A randomized trial of intraoperative autotransfusion during aortic surgery.

PURPOSE: The net benefit of routine intraoperative autotransfusion (IAT) in patients undergoing elective infrarenal aortic surgery was studied. METHODS: One hundred patients undergoing abdominal aortic aneurysm (AAA) repair (n = 50) or aortofemoral bypass (AFB) for occlusive disease (n = 50) were randomized to IAT and control groups. This experience accounted for 58% of patients undergoing aortic surgery during the 16-month study period. RESULTS: IAT and control groups were balanced for preoperative demographics, disease (50:50 split of AFB:AAA in each group), and risk factors. There were no significant differences between patients randomized to IAT and control patients in estimated blood loss (EBL), allogeneic blood transfusion (units administered intraoperatively, postoperatively, and total), proportion of patients not receiving allogeneic blood (34% of patients randomized to IAT and 28% of control patients), postoperative hemoglobin/hematocrit levels, and complications. IAT did not reduce allogeneic blood transfusion among all patients undergoing aortic surgery nor in any subgroups that might be more likely to benefit, such as those undergoing AAA repair, those with 1000 mL or more EBL, and those receiving larger volumes of IAT-processed blood. CONCLUSION: We could find no net benefit of IAT in patients undergoing elective, infrarenal aortic surgery.

Gastrointestinal complications after aortic surgery.

BACKGROUND AND PURPOSE: A major gastrointestinal complication (GIC) after aortic surgery may be disastrous, but these complications have received scant attention. This study was performed to determine the risk factors, associated events, and outcomes for patients with GIC. METHODS: We performed a secondary analysis of a prospective study that examined 120 consecutive patients who underwent transperitoneal aortic revascularization for aneurysmal or occlusive disease. RESULTS: The following 29 GICs developed in 25 patients (21%) within 30 days of aortic surgery: paralytic ileus that required replacement of nasogastric tubes (n = 12), upper gastrointestinal bleeding (n = 5), Clostridium difficile enterocolitis (n = 5), acute cholecystitis (n = 2), mechanical obstruction (n = 2), ascites (n = 2), and colon ischemia (n = 1). Seven patients required operations for GICs after aortic revascularization. A comparison of patients with and without GICs showed no differences in the prevalence of risk factors, presence of mesenteric artery stenoses, coexisting medical illnesses, antecedent gastrointestinal history, operative indication, preoperative fluid administration, or duration of operation. However, patients with GICs had more intraoperative complications (P = .004), greater intraoperative blood loss (P = .02), and more fluids during the postoperative period (P = .008). The mean duration of mechanical ventilation was 71 +/- 23 hours for patients with GICs versus 7 +/- 2 hours for patients without GICs (P = .006). A higher prevalence of pulmonary (P = .004) and renal (P = .001) complications was seen in the patients with GICs. The mean stay in the intensive care unit was 16 +/- 2 days for patients with GICs as compared with 5 +/- 0.4 days for patients without GICs (P < .001). Four deaths occurred, all caused by multisystem organ failure: 3 patients had GICs, and 1 did not have a GIC (P = .007). CONCLUSIONS: These results show that GICs are prevalent in transperitoneal aortic surgery and are associated with severe morbidity rates, increased hospital costs because of prolonged stay, and increased mortality rates. Some GICs appear to be associated with intraoperative events that lead to visceral hypoperfusion, and others can be attributed to mechanical causes. However, none of the variables examined in this study were predictive of GICs. In all, GICs should be considered serious adverse sequela after aortic revascularization. Because no risk factors for GICs have been identified, these complications currently cannot be prevented.

Venous reconstructions using the superficial femoral-popliteal vein.

PURPOSE: To demonstrate the feasibility of venous reconstructions with the superficial femoral-popliteal vein (SFPV). METHODS: Seven patients who underwent a variety of major venous reconstructions using SFPV were reviewed in a retrospective, observational study. RESULTS: Three central venous reconstructions (thoracic and abdominal) and four peripheral major venous reconstructions were performed with SFPV autografts. In all patients, the SFPV grafts provided an excellent size match and were of adequate length without the need for enlargement by paneling or spiraling techniques. Postoperative anticoagulation medication was not used. There were no early graft failures, and patency was documented by duplex ultrasound, venogram, or both in all patients at a mean of 20 months follow-up. Venous thromboembolism has not occurred, and lower extremity venous morbidity has been minimal. CONCLUSIONS: The SFPV graft demonstrates versatility and durability in selected patients who require large-caliber conduits for venous reconstruction. Because of its size and availability, the SFPV is an excellent conduit for major venous reconstruction.