Indian Journal of Vascular and Endovascular Surgery

ORIGINAL ARTICLE
Year
: 2015  |  Volume : 2  |  Issue : 1  |  Page : 12--15

Descending Thoracic Aorto-bifemoral Bypass for Aortoiliac Occlusive Disease


Anil Sharma, Mohit Sharma, Sunil Dixit, Neeraj Sharma, Omeshwar Sharma 
 Department of Cardio Vascular and Thoracic Surgery, S.M.S. Medical College, Jaipur, Rajasthan, India

Correspondence Address:
Dr. Mohit Sharma
Department of Cardio Vascular and Thoracic Surgery, S.M.S. Medical College, Jaipur, Rajasthan
India

Abstract

Introduction: Complete obstruction of the abdominal aorta at the renal artery level is a difficult surgical problem. Methods: From August 2010 to January 2014, descending thoracic aorta to femoral artery bypass grafting was used to re-vascularize the lower limbs of the patients in our center. We analysedd our results Results: Primary indication was lack of a suitable site for aortic clamping. Average duration of surgery was 2.5-4.5 h, and blood loss was 100-400 mL. We use BARD®, IMPRA® expanded polytetrafluoroethylene vascular graft for thoraco-bifemoral bypass surgery. There was one mortality due to myocardial infarction. Major morbidities were graft occlusion in one patient that was managed by embolectomy and ascites in another patient, managed conservatively. Conclusion: Thoracic aorta to femoral artery bypass is a simple extra anatomic bypass technique, which can be used in case of difficulty to use abdominal aorta for lower limb re-vascularization.



How to cite this article:
Sharma A, Sharma M, Dixit S, Sharma N, Sharma O. Descending Thoracic Aorto-bifemoral Bypass for Aortoiliac Occlusive Disease.Indian J Vasc Endovasc Surg 2015;2:12-15


How to cite this URL:
Sharma A, Sharma M, Dixit S, Sharma N, Sharma O. Descending Thoracic Aorto-bifemoral Bypass for Aortoiliac Occlusive Disease. Indian J Vasc Endovasc Surg [serial online] 2015 [cited 2020 Apr 5 ];2:12-15
Available from: http://www.indjvascsurg.org/text.asp?2015/2/1/12/152825


Full Text

 Introduction



Atherosclerotic disease is generally diffuse involving single or multiple regions of blood vessels. Atherosclerosis of peripheral arterial system contributes to significant morbidity and mortality in our patients. Patients with ankle-brachial index <0.3 are labeled as having critical limb ischemia. These patients require aggressive management for improving quality of life and limb salvage.

The standard method of aortoiliac re-vascularization for occlusive disease is through a transabdominal approach. When this option is not feasible, descending thoracic aorto-bifemoral bypass grafting is a good alternative.

The purpose of this study was to evaluate the effectiveness and results of the descending thoracic aorta as an inflow source for aortoiliac re-vascularization in cases where transabdominal approach was considered to be hazardous.

 Patients and Methods



Fifteen patients were treated with descending thoracic aorto-bifemoral bypass for aortoiliac occlusive disease at S.M.S. Medical College and group of Hospitals, Jaipur (Rajasthan) from August 2010 to January 2014. Total 24 limbs were re-vascularized. Demographic data, co-morbid factors, per operative findings were noted.

All patients had disabling intermittent claudication or rest pain. Eight patients were in Rutherford's Class IV with rest pain, five patients were in Class V with ischemic ulcers over toes or distal foot and two patients were in Class III with severe claudication.

Computed tomography (CT) angiography showed stenosis of the infra renal aorta, juxtarenal aortic occlusion and stenosis of common and external iliac artery in all cases [Figure 1]. Abdominal aorto-bifemoral was considered to be hazardous as there was no suitable site for aortic cross clamping. We used BARD ® , IMPRA ® expanded polytetrafluoroethylene (ePTFE) vascular graft for bypass surgery.{Figure 1}

Pulmonary function tests showed mild chronic obstructive pulmonary disease in four, moderate obstructive changes in two, normal in eight and severe restrictive changes in one patient. Other co-morbidities were coronary artery disease in three patients, hypertension in nine, renal impairment in two patients, and diabetes in one patient.

