Acute aortic occlusion-a 16-year single-center experience.
Acute abdominal aortic occlusion (AAO) is a rare vascular emergency associated with high morbidity and mortality. This study analyzed the clinical management and outcomes in a consecutive patient series over a 16-year period.Included were all patients with an acute AAO and bilateral acute limb ischemia (ALI) treated between 2004 and 2019. Patients with dissection, aneurysm rupture, and chronic occlusive disease were excluded. Patient characteristics, surgical procedures, and outcomes were extracted retrospectively from a prospective aortic database, electronic patient files, and outpatient examinations. The extent of ischemia was classified according to the TASC II section on ALI. Primary endpoints were 30-day mortality (safety endpoint) and the combined 6-month amputation and/or death rate (efficacy endpoint). Follow-up outcomes, amputation rates and 30-day complications were evaluated as secondary endpoints. The patient cohort was split into four 4-years-groups (2004-2007, 2008-2011, 2012-2015, 2016-2019) to assess outcome changes over time. Statistics comprised chi-square tests and univariate and linear regression analyses.74 patients (57% male, median age 64.5 years) with acute AAO were identified. Arterial thrombosis was the most common etiology (66%). The extent of ischemia was TASC I, IIa, IIb, and III in 7, 39, 40, and 14%, respectively. Patient numbers increased significantly over time (P = .016). Regarding treatment, 42% of patients underwent open transfemoral recanalization (including hybrid procedures), 35% open aortic surgery, 15% extraanatomic bypass surgery and four patients (5%) endovascular therapy alone. The overall 30-day mortality rate was 23% and the 6-month amputation and/or death rate was 43%. The 30-day mortality rate declined significantly from 54% (2004-2007) to 10% (2011- 2015, Odds Ratio OR, 0.10; 95% CI .001-0.52) and 20% (2016-2019, OR, 0.21; 0.05-0.90), comprising a statistical non-significant trend, that the relative decline of open aortic procedures was associated with the decreased 30-day mortality (P = .06). Univariate analysis indicated that elevated serum lactate on admission (OR, 3.33; 95% CI 1.06-10.48) and an advanced stage of limb ischemia (OR, 4.33), were strongly associated with an increased 30-day mortality rate. Severe postoperative systemic complications were also indicating a higher incidence of both primary endpoints. The 6-month amputation and/or mortality rates were additionally affected by atrial fibrillation (OR, 3.63; 1.34-9.79) and increased patient age (OR, 3.96; 1.49-10.53).Acute AAO remains a life-threatening emergency. Immediate transfemoral open or endovascular techniques should be preferred, if technically possible and proper intraoperative imaging is provided.
Authors: Sabine Sieber, Kerstin Stoklasa, Benedikt Reutersberg, Thomas Stadlbauer, Michael Salvermoser, Thomas Lang, Albert Busch, Hans-Henning Eckstein