Eighteen-year experience with femoro-femoral bypass

BACKGROUND: The role of femoro-femoral bypass in the management of aorto-iliac occlusive disease has evolved during the past two decades. The aim of the present study was to evaluate the early and long-term outcomes of femoro-femoral bypass grafts performed at the University of Hong Kong Medical Centre during an 18-year period. METHODS: From 1981 to 1998, a retrospective analysis of 61 patients who underwent femoro-femoral bypass at the University of Hong Kong Medical Centre was undertaken. Data on demographic features and results of surgical intervention were reviewed. Early outcomes (morbidity, mortality and improvement of clinical category) and long-term outcomes (graft patency, patient survival and limb salvage rates) were analysed. RESULTS: The postoperative morbidity and mortality rates were 16% and 7%, respectively. Clinical success was achieved in 48 patients (79%) after operation. The primary patency of femoro-femoral bypass was 86%, 79% and 71% at 1, 3 and 5 years, respectively. The limb salvage rate was 85% at 3 years. The cumulative survival rate of the study population was 89%, 82% and 73% at 1, 3 and 5 years, respectively. CONCLUSIONS: Femoro-femoral bypass was successful in relieving ischaemic pain and limb salvage in approximately 80% of patients. A 5-year patency rate of 71% was achieved. Femoro-femoral bypass remains a valuable surgical procedure for limb salvage in poor-risk patients with unilateral iliac artery occlusion.     

Extra-anatomic ilio- or femoro-femoral bypass

Twenty-six extra-anatomical by pass operations were performed for iliofemoral arterial lesions (23 crossed, 3 homolateral) due to severe atheroma (22 cases), infection (the 3 homolateral shunt) or iliac aneurysm (1 case). Limb saving was obtained in 73% of patients in whom vitality of limbs was involved. Permeability for crossed by pass procedure was as high as 92% at 1 year follow up. Operative techniques are discussed with emphasis on the need for good iliac artery flow and a sufficient distal vascular bed on the donor side. Indications for operation in this series were mainly poor general condition and/or associated affections (coronary disease in 1 out of 2 cases), but they should be enlarged because of the relative simplicity of the procedure.     

Non-invasive assessment of the steal phenomenon following femoro-femoral bypass

Clinical studies were performed on 42 patients who underwent femoro-femoral bypass and postoperative assessment of the ankle/brachial pressure index (API) and Doppler waveform for each limb was carried out. Patients who had poor runoff of the donor limb showed a significant decrease in API after ankle joint exercise (p less than 0.05), whereas no significant change was observed in patients who had poor runoff of the recipient limb. The response of pulsatility index was similar to that of API. Thirteen of the 42 patients underwent both pre- and postoperative assessments. Six of these patients underwent additional procedures such as thromboendarterectomy or profundaplasty on the anastomotic site of the donor limb, and the other 7 patients had no additional procedures performed. A decrease in API after exercise was prominent in the patients who had not undergone any additional procedures, in the postoperative stage (p less than 0.01). Thus, when performing femoro-femoral bypass, improving poor runoff in the donor limb by carrying out intraoperative additional procedures should be taken into consideration, as any imbalance of peripheral resistance must be kept to an absolute minimum.     

Non-invasive assessment of the steal phenomenon following femoro-femoral bypass

Clinical studies were performed on 42 patients who underwent femoro-femoral bypass and postoperative assessment of the ankle/brachial pressure index (API) and Doppler waveform for each limb was carried out. Patients who had poor runoff of the donor limb showed a significant decrease in API after ankle joint exercise (p<0.05), whereas no significant change was observed in patients who had poor runoff of the recipient limb. The response of pulsatility index was similar to that of API. Thirteen of the 42 patients underwent both pre- and postoperative assessments. Six of these patients underwent additional procedures such as thromboendarterectomy or profundaplasty on the anastomotic site of the donor limb, and the other 7 patients had no additional procedures performed. A decrease in API after exercise was prominent in the patients who had not undergone any additional procedures, in the postoperative stage (p<0.01). Thus, when performing femoro-femoral bypass, improving poor runoff in the donor limb by carrying out intraoperative additional procedures should be taken into consideration, as any imbalance of peripheral resistance must be kept to an absolute minimum.     

