Combined percutaneous transluminal angioplasty and extraanatomic bypass for symptomatic unilateral iliac artery occlusion with contralateral iliac artery stenosis

Factors Affecting the Long-term Patency of Crossover Femorofemoral Bypass Graft

OBJECTIVES

To determine the factors affecting long-term patency of crossover femorofemoral bypass (FFB) graft.

DESIGN

A retrospective clinical study of a prospectively registered database.

MATERIALS

Two hundred and sixteen FFBs performed for 192 patients with atherosclerotic iliac occlusive disease.

METHODS

The clinical and surgical variables influencing graft patency were assessed with log-rank test and Cox's proportional hazard analysis.

RESULTS

The primary patency rates of all FFB grafts at 3 and 5 years were 73+/-4 and 65+/-5%, respectively. By multivariate analysis, hypertension (Odds ratio 2.8, P=0.002) and critical ischemia (Odds ratio 0.42, P=0.01) significantly (P<.05) influenced long-term patency of FFB grafts.

CONCLUSION

The long-term patency of FFB grafts was not affected by procedural modifications. Graft patency was inferior in patients with severe lower limb ischemia but superior in patients with hypertension. Further study is required to clarify the mechanism of an unexpected beneficial effect of hypertension on FFB graft patency.

Iliac angioplasty and stenting in association with infrainguinal bypasses: timing and techniques

Inflow iliac artery balloon angioplasty may be performed simultaneously with open infrainguinal vascular reconstruction in patients with multilevel occlusive disease of the lower extremity. This approach is safe, effective, has satisfactory long-term results, and should be part of the vascular armamentarium.

Management of chronic critical limb ischemia

The patient with CLI is challenging and requires a multi-disciplinary approach to effective management that involves a team of individuals proficient in various aspects of vascular disease. Fig. 4 details the approach at the University of Michigan's comprehensive vascular medicine program.

[Which indications and techniques for lower limb arteriopathy obliterans and proximal aorto-iliac lesions?]

Atherosclerotic aorto iliac occlusive disease are not the most frequent lesions in the lower limbs. Isolated aortic iliac lesions are often associated with intermittent claudication; critical ischemia with proximal aorto iliac lesions can be due to acute occlusion or associated femoropopliteal occlusive lesions. Preoperative explorations need Duplex Scan, Arteriography and CT Scan to define extensive lesions and wall' calcifications. Endovascular procedures are, in this lesion, safe, effective and permit to delay conventional surgery. The best strategy, today, needs to known endovascular procedures and surgical procedures to obtain the most efficient anatomic result.

Crossover iliofemoral bypass grafting for treatment of unilateral iliac atherosclerotic disease

PURPOSE

In patients with unilateral iliac disease, a less invasive procedure than aortobifemoral bypass grafting may be desirable, especially in poor-risk patients or when sexual dysfunction is feared. In these cases, femorofemoral (FF) bypass grafting is often proposed. Compared with FF bypass grafting, iliofemoral (IF) bypass grafting avoids bilateral exposure of the groins, which may reduce the risk of infection. When the primitive iliac artery is occluded from its origin or heavily calcified, one may use the contralateral artery as inflow, after a small retroperitoneal exposure, to perform a crossover iliofemoral (CIF) bypass grafting procedure, through the Retzius space. Our 10-year experience with CIF bypass grafting in a select group of patients was studied.

METHODS

Between 1986 and 1996, 36 patients underwent CIF bypass grafting for symptomatic unilateral iliac occlusion or stenosis. All patients were examined by means of Doppler ultrasound scanning and underwent bilateral multiplane angiography. Patients were considered for this procedure when the ipsilateral common iliac artery was occluded from its origin or was diffusely and heavily calcified. The decision to perform a CIF bypass grafting procedure was made when no significant disease of the contralateral common iliac artery was seen, and patients who had features of contralateral iliac disease were excluded. The main outcomes were perioperative mortality and morbidity, long-term primary and secondary patency rates, and limb salvage rate.

RESULTS

The study included 31 men and five women, with a mean age of 58.8 years. Indications for bypass grafting were disabling claudication (26 of 36 patients, 72%) and limb-threatening ischemia (10 of 26 patients, 28%). Twelve procedures were performed simultaneously: endarterectomy of the recipient common femoral artery (n = 3), femoropopliteal bypass grafting (n = 4, 11.1%), profundoplasty (n = 4, 11%), and right internal carotid endarterectomy (n = 1). New postoperative erectile dysfunction did not develop in any of the patients. The survival rate was 97.3% at 1 year and 68.5% at 5 years. The primary and secondary patency rates were 94% and 100%, respectively, at 1 year and 76.7% and 95%, respectively, at 5 years. The limb salvage rate was 100% at 1 year and 87% at 3 years.

CONCLUSION

The operative mortality associated with CIF is low. The long-term primary and secondary patency rates are satisfactory, and they are lower than those reported for aortobifemoral bypass grafting. This procedure does not preclude a later performance of an aortobifemoral bypass grafting procedure. CIF bypass grafting is not only suitable for poor-risk patients with a limited life expectancy who have the appropriate arterial anatomy, but also may be warranted for young patients in whom erectile dysfunction is feared.

