Axillofemoral Bypass Grafting in the Twenty-First Century

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Aortoiliac disease affects 8 to 10 million people in the United States annually. Treatment algorithms for aortoiliac disease have gone through several iterations over the past half-century. Although aortobifemoral bypass remains the “gold standard” for treating aortoiliac occlusive disease, axillobifemoral bypass avoids a midline laparotomy and aortic cross-clamping, significantly reducing operative stress, making this a favorable choice in high-risk patients. Early patency rates were poor plagued by graft compression and unequal flow rates. The introduction of externally supported protheses dramatically improved the durability of the axillobifemoral bypass. Axillofemoral bypass is typically performed in patients with chronic arterial insufficiency and symptoms of critical limb ischemia such as disabling claudication, rest pain, ischemic ulceration, or gangrene. There are other applications for the procedure, including acute occlusion or aortic dissection resulting in acute lower limb ischemia or aortic graft infection. Axillofemoral bypass may also be used as a temporary bypass or shunt to decrease lower extremity or visceral ischemia time during placement of a fenestrated aortic endograft or during thoracic aortic clamping for thoracoabdominal aortic reconstruction. Reported patency rates with axillofemoral bypass have varied widely over the past several decades in part because of changing patient selection and indications; however, axillofemoral bypass offers fair to excellent limb salvage rates in those presenting with critical limb ischemia. Axillofemoral bypass is an important and valuable option in the treatment of patients with aortoiliac occlusive disease. For many reasons, it is the preferred or only viable option for patients with significant anatomic or medical comorbidities, which preclude standard bypass options. Axillofemoral bypass can be performed with acceptable morbidity, mortality, and long-term results, even in high-risk patients.