Femorofemoral bypass in unilateral iliac artery occlusion

Two cases of recurrent uterine cervical cancer with arterio-enteric fistula treated by femoro-femoral artery bypass in hybrid operation room

Little has been reported regarding aortic-enteric fistula (AEF) as a complication of gynecologic cancers because of its rarity. However, since it is lethal if left untreated, medical practitioners involved with gynecologic diseases should be aware of this deadly condition. In our hospital, we encountered two cases of cervical cancer complicated by AEF. In both cases, contrast computed tomography (CT) revealed leakage of the contrast material from an artery into the small intestine, indicating AEF. Endovascular procedures with complete embolization of the affected arteries and femoro-femoral artery bypass (f-f bypass) were performed in the hybrid operation room. The activities of daily living improved dramatically for both patients, and they survived for 3 months before dying from cervical cancer. While embolization by endovascular methods and f-f bypass performed in a hybrid operation room is, therefore, an available option for treating AEF, literature is lacking and more research is required to improve long-term outcomes for this disease.

Endovascular treatment for unilateral chronic total occlusions of the iliac artery categorized as TASC II type D lesions

PURPOSE

To compare the results of endovascular treatment for unilateral iliac occlusion in types B and D, and confirm its validity for type D.

METHODS

Between 2000 and 2011, 108 patients underwent endovascular treatment for unilateral iliac occlusion. 77 were categorized as type B for occlusion of common iliac artery (CIA) or external iliac artery (EIA) and 31 were categorized as type D for occlusion of both CIA and EIA. The initial success rates, procedure time, penetration time, amount of contrast media used, complication rates, and cumulative primary patency rates were determined and compared between these groups.

RESULTS

Between type D and B groups, the initial success rates were 87.1 % (type D) and 89.6 % (type B) (p = 0.9316). The procedure time was 137.0 ± 55.5 and 97.2 ± 47.2 min (p < 0.05). The penetration time was 49.1 ± 40.6 and 31.6 ± 30.1 min (p < 0.05). The amount of contrast agent used was 193.9 ± 103.1 and 156.5 ± 85.0 ml (p = 0.0722). The complication rates were 6.5 and 3.9 % (p = 0.8491). The cumulative primary patency rates, at 1, 3, and 5 years were 91, 85, and 85 % and 100, 96, and 93 %.

CONCLUSION

Endovascular treatment can be indicated for unilateral occlusion of both CIA and EIA categorized as type D.

[Cross over bypasses ilio-femoral and femoro-femoral. Indications and results about 60 cases]

The goal of this retrospective study is to review indications and results of cross over bypasses.

METHODS AND MATERIAL

between January 1990 and December 2000, 60 patients (all males with mean age = 60 years) underwent cross over bypass for unilateral iliac occlusive disease: femoro-femoral in 48%, ilio-femoral in 44% and ilio-popliteal in 8%.

RESULTS

mortality was 5% while complications occurred in 13.3%. Early limb salvage rate was 92%. During follow-up (mean: 32 months) we noticed 13 late thrombosis. The actuarial patency rate being at 83.5%, 74% and 67% at 1 year, 3 years and 5 years respectively.

CONCLUSION

cross over bypasses are technically simple with low morbidity and acceptable results. In addition to widely accepted indications (general or local unfavourable conditions to approach abdominal aorta), cross over bypasses may be considered as satisfactory challenge even in young patients with how operative risk.

Is the preferential use of ePTFE grafts in femorofemoral bypass justified?

The choice of prosthetic graft material for cross-femoral bypass has been evolving in the past two decades. Expanded polytetrafluoroethylene (ePTFE) has become our preferred graft material since 1995. However, few studies have looked into the optimal graft material in this procedure. Justification for the preferential use of ePTFE graft in lower limb revascularization remains unknown. The aim of the present study was to compare the long-term outcomes of Dacron and ePTFE grafts in femorofemoral bypass. The records of 61 consecutive patients who underwent femorofemoral bypass at the University of Hong Kong Medical Center from 1981 to 1998 were retrospectively reviewed. Dacron grafts were used in 27 patients and 34 patients had ePTFE grafts. The demographic features, patency, and limb salvage rates of the two groups of patients were compared. The 3-year primary patency rates of Dacron and ePTFE grafts were 85% (SE = 9.5%) and 66% (SE = 14.5%), respectively. The difference was not statistically significant. The limb salvage rates of Dacron and ePTFE grafts were 91% and 83% at 3 years, respectively (p = 0.27). The long-term outcomes of Dacron and ePTFE grafts in femorofemoral bypass were equivalent. The preferential use of ePTFE graft in femorofemoral bypass is not evidence based. Selection of an appropriate prosthetic graft for femorofemoral bypass should be based on the cost and its handling characteristics.

