Axillobifemoral Bypass for Aortitis Syndrome in a Living-Donor Liver Transplant Patient

Abstract

A 64-year-old female patient with aortitis syndrome presented with progressive intermittent claudication for 6 months. Her medical history was notable for living-donor liver transplantation for primary biliary cirrhosis 4-years prior and chronic immunosuppressive therapy. Evaluation included normal laboratory examination, and contrast-enhanced computed tomography angiography which demonstrated severely calcified descending aorta with high-grade stenosis below the diaphragm. The patient was treated by axillobifemoral bypass using an 8-mm ringed expanded polytetrafluoroethylene graft under general anesthesia. Medical management included decreased preoperative doses of immunosuppressants and predonisolone, which were resumed after the operation, and chronic anticoagulation. There were no postoperative complications. Keywords: axillobifemoral bypass, aortitis syndrome, livingdonor liver transplant Case ReportA 64-year-old female patient presented with intermittent claudication for six months. Intermittent claudication had been worsening gradually. Her medical history was notable for aortitis syndrome, which was successfully treated by chronic predonisolone therapy at 2.5 mg per day. The patients underwent living-donor liver transplantation for primary biliary cirrhosis (PBC) 4 years prior to presentation, which required chronic immunosuppression with Tacrolimus hydrate 2 mg per day and Mycophenolate Mofetil 500 mg per day. The patient was followed closely at by our department of transplantation.Laboratory examinations revealed total bilirubin of 0.5 mg/dL, glutamic oxaloacetic transaminase of 18 IU/L, glutamic pyruvic transaminases of 10 IU/L, alkaline phosphatase of 346 IU/L, cholinesterase of 309 IU/L, creatinine of 1.04 mg/dL, urea of 7.6 mg/dL, HbA1C of 5.9%, white cell count of 6100/L, hemoglobin of 9.7 g/dL, platelet count of 17.1 × 10 4 /L and international ratio of prothrombin time of 1.07.Transthoracic echocardiography revealed normal left ventricular function (69.7%) and no significant valvular diseases. Coronary angiography also revealed intact coronary arteries.Ankle branchial index could not be measured and maximum claudication distance was less than 50 m. A contrastenhanced computed tomography angiography (CTA) was obtained, which showed that severely calcified distal descending aorta (Figs. 1 and 2A) with high-grade stenosis below the diaphragm (Fig. 1A). Celiac trunk was severely stenotic (Fig. 1B) and superior mesenteric artery was occluded. Abdominal aorta was also occluded (Fig. 1C).This patient had a history of laparotomy in living-donor liver transplant and there was heavily calcified descending and abdominal aorta on CTA. Additionally, she required oral chronic immunosuppressants and predonisolone. Based on these concerns, this patient was not considered an ideal candidate for endovascular or open aortic-based reconstruction. Therefore, an extra-anatomic bypass for atypical aortic coarctation was recommended. The doses of immunosuppressants and predonisolone were decreased in anticipation of th...

Descending Thoracic Aorta–abdominal Aortic Bypass and Bilateral Renal Arterial Blood Circulation Reconstruction Are Effective in Atypical Coarctation of the Aorta With Heart Failure: a Case Report

“…Among these, the route of bypass has been frequently discussed, and many reports have included aorto-aortic bypass or axillary-femoral bypass. Some case reports have presented cases of axillary-femoral bypass that did not require thoracotomy or laparotomy and was effective as well as minimally invasive [1,2]. However, reducing the afterload may be insu cient because it is bypassed by a small-diameter graft and because perfusion of abdominal organ now passed through retrograde blood ow from the femoral artery.…”

“…Some reports have shown that axillary-bilateral femoral bypass is effective in cases of hypertensive heart failure due to atypical coarctation of the aorta [1,2]. Axillofemoral bypass has been reported to have good long-term results [3]; however, there are also reports of poor long-term results, such as graft occlusion [4].…”

Descending thoracic aorta–abdominal aortic bypass and bilateral renal arterial blood circulation reconstruction are effective in atypical coarctation of the aorta with heart failure: a case report

“…Among them, the route of bypass surgery has been frequently discussed, and many reports have included aortic-aortic bypass or axillary-femoral artery bypass. Some case reports have presented axillary-femoral artery bypass that does not require thoracotomy or laparotomy and is effective with minimal invasiveness [ 1 , 2 ]. However, reducing the afterload may be insufficient because it is bypassed by a small-diameter graft and because the perfusion to the abdominal organ becomes retrograde blood flow from the femoral artery.…”

“…Some reports have shown that axillary-bilateral femoral artery bypass is effective in cases of hypertensive heart failure due to atypical coarctation of the aorta [ 1 , 2 ]. Axillary artery-femoral artery bypass has been reported to have good long-term results [ 3 ]; however, there are also reports of poor long-term results such as graft occlusion [ 4 ].…”