Aortobifemoral Research Articles

Institution’s Obese Patient Proportion and Surgeon Case Volume Can Impact the Postoperative Length of Stay for Aortobifemoral Bypass Operations for Aortoiliac Occlusive Disease Among the Obese Patients

Aortobifemoral (ABF) bypass is the gold standard operation for treating patients with the symptomatic aortoiliac occlusive disease. This study is aimed to investigate the impact of obesity on postoperative outcomes after ABF bypass operations.

The Utility of Duplex Ultrasonography Surveillance in Identifying Failing Aortobifemoral Grafts.

The Society for Vascular Surgery stated there are a lack of studies describing long-term surveillance for aortobifemoral (AoBF) bypasses. Our goal was to investigate the value of DU studies as a surveillance tool for AoBF bypasses. We retrospectively identified patients in our prospectively maintained database who underwent AoBF bypasses between 1995-2018. Surveillance was performed routinely with DU post-operatively, every 6 months for 1 year, and then annually. We considered "abnormal" DU findings to include peri-graft fluid, pseudoaneurysm or, peak systolic velocities (PSVs) > 350 cm/sec or PSV ratio > 3.5 anywhere from the proximal aortic to distal femoral anastomosis. If abnormalities were identified patients underwent intervention or shorter surveillance intervals. Of 153 AoBF bypasses, 60 patients with 120 graft limbs fulfilled our post-operative surveillance protocol with a mean follow-up of 4.0 years (0.5-24 years). "Normal" DU surveillance studies were documented throughout follow-up in 112 (93%) limbs. Of these, 2 (1.7%) developed acute limb occlusion. Eight (6.7%) limbs had "abnormal" DU findings: 5 failing grafts with focal elevated PSVs, 2 with peri-graft fluid leading to a diagnosis of an infected graft, and 1 with a pseudoaneurysm (PSA). Contrast arteriography or CT-angiography confirmed > 75% diameter stenosis, fluid or PSA in all 8 limbs. Graft revision (5 endovascular, 2 surgical) was performed in 7 of the 8 limbs initially or after 2 successive "abnormal" DU studies within 6 weeks of each other; 1 patient refused intervention. Without surveillance, urgent or emergent treatment might have proved necessary in 7.5% (7 + 2 = 9/120) of cases instead of only 1.7% (2/120) of cases. Vascular surgeons should adopt DU as a useful surveillance tool to identify AoBF bypasses that are failing or have other problems not identified clinically. Persistence of "abnormal" DU findings should prompt operative or endovascular intervention.

Outcomes after redo aortobifemoral bypass for aortoiliac occlusive disease

Patients presenting with occluded aortobifemoral (ABF) bypass grafts are managed with a variety of techniques. Redo ABF (rABF) bypass procedures are infrequently performed because of concerns about procedural complexity and morbidity. The purpose of this analysis was to compare midterm results of rABF bypass with those of primary ABF (pABF) bypass for aortoiliac occlusive disease to determine if there are significant differences in outcomes. A retrospective review was performed of all patients undergoing ABF bypass for occlusive disease between January 2002 and March 2012. A total of 19 patients underwent rABF bypass and 194 received pABF bypass during that period. Data for an indication- and comorbidity-matched case-control cohort of 19 elective pABF bypass patients were collected for comparison to the rABF bypass group. Primary end points included rate of major complications as well as 30-day and all-cause mortality. Secondary end points were amputation-free survival and freedom from major adverse limb events. The rABF bypass patients more frequently underwent prior extra-anatomic or lower extremity bypass operations compared with pABF bypass patients (P = .02); however, no difference was found in the incidence of prior failed endovascular iliac intervention (P = .4). By design, indications for the rABF and pABF bypass groups were the same (claudication, n = 6/6 [31.6%]; P = 1; critical limb ischemia, n = 13/13 [78.4%]; P = 1). Aortic access was more frequently by retroperitoneal exposure in the rABF bypass group (n = 13 vs n = 1; P < .0001), and a significantly higher proportion of the rABF bypass patients required concomitant infrainguinal bypass or intraprocedural adjuncts such as profundaplasty (n = 14 vs n = 5; P = .01). The rABF bypass patients experienced greater blood loss (1097 ± 983 mL vs 580 ± 457 mL; P = .02), received more intraoperative fluids (3400 ± 1422 mL vs 2279 ± 993 mL; P = .01), and had longer overall procedure times (408 ± 102 minutes vs 270 ± 48 minutes; P < .0001). Length of stay (days ± standard deviation) was similar (pABF bypass, 11.2 ± 10.4; rABF bypass, 9.1 ± 4.5; P = .7), and no 30-day or in-hospital deaths occurred in either group. Similar rates of major complications occurred in the two groups (pABF bypass, n = 6 [31.6%]; rABF bypass, n = 4 [21.1%]; observed difference, 9.5%; 95% confidence interval, -17.6% to 36.7%; P = .7). Two-year freedom from major adverse limb events (±standard error mean) was 82% ± 9% vs 78% ± 10% for pABF and rABF bypass patients (log-rank, P = .6). Two-year amputation-free survival was 90 ± 9% vs 89 ± 8% between pABF and rABF bypass patients (P = .5). Two-year survival was 91% ± 9% and 90% ± 9% for pABF and rABF bypass patients (P = .8). Patients undergoing rABF bypass have higher procedural complexity compared with pABF bypass as evidenced by greater operative time, blood loss, and need for adjunctive procedures. However, similar perioperative morbidity, mortality, and midterm survival occurred in comparison to pABF bypass patients. These results support a role for rABF bypass in selected patients.