The significance of donor leg distal runoff in femorofemoral bypass grafting

BACKGROUND

The aim of this study is to determine if femorofemoral bypass grafting is an effective operation for unilateral iliac occlusive disease, and to assess for factors that may predict a poorer outcome. A retrospective review was conducted of cases identified from a prospective audit database.

METHODS

Information was obtained from the clinical notes of 97 patients who had 100 femorofemoral bypass graft operations. All living patients were invited for assessment which included colour duplex sonography of the graft and measurement of the ankle brachial index.

RESULTS

Using life-table analysis, the five-year graft secondary patency for claudicants was 79% and for those with critical ischaemia 78%. Five-year survival for claudicants was 65% and for those with critical ischaemia, 38%. Poor distal runoff in the infrapopliteal arteries of the donor limb adversely affected graft patency. Graft survival was not affected by the indication for operation, by donor or recipient superficial femoral artery patency, or by the need for endarterectomy, pre-operative angioplasty or the graft material.

CONCLUSIONS

Femorofemoral bypass grafting is the procedure of choice for all patients who require surgical intervention for unilateral iliac occlusion and donor limb distal runoff may be an important determinant of graft patency.

A comparative evaluation of femorofemoral crossover bypass and iliofemoral bypass for unilateral iliac artery occlusive disease

The purpose of this study was to compare the results of extra-anatomic femorofemoral crossover bypass grafting to the anatomic iliofemoral bypass grafting procedure in the treatment of patients with unilateral iliac artery occlusive disease with respect to patency and limb salvage. The records of all patients with unilateral iliac artery disease who underwent revascularization between January 1988 and December 1995 at the University of Iowa Hospitals and Clinics (UIHC) were retrospectively reviewed; 108 patients were identified and divided into two groups. Group I (n=68; male/female=44/24) was composed of all patients who underwent a femorofemoral crossover extra-anatomic bypass. All patients who underwent an iliofemoral anatomic bypass constituted group II (n=40; male/female=24/16). The mean age for group I was 60 years (range 28-87) and for group II, 54 years (range 14-86). The medical risk factors between both groups were comparable. Except for the higher incidence of gangrene in group II the indications for surgery were comparable between both groups. A polytetrafluoroethylene graft was used in 88% of group I patients and in 90% of group II patients (NS). In the remaining patients, an autogenous vein conduit was used. Two patients from group I (2.9%) died in the perioperative period (NS). Graft patency was assessed by clinical evaluation, Doppler-derived ankle/brachial indices, and color duplex imaging. The cumulative primary and secondary patency rates, limb salvage, and patient survival were calculated by use of life table analysis (SE<0.1). The need for simultaneous outflow and inflow procedures at the time of surgery was comparable between both groups. The proportion of patients who underwent further revascularization during follow-up was also comparable. The 5-year primary and secondary graft patency rates were 81.7% and 90.3%, in group I and 61.3% and 80.5% in group II. Although the difference between both groups was not significant there was a tendency toward higher rates with femorofemoral bypass. The 5-year survival rates of 80.3% for group I and 73.3% for group II were comparable. These data suggest that there is no significant difference in the long-term results between the femorofemoral crossover bypass grafts and iliofemoral grafts. Both procedures result in acceptable patency and limb salvage rates. The femorofemoral bypass is, however, more attractive, for it can be performed under local anesthesia if needed and does not involve the creation of the retroperitoneal incision necessary with the iliofemoral bypass.

Femorofemoral crossover grafts for claudication: a safe and reliable procedure

OBJECTIVE

To evaluate the role of femorofemoral crossover grafts in patients with disabling claudication.

DESIGN

Retrospective study.

SETTING

University hospital.

MATERIALS

Two hundred and eleven patients with iliac artery disease undergoing femorofemoral crossover grafts for disabling claudication.

CHIEF OUTCOME MEASURES

Perioperative mortality, follow-up cumulative graft patency, limb loss, survival, graft infection and false aneurysm formation were evaluated to determine the immediate and long-term outcome of the procedure.

MAIN RESULTS

Primary and secondary graft patency at 5 years was 72% and 89% respectively. There were no perioperative deaths (zero 30 day mortality). Dacron was used in 66 patients (31%) and PTFE in 145 (69%). There were no differences in patency between the two graft materials but eight Dacron grafts (12.1%) were removed because of complications (false aneurysm or infection) compared to four PTFE grafts (2.7%) (p < 0.001 Chi-square). Five patients (2%) have undergone a major lower limb amputation. Forty-one patients (19%) have required subsequent inflow procedures which represents a cumulative need for inflow of 5% per year.

