Contemporary outcomes of thoracofemoral bypass

Abstract

Objective: Thoracofemoral bypass (TFB) is an alternative to aortofemoral bypass (AFB) or extra-anatomic bypass for severe aortoiliac occlusive disease (AIOD). TFB may be particularly useful in select patients with concurrent visceral aortic branch vessel disease, infrarenal aortic occlusions, or after failed AFB. However, there are few contemporary series describing the indications and outcomes for TFB. Therefore, the purpose of this analysis was to review our experience with TFB.

Methods: All patients undergoing TFB for occlusive disease from 2002 to 2017 were reviewed. All patients underwent left thoracoretroperitoneal exposure of the supraceliac aorta with division of the diaphragmatic crus and supraceliac cross-clamping. An end-to-side aortic anastomosis was created and each graft limb was tunneled in the retroperitoneum to the femoral bifurcation. Adjunctive visceral/infrainguinal revascularization was performed selectively based on symptoms, end-organ function, and/or preoperative imaging. The primary end points were major complications and 30-day mortality. Secondary end points included limb patency, freedom from major adverse limb events, and survival. Kaplan-Meier methodology was used to characterize the end points.

Results: Forty-one patients (age 61 ± 9 years; 54% female; 7% in a hypercoaguable state) underwent TFB. The mean preoperative ankle-brachial index was 0.4 bilaterally. Indications included critical limb ischemia (56%), claudication (30%), acute limb ischemia (7%), and combined AIOD and mesenteric ischemia (7%). Seven patients (17%) had previously undergone AFB and 15 (38%) had previously undergone any prior aortic operation. Adjunctive visceral bypass occurred in 8 patients (20%; N = 14 grafts, n = 6 renal, n = 5 superior mesenteric artery, and n = 3 celiac). The postoperative duration of stay was 11 days (interquartile range [IQR], 7-16 days) and the 30-day mortality was 5% (n = 2). Major complications occurred in 34% of patients (N = 14; pulmonary, 15%; cardiac, 12%; bleeding, 7%; accidental splenectomy, 5%; renal, 5%; wound, 2%). The mean postoperative ankle-brachial index was 0.9 bilaterally. At a median follow-up of 7 months (IQR, 1-17 months), 5 patients (12%) underwent some form of reintervention (graft/limb related, n = 4 [n = 2 graft thrombosis, n = 2 graft infection], n = 1 mesenteric bypass revision). The estimated 3-year primary limb patency and freedom from major adverse limb events were 80 ± 10%, and 70 ± 10%, respectively. The estimated 5-year survival was 93 ± 5% (median, 27.3; IQR, 14.5-35.2; 95% confidence interval, 17.9-32.8).

Conclusions: This experience represents one of the largest and most current series of retroperitoneal TFB. We demonstrate that TFB can be performed with good outcomes for patients with severe AIOD, especially if concomitant visceral/infrainguinal reconstruction is warranted. These results support a continued role for TFB in select patients.

Keywords: Aortoiliac occlusive disease; Outcomes; Thoracofemoral.

Figure 1.. Positioning and Anatomical Exposure for Left Thoraco-Retroperitoneal Thoracofemoral Bypass

A, Depiction of the patient positioning for thoracofemoral bypass surgery through a left retroperitoneal aortic exposure. Note (inset) that the hips are left as flat as possible to allow access to the right femoral incision, and the patient is placed over the kidney break to facilitate maximal separation of the iliac crest and costal margin. B, Demonstration of the end-to-end proximal anastomosis of a left retroperitoneal thoracofemoral bypass that is constructed in a supraceliac location immediately above the celiac trunk. The left crus of the diaphragm has been divided to facilitate exposure and construction of the anastomosis. The Lambert-Kay side biting, partially occlusive aortic clamp is especially useful in this location. C, The retroperitoneal tunnels are created by reflecting the viscera to the right and performing blunt dissection between the right and left femoral incisions. The main body of the prosthetic graft is left as long as possible to provide enough graft length to reach the femoral incisions. The right retroperitoneal tunnel can occur in an anatomic plane if the patient has not previously undergone prior aortic surgery and if the body habitus allows, otherwise, the limb is tunneled cephalad to the bladder in the pre-peritoneal plane and allows the limb of the graft to course in a long, gentle arc. Importantly, the limbs are tunneled in a retro-ureteral position if attempting to place them in an anatomic position (on the Right side); however, if it is a re-operative field, the both limbs are placed in the pre-peritoneal plane with the right limb having a relatively long, gentle arc-like configuration.

Figure 2.

The Kaplan-Meier curve demonstrates the freedom from any graft related reintervention. The standard error of the mean exceeds 10% at 1.3 years.

Figure 3.

The freedom from major adverse limb event after thoracofemoral bypass is depicted in the figure. MALE included any open/endovascular remediation of the thoracofemoral bypass and/or limb amputation within one year. The standard error of the mean exceeds 10% at 1.3 years.

Figure 4.

The overall estimated survival for thoracofemoral bypass is highlighted in the figure. Notably, the 5-year estimated survival was 93±5% [95%CI 17.9-32.8]. The standard error is less than 10% for all displayed intervals.