Elective femoro-femoral bypass for operations on the heart and great vessels

Femoro-femoral bypass with "circulatory arrest" is no longer used in routine cardiac operations. Its use today is normally limited to operations wherein access to the arch of the aorta is required or the thoracic aorta is to be temporarily occluded. We have recently encountered three patients presenting with complications of previous operations. In all three, the use of this technique allowed us to approach the defect safely.     

Persistent lymphatic fistula. Unusual complication of femoro-femoral arterial bypass

An unusual complication of persistent lymph fistula occurred three months postoperatively following axillo-femoral and femoro-femoral bypass graft. The lymphangiograms demonstrated the precise site of lymph extravasation. Multiple aspirations and local drainage were of no avail and it finally responded to prolonged continuous local pressure over the area of lymph extravasation.     

Influence of a prior iliofemoral reconstruction on the patency of the femoro-femoral bypass

A series of 40 femoro-femoral by-pass grafts (FFBG) is presented; these operations were performed from 1978 to 1987 and the follow-up ranged between 6 and 36 months. The subjects were divided retrospectively into two groups, to evaluate the effect of prior iliofemoral reconstructive operations on the long-term patency of the FFBGs. Thirty-four patients (group A) had no previous surgery and 15 (group B) had 23 previous femoral surgical reconstructions. At operation, 34 recipient deep femoral arteries underwent adjunctive TEA (24 out of group A; 10 out of group B) as well as 9 donor limb deep femoral arteries (all out of group A). No donor limb steal phenomenon was recorded in both groups. FFBG occlusion occurred without any statistically significant differences in the groups (A 12%, B 20%) and only in one case a thigh amputation was needed (group B).     

Repair of abdominal aortic aneurysms with aorto-uni-iliac stentgraft and femoro-femoral bypass

Endovascular repair (EVAR) is accepted as effective treatment for abdominal aortic aneurysms (AAAs) and has become the standard of care in many instances. The standard bifurcated stentgraft (BFG) is often not possible in patients with unfavourable aneurysm morphology. The aorto-uni-iliac (AUI) graft configuration with femoro-femoral bypass (FFBP) is a promising alternative which may extend the scope of EVAR for AAAs. The aim of this study was to evaluate the feasibility, efficacy and durability of AUI with FFBP. Design. The results of a single institution and a single surgeon were prospectively collected from January 2002 to August 2010. All patients were followed up at 1, 3, 6 and 12 months and then annually. Results. There were 33 patients (27 males) with a mean age of 71.7 years (range 46 - 84). Open surgery posed an unacceptably high risk to all patients owing to advanced age and/or American Society of Anesthesiologists (ASA) classification 3/4. Ineligibility for BFG was due to unfavourable anatomy or a combination of factors in most cases (31 patients). Two patients had anastomotic aneurysms after previous open surgery. The technical success rate was 100%. One severe intra-operative complication occurred (perforated iliac artery). Two patients (ASA 4) died within 30 days (peri-operative mortality rate 6.1%). Seven patients (21.1%) developed postoperative wound complications. Eight patients died during follow-up of non-aneurysm-related conditions. Twenty-three patients are alive, with mean follow-up of 24.4 months and a survival rate of 69.7%. Two complications occurred during long-term follow-up, namely 1 case of graft sepsis and 1 of FFBP occlusion. Conclusion. AUI with FFBP is a safe, effective and durable alternative in high-risk patients with AAAs where standard open repair is contraindicated and BFG repair is not possible owing to unfavourable aneurysm morphology.     

剖解外腋—股,股—股动脉旁路移植术治疗主髂动脉闭塞症

目的 探讨剖解外腋－股、股－股动脉旁路移植术治疗主髂动脉闭塞症的疗效。方法 采用解剖外旁路移植术治疗主骼动脉闭塞症患者３２例。１８例腹主动脉或两侧髂动脉闭塞者采用腋－股动脉旁路术,其中２例为腋－两股动脉旁路术;１４例单侧髂动脉闭塞者采用股－对侧股动脉旁路术。采用腋－肌动脉旁路的患者,术中８例用真丝人造血管移植,１０例四氟乙烯（Ｇｏｒｅ－Ｔｅｘ）人造血管;股－股动脉旁路术中６例用真丝人造血管移植,１     

Technical solution in kidney retransplantation in a patient with femoro-femoral bypass

Over the last decade kidney transplantation has become a common therapeutic procedure for patients with end-stage renal diseases. Between 1988 and 1998 donors rate per million population has dramatically increased in our environment, thus providing us with more chances to offer kidney transplantation to a larger number of patients. The technico-surgical difficulties that have to be faced however, are increasingly frequent and require a search for new approaches and innovative changes to the usual surgical techniques for our patient's benefit.     