CONCLUSIONS

Femorofemoral crossover grafts are a safe and reliable procedure in patients with disabling claudication caused by unilateral iliac artery disease.

Does donor iliac artery percutaneous transluminal angioplasty or stent placement influence the results of femorofemoral bypass? Analysis of 70 consecutive cases with long-term follow-up

PURPOSE

Femorofemoral bypass procedures are being performed with increasing frequency in some patients with bilateral disease in whom the "donor" iliac artery undergoes percutaneous transluminal angioplasty or stent placement. This study was undertaken to critically examine the efficacy of this approach.

METHODS

The records of 70 consecutive patients who over a 14-year period underwent elective femorofemoral bypass procedures for chronic occlusive disease, including those who did (group I; n = 26) and did not (group II; n = 44) undergo donor iliac percutaneous transluminal angioplasty or stent placement, were reviewed.

RESULTS

No significant differences were found between group I and II patients with respect to age, gender, risk factors, surgical indications, preoperative ankle-arm indices, and the performance of associated procedures. One patient (1.4%) died of a myocardial infarction; no other major cardiopulmonary complications occurred. The postoperative change in the group I donor limb ankle-brachial index ranged from -0.18 to 0.11 (mean, 0.00), revealing no significant steal. The primary graft patency rates for group I and II patients 30 days after surgery were 92% and 98%, respectively, and at 1, 3, 5, and 7 years after surgery were 87% and 81%, 79% and 73%, 79% and 59%, and 66% and 59%.

CONCLUSIONS

Donor iliac artery percutaneous transluminal angioplasty or stent placement does not compromise the results of femorofemoral bypass procedures in patients with chronic iliac artery occlusive disease.

Autogenous vein grafts for femorofemoral revascularization in contaminated or infected fields

PURPOSE

The purpose of this study was to determine the indications and the long-term results for femorofemoral revascularization with autogenous vein grafts (AVG) rather than conventional synthetic materials.

METHODS

A consecutive series of 13 men and 12 women (mean age 64 years) receiving femorofemoral AVG was collected during a retrospective review of our experience from 1979 to 1992. Sixteen of these 25 patients required revascularization for acute ischemia in the presence of potential groin contamination (group 1), and the remaining nine had frank infections involving previous synthetic grafts (group 2). New grafts were constructed with the greater saphenous vein in 23 patients (92%) and with the cephalic vein in two.

RESULTS

One patient in each group (8%) died after operation with patent grafts. Preoperative and postoperative ankle/brachial indexes (ABI) were available for 12 patients in group 1 and for seven patients in group 2. There was significant improvement in the ABI among 11 patients with ischemia in group 1 (mean 0.33 +/- 0.13; p = 0.0001), whereas no change in the ABI occurred in conjunction with the replacement of patent infected grafts among six patients in group 2 (mean 0.04 +/- 0.17; p = NS). One patient from each group sustained a reduction in postoperative ABI for the recipient limb despite a patent AVG. Cumulative 3-year survival and primary patency estimates for all 23 operative survivors were 63% and 75%, respectively. Late results seemed to be comparable in group 1 and group 2, but each contained too few patients for adequate analysis.

CONCLUSIONS

Despite their infrequent use, AVG seem to represent a reasonable alternative to synthetic bypass for femorofemoral revascularization in patients having either contaminated wounds or established graft infections.

Hydrodynamic simulation of arterial networks which include compliant and rigid bypass grafts

The conditions required to produce an ideal bypass graft have not yet been determined. In order to understand the hemodynamic impact of bypass grafts on cardiovascular function, a hydrodynamic model for the part of the human arterial network below the renal arteries has been constructed. The results from this physical model were used to validate a digital computer model of the arterial network developed by the authors, that incorporated loops which occur due to bypass grafts. The hydrodynamic model was designed to study the interaction between an arterial stenosis and bypass graft and, in particular, the effect of the compliance of the graft on their function. In the model, similarity laws have been maintained with regard to geometry, viscosity, peripheral resistance, wall elastic properties, pulse shape, and blood flow rate. Measured and predicted pressure and flow wave-forms showed an increase in their mean and peak values for the healthy leg when the bypass graft was closed. There was also a severe pressure drop across the stenosis and a marked decrease in mean and pulsatile flow in the stenotic leg. The stenosis in the hydrodynamic model produced similar behaviour to published results obtained on animals. When the graft was open, the agreement between our experimental and theoretical model was within 5% and both the pressure and flow waves were almost similar at the maxima and minima in both legs. Although the arterial system is non-linear, the non-linearities are shown to be of insignificant magnitude and therefore, we have concluded that the pressure flow relationship is essentially linear. The effect of the degree of compliance of the graft and the 'steal' phenomenon due to the graft have been investigated. It was found that there were no significant differences in the flow delivery between the compliant graft and stiff graft. Also, there was no 'steal'. Thus the compliance of the graft is not a significant factor in promoting its patency.

