Combined aorto-iliac and femoropopliteal occlusive disease: limitations of total aortofemoropopliteal bypass

Multilevel bypass grafting: is it worth it?

BACKGROUND

Traditionally, multilevel arterial disease has been treated with an inflow procedure only but simultaneous multilevel bypass graft procedures have been attempted. However, these procedures are potentially high risk. We report our single-center experience of performing multilevel bypass grafts over the last 15 years.

METHODS

We retrospectively identified patients undergoing simultaneous aortoiliac and infrainguinal bypasses between January 1996 and January 2011 at a single district general hospital.

RESULTS

There were 32 multilevel procedures performed. Indication for surgery was acute ischemia in 10 (31.3%), critical ischemia without tissue loss in 10 (31.3%), with tissue loss in 10 (31.3%), and claudication in 2 (6.3%). In 23 (71.9%) cases inflow was restored using a direct iliofemoral or aortofemoral reconstruction. In the remaining 9 (28.1%), an extra-anatomic bypass was constructed. Two (6.3%) patients died within 30 days of surgery. Twenty-nine (90.6%) patients survived to discharge. Twenty-eight patients (87.5%) were alive 1 year after surgery. Limb salvage was 96.9%, 85.7%, and 75.9% at 30 days, 1 year, and 5 years, respectively. Twelve (37.5%) patients required a total of 19 further ipsilateral vascular procedures.

CONCLUSIONS

Our results demonstrate that multilevel bypass procedures can be performed with good long-term outcomes and acceptable mortality, in what is typically a high-risk group with extensive comorbidities. In patients with severe critical limb ischaemia and tissue loss, who have a combination of aortoiliac and infrainguinal disease, there are significant benefits to a primary multilevel grafting procedure.

Limb-threatening ischemia due to multilevel arterial occlusive disease. Simultaneous or staged inflow/outflow revascularization

SUMMARY BACKGROUND DATA

Limb-threatening ischemia due to severe multilevel arterial occlusive disease may require both inflow and outflow bypass to achieve limb salvage. Simultaneous inflow/outflow bypass has been advocated because the cumulative risks of separate staged inflow/outflow procedures can be avoided. However, the magnitude of complete revascularization is substantial; thus, the morbidity and mortality of simultaneous inflow/outflow bypass may be excessive.

METHODS

The medical records of 450 patients undergoing lower extremity arterial reconstruction between 1988 and 1994 were retrospectively reviewed, allowing identification of 54 patients who had undergone simultaneous aortoiliac and infrainguinal bypasses. This group consisted of 38 men and 26 women (mean age: 64.7 years), with significant cardiac disease in 24, smoking history in 53, and diabetes mellitus in 15. Indications for surgery were limb-threatening ischemia in 48 (89%) and severe short-distance claudication in 6 (11%). Inflow disease was corrected by direct aortoiliac reconstruction in 28, whereas other extra-anatomic bypasses were constructed in 26. Outflow revascularization required infrainguinal bypass to the infragenicular arteries in 46 (below-knee popliteal: 21; tibial: 25), a concomitant profundaplasty in 26, and a composite bypass conduit in 14.

RESULTS

Limb salvage was 97% at 30 days whereas morbidity/mortality were 61% and 19%, respectively. However, the majority of complications and deaths occurred in patients undergoing aortic inflow plus complex outflow procedures (profundaplasty and/or composite bypass conduits), in which the morbidity/mortality rates were 84.2% and 47.4%, respectively, compared with rates of 45.7% and 2.9% (p < 0.01) after all other inflow/outflow procedures. The increased difficulty of these complex procedures is reflected in the significantly greater blood loss and operative times (1853 mL and 10.0 hours) compared with similar values (1125 mL and 7.7 hours)(p < 0.01) for all other inflow/outflow procedures.

CONCLUSION

Simultaneous inflow/outflow bypasses are effective and safe in patients with severe, multilevel arterial occlusive disease, except when a complex outflow procedure is needed in conjunction with direct aortoiliac reconstruction. In the latter setting, a staged procedure is recommended because it may be associated with less morbidity and mortality.

Combined aortobifemoral and femoropopliteal bypass in the management of patients with extensive atherosclerosis

Certain patients have atherosclerosis in both aortoiliac and femoropopliteal segments of the arterial tree and thus do not have a good result from reconstruction of the aortoiliac segment. No method has been developed to identify these patients and we do not know whether, by combining a femoropopliteal bypass with an aortobifemoral bypass, the results can be improved. We present a series of 153 patients with severe multilevel occlusive disease treated by simultaneous reconstruction and followed for up to 6.5 years. The cumulative patency of the femoropopliteal bypasses was 80% at four years. Functional and symptomatic improvement was excellent, and operative mortality was low when one considers the age and poor general condition of the patients.