The clinical importance and prediction of steal following femoro-femoral cross-over bypass: study of the donor iliac artery by intravascular ultrasound, arteriography, duplex scanning and pressure measurements.

OBJECTIVES: to evaluate the clinical significance of the steal phenomenon following femoro-femoral bypass, and whether the addition of intravascular ultrasound (IVUS) to the established examinations of the donor iliac artery can improve the prediction of patients who will develop steal. DESIGN: prospective study. MATERIAL AND METHODS: twenty-eight patients, aged 73 (50-81) years, scheduled for femoro-femoral bypass surgery in the period from 1994 to 1997, had the donor iliac artery examined by single-plane arteriography, duplex scanning, IVUS and femoral-artery blood pressure measurements (FABP)+/-papaverine. Three patients were excluded due to simultaneous thromboendarterectomy (TEA) of the donor iliac artery. The clinical stage and the ankle-brachial index (ABPI) were measured pre-, postoperatively and prospectively 1, 6, 12 and 24 months after discharge. RESULTS: two patients developed clinical steal, while an additional five had a measurable (>0.1) decline in the donor ABPI postoperatively, but no symptoms (subclinical steal). The clinical stage of the donor limb did not deteriorate further during the follow-up period (median 8 months) in these seven patients. The decline in donor ABPI correlated with the FABP and the IVUS measurements, but not to duplex scanning or arteriography. FABP after papaverine injection and IVUS examination showed equal sensitivities and and specificities. CONCLUSION: a clinical steal phenomenon following femoro-femoral bypass surgery seems relatively uncommon, although a subclinical steal is more frequent. Both can be predicted by FABP or IVUS. Further follow-up is required to evaluate whether subclinical steal has any consequences in the long term.     

A successful cross-over femorotibial bypass for severe ischemic leg of thromboangiitis obliterans

A case of thromboangiitis obliterans (TAO) successfully treated with a modified vascular reconstruction is reported. A 53 year-old man who had undergone lumber sympathectomy 9 years ago visited our hospital with complaints of rest pain and intractable ulcer at the right big toe. Preoperative angiography could not visualize distal arteries from the right common iliac artery and major amputation above knee was intended. Operative angiography, however, revealed collateral pathways from the posterior tibial artery to plantar arteries. Then, a long bypass from the left common femoral artery to the right posterior tibial artery was made using saphenous vein grafts of both extremities, 75 cm in length. Postoperatively, a solution containing urokinase, PGE1 and heparin was infused continuously for two months through a tube inserted into a branch of the graft. The pain disappeared and the ulcer healed. Now one year after the operation, the bypass graft is patent and the patient is fully rehabilitated. This experience indicates that some of ischemic legs with poor run off due to TAO can be salvaged by such modified vascular reconstruction and postoperative local PGE1 infusion therapy.     

Intra-operative inflow resistance measurement: a predictor of steal syndromes following femoro-femoral bypass grafting

Although femorofemoral bypass grafting was originally used only as a method of limb salvage, it is now used increasingly in patients with claudication. If this trend is to be supported, the haemodynamic consequences of the operation must be carefully assessed. Fifteen patients undergoing femorofemoral grafting were studied prospectively by intra-operative measurement of the inflow resistance (IR) of the donor iliac segment. Three groups were identified by this technique. Patients with an IR less than 0.05 (n = 8) were uncomplicated; those with an IR greater than or equal to 0.05 but less than 0.10 (n = 5) developed a subclinical steal syndrome; and those with an IR greater than 0.10 (n = 2) developed a clinical steal syndrome. High initial IR values were corrected at the time of surgery in two cases. This study demonstrates that steal syndromes can occur after femorofemoral grafting and that the cause is an unmasking of previously unrecognized disease in the donor arterial segment. The measurement of IR allows the prediction of steal syndromes and their correction at the time of surgery. Direct haemodynamic studies are recommended, especially as the availability of balloon angioplasty has made inflow disease amenable to treatment.