Femorofemoral crossover bypass for noninfective complications of aortoiliac surgery

Between 1973 and 1989, 39 femorofemoral crossover bypasses were performed to treat unilateral noninfective complications of aortoiliac surgery. The initial revascularization procedure, performed an average of 79.5 months previously, was an aortobifemoral bypass in 29 cases, an aorto- or iliofemoral bypass in six cases, an inlay graft for abdominal aortic aneurysm and aortoiliac endarterectomy in two cases each. The indications for femorofemoral crossover bypass included prosthetic occlusion in 35 cases, thrombosed false aneurysm in two, and further degradation after endarterectomy (iliac stenosis and occlusion in one case each). There was no operative mortality. One patient with acute ischemia upon admission and another with distal gangrene required below-knee and forefoot amputations, respectively. No amputations were required during the rest of the follow-up period. Three repeat aortobifemoral bypasses were performed because of occurrence of aortic or inflow vessel lesions. Primary and secondary actuarial five year patency rates for femorofemoral crossover bypasses were 59.7% and 78.4%, respectively. Femorofemoral crossover bypass can extend the benefits derived from direct aortoiliac surgery with low mortality and morbidity in the absence of associated aortic pathology (false aneurysm at the aortic implantation site or severe obstructive lesions). kg]Key wordsPresented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.     

Long-term results of thrombectomy for late occlusions of aortofemoral bypass

Sixty-two first episodes of aortofemoral (eight patients) or aortobifemoral (42 patients) bypass thrombosis were operated upon in 50 patients between 1980 and 1985. There were 47 men and three women whose mean age was 58 years. Retrograde thrombectomy through the distal anastomosis was achieved in all cases by using either a balloon catheter or Vollmar rings. If thrombectomy was impossible, revascularization was ensured by an extraanatomic bypass or complete replacement of the graft. Angioplasty, repeat distal anastomosis or femoropopliteal bypass of the native runoff artery were done in 55 (89%) operations. The cause of thrombosis was elucidated in 45 cases. Suture line stenosis and atheromatous stenosis of the native runoff artery were the two most common causes. Three patients died and two required above-knee amputation in the immediate postoperative period. Contralateral embolism occurred in two patients undergoing retrograde thrombectomy. Mean follow-up was 47 months. Thrombectomy was possible in 51 of 62 prosthetic thromboses (Group I). Thirty-nine of these grafts have remained patent. Twelve instances of repeat thrombosis occurred, requiring either repeat thrombectomy or a new bypass. Primary patency in group I was 97.8%, 81.2%, and 71.3% at one, three, and five years, respectively. Thrombectomy was impossible in 11 graft thromboses (Group II). A new bypass was performed in all 11 cases. Primary patency in Group II was 100%, 75% and 50% at one, three, and five years, respectively. Retrograde thrombectomy combined with treatment of native runoff artery anomalies can restore long-term patency when thrombosis occurs late after aortofemoral bypass and is associated with low mortality and morbidity.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.     

Intraoperative flow waveform analysis aids in preventing early graft failure following reconstruction of arteries of the legs

To enable early detection and treatment of vascular defects leading to early graft failure, intraoperative flow waveform analyses were carried out during lower extremity arterial reconstructions in 226 patients undergoing 102 aortoiliac/femoral and 124 femorodistal bypass grafts. Flow waveform types III or IV indicated early graft failure. These were noted in seven grafts (6.9%) in the aortoiliac/femoral position and in eight grafts (6.5%) in the femorodistal position. The main cause of the abnormal flow waveform pattern was misinterpretation of preoperative arteriographic findings in aortoiliac/femoral reconstructions and technical errors in anastomoses in femorodistal reconstructions. Of 15 grafts with an abnormal flow waveform pattern, 13 were effectively repaired with patch angioplasty, graft extension, or replacement with thrombectomy. In two grafts, the repair failed and amputation had to be done. Thus, intraoperative flow waveform analysis is a simple, useful, and safe method to detect vascular defects leading to early graft failure. Unless assessment of preoperative arteriographic findings in aortoiliac/femoral reconstructions are accurate and anastomotic techniques in femorodistal reconstructions are refined, early graft failure may occur.     

