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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 1, January/February 2015
AFRICA
47
Discussion
The gold-standard treatment for aorto-iliac occlusive disease is
ABFB. This procedure has been performed for many years with
good long-term results. Despite many modifications for reducing
complications (retroperitoneal approach and minimally invasive
approach), the transperitoneal approach is still the most widely
used technique.
1,7
Many studies have proved that theminimally invasive approach
has advantages for cardiac risk, postoperative complications and
postoperative ileus, but a randomised, prospective study did not
prove any significant advantage over the conventional technique.
1
The minimally invasive approach is advised for patients with
previous abdominal surgery or co-morbidities, and the elderly.
In this study, we preferred the conventional approach. There
were some complications of ABFB with the conventional
approach, which may have been specific to the surgery, such as
SAEF, vascular injury, bleeding, intestinal injury, ileus,myocardial
infarction, renal failure, sexual dysfunction, infection, graft
thrombosis, anastomotic pseudo-aneurysm (which may differ in
different abdominal approaches), or non-specific complications
such as myocardial infarction, pulmonary complications and
renal dysfunction.
1,4-7
Chiu
et al.
revealed that, although there were different rates of
complications in different series, rates were approximately 16%
in their review.
8
The rates ranged between 0 and 11% in other
reviews.
8-12
Postoperative bleeding is a common early complication and
causes re-operation in 1–2% of patients.
13
Inadequate control of
bleeding, anastomotic technique, intra-operative use of heparin,
and dilutional coagulopathy occurring after blood loss have been
shown to be the most common causes of this complication.
13
Another complication in the postoperative period is acute
renal failure. Declamping and lack of fluid balance are thought
to be the cause of this complication.
13
Mortality rates in our
study were 6.15% in group 1 and 6.3% in group 2, which was
similar to that in the literature.
Complication rates (excluding death) were 15% in group 1
and 10% in group 2. Acute renal failure was found in only one
patient in group 2. Bleeding requiring re-operation was found in
seven patients in group 1 and one in group 2. SAEF, rarely seen
in our series but commonly encountered in the literature, was
not observed in any of our patients. Inferior vena cava injury,
termed vascular injury, was seen in two patients in group 1 but
none in group 2.
We believe some of the complications seen in other cases
may have been associated with manipulation by the tunneller
during surgery. A study by Luo and colleagues, comprising a case
report accompanied by a literature review, is one of the studies
supporting our theory.
14
In our study, the tunneller was not used and forceps were
introduced into the tunnel a second time in the conventional
method. Postoperative bleeding amounts were higher but not
statistically significant in the conventional method. Peri-operative
blood usage was significantly higher in the conventional method.
Although it was not statistically significant, ileus rates were
higher in the conventional method. This situation may have been
related to longer hospital stay due to bleeding.
Our study has some limitations. Group sizes were particularly
small and graft patency data were not obtained for all patients.
Conclusion
Some complications of ABFB, which are directly related to the
surgery, may be avoided, especially in cases where the tunneller
is not used. Nylon tapes that are left in the tunnel while creating
it may be used to introduce the distal end of the graft into the
femoral area. This alternative method must be kept in mind as
it has lower complication rates than the conventional method.
References
1.
Emrecan B, Onem G, Ocak E, Arslan M, Yagci B, Baltalarli A,
et al
.
Retroperitoneal approach via paramedian incision for aortoiliac occlu-
sive disease.
Tex Heart Inst J
2010;
37
(1): 70–74.
2.
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes
FG, TASC II working group, Bell K, Caporusso J, Durand-Zaleski
I, Komori K, Lammer J, Liapis C,
et al
. Inter-society consensus for
the management of peripheral arterial disease (TASC II).
Eur J Vasc
Endovasc Surg
2007;
33
(Suppl 1): S1–75.
Table 2. Operative data of patients
Parameters
Group 1
Group 2
p
-value
Operation length (min)
246.1
±
101.62 231.38
±
65 0.490
Additional vascular
procedures,
n
(%)
17 (35)
12 (38)
0.789
Embolectomy,
n
(%)
4 (8)
3 (9)
Endarterectomy,
n
(%)
4 (8)
4 (13)
Femoropopliteal bypass,
n
(%)
9 (19)
5 (16)
Table 3. Postoperative data of patients
Parameters
Group 1
(
n
=
49)
Group 2
(
n
=
32)
p
-value
Extubation time (hours)*
15.07
±
9.73 16.3
±
12.61 0.975
Intensive care length of stay
(days)*
2.30
±
1.26 2.25
±
1.04 0.940
Hospital length of stay (days)* 6.92
±
1.81 6.09 1.86 0.039
Revision for bleeding,
n
(%)
7 (15)
1 (3)
0.137
Other complications,
n
(%)*
0.731
Ileus
7 (15)
3 (10)
Inferior vena cava injury
5 (11)
2 (7)
Acute renal failure
2 (4)
1 (3)
Postoperative infection,
n
(%)
7 (15.2)
6 (20)
0.588
Postoperative drainage (ml)
490 ± 613 257 ± 318 0.219
Postoperative blood product
usage (units)
4.02 ± 2.87 2.04 ± 2.01 0.042
30-day mortality
3 (6.1)
2 (6.3)
0.981
*Parameters of the deceased patients were excluded from the calcula-
tion.
Table 1. Pre-operative data of patients
Parameters
Group 1
Group 2
p
-value
Age (years)
60.98
±
11.92 62.88
±
9.22 0.448
Females
5 (10.2)
2 (6.3)
0.698
Diabetes mellitus,
n
(%)
15 (30.6)
12 (37.5)
0.520
Hypertension,
n
(%)
22 (44.9)
22 (68.8)
0.035
Chronic obstructive
pulmonary disease,
n
(%)
7 (14.3)
7 (21.9)
0.377
Hyperlipidaemia,
n
(%)
18 (36.7)
18 (56.3)
0.084