An optimal inflow procedure for multi-segmental occlusive arterial disease: ilio-femoral versus aorto-bifemoral bypass

Abstract

Treatment of chronic critical limb ischemia still remains one of the most serious problems of vascular surgery. Most often, chronic critical limb ischemia is caused by multi-segmental disease of arterial tree, involving both the aorto-femoral and infrainguinal vessels. In the majority of these cases, proper correction of aorto-iliac arteries is sufficient to restore the circulation in lower limbs. However, in 10–15% it is necessary to perform multi-segmental reconstructions. In these cases it is extremely important to choose the optimal inflow procedure. The aim of this retrospective study was to compare perioperative and long-term results of multi-segmental reconstructions, using aorto-bifemoral, unilateral ilio-femoral, and extra-anatomical bypass as inflow procedures. During the 10-year period (1984–1994), 4074 aorto-femoral reconstructions were performed for treatment of occlusive arterial disease. In 449 cases (11%), multi-segmental aorto-femoro-poplteal/tibial reconstructions were undertaken. Aorto-bifemoral bypasses was performed in 131, unilateral ilio-femoral bypasses in 288, and extra-anatomical bypasses in 30 cases. In 221 cases, the operations were performed in one stage, and in 228 cases a two-stage procedure took place. Postoperative mortality was 3.8% in the aorto-bifemoral bypass group, 1.3% in the unilateral ilio-femoral group, and 3,3% in the extra-anatomical group. Primary inflow graft patency rate after 12 months was 94.7% in the aorto-bifemoral bypass group, 94.1% in the unilateral ilio-femoral group, and 80% in the extra-anatomical group. Secondary inflow graft patency rate was 97.8% in the aorto-bifemoral bypass group, 96.2% in unilateral ilio-femoral group, and 96.7% in extra-anatomical group. The 5-year primary and secondary graft patency rates were 90.9% and 94.7% in the aorto-bifemoral bypass group, 88.5% and 93.4% in the unilateral ilio-femoral group, and 66.7% and 77.3% in the extra-anatomical group, respectively. Conclusion: Unilateral ilio-femoral bypass as an inflow procedure for treatment of multilevel occlusive arterial disease is as effective as aorto-bifemoral bypass, with lower perioperative mortality and morbidity rates. Extra-anatomical bypasses are, however, less effective.