Proximal Anastomotic Failure Following Infrarenal Aortic Reconstruction: Late Development of True Aneurysms, Pseudoaneurysms, and Occlusive Disease

Distal anastomotic failure of aortic reconstructions attributable to femoral pseudoaneurysm or outflow stenosis has been well described, but little is known about proximal aortic anastomotic graft failure. A retrospective review was performed between January 1987 and March 1992 to characterize the presentation and management of proximal aortic anastomotic failure. Of 329 consecutive aortic reconstructive operations during this period, 11 (3.3%) were performed to correct complications arising at or adjacent to the proximal anastomosis of an aortic prosthesis. These included anastomotic pseudoaneurysm (n = 6), true aneurysmal dilatation of the residual infrarenal or suprarenal aorta (n = 4), and stenosis of the residual infrarenal aorta (n = 1). The 11 patients had undergone prior infrarenal aortic reconstruction for either aneurysmal (n = 5) or occlusive (n = 6) disease an average of 120 months (range 36 to 175 months) before detection of proximal para-anastomotic graft failure. Eighty-two percent (n = 9) of the proximal lesions were asymptomatic and were discovered incidentally during unrelated medical evaluations. Excluding the six pseudoaneurysms, four of the remaining five lesions developed in a relatively long segment of residual infrarenal aorta, including aneurysm above the graft (n = 2), aneurysm below a proximal end-to-side anastomosis (n = 1), and progressive proximal aortic atherosclerosis (n = 1). Tube graft replacement of the proximal lesions was the most frequently performed operation (n = 7); renal artery reimplantation or bypass was necessary in five cases (45%). Although there was no operative mortality, significant surgical morbidity occurred in three patients (27%). Proximal aortic graft complications tended to be asymptomatic and difficult to repair. Our data suggest that some lesions may be avoided by placing the original proximal aortic anastomosis end to end near the renal arteries. Appropriate noninvasive screening modalities may allow for more complete detection of these proximal anastomotic problems, especially in patients with remote aortic reconstructions.