Staging the NAIS procedure: Feasibility and Short term Outcomes

Background: The neoaortoiliac system (NAIS) has gained popularity as a durable procedure for treating aortic graft infections (AGI). However, one of the disadvantages has been the long, arduous operation which can, on average take up to 10 hours despite having a two-team approach. The goal of this study was to assess the feasibility of staging the NAIS with deep vein harvest a day prior to the aortofemoral bypass and evaluate if staging affected graft patency as well as patient morbidity and mortality.
Methods: We reviewed and analyzed data for all the NAIS procedures performed in the last 4 years (n = 18). Patients undergoing the staged procedure had their femoral popliteal veins [FPV] harvested a day in advance and left in-situ. The next day they underwent graft excision and bypass using FPV. Patients with aortic or graft occlusion on presentation were not candidates for vein harvest in advance and underwent unilateral bypass instead of a bilateral bypass. The revascularization of the contralateral limb was done as a staged procedure.
Results: Eighteen patients underwent the NAIS procedure for AGI. Patients consisted of 12 men and 6 women with a mean age of 61.4 ± 8 years. Overall procedure-related mortality was 5.8%. Mean follow up was 14.07±6.9 months with a graft patency of 100%. Twelve out of 18 patients were staged. Nine underwent preoperative vein harvest, while three patients with an occluded aorta underwent unilateral revascularization with a subsequent femorofemoral bypass as a second stage. The average duration of the staged procedure was 9.19 hrs versus 11.68 hrs (p<0.05). Operative blood loss and rate of fasciotomy was significantly lower in the two-staged group compared to the a single staged procedure. (2.2 L vs. 4.0 L and 17% vs. 41%). There was no incidence of DVT in the grafts.
Conclusions: In patients with a patent aortic graft, the NAIS can sequenced as 2-stage procedure which saves approximately 2 hours off the second procedure. This may be benficial in decreasing surgeon fatigue. Staging did not affect the quality or patency of the grafts. Furhtermore, it may lower the operative blood loss and rate of fasciotomy.