: 15 1 Vol. 15, No. 1, April, 1999 = Abstract = A Clinical Analysis of Chronic Aortoiliac Occlusive Disease Jin Myoung Huh, M.D., Woo Hyung Kwun, M.D.

: 15 1 Vol. 15, No. 1, April, 1999 = Abstract = A Clinical Analysis of Chronic Aortoiliac Occlusive Disease Jin Myoung Huh, M.D., Woo Hyung Kwun, M.D., Bo Yang Suh, M.D. and Koing Bo Kwun, M.D. Department of Surgery, College of Medicine, Yeungnam University Chronic Aorto-Iliac Occlusive Disease (CAIOD) commonly occurs in conjunction with obstruction in the femoral and popliteal arteries, resulting in ischemia of the lower extremities. To analyze the characteristics of CAIOD among Koreans, we relied on 110 cases of aorto-iliac occlusive disease in-patients who underwent operative treatment at Yeungnam university hospital during the last 15 years. Among the 110 total cases, the mean age was 61, with the highest incidence among people in their 60s, followed by those in their 50 s and then in their 70 s. 88.2% of the cases occurred in males with the remaining 11.8% occurring among females. Co-existing diseases included hypertension 46 cases (41.8% of the cases), coronary arterial diseases 17 cases (15.4%), diabetes mellitus 22 cases (20%), chronic pulmonary diseases 14 cases (12.7%) and cerebrovascular diseases 10 cases (9.1%). 80% of the cases involved patients with a history of smoking. The level of serum total cholesterol was higher than normal in 32.7% of cases. Advanced arteriosclerotic manifestation was found in over two-thirds of the cases, with the anatomical distribution as follows: Type I 5 cases (4.5%), Type II 30 cases (27.3%) and Type III 75 cases (68.2%). According to the Fontaine classification of clinical symptoms, the distribution was as follows: Grade I (0 case), Grade II 52 cases (47.3%), Grade III 36 cases (32.7%) and Grade IV 22 cases (20.0%). Among the 110 cases, 75 received only inflow procedures, 19 received both inflow and outflow procedures at the same time, and 16 received only outflow procedures. Among the 94 cases of inflow procedures, PTA accounted for 11 cases, PTA with stent accounted for 5, endarterectomy for 3, and bypass operations for 75. The breakdown for the 75 cases of bypass operations was as follows: aortofemoral or aortoiliac (21 cases): iliofemoral (12 cases): extraanatomic bypass including axillobifemoral bypass (15 cases): and fem-fem bypass (27 cases). Thirty-five outflow procedures included femoropopliteal and femorotibial bypass (22 cases), thromboembolectomy (6 cases), endarterectomy (5 cases) and profundoplasty (2 cases). 19 out of these 35 outflow procedures were performed in conjunction with inflow procedures at the time of the initial operation, but 16 were used without inflow procedure, mainly for Type III cases with relatively mild aortoiliac pathology. In over 90% of the 110 operative cases, the early outcome was good with 3 to 2 rating according to Rutherford criteria. The early outcome seemed to be related to the extent of disease and preoperative clinical symptoms but not with the surgical procedures used. 45

46 : 15 1 1999 Among the 110 total cases, 26 (23.6%) required second procedures. Among the 94 cases of inflow procedures, 24 (25.5%) required the second procedures, while among the 16 cases of outflow procedures, 2 (12.5%) required the second procedures. Among the 94 cases of inflow procedures, the need for second operations was higher in cases undergoing both inflow and outflow procedure at the same time (36.8%, 7 out of 19 cases) compared to the cases that underwent inflow procedure only (22.6%, 17 out of 75 cases). Among the inflow procedures, axillofemoral (46.7%) and iliofemoral (41.7%) bypass required the 2nd procedures much more frequently than aorto-fem (23.8%), fem-fem (14.8%) bypass and PTA (18.8%). An overall 5-year cumulative patency rate demonstrated significant statistical differences between procedures (p=0.001 Log Rank test): aortofemoral or aortoiliac: 0.81, fem-fem: 0.77, PTA: 0.74, iliofemoral: 0.56, and axillofemoral: 0.50. A 5-year cumulative patency rate also showed a significant correlation with the extent of disease (p=0.01), preoperative ischemic symptoms (p=0.05) and Ankle Brachial pressure Index (ABI.). Operative mortality for the 110 cases was 3.6% (4 cases), including 3 resulting from associated cardiac conditions and 1 resulting from aortoduodenal fistula. Key Words: Aortoiliac occlusive disease, Clinical analysis,,. 1923 Leriche1),,. - 1947 dos Santos2) 1952 Oudot,3) DeBakey,4) Dubost5). 1956 DeBakey6).,,. -,. 1984 12 1998 4-110,, 5. 1984 12 1998 4 Doppler test, - 110,,,,