Femorofemoral versus aortobifemoral bypass: outcome and hemodynamic results

PURPOSE

Femorofemoral bypass (FFB) is used in selected patients when aortobifemoral bypass (AFB) is believed to be inappropriate because of high operative risk or predominantly unilateral iliac artery occlusive disease. We examined concurrent patients who underwent either FFB or AFB to better understand the appropriate use of FFB.

METHODS

The characteristics and outcomes of patients who underwent FFB and AFB during 1986 to 1991 at our institution were retrospectively reviewed. Primary measures of outcome included patient survival, graft patency, limb salvage, and hemodynamic performance of FFB and AFB. Further analysis was performed after substratification for low versus high risk and claudication versus limb threat as the indication for surgery.

RESULTS

FFB was performed in older patients with more medical comorbidities when compared with AFB. Long-term graft patency was inferior after FFB compared with AFB (60% vs 85% at 3 years, p < 0.01). However, both FFB and AFB achieved limb salvage in more than 85% of patients at 3 years. When patients at low risk undergoing nonemergency AFB were compared with patients at low risk who underwent FFB and who had no contraindication to AFB, FFB proved inferior to AFB as measured by graft patency (primary patency 61% vs 87% at 3 years, p < 0.03) and hemodynamic performance (predicted ankle-brachial index with perfect outflow 0.82 after FFB vs 1.03 after AFB). On the basis of a detailed analysis of patient and graft risk factors, we could not explain the inferior patency rate of FFB, although our analysis suggested that inadequate inflow may contribute.

CONCLUSIONS

FFB is inferior to AFB as measured by patency and hemodynamic function. This inferior performance is independent of indications for FFB. AFB should remain the standard therapy for patients at low risk with iliac occlusive disease, but FFB provides adequate function and limb salvage in patients at high risk.

Haemodynamic model of a unilateral iliac stenosis with an aortoiliac bypass

A hydrodynamic model for the part of the human arterial network below the renal arteries has been constructed using specially fabricated distensible tubes and a pulsatile pump to simulate an aortoiliac bypass. The experiments and the computer model indicated that no 'steal' occurred due to the insertion of the bypass graft. Also, the results showed that the length of the stenosis had a non-systematic apparent effect on the physiological significance of the obstruction and that the kinetic power represented only a small percentage of the total power. The total power efficiency of the bypass graft was unaffected by its elastic properties. The experimental investigation also indicated that the pressure drop across the stenosis was considerably larger than the drop calculated using the Poiseuille flow relationship when the stenosis was severe. Therefore, a critical arterial stenosis value cannot be defined as an obstruction of a constant percentage reduction of luminal area. It varies directly with the effective cross-sectional area and inversely with the flow rate. The value of angiography in assessing the functional significance of any arterial stenosis is therefore limited. A better method for evaluation requires quantitative measurements of local blood pressure and blood flow, not only at rest, but also under conditions creating augmented flows due to exercise.

Iliofemoral versus femorofemoral bypass: a 6-year audit

Iliofemoral and femorofemoral crossover bypass operations performed over a 6-year period were reviewed. A total of 226 patients underwent 231 operations from 1984 to 1990. Seventy-two patients had 75 iliofemoral grafts and 154 patients had 156 femorofemoral grafts. The early mortality rate was 6 per cent for the iliofemoral group and 1.3 per cent for femorofemoral reconstruction. There was a higher reoperation rate in the iliofemoral group (31 versus 16.0 per cent). The cumulative patency rate at 6 years was 75 per cent for iliofemoral bypass and 92 per cent for the femorofemoral procedure (P < 0.01), while the survival rates for the same period were 55 and 74 per cent respectively (P < 0.01). Hospital stay was significantly shorter for patients undergoing femorofemoral bypass (P < 0.05).

