The Role and Outcomes of Thoracodistal Bypass in the Endovascular Age

Abstract

Endovascular procedures are the treatment of choice for aortoiliac and lower extremity revascularization secondary to the low morbidity and mortality and faster rate of recovery. In this setting, the role of open bypass must be considered. Aortobifemoral bypass is the first line of treatment for extensive aortic and iliac disease; however, thoracodistal bypass continues to hold a niche position. We investigate the indications and outcomes of thoracodistal bypass via a review of literature. A review of the literature was performed in PubMed and Scopus using the search terms “thoracofemoral bypass,” “thoracic bifemoral bypass,” “juxtarenal Leriche syndrome,” and “aorto-iliac occlusive disease.” Thirty-nine papers were identified; articles published before 2000 and case studies published between 2000 and 2019 were excluded. Seven of eleven articles published between 2000 and 2019 met the exclusion criteria. In addition, five patients underwent thoracodistal bypass at Thomas Jefferson University Hospital between 2012 and 2019. A total of 129 cases of thoracodistal bypass were identified, including the five patients at Thomas Jefferson University Hospital. Our search included indications for the procedure. Primary outcomes included graft patency and 30-day mortality; secondary outcomes included surgical complications. A total of 129 cases of thoracodistal bypass were identified. Indications included complex or calcified paravisceral pathology (38.8%), previous failed bypass (22.5%), prior abdominal operations (18.6%), and infection (7.8%). For patients whose graft patency could be followed for at least 1 year (111/129 patients), the 1-year patency was 89% (Table I). Thirty-day mortality for all 129 cases was 4.7%. Complications occurred in 38% of patients. Major complications (cardiac, splenectomy, stroke, paraplegia, multiple organ failure) occurred in 7% of patients (Table II). Minor complications occurred in 31% of patients. Despite the advances and adoption of endovascular techniques, TFB continues to be a useful tool in a specific subset of patients. High graft patency and low 30-day mortality suggest that TFB is a safe and effective procedure for patients with specific indications. Short- and intermediate-term outcomes are promising but further studies are needed to evaluate long-term outcomes.Table IPatencyReferenceNo. of patients with patent graft at 3 monthsNo. of patients with patent graft at 6 monthsNo. of patients with patent graft at 1 yearCrawford et al. 2019393939Koksal et al. 2012202020Reppert et al. 20141111N/AMagnan et al. 2000292929Wistuba et al. 2015444Fukui et al. 2010444Koksal et al. 20025N/AN/AThomas Jefferson University Hospital553Total11711299Percent90.790.389.2 Open table in a new tab Table IIMajor complicationsReferenceCardiacSplenectomyStrokeParaplegiaMultiple organ failureCrawford et al. 201921000Koksal et al. 201210000Reppert et al. 201400100Magnan et al. 200001012Wistuba et al. 201500000Fukui et al. 201000000Koksal et al. 200200000Thomas Jefferson University Hospital00000Total32112Percent2.31.60.80.81.6 Open table in a new tab