Asian Cardiovasc Thorac Ann 2002;10:141-144
© 2002 Asia Publishing EXchange Pte Ltd
Thoracofemoral Bypass for Treatment of Juxtarenal Aortic Occlusion
Cengiz Köksal, MD,
Sabit Sarikaya, MD,
Mustafa Zengin, MD
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Department of Cardiovascular Surgery Sureyyapasa Thoracic and Cardiovascular Disease Hospital Istanbul, Turkey
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Cengiz Köksal, MD Tel: 90 212 696 8602 Fax: 90 216 352 0954 email: ckoksal{at}hotmail.com Department of Cardiovascular Surgery, Sureyyapasa Thoracic and Cardiovascular Disease Hospital, D-Blok, Basibuyuk, Maltepe, Istanbul 81551, Turkey.
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ABSTRACT
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Descending thoracic aorta-to-femoral artery bypass grafting is considered a good alternative procedure for revascularization in cases of aortic graft failure, graft infection, and other intraabdominal pathologies not amenable to standard aortofemoral revascularization. Its use as the primary mode of treatment in selected cases is still under investigation. From January 1998 to June 2001, 5 patients underwent descending thoracic aorta-to-femoral artery bypass grafting as primary treatment for juxtarenal aortic occlusion. There was no operative mortality nor major morbidity; a groin incision infection occurred in one case. The mean hospital stay was 8.2 days and intensive care unit stay was 2.6 days. Graft failure was not encountered in the short-term follow-up. In spite of the small number of patients, it was concluded that thoracic aortofemoral bypass offers excellent inflow and reliable patency and may be considered for primary revascularization in cases of juxtarenal aortic occlusion.
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INTRODUCTION
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Juxtarenal aortic occlusion is awkward to deal with surgically because of thrombus extending to the level of the renal arteries. To create a site for proximal anastomosis, thromboendarterectomy is warranted in the face of renal embolism. For treatment of juxtarenal aortic occlusion, simple thromboendarterectomy at this level is currently preferred for preparation of a proximal anastomosis site. Thoracofemoral bypass grafting, once used for remedial reconstruction in aortic graft failure and graft infection, is now gaining popularity as the primary treatment modality for juxtarenal aortic occlusion.1,2 It has the advantage of avoiding any risk to renal function as well as being technically less demanding than standard aortofemoral revascularization entailing thromboendar-terectomy for preparation of the proximal anastomosis site. Although descending thoracic aorta-to-femoral artery bypass grafting is well defined as a secondary recon-struction procedure, its role as a primary surgical method remains controversial. The purpose of this study was to evaluate our initial results with descending thoracic aorta-to-femoral artery bypass grafting as a primary treatment modality in selected cases.
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PATIENTS AND METHODS
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Five patients with juxtarenal aortic occlusion underwent descending thoracofemoral artery bypass grafting at Sureyyapasa Thoracic and Cardiovascular Disease Hospital from January 1998 to June 2001. All patients were male and their mean age was 67 years (range, 59 to 74 years). Presenting symptoms were claudication in 4 cases and pain at rest in one. A history of impotence was documented in 3 patients. Accompanying subsystem problems were diabetes in 1 patient, chronic obstructive pulmonary disease in 2, and hypertension in 2. One patient had undergone coronary artery bypass grafting 2 years previously and was free of symptoms. In addition to the standard preoperative evaluation, pulmonary function tests and baseline arterial blood gas analysis were obtained in all cases. Complete angiography of the aortoiliac and lower extremity vessels was performed preoperatively using the standard technique. The angiograms revealed juxtarenal occlusion of the aorta with visualization of the distal part in the area of the common femoral artery (Figure 1
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After administration of a general anesthetic and placement of a double-lumen endotracheal tube, the patient was positioned with the left thorax elevated 45 to 60 degrees to a right lateral decubitus position. Exposure of the femoral arteries was obtained by bilateral groin incisions. Leaving the inguinal ligament intact, the oblique and transverse muscles were split and the left retroperitoneal space was entered. A tunnel was constructed from the left retroperitoneal space to the left and right groin. A left posterolateral thoracotomy was made through the 8th intercostal space. After exposing the descending aorta, a site with minimal atherosclerotic disease was selected for proximal anastomosis. A tunnel was created in the posterior part of the diaphragm. Using a partial occlusion clamp, a bifurcated polytetrafluoroethylene graft was anasto-mosed proximally in an end-to-side fashion. The graft was inserted through the tunnel for distal anastomosis. A chest tube was placed in the left pleural space and all incisions were closed. After the operation, intravenous patient-controlled analgesia with morphine sulphate was administered in the intensive care unit. All patients were followed up at 2 months after discharge from the hospital, and postoperative angiograms were obtained at 3 months.
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RESULTS
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There was no hospital mortality. Mean hospital stay was 8.2 days (range, 7 to 10 days). One of the patients diagnosed to have chronic obstructive pulmonary disease was extubated in the intensive care unit, the other 4 were extubated early after the operation. The mean intensive care unit stay was 2.6 days (range, 2 to 3 days). There was no morbidity except for one groin incision infection that required 7 days of intravenous antibiotic therapy and local wound care.
