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Neoaortoiliac System (NAIS) for Failed Aortic Reconstructions is a Durable Solution in Young Patients
Martyn Knowles, Gregory A Stanley, Stephen T Smith, Carlos H Timaran, G Patrick Clagett, R James Valentine, J Gregory Modrall
University of Texas - Southwestern, Dallas, TX

Objective: Failure of prosthetic aortofemoral bypass (AFB) in young patients with premature atherosclerosis is a difficult problem that requires complex re-interventions, with high rates of failure leading to major amputations. We hypothesize that secondary reconstruction with femoral vein (Neoaortoiliac System, NAIS) after failed AFB provides excellent patency and limb salvage in these complex patients.
Methods: 18 patients with NAIS reconstructions performed after failed AFB between April, 1997 and December 2011 were identified from our prospectively gathered registry. The median age of the cohort was 53.5 (IQR 49 - 60) years. Patency and clinical outcomes after NAIS reconstruction were compared with the original AFB. Survival was analyzed using Kaplan-Meier life tables and compared with a log-rank test. Patients with evidence of graft infection were excluded.
Results: The median number of interventions after AFB was 1 (IQR 0 - 2) including thrombectomy (n=5), thrombolysis (n=2), angioplasty/stenting (n=3), limb revision (n=4),
femoral crossover graft (n=5), and repeat AFB (n=4). All patients exhausted their endovascular options before reoperative surgery was considered. Prior to NAIS, all patients had critical limb ischemia with a median ankle brachial index of 0.47 (IQR 0.2 - 0.69) (n=34 limbs). After NAIS, all patients had marked improvement in symptoms, and the median postoperative ankle brachial index increased significantly to 0.9 (IQR 0.7 - 0.99; P<0.0001, Mann Whitney test) (n=30 limbs). At a median follow-up of 79.5 months (IQR 22.5 - 108 months), the median ankle-brachial index remained 0.9 (IQR 0.76 - 1.0). Primary patency rate of the NAIS reconstruction was superior to the original AFB at 1, 3, 5 and 10 years (Table 1) (P=0.0009), and secondary patency was also superior (Table 1) (P<0.0001). Limb salvage for NAIS reconstruction after failed AFB was 97% at 10 years.
Conclusions: Secondary aortoiliac reconstruction with femoral vein is a durable solution in young patients with critical limb ischemia after failed AFB. It is a reasonable option after other endovascular and open options have failed.
Table 1: Patency of original aortic reconstruction versus subsequent NAIS aortic reconstruction
Primary Patency (%)P=0.0009
1 year8188
3 years7447
5 years6729
10 years676
Secondary Patency (%)P<0.0001
1 year10088
3 years10052
5 years10041
10 years10012

*Statistical significance P<0.05

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