Axillofemoral bypass with externally supported, knitted Dacron grafts: a follow-up through twelve years

The Comparison between Axillofemoral Bypass and Endovascular Treatment for Patients with Challenging Aortoiliac Occlusive Disease as Alternative Treatment to Aortofemoral Bypass

Objective: Although aortofemoral bypass (AoFB) is the standard treatment for challenging aortoiliac occlusive disease (AIOD), less-invasive treatments, such as axillofemoral bypass (AxFB) or endovascular treatment (EVT) have been conducted for patients with severe comorbidities. In this study, we compared the clinical outcomes between AxFB and EVT for AIOD. Materials and Methods: We retrospectively reviewed 9 patients with AxFB and 10 with EVT for challenging AIOD. The patients' information and operative results were evaluated. The rates of patency and limb salvage were analyzed according to the Kaplan-Meier method. Results: In the EVT group, 5 of 10 (50%) patients had aortic stenting alone, 3 (30%) received aorto-uniiliac stenting, and 2 (20%) received aorto-biiliac stenting. In the AxFB group, 2 cases (22.2%) showed acute graft thrombosis; however, in the EVT group, no acute thrombotic complications were seen. The primary patency rates in the AxFB and EVT groups at 5 years were 53.6% and 81.2%, respectively (log rank P=0.225), and the assisted primary patency rates at 5 years were 53.6% and 100%, respectively (log rank P=0.012). Conclusion: EVT exhibited a more durable, better long-term patency rate than AxFB. EVT may, therefore, be a viable treatment alternative to AoFB for challenging AIOD.

Subintimal stent graft reconstruction of an infrarenal aortic occlusion

The traditional approach to revascularization in aortoiliac disease is surgical. Endovascular treatment techniques for revascularization have emerged in recent years and have resulted in less invasive options for management of vascular disease. In this article, we describe a novel approach to endovascular stent graft reconstruction of a heavily calcified infrarenal aortic occlusion. The interventional management of aortic occlusions is subsequently discussed.

[Axillobifemoral bypass grafting]

INTRODUCTION

Axillo-femoral bypass (AxF) means connecting the axillar and femoral artery with the graft that is placed subcutaneously. Usually, this graft is connected with contralateral femoral artery via one accessory subcutaneous graft, and this connection is known as axillobifemoral bypass (AxFF). This extra-anatomic procedure is an alternative method to the standard reconstruction of aortoiliac region when there are contraindications for general or local reasons.

OBJECTIVE

The objective of this paper is to show early and late results of AxFF bypass grafting as well as to show the indications for AxFF bypass.

METHODS

The sample consisted of 37 patients. The procedure was performed in 28 patients who suffered from aortoiliac occlusive disease and who were at high risk due to the comorbidity--in one patient with the rupture of juxtarenal aneurysm of abdominal aorta; in five patients with aortoenteric fistula, in two patients with latrogenic lesion of abdominal aorta and in one female patient with anus preternaturalis definitivus who was treated for rectovaginal fistula. Donor's right axillary artery was used in 26 cases (70.3%), and donor's left axillary artery was used in 9 cases (29.7%). Dacron graft was used in 34 patients and Polytetrafluoroethlylene graft was used in three patients. Simultaneously, profundoplastic was done in four patients and femoro-popliteal bypass was performed in three patients. In five patients who suffered from aortoenteric fistula, simultaneous intervention of gastrointerstinal system has been done. Chi2 test was used for statistical evaluation and life table method was used for verification of late graft patency.

RESULTS

The rate of early postoperative mortality was 13.5%. The causes of death were: sepsis--1, MOFS--3, and infarct myocardium--1. The mean follow up period was 40.1 months, ranging from six months to 17 years. During the follow up period, an early graft thrombosis was identified in two and late graft occlusion was reported in four patients. As the cause of occlusion, the progression of occlusive disease of receptive artery was identified in three patients, while anastomotic neointimae hyperplasia of recipient artery was identified in one patient. Three patients died during the follow up period. As the cause of death, CVI was reported in two patients and malignancy of the urinary tract was found in one patient. The other complications were--artery angulation on the level of proximal anastomosis in one patient (Figure 1), false aneurysm in one patient, perigraft seroma in one patient and graft infection in three patients. Life table method has shown that cumulative rate of late graft patency is 80.39% after five years (Graph 1).

DISCUSSION

Our results were analyzed and compared with the results of the study on 283 patients who had undergone aortobifemoral bypass (AFF) operation due to the aortoiliac occlusive disease. This study was completed in 1995 (18). The results showed that there was no statistically significant differences between AxFF and AFF group (p > 0.05), considering early mortality rate and late graft patency (Graph 2). The review of mortality and late patency rate after AxFF bypass grafting in a world well known studies has shown the similar results (Table 1). CONCLUSION The authors suggest that axilobifemoral bypass is indicated when there are contraindications or difficulties to perform anatomic reconstruction due to the abdomen condition (infection, adhesion, comorbidity) as well as in high risk patients with low life expectancy.

Options in the surgical management of aorto-iliac occlusive disease: a changing perspective

The numerous options available for the treatment of aortoiliac occlusive disease have led to controversy over which is best. Not only are the technical aspects of direct aortoiliac reconstruction debated but the role of lower risk but less durable options such as extraanatomic bypass and balloon angioplasty and/or stenting is still unsettled. Rather than yield to the tendency to apply one method preferentially over the others, it is important to realize that each approach has a selective role to play in the overall management of aortoiliac occlusive disease, if applied in appropriate settings. In discussing these applications, the history of these controversies, and the pros and cons of each competitive approach are reviewed, along with the results of experiences with them by the author and others. While it is apparent that outcome data, stratified for location, and degree and extent of the occlusive disease being treated, are still needed for proper comparisons of some competitive techniques, especially balloon angioplasty and stenting, there is sufficient evidence to make certain general recommendations: endarterectomy should be limited to younger patients with soft atheromatous disease of the lower aorta and proximal iliac arteries; a femoral distal anastamosis is preferable to one at the iliac bifurcation; choice of proximal anastamosis should be based on the distribution of aortoiliac occlusive disease; concomitant profundaplasty is effective only if significant profunda narrowing is present (and not simply superficial femoral artery occlusion); the need for concomitant distal bypass can and should be predicted; axillobifemoral bypass should be limited to patients with 'prohibitive' risk or 'hostile' abdominal pathology; and, in view of the low risk and good long term patency of unilateral iliac bypasses, iliac PTA and stenting should not be extended to category III and IV lesions without demonstrating superior long term results for such lesions.