Donor iliac angioplasty and crossover femorofemoral bypass

We reviewed our experience with 99 patients who had 111 femorofemoral bypass grafts placed over a 10-year period. Mean follow-up was 36 +/- 28 months (range: 1 to 120 months). Bypass alone was performed in 89 cases (group 1). Preoperative donor iliac angioplasty was utilized in 22 cases (group 2). Overall graft failure was 21 of 89 in group 1 and 2 of 22 in group 2 (difference was not significant by chi 2: p greater than 0.05). Clinical success as calculated by life-table analysis was 95%, 83%, 75%, and 67% at 1, 3, 5, and 7 years, respectively, for group 1. Clinical success was 100% and 91% at 1 and 3 years, respectively, and 91% at 42 months for group 2. The success rates were not different for the two groups when analyzed by the log-rank test at 42 months (p greater than 0.30). We conclude that donor iliac angioplasty and femorofemoral bypass is an excellent option for patients with severe occlusive disease of one iliac artery and contralateral disease amenable to angioplasty.

Thrombolysis and the femorofemoral bypass graft: a new technique

Two patients with acutely thrombosed femorofemoral bypass grafts are presented. Recombinant human tissue-type plasminogen activator (rt-PA) was used successfully in thrombolysis of the occluded grafts. Utilizing a new technique the grafts were punctured directly and bolus doses of rt-PA administered.

Comparison of iliofemoral and femorofemoral crossover bypass in the treatment of unilateral iliac arterial occlusive disease

Between 1981 and 1988, 74 synthetic crossover bypass grafts were inserted for unilateral iliac arterial occlusive disease. In 32 patients the bypass procedure was iliofemoral and in 42 femorofemoral. The cumulative patency rate at a mean of 2.7 years was 79 per cent in both groups. There was no significant difference in either postoperative mortality rate or duration of hospital stay. Iliofemoral bypass may offer significant advantages over the femorofemoral approach. In particular it avoids a groin incision in the donor limb, leaving the common femoral artery intact for subsequent angioplasty or reconstruction should proximal stenotic disease develop in the donor iliac vessel.

Extra-anatomic femoro-femoral crossover bypass (FF) vs. unilateral orthotopic ilio-femoral bypass (IF): an attempt to compare results based on data matching

Some surgeons feel that femoro-femoral suprapubic crossover bypass (FF) is the treatment of choice in unilateral artery disease, whereas others reserve this procedure for the rare high risk patient. Results and their evaluation seem to differ depending upon the indications and the patients elected for comparison. We analysed 57 consecutive patients, who received a FF-PTFE graft between 1977 and 1989 (age 48-95 years; male/female 47/10; preoperative clinical status [Fontaine Classification] St. II: 19%, St. III: 58%, St. IV: 23%; diabetics: 14; smokers: 40). The estimated cumulative primary and secondary patency according to the Kaplan-Meier method were 52 +/- 10% (three grafts at risk) and 63 +/- 10% (six grafts at risk), respectively at 5 years. There was no statistical difference in the secondary patency comparing patients with a good and bad run-off (Breslow, Mantel-Cox). The cumulative 5-year survival was 35 +/- 7% (nine patients at risk). The results were compared with those obtained in a group of 150 patients, in whom an unilateral ilio-femoral (IF) retroperitoneal orthotopic graft had been implanted for the same indication and within the same period. Comparing the primary patency of FF and IF patients (55 +/- 6%; 24 grafts at risk) no significant difference could be seen at 5 years. But there was a significant difference in the 5-year survival rates, being in favour of the IF-group (43 +/- 5%; 43 patients at risk) suggesting that both groups were not comparable.(ABSTRACT TRUNCATED AT 250 WORDS)

Femorofemoral crossover bypass for noninfective complications of aortoiliac surgery

Between 1973 and 1989, 39 femorofemoral crossover bypasses were performed to treat unilateral noninfective complications of aortoiliac surgery. The initial revascularization procedure, performed an average of 79.5 months previously, was an aortobifemoral bypass in 29 cases, an aorto- or iliofemoral bypass in six cases, an inlay graft for abdominal aortic aneurysm and aortoiliac endarterectomy in two cases each. The indications for femorofemoral crossover bypass included prosthetic occlusion in 35 cases, thrombosed false aneurysm in two, and further degradation after endarterectomy (iliac stenosis and occlusion in one case each). There was no operative mortality. One patient with acute ischemia upon admission and another with distal gangrene required below-knee and forefoot amputations, respectively. No amputations were required during the rest of the follow-up period. Three repeat aortobifemoral bypasses were performed because of occurrence of aortic or inflow vessel lesions. Primary and secondary actuarial five year patency rates for femorofemoral crossover bypasses were 59.7% and 78.4%, respectively. Femorofemoral crossover bypass can extend the benefits derived from direct aortoiliac surgery with low mortality and morbidity in the absence of associated aortic pathology (false aneurysm at the aortic implantation site or severe obstructive lesions).