Contemporary outcomes of thoracofemoral bypass

Abstract

Objectives: Thoracofemoral bypass (TFB) is an alternative to aorto-femoral (AFB) or extraanatomic bypass for severe aorto-iliac occlusive disease (AIOD). TFB may be particularly useful in select patients with concurrent visceral aortic branch vessel disease, infrarenal aortic occlusions or after failed AFB. However, there are few contemporary series describing the indications and outcomes for TFB. Therefore, the purpose of this analysis was to review our experience with TFB. Methods: All patients undergoing TFB for occlusive disease from 2002-2017 were reviewed. All subjects underwent left thoraco-retroperitoneal exposure of the supra-celiac aorta with division of the diaphragmatic crus and supra-celiac cross-clamping. An end-to-side aortic anastomosis was created and each graft limb was tunneled in the retroperitoneum to the femoral bifurcation. Adjunctive visceral/infra-inguinal revascularization was selectively performed based on symptoms, end-organ function and/or preoperative imaging. The primary end-points were major complications and 30-day mortality. Secondary end-points included limb patency, freedom from major adverse limb events (MALE), and survival. Kaplan-Meier methodology was used to characterize end-points. Results: Forty-one patients [age: 61±9 years; female-54%, hypercoaguable state-7%] underwent TFB. Mean preoperative ankle brachial index (ABI) was 0.4, bilaterally. Indications included: critical limb ischemia (56%), claudication (30%), acute limb ischemia (7%) and combined AIOD +mesenteric ischemia (7%). Seven (17%) had previously undergone AFB and 15(38%) underwent any prior aortic operation. Adjunctive visceral bypass occurred in 8(20%) (14 grafts: renal-6, superior mesenteric artery-5, celiac-3). Postoperative LOS was 11 [IQR 7, 16] days and 30-day mortality was 5% (n=2). Major complications occurred in 34% (n=14; pulmonary-15%, cardiac-12%, bleeding-7% [accidental splenectomy-5%], renal-5%, wound-2%). Mean postoperative ABI was 0.9, bilaterally.

Thoracobifemoral bypass for infrarenal aortic occlusion caused by retroperitoneal fibrosis

“…Although performed infrequently in the modern era of vascular intervention, the operation remains effective, with recent studies showing one-year primary patency over 85% and one-year survival over 90%. [24][25][26] Herein is reported the use of this historic procedure for aortic occlusion as a complication of RPF. Given severe pathology and complex occlusion demonstrated on imaging, endovascular reconstruction was not considered.…”

“…Although performed infrequently in the modern era of vascular intervention, the operation remains effective, with recent studies showing 1-year primary patency over 85% and 1-year survival over 90%. 24 , 25 , 26 …”

Descending thoracic aorta to bilateral femoral artery bypass and thoracic endovascular aortic repair in the management of atypical aortoiliac occlusive disease

“…Thus, DTFB appeared the most appropriate bypass option for our patient. Compared with the more invasive retroperitoneal tunnels created during DTFB, 18 the combined retroperitoneal and preperitoneal space tunneling approach minimized the occurrence of postoperative gastrointestinal complications. The bifurcated graft choice also adequately accommodated the concurrent TEVAR.…”

“…Second, most surgeons have used the side-biting clamp to partially occlude the distal descending thoracic aorta during the proximal end-to-side anastomosis of the DTFB and have used a handheld Doppler probe to confirm distal perfusion. 10 , 11 , 12 , 13 , 14 , 15 , 16 , 18 However, such a method is incapable of providing direct visualization of the residual lumen and an estimation of the volumetric flow to the visceral organs distally. In the present case, the use of intraoperative TEE provided a high precision view of the side-biting partial clamping site within a very tight region and depicted, in real-time, blood flow to the distal organs during the anastomosis.…”

On‐pump coronary artery bypass with concomitant descending thoracic aorta‐bi‐iliac bypass: A case report

“…Since its first description by Blaisdell et al, 1 various thoracic aorta‐bifemoral bypass techniques have been described 2–4 . These techniques provide a safe approach with good outcomes for treating juxtarenal aortic occlusions, preventing laparotomy‐related complications, and using the less atherosclerotic thoracic aorta as an inflow source 5 .…”