Mini-Incision Thoraco-bifemoral Bypass in the Endovascular Era

Abstract

Endoluminal revascularization has supplanted open techniques for aortoiliac occlusive disease. Today, patients undergo open surgery following multiple endovascular failures or complete aorto-iliac occlusions. Hostile abdomens, calcified aortic anatomy, and tenuous pelvic circulation with significant inferior mesenteric artery contribution make the abdominal reconstruction suboptimal. Given these constraints, and the high faliure rates of extra-anatomic bypass, we prefer a mini incision thoracic-bifemoral (mini-TBF) approach to aortic bypass. Mini-TBF were performed in high risk patients with aorto-iliac occlusive disease and critical limb ischemia. Workup involves CT imaging of the thoracic aorta through the lower extremities to determine suitability of inflow along with magnitude of femoral reconstruction. Non-invasive studies provide physiologic data to supplement imaging. Cardiac risk stratification along with pulmonary function tests are also performed. Anesthetic considerations include invasive monitoring, double lumen intubation with one lung ventilation and positioning with left chest elevation. Inflow is constructed from the distal descending thoracic aorta via a ≤8 cm thoracotomy. A left flank incision for retroperitoneal exposure and two inguinal incisions are also created. Once proximal anastamosis is established, the limbs of the bifurcated graft are delivered through the diaphragm and the left limb is tunneled retroperitoneal over the psoas. The right limb is tunneled posterior to the anterior abdominal fascia or subcutaneously below the umbilicus to the right groin. Standard femoral anastomoses are performed and further adjuncts such as endarterectomy are performed if needed. Hemostasis is achieved and the incisions are closed in the usual three layer fashion. The patient is then returned to a supine position and bronchoscopy is performed through both lumens of the endotracheal tube. The patient is then extubated and delivered to the ICU.