) 7 (33%) 4 (19%) (8%) 6 (16%) 3 (8%) Renal endarterectom.y No 81 5 (6%) (41%) (7%) 0.50 Yes (11%) 45 (24%) 19 (10%) Celiac treated No (10%) (31%) (9%) 0.81 Yes 60 5 (8%) 12 (20%) 6 (10%) S/vIA treated No (10%) (29%) (7%) Yes 69 6 (9%) 20 (29%) 10 (14%) Celiac or SMA treated No (10%) (29%) (8%) 0.17 Yes 86 8 (9%) 25 (29%) 11 (]3%) Right ren~ treated No (10%) (28%) (9%) 0.85 Yes (10%) 43 (29%) 14 (10%) Left renal treated No 50 4 (8%) (32%) (10%) 0.83 Yes (10%) 62 (28%) 20 (9%) Either renal treated No 11 1 (9%) (55%) (18%) 0.29 Yes (10%) 72 (28%) 23 (9%) No. VV reattached (17%) (42%) (12%) (0%) 3 (30%) 0 (0%) (11%) 9 (33%) 3 (11%) (7%) 23 (29%) 10 (12%) (10%) 33 (26%) 9 (7%) Pulmonary complications No (7%) (23%) (8%) 0.21 Yes (14%) 38 (38%) 12 (12%) Cardiac complications No (5%) < (26%) (9%) 0.67 Yes (42%) 17 (47%) 4 (11%) Bleeding complications No (8%) (28%) (10%) 0.54 Yes 32 8 (25%) 12 (38%) 2 (6%) Sepsis complications No (8%) (26%) (9%) 0.23 Yes 25 6 (24%) 13 (52%) 4 (16%) Coagulation complications No (8%) (28%) (9%) 0.50 Yes 14 5 (36%) 7 (50%) 2 (14%) Paraplegia/paraparesis complications No (9%) (26%) (8%) 0.19 Yes 41 6 (15%) 18 (44%) 6 (15%) GI complications No (10%) (27%) Yes 25 2 (8%) 12 (48%) - Renal complications No (5%) Yes (20%) Appendix B. Renal parameters in 271 patients Renal artery occlusive disease Renal artery Preoperative detected before occlusive disease No. of Postoperative renal dysfunction operation treated patients renal failure (%) No No No 5 1 (20%) No No Yes 30 7 (23%) No Yes No 2 1 (50%) No Yes Yes (18%) Yes No No 2 2 (100%) Yes No Yes 6 3 (50%) Yes Yes No 2 2 (100%) Yes Yes Yes (52%)

11 388 Svensson et al. )rournal of VASCULAR SURGERY Appendix C. Results by repair technique and renal dysfunction Preoperative Renal artery Renal artery No. of Postoperative renal dyt~unction ~ endarterectomy bypass patients renal failure (%) 7 ~ No No No 7 2 (29%) No No Yes (31%) No Yes No (15%) No Yes Yes 10 0 (0%) Yes No No 4 4 (100%) Yes No Yes 12 9 (75%) Yes Yes No (46%) Yes Yes Yes 1 1 (100%) ~History of renal dysfunction or preoperative creatinine > 3 mg/dl. tpostoperative dialysis or postoperative creatinine > 3 mg/dl. Appendix D. Results by repair technique in 198 patients without preoperative renal dysfunction Preoperative renal Renal artery Renal artery No. of Postoperative renal occlusive disease endartereetomy bypass patients failure (%) No No No 5 1 (20%) No No Yes 15 5 (33%) No Yes No 13 2 (15%) No Yes Yes 2 0 (0%) Yes No No 2 1 (50%) Yes No Yes (30%) Yes Yes No (15%) Yes Yes Yes 8 0 (0%) Of these 198 patients, 35 (18%) did not have renal occlusive disease detected before operation. Appendix E. Correlation between preoperative renal dysfunction and postoperative dysfunction Postoperative renal dy~unction~ Preoperative renal ~ dysfunction No Yes (% yes) No (19%) Yes (55%) Total *History of renal dysfunction or preoperative creatinine > 3 mg/dl. ~Postoperative dialysis or postoperative creatinine > 3 mg/dl. Appendix F. Relationship of mesenteric artery occlusive disease to symptoms and complications ASesenteric artery occlusive disease No. of Gastrointestinal symptom Mesenteric artery occlusive disease Postoperative gastrointestinal detected before operation patients before operation (%) treated (%) complications (%) No (8%) 13 (8%) 11 (7%) Yes (12%) 73 (71%) 14 (14%)