Isolated pharmaco-mechanical thrombectomy (IPMT) for the endovascular treatment of acute axillofemoral graft occlusion

Since the long-term patency of axillofemoral (AXF) grafts is inferior to aorto-bifemoral (ABF) grafts, limb salvage procedures are crucial in this group of patients. Emerging endovascular devices have helped in the successful restoration of flow for acute limb ischemia in both native arteries as well as bypass grafts. One such device, the Trellis thrombectomy system is being used more frequently in this setting. The device has previously been used in veins, native arteries, and rarely in aortofemoral grafts. We present its first successful use for the treatment of occluded AXF bypass graft. The use of this device helped to isolate the treatment zone in the occluded graft, which allowed the use of a lower dose of thrombolytics, less systemic release of thrombolytics, and less distal embolization. Resolution of extensive clot burden was achieved and, with subsequent stenting of the graft at the distal anastomotic site, arterial flow to the leg through the AXF graft was restored and a revision surgery was avoided.

Results of iliac stenting and aortofemoral grafting for iliac artery occlusions

To compare long-term results of percutaneous iliac artery stenting (PCIS) with aortobifemoral (ABF) grafting for patients with symptomatic iliac artery occlusions. A retrospective review of 229 patients (January 2000 to December 2011) with symptomatic iliac artery occlusions was performed. In 100 patients, 103 PCIS procedures were performed, and 101 patients underwent ABF grafting. Outcome data including periprocedural complications, improvement in ankle-brachial index, morbidity, and mortality were collected in a vascular registry. Kaplan-Meier estimates for patency and survival were analyzed. Univariate (Fisher exact test) and multivariate analyses of variables associated with the loss of primary patency were performed. Patients in the ABF grafting group were younger (60 ± 0.9 years old vs 65 ± 1.2 years old; P = .002) and more commonly had a history of nicotine abuse (97% vs 86%; P = .002), chronic obstructive pulmonary disease (85% vs 70%; P = .02), and a greater incidence of superficial femoral artery disease (45% vs 24%; P = .001). The most common presenting symptoms in both groups consisted of intermittent claudication (66% ABF vs 71% PCIS), rest pain (20% ABF vs 17% PCIS), and ulceration or gangrene of toes (14% ABF vs 15% PCIS). At 72 months, the primary patency for ABF bypass was greater than for PCIS (91% vs 73%; P = .010). Secondary patency rates were equivalent in both groups (98% ABF vs 85% PCIS). Survival in the ABF bypass group was significantly greater than in the PCIS group (76% vs 68%; P = .013). Hyperlipidemia (hazard ratio, 2.55; P = .049) and concurrent superficial femoral artery lesion (hazard ratio, 2.61; P = .026) were factors associated with the loss of primary patency for the entire cohort. The average hospital stay was 7 ± 2 days in the ABF group and 1 ± 0.3 days in the PCIS group (P = .0001). There were no periprocedural deaths in the PCIS group; there were four deaths in the ABF group (P = .058). In the PCIS group, ankle-brachial index increased from 0.66 to 0.89, and in the ABF group, ankle-brachial index increased from 0.54 to 0.98 (both groups, P < .001). This study demonstrates that PCIS remains a suitable, less invasive first-line therapy for iliac artery occlusions. PCIS has lower morbidity, shorter hospital length of stay, and equivalent secondary patency but inferior primary patency compared with ABF.