Surgical technique

Patients were given general anesthesia with hemodynamic monitoring. The patient was positioned with the left hemi thorax elevated 30-45° and the pelvis as flat as possible to allow access to both groins. The chest, abdomen, and both groins were prepared and draped. Antero-lateral thoracotomy was done, via 7 th intercostals space. Proximal anastomosis of a 14 mm × 7 mm BARD ® , IMPRA ® ePTFE bifurcated graft was performed end-to-side at the lower descending thoracic aorta [Figure 2]. The graft limbs were drawn through a tunnel between rectus abdominus muscle and peritoneum to a short midline incision at level of umbilicus, from which each limb of the graft was drawn through a subcutaneous tunnel to each side of the groin and anastomosis to each common femoral artery.{Figure 2}

In postoperative period, all patients were evaluated for appearance of distal pulsations, primary patency, warmness of foot, symptom relief, wound infection, healing of the ulcer, and complications. CT angiography was done in follow-up. In [Figure 3], CT angiography is showing normal flow pattern in graft.{Figure 3}

 Results



Fifteen patients with a range of 48-77 years of age, with a mean age of 58.6 years were treated in S.M.S. Hospital, Jaipur during study period. All patients were male. Pulmonary function tests showed mild chronic obstructive pulmonary disease in four, moderate obstructive changes in two, normal in eight and severe restrictive changes in one patient. Other co-morbidities were coronary artery disease in three patients, hypertension in nine, renal impairment in two patients, and diabetes in one patient. Indication for surgery is juxtarenal occlusion of the abdominal aorta, in most of the cases.

Mean duration of surgery was 2.5-4.5 h and mean blood loss was 283.6 mL. There was single surgical mortality, caused by myocardial infarction. Major morbidity includes one graft occlusion and ascitis in other one. None of the patients developed proximal propagation of aortic thrombus. Ulcers showed healing. All patients had a good quality of life postoperatively. Postoperative angiography showed good re-vascularization [Figure 3].

 Discussion



Aorto-femoral bypass grafting is the standard surgical treatment for aortoiliac occlusive disease, partly because of a 5 years patency rate that exceeds 80% in many reports. When abdominal aortic surgery is contraindicated because of severe disease at the inflow site, axillo-femoral bypass or thoraco-bifemoral bypass are alternative procedures. However, the results of axillo-femoral bypass are generally less than ideal in terms of patency and quality of life. [1],[2]

Thoraco-femoral bypass has major advantages over axillo-femoral 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. Thoraco-femoral bypass was first described by Blaisdell et al. as an alternative to standard aorto-femoral bypass. [3] Criado et al.[4] described 16 cases that in addition to those reported in the English language literature, gave a combined surgical mortality rate of 6.4% and the primary graft patency was 98% at 1-year, 88% at 2 years, and 70.4% at 5 years. [5]

The risk of subsequent renal artery thrombosis is a concern with the use of thoraco-femoral bypass in patients with juxtarenal aortic occlusion. Using radioisotope renography prospectively, Cevese and Gallucci [6] confirmed normal renal perfusion up to 5 years after thoraco-femoral bypass in 6 patients with complete juxtarenal aortic occlusion. In our patients, renal function tests were normal postoperatively in all cases.

In our series, two patients having coronary artery disease were advised coronary artery bypass grafting followed by thoraco-femoral bypass. But on patient's choice, thoraco-femoral bypass was done first. Among these two patients, one had expired in the postoperative period after 24 h due to myocardial infarction. While most of the patients having mild pulmonary function test impairment, diabetes or hypertension behave normally in the postoperative period and discharged uneventfully.

In other series, [4],[5],[8] the graft was tunneled through posterior aspect of diaphragm to the left short transverse incision from this to both femoral arteries, but in our study we tunneled the graft anteriorly through anterior aspect of the diaphragm to the short midline incision then to both femoral arteries. All patients have good distal pulses.

Operative mortality rate was 0-12% in different series [4],[5],[8],[9] but in our series of 12 patients, no operative mortality was there and late mortality was 25-36% in other series [5],[7],[8] due to myocardial infarction, renal failure, stroke, respiratory insufficiency or septicemia. In our series, one patient died due to myocardial infarction 36 h postoperatively among two patients who also had coronary artery disease.

Graft failure or occlusion occurred in 4-30% cases on 3-5 years in another series. [4],[5],[8],[9] In our series one graft limb occluded, which was managed by embolectomy, had good distal flow and patient made a good recovery.

Our series demonstrated superior inflow, excellent quality of life, and more reliable patency with thoraco-bifemoral bypass. This approach is recommended in selected patients when conventional approaches to the abdominal aorta are considered hazardous [Table 1] and [Table 2].{Table 1}{Table 2}

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