3 47. 5. Brewster7) Type I, Type II, Type III. Fontine Classification8) Grade I (Asymptomatic) Grade II (Intermittent claudication), Grade III (Rest pain), Grade IV (Gangrene or Non-healing ulcer). Rutherford 8). 1 ABI (Ankle brachial Index) (markedly improvement), (moderately improvement), (minimal improvement), (no change), (mildly worse), (moderately worse), (markedly worse).,, Doppler, Duplex scan. Chi-square test, 5 Kaplan-meier test Log-rank test. 1) 31 84 61, 60 50, 70, 40. Table 1. Age and sex distribution of patients with aortoiliac occlusive disease No. of patient (Male/Female) Age group Total (M/F) Type I Type II Type III 30 39 1/0 2/0 3/0 40 49 1/0 4/0 7/1 12/1 50 59 2/0 11/0 16/1 29/1 60 69 1/1 9/1 25/3 35/5 70 79 0/0 2/2 14/4 16/6 80 89 0/0 0/0 2/0 2/0 Total 4/1 27/3 66/9 97/13 Table 2. Comparative analysis of age and clinical symptoms 7.4 1 (Table 1)., 30, 70 Grade IV (p=0.03 Chi-square test) (Table 2).. 2) Brewster Type I 5 (4.5%), Type II 30 (27.3%), Type III 75 (68.2%) Type Grade 2 Grade 3 Grade 4 30 1 (33.3%) 2 (66.7%) 40 7 (50.0%) 6 (42.9%) 1 (7.1%) 50 18 (62.1%) 7 (24.1%) 4 (13.8%) 60 21 (52.5%) 12 (30.0%) 7 (17.5%) 70 5 (22.7%) 9 (40.9%) 8 (36.4%) 80 2 (100%) (p=0.03 Chi-square test) III (Table 1), Grade III, IV Type III (p=0.009, Chi-square test) (Table 3).

48 : 15 1 1999 Table 3. Comparative analysis of anatomical type and clinical symptoms. 3) Grade I 0, Grade II 52 (47.3%), Grade III 36 (32.7%), Grade IV 22 (20.0%) (Fig. 1),. 4) 46, 22, 17, 10, 14 (Table 4), 89 (80.9%). 36 Total cholesterol 200 mg/dl. 5) Type I Type II Type III Grade 2 3 (5.8%) 22 (42.3%) 27 (51.9%) Grade 3 2 (5.6%) 4 (11.1%) 30 (83.3%) Grade 4 4 (18.2%) 18 (81.8%) (p=0.009, Chi-square test) Fig. 1. Distribution of clinical symptoms. 110 75 (Inflow procedure) 16 (Outflow procedure), 19. 94 16 (PTA, Percutaneous Transluminal Angioplasty) 5 Table 4. Associated diseases Associated disease No. of patients (%) Hypertension* 46 (41.8%) Diabetes mellitus 22 (20.0%) Cardiologic disease 22 (20.0%) Coronary arterial disease (17 ) Congestive heart failure (4 ) Rheumatoid heart disease (1 ) Chronic Pulmonary disease 14 (12.7%) COPD** (8 ) Asthma (3 ) Malignancy (2 ) Bronchiectasis (1 ) Cerebrovascular disease 10 (9.0%) Other ASO*** 6 (5.4%) Others Hyperthyroidism (1 ) Stomach malignancy (1 ) Hypercholestolemia**** 36 (32.7%) *Hypertension: Blood pressure 150/90 mmhg, **COPD: Chronic Obstructive Pulmonary Disease, ***ASO: Arteriosclerosis obliterans, ****Hypercholestolemia: Serum Total Cholesterol Level 200 mg/dl Table 5. Inflow procedures for Aorto-iliac occlusive disease Procedures Stent. 3 (Endarterectomy), No of patients PTA 16 Endarterectomy 3 Aortic bypass 21 Aorto-Bifemoral bypass 11 Aorto-unifemoral bypass 5 Aorto-Biiliac bypass 1 Aorto-Uniiliac bypass 2 Aorto-Bipopliteal bypass 2 Ilio-femoral bypass 12 Extraantomical bypass 42 Axillo-unifemoral bypass 1 Axillo-Bifemoral bypass 14 Fem-Fem bypass 27 75 (Bypass operation).