Haemodynamic assessment of the femoropopliteal segment: comparison of pressure and Doppler methods using ROC curve analysis

Combined aorto-iliac and femoropopliteal vascular disease remains a problem in vascular surgery. Arteriography does not provide information on the relative contributions of the two lesions to the presenting symptoms. Aorto-iliac haemodynamics may reveal occult aorto-iliac disease but does not show whether combined proximal and distal reconstruction will be required to provide symptomatic relief. Haemodynamic assessment of both segments may help in this respect. A haemodynamic assessment of the femoropopliteal segment of 72 limbs in 38 patients is reported. The segmental pressure drop between a common femoral arterial cannula and a below-knee occlusion cuff is compared with a non-invasive Doppler method combining both transit time and damping factor. Comparison is made using receiver operating characteristic (ROC) curve analysis. The measurement of segmental pressure drop is more accurate than the Doppler method in detection of femoropopliteal stenoses of greater than 50 per cent of the luminal diameter (P less than 0.05).

Eversion endarterectomy of the superficial femoral artery and end-to-side anastomosis to the deep femoral artery. An alternative to extended profundoplasty

The success of aortofemoral reconstruction in patients with superficial femoral artery occlusion depends on the restoration of a satisfactory pulsatile flow to the deep femoral artery. In 18 patients with multilevel disease, widespread involvement of the deep femoral artery, and poor distal outflow, we performed an eversion endarterectomy of the proximal segment of the superficial femoral artery and constructed an end-to-side anastomosis between this segment and the distal deep femoral artery. In 10 patients, the reconstruction was performed after thrombectomy of the occluded aortofemoral graft, and in 8 the two reconstructions were simultaneous. The actuarial patency rate was 93.5 percent at 1 year and 75.2 percent at 5 years. Four late femorodistal bypasses were performed that gave an actuarial limb salvage rate of 68.8 percent at 1 year and 61.6 percent at 5 years. In selected cases, this technique is a valid alternative to an extended profundoplasty or to a femorodistal bypass.

Criteria from intra-arterial femoral artery pressure measurements combined with reactive hyperaemia to assess the aorto-iliac segment; a prospective study

Direct femoral artery blood pressure measurements combined with reactive hyperaemia (FAP study) were performed on 50 extremities (45 patients) with multilevel arterial occlusive disease of the lower extremities. In a previous retrospective study we established criteria for detection of significant aorto-iliac occlusive disease. These criteria were used in a prospective way in this study. Twenty-seven extremities were subjected to a proximal and 23 extremities to a distal reconstruction. The half-year postoperative results were evaluated. The criteria used were 86 per cent sensitive, 100 per cent specific and 93 per cent accurate in relation to predicting the postoperative haemodynamic result. The positive predictive value was 100 per cent and the negative predictive value 89 per cent. The criteria are presented and compared with data from the literature. It is concluded that FAP studies are a simple and excellent way to assess the aorto-iliac segment and to predict the outcome of a reconstruction in multilevel arterial occlusive disease.

Assessment of aorto-iliac disease by non-invasive quantitative Doppler waveform analysis

The results of this study demonstrate that frequency analysis recordings of the femoral artery waveform are of value in the quantitative analysis of the severity of aortoiliac disease. In 45 patients, pulsatility index measurements were found to correlate (r = 0·82) with the pressure gradient measured directly across the aortofemoral segment. The implications and the limitations of this technique are discussed.

Surgical treatment of aorto-iliac artery disease

In a period of 6 years, up to January, 1980, the author has treated 248 cases of aorto-iliac artery disease. There were 109 cases of abdominal aortic aneurysm, and the remainder was obstructive aorto-iliac artery disease. All but 20% of elective abdominal aortic aneurysms were asymptomatic. There were 100 cases of elective abdominal aortic aneurysm resection with operative mortality of 2%. There were 19 cases of ruptured aortic aneurysm with hospital mortality of 47%. There were 49 cases of aorto-femoral artery bypasses with 6th year cumulative patency rate of 89% in aorto-femoral bypass with Dacron graft, and 69% in aorto-iliac artery bypass with Dacron graft, and 2 year cumulative patency rate of 75% in descending thoracic aorto-femoral artery bypass with Poly Tetra Fluoro Ethylene graft. There were 32 cases of axillo-femoral artery bypasses and 48 cases of femoral-femoral artery bypasses. The 3 year cumulative patency rate of axillo-femoral artery bypass with PTFE graft was 89%, and that of femoral-femoral artery bypass with PTFE was 85%. However, axillo-femoral artery bypass with Dacron graft had 3-year patency rate of 67% and femoral-femoral artery bypass with Dacron graft was 62%. The 4 year cumulative patency rate of axillo-femoral artery bypass with Dacron graft was 39%. The 5 year cumulative patency rate of femoral-femoral artery bypass with Dacron graft was 62%