12 Volume 16 Number 3 September 1992 Visceral occlusive disease 389 Appendix G. Relationship of gastrointestinal symptoms to mesenteric artery occlusive disease Preoperative Preoperative Mesenteric artery gastrointestinal mesenteric artery occlusive disease No. of symptom occlusive disease treated patients Postoperative gastrointestinal complication (%) No No No (8%) No No Yes 12 0 (0%) No Yes No 26 3 (12%) No Yes Yes (15%) Yes No No 12 0 (0%) Yes No Yes 1 0 (0%) Yes Yes No 4 0 (0%) Yes Yes Yes 8 1 (13%) Preoperative Preoperative gastrointestinal mesentehc artery No. of symptom occlusive disease patients Mesenteric artery occlusive disease treated (%) No No (8%) No Yes (71%) Yes No 13 1 (8%) Yes Yes 12 8 (67%) Appendix H. Results of mesenteric artery repairs according to technique and preoperative symptoms 21/lesenteric Postoperative artery 2kIesenteric No. of gastrointestinal endarterect~my artery bypass patients complications (%) No No (8%) No Yes 4 1 (25%) Yes No 81 9 (11%) Yes Yes 1 1 (100%) Appendix I. Postoperative gastrointestinal complication No Yes Total (% Y) Preoperative N (10%) Gastrointestinal symptom Y (4%) Total DISCUSSION Dr. Larry H. HoUier (New Orleans, La.). I congratulate Dr. Svensson and his colleagues for presenting a very detailed description of visceral artery reconstruction in conjunction with thoracoabdominal aneurysm repair. The authors stated that the purpose of the study was to evaluate whether patients with visceral occlusive disease have an increased risk of surgery if the visceral occlusive disease is repaired concomitantly with the aneurysm. An analysis of the mortality rates suggests that adding visceral revascularization did not significantly increase mortality. The data in the paper, however, do not answer whether the mortality rate in patients with visceral artery stenoses might be signiiicantly higher if visceral revascularization is not done. How many patients with visceral artery stenoses did not undergo repair of the occlusive disease concomitantly with the thoracoabdominal aortic surgery, and were there enough patients in that subgroup to determine whether they are at any increased risk in the postoperative period? You quote a 30-day mortality rate of 7% in the last 4 to 5 years. Whereas these data are important in assessing the incidence of neurologic injury, a more important issue is how many people actually survive the operation and return to a satisfactory life-style. Can you provide us with the overall hospkal mortality rate in addition to the 30-day mortality rate? In previous publications from your group, you stated that cold perfusion of the kidneys did not appear to influence postoperative renal dysfimction. I have routinely used cold perfusion, and it is my belief that it is particularly beneficial in those patients who have preexisting renal dysfimction. In this paper you noted that the use of cold Ringer's lactate solution for renal perfusion was associated with a decreased risk of postoperative renal cornplications~ with ap value of 0.2. Do these new data now compel you to recommend routine cold perfusion of the kidneys in all thoracoabdominal aortic surgery, or do you find that this beneficial effect is limited to a subgroup of patients, such as those with preexisting renal dysfunction? I found this paper to be important because it documents the magnitude of the problems associated with

13 390 Svensson et al. Journal of VASCULAR SURGERY thoracoabdominal aortic replacement. Nonetheless, this paper also documents that with experienced surgeons and skilled postoperative management, the immediate and long-term results of thoracoabdominal aortic replacement are quite gratifying both for the surgeon and the patient. Dr. Lars Svensson. We did search for patients with disease of the visceral arteries but who did not have visceral artery repair. We did this on the basis of the arteriograms and the data that we had. We thought, however, that the data were not entirely accurate because they were examined retrospectively. The data we did have in the few patients who did not have repairs, showed that the incidence of complications was not increased. The numbers were small, however, and the policy has always been to perform bypasses for occluded vessels and endarterectomies for stenotic lesions at the orifices of the vessels. The second question was about the 30-day mortality rate, and you are indeed correct in that the 30-day mortality rate does tend to underestimate what happens to these patients. Since multiple organ failure is one of the problems in these patients, we can often keep them alive in the intensive care unit for extended periods as long as they do not develop severe myocardial infarction or severe sepsis, and even the latter we can control to a large extent. Thus referring to our prospective study that we did on 210 patients over a 13-month period, in those patients the 30-day survival rate was 97%. The in-hospital survival rate was 91%. I think it is more important to look at the 6-month survival rate, and in that group of patients it was 90%. In the study that has just been presented, the 6-month survival rate was 83%. Perhaps we should be reporting the &month survival rate. As with other types of aortic surgery, at 5 years in this group of patients, the survival rate was 53%. You accurately point out that in this study the Ringer's lactate was shown to be protective. In a previous report we could not show that cold Ringer's lactate was protective in an entire group of 1525 patients or in just the patients with preoperative renal dysfimction or high preoperative creatinine levels. With a larger sample size in the present study of patients who had preoperative renal dysfunction, it was, however, protective. I think the implication is that with a quick repair for thoracoabdominal aneurysm with a crossclamp time of 30 to 45 minutes, the kidneys tolerate this ischemia without any problems. It is when there is prolonged ischemia or when one has to do a more extensive procedure to repair the renal arteries that the time factor becomes more important and the kidneys should be protected. Similarly, in those patients who do have preoperative renal dysfunction or have high serum creatinine levels, we advocate that they should be protected with cold Ringer's lactate, despite not having been able to show that this was protective in the previous study. Dr. G. Patrick Clagett (Dallas, Texas). We have noted that in our patients with renal and visceral artery occlusive disease combined with aortic aneurysm or occlusive disease, the incidence of coronary disease is strikingly higher. Did you note this in your patients, and might that account for the lower 5-year survival rate? Dr. Svensson. Yes, Dr. Clagett, you are correct. We found that in this group of patients the incidence of coronary artery disease was 42%. The other interesting fact was that one quarter of the patients had a history of cerebrovascular disease, either strokes, or transient ischemic attacks. Since this is a retrospective analysis, I suspect the incidence of coronary artery disease is probably underestimated. As you have pointed out in one of your recent reports, we also found that there is a very close association between the presence of visceral disease of the celiac artery or superior mesenteric artery and renal artery disease. We thus concur with your previous findings and your statement concerning coronary artery disease.