3 49 Aorto- Bifemoral bypass 11, Aorto-Unifemoral bypass 5, Aorto-Biiliac bypass 1, Aorto-Uniilac bypass 2, Aorto-Bipopliteal bypass 2, Iliofemoral bypass 12, Axillo-unifemoral bypass 1, Axillo-Bifemoral bypass 14, Fem-Fem bypass 27 (Table 5). 35 2. 94 19 Table 6. Outflow procedures for Aorto-iliac occlusive diseases Procedures No of patients Adjunctive outflow procedure 19 Fem-Popliteal bypass 11 Endarterectomy 5 Profundoplasty 1 Thromboembolectomy 2 Outflow procedure 16 Fem-Popliteal bypass 9 Fem-Tibial bypass 2 Profundoplasty 1 Thromboembolectomy 4. Femoro-Popliteal bypass 11, Endarterectomy 5, Profundoplasty 1, Thromboembolectomy 2. 110 16 Type III Femoro-Popliteal bypass 9, Femorotibial bypass 2, Profundoplasty 1, Thromboembolectomy 4 (Table 6)., Graft 62 PTFE (Polytetrafluoroethylene) 21 Dacron 83 Table 7. Early outcome of treatment for Aorto-iliac occlusive diseases (n=142) Outcome No. of limbs (%) Markedly improved 87 (61.3%) Moderately improved 48 (33.8%) Minimally improved 3 (2.1%) No change 0 Mildly worse 0 Moderately worse 2 (1.4%) Markedly worse 2 (1.4%) Table 8. Comparative analysis of anatomical type and early clinical outcome 3 2 1 0 1 2 3 Type I 7 (77.8%) 2 (22.2%) Type II 32 (84.2%) 5 (13.2%) 1 (2.6%) Type III 48 (50.5%) 41 (43.2%) 3 (3.2%) 2 (2.1%) 1 (1.1%) (p=0.04, Chi-square test) Table 9. Comparative analysis of clinical grade and early clinical outcome 3 2 1 0 1 2 3 Grade 2 46 (66.7%) 23 (33.3%) Grade 3 29 (63.0%) 15 (32.6%) 2 (4.3%) Grade 4 12 (44.4%) 10 (37.0%) 1 (3.7%) 2 (7.4%) 2 (7.4%) (p=0.006, Chi-square test)

50 : 15 1 1999 Table 10. Comparative analysis of preoperative ABI and early clinical outcome 3 2 1 0 1 2 3 0.5 37 (48.7%) 36 (47.7%) 2 (2.6%) 1 (1.3%) 0.5 44 (88.0%) 6 (12.0%) (p=0.000, Chi-square test) Fig. 2. Cumulative patency rate of all cases. Fig. 3. Cumulative patency rate of alternate procedures (p=0.004, Log rank test). 16 (Greater saphenous vein). 2 Reverse bypass, 14 In situ bypass. 6) 142 95% (Table 7).,, ABI (Ankle-brachial Index) (Table 8 10),,. Fig. 4. Comparative cumulative patency rate of anatomical pattern (p=0.008, Log rank test). 7) 5 Kaplan-meier test 110 12 0.79, 24 0.73, 36, 48, 60 0.70 (Fig. 2). 5 Aorto-Fem or Iliac bypass 0.81, Fem-Fem bypass 0.77, PTA 0.74, Ilio-Fem bypass 0.56, Axillo-Fem bypass 0.50 (Fig. 3)., (Fig. 4, 5). ABI ABI 0.5

