Surgical treatment of aorto-iliac artery disease

Axillo-Femoral Bypass

Axillo-femoral artery bypass has been an alternative extra-anatomic bypass procedure for aorto-iliac occlusive disease since its introduction in 1963. This extra-anatomic bypass has been used in special conditions where the conven tional aorto-femoral bypass is not possible because of intra-abdominal sepsis or extremely high operative risk for aortic procedure. In order to have reasonable long-term patency report, retrospective review is done on a patient undergoing axillo-femoral artery bypass grafting performed between 1976 to 1981. Twenty- eight axillo-unifemoral bypasses and 43 axillo-bifemoral bypasses were per formed in this period. Fifty percent of the patient population had multiple risk factors. Arteriosclerotic heart disease was found in 41 %, central nervous system problem and stroke were found in 31%. Twenty-five percent of the patients were diabetic. Five-year patency rate of axillo-bifemoral bypass graft was 75%. Axillo-unifemoral bypass had a five-year patency of 33%. Axillo-unifemoral bypass with femoral-distal bypass had a five-year patency rate of 6 to 8%. Ax illo-bilateral femoral bypass with femoral-distal bypass had 56.2% of a five- year patency. Overall, five-year patency, without thrombectomy was 60%.

A prospective study of 100 gelatin-sealed aortic grafts

A gelatin-sealed knitted Dacron graft has been developed which has zero porosity at implantation and does not require preclotting. Its patency rate up to 57 months and effectiveness at saving blood loss have been studied. Gelatin-sealed aortic grafts were implanted into 100 consecutive patients--77 men, 23 women. Surgery was performed for aneurysm in 36 patients (including four with rupture), intermittent claudication in 44, rest pain in 17, and gangrene in three, over an 18 month period. The patients were followed up prospectively for 57 months. Perioperative mortality was 1%. Cumulative primary graft patency was 99%. There was no measurable blood loss at implantation. Forty-seven patients required blood transfusion: mean volume transfused was 430 ml. There were no problems related to the sealant.

Femoro-femoral or ilio-femoral bypass for unilateral inflow reconstruction?

Femoro-femoral and ilio-femoral bypass are two popular options for unilateral inflow reconstruction. In order to evaluate these alternative approaches, the records of 70 consecutive patients who underwent either femoro-femoral (n = 50) or ilio-femoral (n = 22) grafts were retrospectively reviewed. There were 46 men and 24 women, ranging in age from 27 to 84 years (mean: 66 years). Operative mortality was 10% for all femoro-femoral procedures, including 50% for emergent, 14% for synchronous, and 0% for solitary procedures; mortality was 9% for all ilio-femoral grafts including 20% for synchronous and 6% for solitary procedures. Among the elective solitary procedures, there was no significant difference with respect to operative time, blood loss, fluid requirement, time until resuming an oral diet, or duration of postoperative course for the two procedures. Five-year patency was 93% for all ilio-femoral and 57% for all femoro-femoral grafts. Although femoro-femoral bypass has been the more popular option for unilateral inflow reconstruction in this and other institutions, these findings justify the more widespread use of ilio-femoral bypass.

Current state of extraanatomic bypasses

From my personal experience with a series of 227 extraanatomic bypasses, it is concluded that a high risk group of patients with multiple problems may have a reasonable alternative mode for limb salvage with extraanatomic bypass procedures. Axillo-bilateral femoral artery bypass grafts have a primary patency rate of 75 percent at the fifth year. With appropriate measures, net limb salvage can be accomplished in 84 percent of surviving patients at the fifth year. The result of a small group of patients with descending thoracic-aortofemoral artery bypass in this series was poor because of meager distal runoff and multiple previous operations. Axilloaxillary artery bypass grafts have shown an excellent long-term patency rate. A group of patients who underwent simultaneous axilloaxillary artery bypass and carotid endarterectomy have shown symptom-free long-term results with no subsequent stroke. This combined procedure showed no added neurologic morbidity. By proper application of extraanatomic bypass procedures, adequate palliation can be accomplished without major procedures in many patients who otherwise are high surgical risks.