Currently, cardiovascular diseases are the leading
cause of death worldwide. Over the past two decades,
the mortality from cardiovascular disease has decreased
in developed countries, while it still high in less
developed ones.[
1,
9] Recent technology has played a
key role in the development of treatment modalities.
In the past, aortoiliac occlusive artery disease was
primarily treated by transperitoneal laparotomy with a
midline incision using vascular grafts, while it can be
treated nowadays using novel methods of endovascular
intervention techniques or by a paramedian incision
and retroperitoneal technique.
In our study, the male-to-female ratio was 12.9:1.
The reason for this distinct prevalence difference
compared to the literature data can be attributed to our
small sample size. In addition, elderly women living in
the conservative region where the study was conducted
were usually not active and remained asymptomatic,
and the number of health institutions in this region
is high. Also, the peripheral arterial revascularization
operations performed in external centers were not
included in this study.
In the present study, two patient groups who
underwent revascularization for aortoiliac occlusive
diseases were evaluated. We compared the ABI,
glucose, hemoglobin, hematocrit, and serum creatinine
levels pre- and postoperatively. Comorbidities of the
patients, the need for blood transfusion, the length
of stay in ICU and hospital, starting time for oral
intake, and follow-up periods were examined. Risk
factors for morbidity were also assessed. As it is
well known, atherosclerosis is one of the risk factors
of peripheral arterial disease. Diseases caused by
atherosclerosis such as myocardial infarction, stroke,
aortic, and lower extremity vascular disease are the most important causes of mortality and morbidity in
developed countries. Risk factors such as the use of
tobacco products, dyslipidemia, hypertension, and
diabetes mellitus increase the risk of atherosclerosis,
leading to a more complicated course of clinical
conditions due to atherosclerosis.[10-12] In our study, we
found no significant relationship between any variable
and the surgical technique used. The main findings
of this study are that the mean oral intake starting
time and length of ICU (p<0.001) and hospital stay
were shorter, and the amount of blood transfusion was
lower in the retroperitoneal technique, compared to
the transperitoneal technique.
In a study comparing retroperitoneal versus
transperitoneal approach in revascularization of
aortoiliac artery occlusive patients, Sicard et al.[13]
reported similar results. The amount of intraoperative
blood loss significantly increased (p<0.001) and the
postoperative oral intake starting time was longer
(p<0.001) in the transperitoneal technique, while the
length of stay in the hospital was shorter (p<0.02)
in retroperitoneal technique. Similar results were
also reported in other studies,[14,15] consistent with
our findings. In another study which was done by
Kalko et al.,[16] similar results were reported. In this
study, 153 patients were included and 85 of them
were operated with a transperitoneal approach, while
68 with a retroperitoneal approach for aortoiliac artery
occlusion. The mean oral intake starting time was also
shorter in the retroperitoneal approach in this study
(p<0.001).
In cases where aortoiliac occlusion is accompanied
by femoropopliteal occlusion, it is a matter of debate
whether revascularization should be done for both
aortoiliac and femoropopliteal occlusions or it is
enough to do it for aortoiliac occlusion alone. It
has been supported in many publications that if
the blood flow of a deep femoral artery (DFA)
is sufficient, peripheral arterial revascularization
is not required.[17] The cornerstone for peripheral
arterial revascularization decision is the flow of DFA.
Recently, hybrid interventions have also started to take
place in the treatment of peripheral arterial occlusive
diseases.[18] In a study conducted by Madiba et al.,[19]
984 lower extremities of 492 patients were evaluated.
All patients underwent aortobifemoral graft bypass
operation due to aortoiliac artery occlusion disease.
A total of 123 extremities of the superficial femoral
artery were found to be patent, while it was occluded in
861 extremities. The effect of the patent DFA as runoff was investigated. Five-year patency rate was 80% in
the extremities with the occluded superficial femoral
artery and 87% in the extremities with the patent
superficial femoral arteries. The main finding of this
study is that, when DFA is patent the development of
collateral arteries to the popliteotibial artery is high so,
there is no need for distal revascularization.[19]
In our study, additional interventions were applied
only to the patients with advanced peripheral arterial
disease. Intermittent claudication alone was not
considered as an indication for distal revascularization.
In our clinic, in case of aortoiliac occlusive disease
associated with peripheral arterial occlusions, the
decision to perform extra-revascularization to the
peripheral vessels depends on the flow of the DFA
and whether there are signs of acute ischemia or
non-healing ischemic wounds distally. Considering
the possible relationship between reoperation and
surgical technique, no significant difference was found
between the techniques used in this study.
Furthermore, there was no significant difference
in the follow-up duration between the two
techniques. The prolonged follow-up was mainly
due to the causes of acute circulatory disorders
(i.e., thromboembolism) or to the situations in which
complete revascularization was not achieved in the
first operation. In our study, mortality was seen only
in Group 1 (n=4, 3%), indicating no statistically
significant difference. This may be related to the
number of patients in each group.
Considering the difficulties of the surgical
techniques, the surgical field was limited in Group 1
compared to Group 2. In general, there was a need
for one more assistant specialist in Group 1 to help
in retracting the nearby organs and tissues to achieve
a better surgical field for the primary surgeon. In
aortobifemoral or aortobiiliac operations, extending
the femoral/iliac graft to the contralateral side was
difficult, as well. At the same time, it is safer with
less possibility of intestinal injury.[20] In Group 2,
there were difficulties in operating abdomens with
adhesions due to previous surgeries or inflammatory
processes, resulting in incisional hernia, evisceration,
peritonitis, and long-lasting ileus.[21]
The main limitation to this study is that the
number of transperitoneal group patients may have
affected the study results. The retrospective nature
of the study is also another limitation. Further largescale,
long-term, prospective studies are needed to
confirm these results.
In conclusion, retroperitoneal approach with a
paramedian incision in treating aortoiliac artery
occlusive disease seems to be superior to the
transperitoneal approach with a median incision with
less blood transfusion, shorter ICU and hospital stay,
and earlier start of oral intake.
Declaration of conflicting interests
The authors declared no conflicts of interest with respect
to the authorship and/or publication of this article.
Funding
The authors received no financial support for the research
and/or authorship of this article.