3 51 graft. Intestinal obstruction Transabdominal approach Aorto-Bifemoral bypass. 9) Fig. 5. Comparative cumulative patency rate of clinical grade (p=0.03, Log rank test). 4 3, 1 Aortoduodenal fistula 6. Aorto- Fem bypass 2, 1 Axillo-Fem bypass, 1 Fem-Tibial bypass. Fig. 6. Comparative cumulative patency rate of preoperative ABI (p=0.17, Log rank test). (Fig. 6). 8) 6 Graft Fem bypass graft 1 Graft. Pseudoaneurysm Aorto-Popliteal infection 4, Pseudoaneurysm 1, Intestinal obstruction 1. Graft infection 4 Axillo-Bifemoral bypass graft 3, Ilio- bypass 27 Pseudoaneurysm resection Greater saphenous vein Fem-Tibial reverse bypass,.9),, multilevel occlusive disease.,,.,. Brewster7) Type I, Type II Type III Type I 5 10%, Type II 25%, Type III 65%.10) Type I,,, 30 50%.7) 1923 Leriche1),,

52 : 15 1 1999,, Type I Leriche syndrome. Type I Type III, (Type IV hyperlipoproteinemia) 11).. Type III, Type I,,,.7,12). 110 60 40 (36.3%), 50 30 (27.2%), 70 22 (20.0%), 40 13 (11.8%) 60 61. 97, 13 7.4 1 10,13 17),. Type I 5 (4.5%), Type II 30 (27.3%), Type III 75 (68.2%).10,13 17) Fontine classification Grade I 0, Grade II 52 (47.3%), Grade III 36 (32.7%), Grade IV 22 (20.0%). 40 (50.0%) 50 (62.1%) Grade II, 70 80 Grade III, Grade IV. Type III Grade III, Grade IV (p=0.009),. 46 (41.8%), 22 (20.0%), 17 (15.0%), 10 (9.0%), 14 (12.7%) Szilagyi,13) Eugene,18) Bartlet19) (35 73.9%). 1947 dos Santos2) 1951 Oudot,3) Dubost,4) DeBakey5). 1956 DeBakey6) - -. 1952 Freeman, Leeds,20) Vetto21) - 1963, Blaisdell, Hall,22) Louw23) -. 1950 1960, 1970.,,, thrombosis late failure.,,, Type 1 1 5 cm.24,25) PTA 1964 Dotter Judkins26),. PTA.27) PTA.28,29) -

3 53.,.24,30) -.,,, -, graft,. Inferior mesentery artery,,.10,17,31,32), -,. -,,.21,33,34) - graft, - graft 2,.34 36),. Type III. Type III,, - - 37,38) graft graft graft Type III.39,40) Melone,41) Mozersky42) Type III 60 80%. Type III Grade III, Grade IV 19, - 11, 5, 1, thromboembolectomy 2. 142 (markedly improvement) 87 (61.3%), (moderately improvement) 48 (33.8%), (minimal improvement) 3 (2.1%), (moderately worse) 2 (1.4%), (markedly worse) 2 (1.4%) 95%. (P=0.04), (P=0.006), ABI (P=0.000),,,..

54 : 15 1 1999 Kaplan-meier test 110 12 0.79, 24 0.73, 36, 48, 60 0.70.,. ABI, ABI 0.5. 5 - - 0.81, - 0.77, PTA 0.74, - 0.56, - 0.50. 6, 4 graft infection. - 3, - 1, graft. pseudoaneurysm 1-27 pseudoaneurysm saphenous vein -. 1 intestinal obstrution transabdomimal approach -. 4, 3 1 aorto-duodenal fistula 6. 50%.43) 4 3.,. 1984 12 1998 4 110,, 5. 31 84 61, 7.4 1. Type I 5 (4.5%), Type II 30 (27.3%), Type III 75 (68.2%) Type III. Fontaine Classification grade II 52 (47.3%), grade III 36 (32.7%), grade IV 22 (20.0%). 110 (94 ) (PTA: 16 ). 3, 75 (inflow procedure). - - (21 ), - (12 ), - (15 ), - (27 ). (outflow procedure) 35 19. 142 95% Rutherford,. (p=0.04, Chi-square test) (p=0.006, Chi-square test). 5 (p=0.004, Log rank test) - 0.81, - 0.77, PTA 0.74, - 0.56, - 0.5., (p= 0.008, Log rank test) (p=0.03, Log rank test). 4 3, 1

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