At follow-up, the patency of the graft was checked by a duplex scan when occlusion was suspected. Postoperative angiograms were obtained after 3 months in all patients (Figure 2). No incidence of graft failure was encountered.
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DISCUSSION
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In current practice, direct aortoiliac reconstruction offers the most durable means of surgical revascularization in cases of aortoiliac occlusion.3 Extraanatomic procedures are reserved for high-risk patients or those unable to tolerate conventional anatomic reconstruction, or for cases of infection. When the diagnosis is juxtarenal aortic occlusion, which accounts for 8% to 10% of all forms of occlusive disease of the aortoiliac segment, revasculari-zation is more demanding and risky.4,5 The pathogenesis of juxtarenal aortic occlusion is progression of athero-sclerotic disease with subsequent infrarenal aortic thrombus formation. However, outflow to the lowresistance renovascular bed maintains the patency of the suprarenal aorta. For revascularization, thrombo-endarterectomy is needed to prepare the proximal anastomosis site, which has a risk of renal embolization. To prevent this complication, Gupta and Veith6 devised suprarenal clamping; this reduces the risk of renal embolization but jeopardizes renal blood flow. Miani and colleagues7 in a series of 206 patients diagnosed to have juxtarenal aortic occlusion, analyzed renal function in the postoperative period and concluded that standard aortofemoral bypass grafting might be risky because of potential renal embolization.
Since it was first introduced by Stevenson and colleagues8 and Blaisdell9 in 1961, many investigators have approved the role of descending thoracic aorta-to-femoral artery bypass grafting as a secondary procedure, on the basis of low perioperative mortality and good long-term patency rates.10,11 With improved results of surgical procedures on the thoracic aorta, the indications for extraanatomic bypass, apart from aortic graft infection, must now be reassessed.12 In 1990, Bowes and colleagues13 reported long-term results of descending thoracic aortoiliac/femoral bypass and found the primary cumulative patency after 42 months to be 86%. Although they performed the technique mainly as a secondary procedure, it was applied as a primary revascularization procedure in 8 patients diagnosed to have juxtarenal occlusion.13 In 1999, Passman and colleagues,1 in the largest series published so far (50 patients), assessed the role of this procedure as a first-line treatment modality in infrarenal aortic occlusion; the primary patency rate at 5 years was 81%, comparable to the 83% to 92% patency rates for standard aortofemoral bypass grafting in most series. Kolvenbach14 studied descending aorta-to-iliofemoral artery bypass grafting with thoracoscopic techniques as the primary procedure in 11 patients; this minimally invasive approach was proposed as an alternative to the technique described by Passman and colleagues.1
Although descending thoracofemoral bypass grafting as the primary choice of treatment for infrarenal aortic occlusion is controversial, there are several reasons for using the descending aorta as an inflow source. First, the descending thoracic aorta is less prone to atherosclerotic disease than the infrarenal aorta.15 In our experience, although we did not obtain angiograms of the distal descending aorta, we did not encounter severe athero-sclerosis that would complicate proximal anastomosis. Moreover, the use of a partial occlusion clamp on the aorta during proximal anastomosis maintains spinal cord, mesenteric, and renal blood flow. Passman and colleagues1 achieved comparable results in terms of operative mortality, major complications, and 5-year patency rates after aortofemoral bypass grafting. The retroperitoneal approach also prevents unfavorable intraabdominal conditions. Siting the proximal anastomosis in the chest eliminates the risk of aortoenteric fistula. Finally, aortofemoral bypass grafting in cases of juxtarenal aortic occlusion is more demanding than descending thoraco-femoral bypass grafting and may jeopardize renal function.
Some investigators have pointed out the possibility of proximal thrombus propagation when remote bypass grafting is used in infrarenal aortic occlusion, and advocated the use of standard proximal aortic thrombo-endarterectomy and in-line revascularization. Starrett and Stoney16 encountered occlusion of one or both renal arteries in 6 of 13 patients observed without surgery. In contrast, Ligush and colleagues17 in a series of 25 remote bypass operations for infrarenal aortic occlusion, con-cluded that in-line aortic reconstruction with thrombo-endarterectomy or aortobifemoral/iliac bypass offered no significant advantage with regards to renal function unless renal artery anatomy was compromised. These findings correlate with other studies.18,19 In this series, no renal artery pathology was encountered.
Apart from its use as a remedial procedure, there are only a few reports concerning descending thoracic aortofemoral bypass grafting as the primary operative modality for infrarenal aortic occlusion. In the largest series, peri-operative morbidity, mortality, major complication rates, and long-term results are encouraging. In view of the literature and our initial results, we strongly advocate more liberal use of descending thoracofemoral bypass grafting for primary revascularization in selected patients diagnosed with juxtarenal aortic occlusion.
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REFERENCES
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ABSTRACT
INTRODUCTION
