Axillofemoral bypass with local anesthesia: a way forward to enable limb salvage in high-risk patients

Abstract

For an active, ambulant patient with critical, lower limb ischemia, amputation can lead to a poor quality of life. A small group of older people with critical limb ischemia are considered at high risk for revascularization under conventional anesthesia owing to their comorbid conditions. In these cases, when endovascular therapy is not an option, the decision to amputate or revascularize presents a dilemma, especially in ambulant patients. In this article, we present 2 cases in which the individuals had diabetic foot gangrene, rest pain, and multiple comorbidities, and were unfit to undergo conventional anesthesia. In addition, they had severe aortoiliac occlusive disease, which cannot be managed by endovascular methods. Both patients were living independently and were ambulant before their foot ulcer and ischemia. They underwent an axillofemoral bypass under local anesthesia. The postoperative course was uneventful. After a 3-year follow-up, both patients continue to be ambulant and have no complaints. With selective use of local anesthetic techniques, surgical teamwork to shorten the procedure time, and close meticulous postoperative care, an axillofemoral bypass can enable limb salvage for ambulant patients who are considered unfit for conventional anesthesia.

Keywords: axillofemoral bypass; high-risk patients; limb salvage; local anesthesia.

Figure 1

Angiogram of the case 1 patient showing complete occlusion of infrarenal aorta.

Figure 2

Computerized tomography angiogram A) and angiography B) of case 2 patient showing complete occlusion of infrarenal aorta with reconstitution at femoral vessels, and occluded iliac stents B).

Figure 3

Case 2, right foot stump with good granulation tissue 10 days post bypass A). The left foot with previous toes amputation B).