Indications and benefits of simultaneous endoluminal balloon angioplasty and open surgery during elective lower limb revascularization

Combined balloon angioplasty and conventional revascularization are occasionally performed but some points are still controversial: which patients are eligible for this associated procedure?; should the procedures be performed simultaneously or successively?; and in case of simultaneous procedure, which one should be performed first? To answer these questions, the notes of 64 patients consecutively submitted to this procedure at the Henri Mondor hospital were reviewed. Arterial dilatation was performed on the iliac artery, superficial femoral artery, popliteal artery or tibioperoneal trunk in 31, 26, four and four patients, respectively. Reasons for simultaneous procedures were multiple occlusive lesions in 67% of patients and inflow improvement in 14%. The others reasons included iliac obstruction in poor risk patients, unilateral failure of planned bilateral iliac balloon angioplasty, outflow improvement, local contraindication to arterial approach, shortness of vein graft, clamp injury during open surgery and inadequate patient position for both procedures. Complications were rare. One patient died of recurrent sepsis of the femoro-femoral bypass. The 5-year limb salvage rate was 91%. In this study, simultaneous procedures were associated with three advantages: the risk of septic complications associated with graft implantations in a previously punctured site was decreased, anticoagulant and/or antiplatelet therapy did not need to be modified before the second procedure, hospital length of stay and cost appeared to be lower. On a simultaneous procedure, it is recommended that the balloon angioplasty be performed after the conventional procedure in order to avoid clamping a recently dilated artery when performing the bypass.

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.

The value of donor iliac artery pressure gradients in predicting the outcome of femorofemoral bypass

PURPOSE

This study tests the clinical value of femoral artery pressure measurements by analysis of the relationship between iliac artery pressure gradients (PGs) and both femorofemoral bypass graft patency and the hemodynamic changes produced in the donor and recipient limbs.

METHODS

Systemic and donor femoral artery systolic and mean pressures were measured during surgery at rest and during papaverine-induced hyperemia before 94 femorofemoral bypasses. Ankle/brachial (A/B) pressure ratios and pulse volume recordings (PVRs) were measured before and early after surgery. Donor iliac artery stenosis was 25% +/- 23% (mean +/- 1 SD). Follow-up was 23+/- 20 months.

RESULTS

Eight bypasses failed at 21 +/- 20 months. Patients with failed bypasses had a resting systolic and mean PG of 23 +/- 22 mm Hg and 5 +/- 7 mm Hg, respectively, compared with 10 +/- 11 mm Hg (p = 0.007) and 1 +/- 2 mm Hg (p = 0.001) for the 86 patent bypasses. Donor limb A/B ratios and PVRs decreased 9% +/- 5% and 15% +/- 14%, respectively, had a linear regression slope less than 0 (p < 0.05) with resting and hyperemic PGs, and correlated best with resting PGs (p < 0.05). Recipient limb A/B ratios and PVRs increased 86% +/- 48% and 191% +/- 111%, respectively, had a linear regression slope greater than 0 (p < 0.05) with all resting and hyperemic PGs, and correlated best with hyperemic systolic PGs (p < 0.05). However, all regressions had a large SD, wide 95% confidence limit, and a low correlation coefficient. Sensitivity-specificity receiver-operating characteristic curves for optimal PG criteria for both graft failure and donor limb hemodynamic impairment are weak, with an accuracy of 50% to 75%. Recommended criteria for not performing a femorofemoral bypass are a resting systolic PG of 28 mm Hg or greater or a resting mean PG of 6 mm Hg or greater.

CONCLUSIONS

Although iliac artery PGs correlate with graft failure and both the degree of donor limb hemodynamic impairment and recipient limb improvement, the large variability in PGs between patients with similar outcomes and the low accuracy of optimal PG criteria indicate that they have limited clinical value in decision making.

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.

Laser angioplasty of the iliac arteries

Laser-assisted balloon angioplasty has the potential to reduce mortality and morbidity by replacing aorto-femoral bypass operations in patients with occlusion of the iliac arteries. We present our early experience with 16 patients undergoing this procedure, using a Cardiolase neodymium:yttrium aluminum garnet (Nd:YAG) laser in the operating room. Initial recanalization was achieved in 14 of the 16 patients. Early re-occlusion occurred in 4 patients, one of whom had a successful repeat laser angioplasty. This patient, together with the remaining 10 patients with successful initial recanalization remain patent at a mean follow-up period of 10 months. There were no deaths or chest complications. Angiographically demonstrated arterial perforation occurred in 2 patients, neither of whom required operation on the perforated segment. We conclude that recanalization of the iliac arteries is possible and safe. The procedure is unlikely to replace aorto-femoral bypass until the proportion of early failures is reduced. This may require larger probes or the immediate placement of intra-arterial stents following laser angioplasty.