In the Current Era of Endovascular Surgery, What is the Role of Axillofemoral Bypass?

Abstract

Introduction - Nowadays, axillofemoral bypass (AxFB) is viewed as an end-of-line solution for lower limb revascularization, owing to its classically described poor long-term patency and recent advances in endovascular surgery. There is a marked difference in patient profiles in published series of AxFB, reflecting changing procedures indications. The objective of this study is to determine the contemporary profile of patients treated with AxFB and their outcome. Methods - Patients who underwent AxFB surgery in a tertiary hospital from April 2011 to December 2017 were identified. Surgical indication, primary patency, major amputation and death rates were recorded. Patients were grouped in:-Bypass configuration: axillouni vs axillobifemoral;-Previous vascular surgery status: first revascularization procedure vs reintervention;-Primary vascular disease: aortoiliac occlusive disease vs aneurysmal disease,-Emergency character of procedure: urgent (initiated less than 24hours from patient presentation) vs planned (more than 24hours from patient presentation). Groups were compared using Kaplan-Meier survival analysis. Results - 56 patients were included. 44 (78,6%) underwent axillobifemoral bypass; remaining patients underwent axillounifemoral bypass. Median age was 68,18±9,59 years; 94,6% were male. The most prevalent cardiovascular risk factors were HTA (77%) and history of smoking (76%). Primary vascular disease was aneurysmal in 14 patients (25%). The remaining group had aortoiliac occlusive disease. AxFB was an urgent procedure in 11 patients (19,6%). In 30 patients (53,6%), AxFB was the first revascularization performed. Indications for procedure on this group were aorto-iliac occlusive disease (25; 83,3%) and AA thrombosis (5; 16,7%). In patients previously submitted to revascularization (26; 46,4%), the most common previous procedures were aortobifemoral bypass (12; 46,2%), femoro-femoral bypass (12; 46,2%) and EVAR (9; 34,6%). Indications for AxFB on this group were: prosthesis thrombosis (17; 65,4%), secondary aorto-enteric fistulae (7; 26,9%) and prosthesis infection (2; 7,7%). Global primary patency of AxFB was 91,5±4,1% at 1 month, 74,8±7,6% at 1 year, and 56,1±12,8% at 5 years (Fig.1). Group survival analysis showed superior primary patency in aneurysmal disease group (p=0,063), and after urgent procedures (p=0,113). Previous vascular surgery and bypass configuration did not affect long-term primary patency. No patient with aneurysmal disease required major amputation during follow-up. In primary occlusive disease group, 83,4±5,7% patients were free-of-amputation at 1 month, 77,2±6,8% at 1 year and 5 years. Amputation rates were similar regardless previous vascular surgery status, bypass configuration and urgency character of procedure. Median time of survival was 5,1±1,1years. Patients who underwent AxFB had a survival rate of 76,8±5,6% at 1 month, 64,7±6,6% at 1 year, and 50,0±7,8% at 5 years. Survival rates were similar regardless bypass configuration and primary vascular disease. However, patients whose AxFB was a vascular reintervention or an urgent procedure had significant worse long-term survival (p=0,042 and p=0,017, respectively). Conclusion - Axillofemoral bypass, although being an increasingly uncommon procedure, still allows acceptable rates of patency and limb salvage. As patients with aortoiliac disease usually have multiple comorbidities and a short life-expectancy, axillofemoral bypass is attractive owing to its less invasive character.