Graft occlusion following aortofemoral Dacron bypass

We report on a series of 930 patients who received an aortobifemoral Dacron graft between 1963 and 1988. The operative mortality was 5.6% and the mean follow-up reached 5.45 years (range one month to 23.6 years). Late occlusion was noted in 125 patients and the primary patency rate decreased to 74% and 69%, respectively at 10 and 15 years. Long-term patency was primarily (p < 0.05) dependent on (1) the date of operation, (2) postoperative smoking habits, (3) distal occlusive disease, and (4) age of the patients at the time of surgery. Vascular reconstruction for late thrombosis was performed for 110 late occlusions in 103 patients. Included were 95 unilateral and 15 bilateral occlusions. The method of choice was graft limb thrombectomy (unilateral occlusion) or anatomical graft replacement (bilateral occlusion or unilateral occlusion when thrombectomy proved to be impossible). Associated outflow reconstructions consisted of profundaplasty in 73.3% of the cases. A mean yearly thrombosis rate of 9.4% (range 4–14%) resulted in a five year patency rate of 59%. Differences between graft thrombectomy and anatomical replacement were not statistically significant. Reconstruction for secondary occlusions was associated with a 25% thrombosis rate. Tertiary occlusion in six cases invariably led to major amputation. A total of 20 patients ultimately needed a major amputation, resulting in an eight year limb salvage rate of 79%.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990 Nancy, France.     

Use of the descending thoracic aorta as an inflow source in aortoiliac reconstruction: Indications and long-term results

Bypass grafting from the descending thoracic aorta to the iliac or femoral artery is an underutilized procedure; fewer than 200 cases were reported in the past 30 years. Over the last decade we performed 32 bypasses to the femoral iliac or popliteal arteries using the descending thoracic aorta as the inflow source. In 19 (59%) patients the procedure was a primary aortic reconstruction, whereas in 13 (41%) it was secondary. The 30-day in-hospital mortality rate was 6.2%. Primary graft patency was 86% (±7.8) at 2 years. To obtain a meaningful long-term patency analysis, we combined our experience with that reported in the literature during the same period. Follow-up data were available in 146 patients in whom the mean follow-up time ranged from 15 to 53 months. The operation was a secondary aortic reconstruction in 84 (58%) patients and was a primary procedure in 62 (42%). Reasons for the selection of the descending thoracic aorta as the inflow source included previous abdominal aortic graft failure in 56 (38%) patients, abdominal aortic graft infection in 26 (18%), unfavorable abdominal conditions in 30 (21%), and miscellaneous causes in 34 (23%). The 30-day in-hospital mortality rate for the collective experience was 5.5%. Life-table analysis of the collective primary graft patency rate was 88.3% (±2.9) at 1 year, 81% (±4.3) at 3 years, and 72.7% (±8.5) at 6 years. Secondary graft patency for the collective experience was 93.1% (±2.3) at 1 year, 88.2% (±3.7) at 3 years, 82.7% (±7.3) at 6 years, and 82.7% (±10) at 8 years. Patient survival was 67.5% (±6.9) at 5 years and 55.4% (±9.9) at 7 years. These data suggest that bypass from the descending thoracic aorta to the iliac or femoral arteries offers low mortality and excellent durability and should be considered as the procedure of choice for secondary or extra-anatomic aortoiliac reconstruction.Presented at the Eighteenth Annual Meeting of the Peripheral Vascular Surgery Society, Washington, D.C., June 6, 1993.We thank Professor Branchereau for providing us with his most recent data and Ivis Reed Bohlen for editorial assistance.     