A Laparoscopic Endovascular Aortobifemoral Conduit That Can Be Retained as a Long-term Bypass: A Solution for Patients With Inadequate Iliac Access

To present a laparoscopic technique for placing a partially stented aortobifemoral (ABF) conduit that can be used for more proximal endovascular manipulations and then be retained as a permanent bypass of occlusive iliac disease. Ethical approval was obtained to use a fresh frozen cadaver. The left common iliac artery, distal aorta, and proximal right common iliac artery were dissected laparoscopically. A curved hollow needle was inserted into the distal aorta, and wire access was obtained. A partially stented bifurcated Dacron bypass graft was deployed under fluoroscopic guidance into the distal aorta. The limbs of the bypass were then used as conduits for endovascular access before being tunneled behind the ureters and anastomosed to the femoral arteries in the usual way, retaining the stented graft as an ABF bypass. This novel technique combines laparoscopic access with endovascular manipulation to place an ABF conduit, which can be retained as a permanent bypass without the need for an abdominal incision. This technique could provide a minimally invasive solution for pelvic occlusive disease that hinders endovascular repairs, as well as a minimally invasive means of securing endoluminal access in patients with iliac arteries of inadequate caliber.

Endovascular occlusion of a common iliac artery aneurysm after open repair of an abdominal aortic aneurysm

Endovascular therapy is a safe alternative to treat the late complications of open aortic surgery. Here we report the endoluminal treatment of a recurrent common iliac aneurysm. A 68-year-old man, who submitted five years previously to an aorto bifemoral in order to exclude a juxta renal aortic aneurysm, developed a recurrent aneurysm of the left common iliac artery. He underwent an occlusion of the external iliac artery with a self-expandable nitinol mesh occlusion device and the aneurysm was embolized with detachable coils, with a good outcome. Endoluminal therapy does not expose patients to elevated risks, and may be indicated in selected cases to treat the complications of open surgery.

Selective application of sartorius muscle flaps and aggressive staged surgical debridement can influence long-term outcomes of complex prosthetic graft infections

The complexity of variables associated with vascular surgical site infections (VSSI) often contribute adversely to reinfection, limb salvage, and mortality rates. This report details our experience with the selective use of a sartorius muscle flaps (SMF) as part of an overall treatment strategy focused on staged surgical debridement (SSD) to control prosthetic graft bed infection prior to a graft preservation or revision plan. From our vascular registry, we identified 422 VSSI of which 89 (21%) had SMF for 24 aorto-bifemoral (ABF), 19 extra-anatomic bypasses (EAB), 34 infrainguinal bypasses, and 12 combined inflow/outflow reconstructions. All 86 patients had Szilagyi grade III prosthetic (Dacron-36, polytetrafluoroethylene [PTFE]-50) graft infections. The treatment algorithm included: SSD, culture-directed parenteral antibiotics, graft preservation (n = 3), or reconstruction (graft excision/EAB, n = 4; rifampin-bonded PTFE, n = 22; autologous conduit, n = 57) based on microbiology and consideration for SMF for extensive soft tissue defects (n = 43) or non-sterilized graft beds (n = 40). Analysis of microbiology, recurrent infection, vascular reconstruction, limb salvage, and mortality was completed over a mean follow-up of 52 months (range: 12 to 132 months). Thirty-day mortality was 2% with two aortic graft infections dying from sepsis. Survival by life table analysis at 1, 3, and 5 years was 94%, 92%, and 90%, respectively. Wound isolates were most commonly gram positive organisms (n = 58, 65%), with gram negative isolates and mixed infections accounting for 19% and 10%, respectively. A single recurrent groin infection was documented at 30 days. Freedom from recurrent infection (n = 6) at 1 and 5 years was 98% and 92% by life tables. Methicillin-resistant Staphylococcus aureus (MRSA) was involved for 50% of reinfections. No amputations were attributable to uncontrolled VSSI and graft patency was 100% in surveillance monitored patients. These results suggest that selective utilization of SMF as part of SSD treatment plan in an attempt to achieve graft bed sterilization can effectively control the complex infectious process allowing for potentially improved outcomes for in situ or preservation graft salvage techniques. Lifelong graft surveillance is recommended.

