Asian Cardiovasc Thorac Ann 2001;9:97-100
© 2001 Asia Publishing EXchange Pte Ltd
Descending Thoracic Aortobifemoral Bypass for Aortoiliac Occlusive Disease
Akio Ihaya, MD,
Yukio Chiba, MD,
Tetsuya Kimura, MD,
Koichi Morioka, MD,
Takahiko Uesaka, MD
Second Department of Surgery
Fukui Medical University Hospital
Fukui, Japan
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For reprint information contact: Akio Ihaya, MD Tel: 81 776 61 3111 Fax: 81 776 61 8114 email: iakio{at}fmsrsa.fukui-med.ac.jp Second Department of Surgery, Fukui Medical University Hospital, 23 Shimoaizuki, Yoshida-gun, Matsuoka-cho, Fukui 910-1193, Japan.
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Abstract
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Descending thoracic aortobifemoral bypass was evaluated in 3 patients with Leriche's syndrome and 1 with severe arteriosclerosis obliterans. Indications for this approach were lack of a suitable site for aortic clamping in 3 and history of laparotomy in 1. Duration of surgery was 4.5 to 5.25 hours, and blood loss was 450 to 1,900 g. There was no surgical mortality. Major morbidity comprised visceral arterial ischemia postoperatively in 1 patient. During a mean follow-up of 60 months (range, 36 to 84 months), 2 limbs of the grafts became occluded. No patient developed proximal propagation of an aortic thrombus. This approach is recommended in selected patients without impaired pulmonary function, when conventional approaches to the abdominal aorta are considered hazardous.
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Introduction
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The standard method of aortoiliac revascularization for occlusive disease is through a transabdominal approach. When this option is considered hazardous or not feasible, the usual alternative is axillobifemoral bypass. Axillo-bifemoral bypass is suitable for certain patients with high medical risks. However, a more durable long-term alternative is desirable for those with a longer life expectancy. The purpose of this study was to evaluate the efficacy and safety of the descending thoracic aorta as an inflow source for aortoiliac revascularization in selected cases where the traditional transabdominal approach was considered to be hazardous.
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Patients and Methods
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In a 7-year period from 1993, 4 patients were treated with descending thoracic aortobifemoral bypass for aortoiliac occlusive disease at Fukui Medical University Hospital. The mean age was 64 years, and all had disabling intermittent claudication (Table 1
). Angiography showed stenosis of the infrarenal aorta that was occluded 7 cm distally with a patent lumbar artery in 1 case, juxtarenal aortic occlusion in 2, and severe stenosis of the common and external iliac arteries in 1 (Figure 1). The traditional surgical approach was considered to be hazardous: there was no suitable site for aortic crossclamping in 3 patients (mural thrombus in 2 and severely calcified aorta in one), and history of laparotomy for ileus in 1. Pulmonary function tests showed no impairment in 3 patients and mild chronic obstructive pulmonary disease in 1 (Table 1).
Following standard general anesthesia with hemodynamic monitoring, endotracheal intubation was performed with a double-lumen tube to facilitate aortic exposure by collapsing the left lung. The patient was positioned with the left hemithorax elevated 30 to 45 degrees and the pelvis as flat as possible to allow access to both groins. The chest, abdomen, and both groins were prepared and draped, and clear foot bags were used for assessment of the peripheral circulation. Proximal anastomosis of a Dacron bifurcated graft was performed end-to-side at the lower descending thoracic aorta through a left anterolateral thoracotomy in the 7th interspace. A 3-cm incision was made at the posterior diaphragm at its attachment to the 12th rib. The graft limbs were drawn through a retro-peritoneal tunnel to a short left transverse trunk incision, from which each limb of the graft was drawn through a subcutaneous tunnel to each side of the groin and anastomosed to each common femoral artery.
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Results
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Mean duration of surgery was 4.75 hours and mean blood loss was 925 g (Table 2). There was no surgical mortality. The only major morbidity was 1 case of postoperative visceral arterial ischemia (Table 2). Hepatic and renal failure, ileus, and pancreatitis developed postoperatively in case 4; graft limb banding was performed, which diminished the ankle brachial pressure index and induced daily improvements in hepatic and renal function. When the banding was removed, the right limb of the graft became occluded. Thrombectomy was unsuccessful. Additional bypass to the right common femoral artery was later established. During a mean follow-up of 60 months (range, 36 to 84 months), 2 graft limbs became occluded following graft-limb banding and excessive exercise. One patient died of acute pancreatitis 48 months after surgery but the graft was patent. None of the patients developed proximal propagation of aortic thrombus. All patients had a good quality of life postoperatively.
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Discussion
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Infrarenal aortobifemoral bypass is currently considered the gold standard for aortoiliac reconstruction in occlusive disease. When abdominal aortic surgery is contraindicated because of severe disease at the inflow site, axillofemoral bypass is currently the most common alternative pro-cedure. However, the results of axillofemoral bypass are generally less than ideal in terms of patency and quality of life, although some better primary patency rates have been reported recently.1,2
Thoracofemoral bypass has major advantages over axillofemoral bypass because it provides better inflow, requires a shorter graft length, offers better protection of the graft from infection and mechanical trauma, and carries a superior patency rate. Thoracofemoral bypass was first described by Blaisdell and colleagues3 as an alternative to standard aortofemoral bypass. Subsequently, several groups have recommended this technique as an alternative or first-choice procedure for aortoiliac occlusion.4,5 In fact, long-term follow-up studies have documented excellent patency rates. Criado and colleagues6 described 16 cases that in addition to those reported in the Englishlanguage literature, gave a combined surgical mortality rate of 6.4% and the life-table primary graft patency was 98% at 1 year, 88% at 2 years, and 70.4% at 5 years.
The risk of subsequent renal artery thrombosis is a concern with the use of thoracofemoral bypass in patients with juxtarenal aortic occlusion. Using radioisotope renography prospectively, Cevese and Gallucci7 confirmed normal renal perfusion up to 5 years after thoracofemoral bypass in 6 patients with complete juxtarenal aortic occlusion. In their experience combined with a review of the English language literature, only one case of renal failure as a result of proximal progression of the aortic thrombus was documented.8 In our patients, radioisotope renograms using iodine-131 were obtained pre- and postoperatively, which confirmed the existence of abnormal renal perfusion postoperatively only in case 4. This patient developed visceral ischemia as a result of postoperative hypotension due to splenic injury. With the recent advance of tho-racoscopic techniques, thoracofemoral bypass may become an alternative to the standard open thoracofemoral bypass. McMillan and McCarthy9 reported a clinical case initially treated with thoracoscopic thoracofemoral bypass. This procedure is less invasive than traditional open surgery, but further studies comparing the results of open and endoscopic techniques are needed.
Our series demonstrated superior inflow, excellent quality of life, and more reliable patency with descending thoracic aortobifemoral bypass compared to axillobifemoral bypass. This approach is recommended in selected patients without impairment of pulmonary function when conventional approaches to the abdominal aorta are considered hazardous.
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References
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Abstract
Introduction
