title: Contemporary Management of Acute Aortic Occlusion Has Evolved but Outcomes Have Not Significantly Improved.
abstract: BACKGROUND
  Most existing series of acute aortic occlusion (AAO) predate the changes in surgical and endovascular therapy of the last 2 decades. We examined the contemporary management and outcomes of AAO.
  
  
  METHODS
  We reviewed consecutive patients with AAO at a tertiary referral center from 2004 to 2012. Outcomes were stratified and compared according to etiology and procedure performed.
  
  
  RESULTS
  AAO in 29 patients was due to in situ thrombosis in 21 (72%) and embolism in 8 (28%) patients. Vascular patients with embolism were on average older (77 ± 7 vs. 66 ± 12 years, P = 0.02) and had higher rates of atrial fibrillation (100% vs. 20%, P = 0.0002) and congestive heart failure (75% vs. 0%, P = 0.0001) in comparison with those with in situ thrombosis. Neurologic deficit was present in 16 (55%) patients. Six patients (21%) presented with bilateral paresis/paralysis secondary to spinal cord or lumbosacral plexus ischemia, and primary neurologic etiology was investigated before vascular consultation was obtained in 4 of these 6 patients. Of the 29 patients, 28 (97%) underwent revascularization including transfemoral embolectomy (n = 6), transperitoneal aortoiliac thrombectomy (n = 2), axillobifemoral bypass (n = 10), aortobifemoral bypass (n = 6), and endovascular therapy including thrombolysis, angioplasty ± stenting (n = 4). In-hospital mortality was 31% and did not vary significantly according to etiology (embolism 38% vs. in situ thrombosis 29%, P = 0.67). In-hospital mortality varied widely according to procedure (transfemoral embolectomy 50%, aortoiliac thrombectomy 100%, axillobifemoral bypass 30%, aortobifemoral bypass 0%, and endovascular therapy 25%, P = 0.08). Major morbidity (59%), length of stay (8.6 ± 8.0 days), and discharge to a rehabilitation facility (50%) did not vary by etiology or procedure. At a media follow-up of 361 ± 460 days (range 3-2014), overall survival was 42%. There were no amputations among 20 survivors of initial hospitalization.
  
  
  CONCLUSIONS
  AAO is now more commonly caused by in situ thrombosis rather than embolism. A high index of suspicion for AAO is required for prompt diagnosis and treatment, particularly when patients present with profound lower extremity neurologic deficit. In comparison with previous reports, the contemporary management of AAO includes increased use of axillobifemoral bypass and now involves endovascular revascularization, although a variety of open surgical procedures are utilized. However, the in-hospital mortality and morbidity of AAO has not decreased significantly over the last 2 decades and mid-term survival remains limited. Further study is required to identify strategies that improve outcomes after AAO.
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, MA. Electronic address: wprobins3@gmail.com.
authors.forename: William P
authors.initials: WP
authors.lastname: Robinson
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, MA.
authors.forename: Rupal K
authors.initials: RK
authors.lastname: Patel
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, MA.
authors.forename: Jesse A
authors.initials: JA
authors.lastname: Columbo
authors.affiliation: Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA.
authors.forename: Julie
authors.initials: J
authors.lastname: Flahive
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, MA.
authors.forename: Francesco A
authors.initials: FA
authors.lastname: Aiello
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
authors.forename: Donald T
authors.initials: DT
authors.lastname: Baril
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, MA.
authors.forename: Andres
authors.initials: A
authors.lastname: Schanzer
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, MA.
authors.forename: Louis M
authors.initials: LM
authors.lastname: Messina
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D001018:Aortic Diseases / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D001157:Arterial Occlusive Diseases / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D000072226:Computed Tomography Angiography; D016208:Databases, Factual; D017128:Embolectomy / Q000639:trends; D004617:Embolism / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality / Q000639:trends*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D010414:Pennsylvania; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality; D058996:Quality Improvement / Q000639:trends; D019984:Quality Indicators, Health Care / Q000639:trends; D012307:Risk Factors; D062606:Tertiary Care Centers; D017131:Thrombectomy / Q000639:trends; D013927:Thrombosis / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D013997:Time Factors; D016896:Treatment Outcome; D058017:Vascular Grafting / Q000639:trends; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality / Q000639:trends*