Bilateral obturator bypass for combined aortic and femorofemoral graft infection

A 60-year-old man underwent end-to-end aortobifemoral (ABF) bypass for occlusive disease. 1,2 He subsequently underwent a right-to-left femorofemoral bypass (FFB) for occlusion of the left limb of the ABF. He was referred 4 years later with fever, malaise, and purulent drainage from the right groin. A computed tomographic scan demonstrated fluid surrounding the FFB and the right limb of the ABF (A). A segment of infrarenal aorta proximal to the ABF graft appeared normal. Standard inframesocolic exposure was obtained via the previous midline incision. No fluid was evident at the graft bifurcation, and it appeared well incorporated. The residual infrarenal aorta was dissected free and prepared for an anastomosis. Openings were made in the ventromedial aspect of the obturator membrane bilaterally while standard medial exposure of the above-knee popliteal arteries was performed. Expanded polytetrafluoroethylene grafts ((W.L. Gore & Association, Inc., Tempe, Ariz) Intering; 8 mm 40 cm) were tunneled from the popliteal sites through the obturator foramina into the abdomen. (B) The limbs of a bifurcated expanded polytetrafluoroethylene graft (Gore-Tex; 18 9 mm) were cut 1 cm from the graft bifurcation, and graft-to-graft anastomoses were performed bilaterally. After systemic anticoagulation, the infrarenal aorta and the limbs of the ABF were clamped. The limbs were then transected, ligated, and advanced antegrade along the iliac tunnels. The residual body of the ABF graft was excised. The new bifurcated graft was sewn end to end to the infrarenal aorta proximally. The graft-to-graft anastomoses were assessed for hemostasis before the grafts were pulled through the previously fashioned obturator tunnels. End-to-side anastomoses were performed distally. The wounds were closed and covered with occlusive dressings before complete excision of the residual ABF limbs and the FFB via bilateral femoral and suprapubic incisions. The femoral and suprapubic incisions were packed, and the patient was maintained on chronic oral antibiotic therapy. At 24 months, he had no evidence of recurrent infection and was ambulatory at home. A follow-up computed tomographic scan demonstrated no fluid collections and patent grafts (C; cover image). The treatment of infected ABF grafts is a difficult problem. Options include in situ reconstruction with femoral vein, cryopreserved allografts, or antibiotic-impregnated synthetic grafts. Extra-anatomic reconstruction to the popliteal level is not an ideal solution secondary to poor patency. We suggest that reconstruction with synthetic bilateral obturator bypass is a viable option if there is adequate residual infrarenal aorta. This procedure allows for complete treatment of the femoral pathology and should have improved patency compared with longer extra-anatomic bypasses.

Exclusion Bypass in Peripheral Vascular Surgery

Although the technique of end-to-end proximal aortic anastomosis for peripheral bypass surgery has been widely accepted, the distal exclusion of the proximal native circulation has not been given much attention. Experimentally it has been shown that an end-to-end anastomosis at the distal end of the bypass graft has better hemodynamics and flows than an end-to-side. A group of 20 patients are reported here in whom a total exclusion bypass was carried out proximal and distally. One single case of aorto bifemoral is reported, 6 ileo-femoral, 12 femoro-popliteal, and 1 femoro-femoral bypass. Gortex grafts were used in all instances. Blood flows measured beyond the distal anastomosis show an increase in flow after the proximal native vessel is excluded completely at the distal anastomotic site. This technique, therefore, is advocated and recommended over the classic proximal and distal end-to-side anastomosis for ileo- femoral and femoro-popliteal bypass reconstructions.