Discussion and management of late failures in reconstructive procedures involving the abdominal aorta

Review of fifty-eight late failures of 326 procedures performed for revascularization of the abdominal aorta over the past six years showed a low overall operative mortality of 9 per cent. Secondary vascular procedures directed at the aorta itself or at its graft substitute proved more effective in relieving symptoms and restoring flow than did secondary procedures directed at more distal problems in the lower extremities. The aortofemoral graft in conjunction with profundaplasty proved to be the most effective means of restoring flow to the lower extermity after graft occlusion in a previous aortoiliac or aortofemoral graft.

The role of the profunda femoris in aorto-iliac surgery

The results of aorto-iliac surgery in 90 ischaemic limbs (68 patients) have been reviewed. The mean follow-up period was 18 months (rang 6 monts to 3.5 years). In 48 limbs the disease was confined to the aorto-iliac segment (group 1), while in 42 limbs severe occlusive changes were present in both the aorto-iliac and superficial femoral segments (group 2).

In group intermittent claudication was obolised or substanitally improved in 86 per cent. Rest pain was relieved in all cases. Lumbar sympathectomy was with out obvious additional benefit in either group. Pedal pules were restored in all except 3 limbs. A highly significant (P &lt;0.001) increase in the ankle systolic pressure (ASP) index occurred after surgery and normal values were restored both in claudicants and in those with rest pain. This response was maintained through out the follow-up period.

Claudication was effectively relived in 38 per cent of cases in group 2 following aortoprofunda reconstruction. Rest pain was abolished in 83 per cent of cases, the remainder requrining a major amputation. Lumbar sympathectomy failed to produce any additional benefit among either claudicants or those with rest pain. Pedal pulses were restored in only 2 limbs. Among claudicants the ASP index was uncharged, and although a significatn (P &lt;0.001) increase occurred in the rest pain group, the index remained within the ischaemic range. There was little variation in the value of the ASP index throughout the follow-up period in either group. The difference between the ASP response to surgery in patients with aorto-iliac disese alone and those with dual occlusion was highly significant (P &lt;0.001).

The present results suggest that among claudicants revascularization of the profunda alone may be followed by a limited clinical and hoemodynamic response. However, as a limb salvage procedure, aortoprofunda reconstruction can be recommended with confidence. When both the superficial and deep femoral vessels are patent, on excellent response is to be expected after aorto-iliac surgery in claudicants and patients with rest pain alike.

Value of segmental limb blood pressures in predicting results of aortofemoral bypass

The efficacy of segmental limb blood pressure measurements, assessed noninvasively by Doppler ultrasound, in predicting the result of aortofemoral reconstruction was evaluated in fifty-two extremities with varying extent of aortoiliac and more distal arterial occlusive disease. Three prognostic correlates were analyzed: (1) preoperative proximal thigh/arm pressure index (TPI); (2) preoperative pressure gradient between adjacent leg segments (proximal thigh, above-knee, below-knee, and ankle), normally less than 30 mm Hg; and (3) early postoperative increase in the ankle/arm pressure index (API). After aortofemoral bypass, forty-one limbs (79 per cent) were asymptomatic or improved and eleven were unimproved. The mean TPI in extremities benefiting from aortofemoral bypass, 0.82 +/- 0.17 (+/-1SD) was significantly less than that of unimproved limbs, 1.01 +/- 0.09 (p less than 0.01). Aortofemoral bypass was beneficial in all twenty limbs with normal leg pressure gradients. Conversely, six of twenty-five legs with one abnormal gradient and five of seven with two abnormal gradients failed to improve. The postoperative increase in API was 0.1 or more in all forty-one improved extremities and was less than 0.1 in all eleven failures. Although eleven of thirty-two limbs (34 per cent) with arteriographic evidence of combined aortoiliac and subinguinal occlusive disease were not improved after proximal bypass, the result of operation could not be predicted from the angiographic pattern or severity of distal disease. Segmental limb blood pressures provide useful predictive indices of the efficacy of aortofemoral bypass and the potential need for more distal reconstruction in multisegmental disease.

Limb salvage procedures for lower extremity ischemia

Limb salvage procedures were performed in ninety patients during the period from 1965 to 1975. Sixteen different procedures were performed with an associated complication rate of 8.9 per cent and a mortality rate of 8.9 per cent. The patency rates were 79.7 per cent at thirty days and 72.9 per cent at last follow-up.