Optimal methods of aortoiliac reconstruction.

Alternate methods of aortic reconstruction for aortoiliac occlusive disease were reviewed in one author's (R.C.D.) personal series of 582 patients (1,105 limbs) during the 15 year period from 1963 to 1977. To illustrate certain trends, separate analysis was done for periods 1963 to 1969 (interval I) and 1970 to 1977 (interval II). During the earlier period, endarterectomy was performed in 72% of patients, with unilateral operations carried out in 15% of patients. Operative mortality was 5.1% and early failure occurred in 4% of patients. In contrast, in interval II graft procedures were done in 89% of patients, with mortality of only 2% and early failure in less than 1% of patients. Unilateral procedures were utilized infrequently (4%). Our analysis suggests that aortoiliac endarterectomy is still the procedure of choice for a small group (approximately 10%) with localized disease. For more extensive disease, aortofemoral grafts appear to be the procedure of choice. Patency of such grafts in the most recent interval was 91% at 5 years. Superior long-term function of aortofemoral grafts appears to be associated with use of a knitted Dacron prosthesis, end-to-end proximal anastomosis, and distal anastomosis which ensures patency of the profunda femoris outflow. The incidence of infection (0.3%) and false aneurysm formation (1.4%) was extremely low. In view of the low mortality rate and superior long-term success of direct reconstructions, extraterritorial grafts are felt to be rarely indicated.