Thoracic aorta as source of inflow in reoperation for occluded aortoiliac reconstruction

We reviewed our experience with reoperations for recurrent obstruction occurring after aortoiliac or aortofemoral reconstruction. Patients who underwent successful transfemoral thrombectomy of the aortofemoral graft or femorofemoral crossover graft were excluded from the study. A more proximal source of inflow to revascularize the ischemic limbs was required in the remaining 35 patients. Bilateral reconstruction was performed in 22 patients. Operative indication was rest pain or necrosis in 36 limbs and severe claudication in 21 limbs. Preoperative ankle/brachial pressure index (API) ranged from 0.05 to 0.61. Thirteen patients (21 limbs, group I) underwent transabdominal reoperation. Since the transabdominal approach was considered hazardous because of multiple previous operations, the remaining patients underwent retroperitoneal descending thoracic aorta-femoral artery bypass (15 patients, 25 limbs; group II) or axillofemoral bypass graft (7 patients, 11 limbs; group III). No statistically significant difference was present between the three groups in regard to the operative indication, API, and angiographically determined outflow (analysis of variance, p greater than 0.2). Axillofemoral bypass was preferred in patients with severe chronic pulmonary disease. Postoperative deaths (2 of 35 patients) and morbidity (6 of 35 patients) had a similar incidence in the three groups (p greater than 0.2). Follow-up ranged from 3 to 120 months (mean 37 months). The 5-year actuarial patency rate was 80.5% for group I and 80.2% for group II. In group III it was statistically lower (32.9%, p less than 0.05). Serial measurement showed a significant decrease of API in group III compared with group I and group II. We conclude that retroperitoneal descending thoracic aorta-femoral artery bypass is a valid alternative to transabdominal reoperation when exposure or availability of the abdominal aorta poses a specific hazard and is preferable to axillofemoral bypass in terms of long-term patency and hemodynamic results.     

Late upper extremity embolic complications of occluded axillofemoral grafts

The use of axillary femoral grafting in the treatment of patients at high risk for aortoiliac reconstruction has become a widely accepted treatment modality. Ischemia and even loss of the donor upper extremity have been reported to occur early after graft occlusion. This report describes three patients who developed emboli to the upper extremity at nine, 15, and 34 months following occlusion of their axillary femoral graft. Based on our experience, we consider an occluded axillofemoral graft a permanent threat to the viability of the donor upper extremity. Anatomic changes suggestive of potential ischemia include: presence of a blind pouch in the graft stump, or Y elongation of the artery with proliferative changes in the intima.     

Monobloc resection of the upper extremity of the leg for bone tumor with distal vascular reconstruction

A patient with juxtacortical osteosarcoma of the upper extremity of the left tibia which encased the popliteal neurovascular bundle was treated by monobloc resection of the superior extremity of the tibia and the tibial nerve. The knee joint was replaced by a Guepar prosthetic knee. Arterial and venous continuity was reestablished by a double bypass using the contralateral greater saphenous vein. One year later the patient had good lower limb function and was free of local or general disease. This observation confirms that preservation of lower limb function is possible using reconstruction techniques of bone, nerves, and vessels in sarcoma of the musculoskeletal system.     

Hyperparathyroidism presenting as an unusual cause of lower extremity gangrene

Vascular surgeons are often consulted on the management of lower extremity ulcerations and gangrene which are commonly due to atherosclerotic arterial occlusive disease or to chronic venous insufficiency. The following report describes an unusual case of severe lower extremity cutaneous gangrene associated with secondary hyperparathyroidism and a review of the literature.     

“Half and half” woven and knitted Dacron grafts in the aortoiliac and aortofemoral positions: Seven and one-half years follow-up

One-hundred fifty-eight patients received specially manufactured aortoiliac or aortofemoral bifurcated grafts with one limb woven, the other knitted from Dacron. During an observation period ranging from 1,567 to 2,555 days (average 2,130 days) no statistically significant difference was found in either platelet adherence (30 patients studied) or in clinical patency. According to the results of the study, the type of graft (woven or knitted) did not seem to influence either platelet adherence or patency rate in the aortoiliac or aortofemoral positions.