Re-discovering an Old Standard: Ilio-Femoral Bypass, with Adjunctive Procedures, for Primary orSecondary Iliac Artery Occlusion

Abstract

<h3>Introduction and Objective</h3> Endovascular techniques constitute first-line treatment for iliac artery occlusions and enjoy outstanding primary and long-term durability. Some iliac occlusions are not amenable to endovascular repair because of calcification, chronic occlusion, and failed stents. Twenty-eight patients with unilateral iliac occlusion who were not candidates for or failed endovascular repair underwent ilio-femoral bypass. Extra-anatomical bypass was avoided because of previous contralateral procedures or risk to the contralateral extremity. This abstract reviews one surgeon's experience with ilio-femoral bypasses from December, 2014 to November, 2020. <h3>Case Report</h3> Twenty-eight (28) patients, 74% males, with an average patient age of 63.8 years and unilateral iliac occlusion, underwent ilio-femoral bypass. 88% were smokers, 38% were diabetics, and 30% had severe heart disease. Two patients had severe kidney disease requiring dialysis. Twenty-four patients underwent previous attempts at revascularization: 14 received iliac stents and 4 patients had failed aorto bifemoral or axillo/ilio femoral bypasses. There were 6 previous open interventions involving the femoral arteries. Two patients sustained rupture while undergoing endovascular procedures and required emergent bypasses. Indications for intervention were rest pain in 11, tissue loss in 8, and disabling claudication in 5. There were 3 urgent interventions: two required immediate intervention following rupture of an iliac artery angioplasty, and a third occurred during insertion of a thoracic stent. One procedure was performed fora 2-year-old infected iliac bypass with impending rupture. All operations were performed under general anesthesia. Proximal retro-peritoneal exposure of the iliac arteries was obtained via a curvilinear incision in the ipsilateral lower quadrant. Twenty-four (24) patients received a Dacron conduit, 2 PTFE, 1 bovine, and 1 femoral vein. Thirty-five (35) adjuvant procedures were done in conjunction with the bypass. In 14 cases (54%,) retrograde endarterectomy/thrombectomy/stent extraction was performed. Eleven patients (35%) required a femoral endarterectomy/thrombectomy. Angiography was used selectively if inflow was deemed inadequate. Six (6) intraoperative angiograms were needed with 2 patients requiring proximal stent insertions. Two patients received simultaneous femoral to distal bypasses done for tissue loss. <h3>Results</h3> Procedures were technically successful in 100% of patients. All bypasses were patent at the time of their loss to follow-up or death. Patients were followed for an average of 22.3 months. No secondary interventions were required. There was 1 groin infection that required excision of the graft; one above knee amputation was required for an infected knee prothesis. There was one groin hematoma. Two patients died within thirty days (8%), one from SIRS (multi-organ system failure following recent myocardial infarction) and one patient died of a coagulopathy following rupture of a calcified common iliac artery during angioplasty. There were no amputations due to vascular disease. 100% patency in this series was enhanced by adjunctive procedures. Ilio-femoral bypasses done to symptomatic elderly patient with occluded superficial femoral arteries frequently enjoyed relief of rest- pain without the morbidity of distal incisions. This group required endarterectomy of the common and deep femoral arteries. No hernias, local nerve injuries, lymphorrhea, damage to ureters, or major infections occurred. One groin infection was a catabolic, nursing home patient with an infected, ischemic, above knee residual limb. He required excision of the exposed graft. Patients tolerate the retroperitoneal approach usually without paralytic ileus and prompt restoration of bowel function. Respiratory insufficiency is also minimal since a major body cavity is not entered. The majority of patients were extubated before transfer to the post-operative acute care unit. <h3>Discussion</h3> Historically, ilio-femoral bypass is considered a durable operation with a cumulative patency of 92% 3- year patency and exhibit superior patency when compared to extra-anatomical bypasses that demonstrate a 73% 3-year patency. The operation has been largely supplanted by endovascular procedures which are equally durable and less invasive. There is a subset of patients in whom angioplasty/stents are not possible or who have failed endovascular intervention and require in flow procedures. In this series, ilio femoral bypass was only performed in 5 patients (19%) with claudication.The remaining patients had critical limb ischemia and required intervention for limb preservation. Ilio-femoral bypass with adjunctive procedures provided acceptable short term and mid-term results in complicated patients, 85% of whom had previously undergone ipsilateral vascular intervention.