18.5 

Aortobifemoral Bypass

ABF with distal anastomoses on to the profunda femoris arteries is an option for this relatively young patient with CLI. The patency rate of ABF is 85% to 90% at 5-year, and 70% at 10-year. ABF remains one of the most durable reconstruction in vascular surgery10 and with proper patient selection, the operative mortality is an acceptable 2%. However this patient had severe COPD which is a leading cause of postoperative morbidity and mortality in aortic surgery. A less aggressive alternative was therefore sought.

18.6 

Iliac Angioplasty and Stenting

In this case, according to TASC II,11 right common and external iliac artery lesions could beclassifiedascategoryBandtheoccludedleftexternaliliacarteryascategoryD.Inaddition, this patient had multiple stenoses involving the common femoral artery with an occlusion of the superficial femoral artery on both sides.

On the right side, we did the profunda revascularization first using an open technique, that will be described below. This bypass was followed by a primary stenting of the right common and external iliac arteries. In this case, the plaque on the right external iliac artery was not extending into the common femoral artery (CFA), leaving an area relatively free of disease with the distal endpoint of the stent being above the inguinal ligament. On the left side, the presence of a significant CFA/EIA disease was defined by an absent femoral pulse and a 3x peak systolic velocity step-up across the diseased CFA artery with more than 80% luminal narrowing (B-mode imaging) extending proximally in the EIA and distally into the profunda. In this case, the distal endpoint of the iliac stent will have been located at the level of the CFA below the inguinal ligament with a potential risk of kinking. As for open surgery, an adequate femoral outflow is necessary for aortoiliac angioplasty. We considered therefore that left iliac stenting was not appropriate in this patient and decide to use a crossover femorofemoral bypass to the left profunda with stenting of the right common and external iliac arteries.

18.7 

Iliac Stenting Combined with Profunda Femoris Artery Revascularization

Hybrid surgery with right iliac stenting and bilateral femoral revascularization appeared as the best solution in this case. The procedure was done in the operating room with the use of epidural anesthesia. On the right side, revascularization of the profunda was done first using an 8 mm diameter PTFE bypass (Fig. 18.4). Proximal anastomosis was done on the terminal portion of the external iliac artery, distal anastomosis was done on a non-diseased

Fig. 18.5  Contrast-enhanced CT scan (CTA) showing a patent right iliac stenting with revascularization of the right profunda femoris artery and femorofemoral crossover bypass to the left profunda femoris artery

andpatency.Severalauthorshavenowreportedexperiencewithtransluminalballoonangioplasty prior to or concomitant with femorofemoral bypass.12,13 Results of these studies have supported the view that donor iliac artery balloon angioplasty with stenting in selected cases is associated with a satisfactory hemodynamic outcome and patency rate. The results of balloon angioplasty have probably improved since those initial prior studies were published. AbuRahma and colleagues have shown that the likelihood of success with this approach is substantially higher if the dilated donor iliac artery lesion is short and in the common iliac artery.14 Ricco et al.15 published the long-term results of a multicentre randomized study on direct bypass versus crossover bypass for unilateral iliac artery occlusive disease. The objective of this trial was to compare late patency after direct and crossover bypass in 143 goodrisk patients with unilateral iliac occlusive disease not amenable to angioplasty. These patients with unilateral iliac artery occlusive disease and disabling claudication were randomized into two surgical treatment groups, i.e., crossover bypass (n = 74) or direct bypass (n = 69). Iliac lesions TASC class [C in 87 (61%) patients and D in 56 (39%) patients], and superficial femoral artery (SFA) run-off were comparable in the two groups. Patients underwent yearly follow-up examinations using color flow duplex scanning with ankle-brachial systolic pressure index measurement. Median follow-up was 7.4 years. Primary endpoints were primary patency and assisted primary patency. Primary patency at 5 years (Fig. 18.6) was higher in the direct bypass group than in the crossover bypass group [92.7 ± 6.1% vs.

Fig. 18.6 Primary patency of 69 direct (D) and 74 crossover (C) bypass procedures analyzed according to the Kaplan-Meier method. The number of patients at risk in each group at various intervals is indicated at the bottom of the figure. Results are expressed as percentage with 95% confidence interval (95%CI). Primary patency rates at 5 and 10 years were 71.8±10% and 55.6± 12% respectively in the crossover bypass group as compared to 92.7±6% and 82.9±13% respectively in the direct bypass group (p=0.001, hazard ratio: 4.1 with 95% CI: 1.8–6.7). (reprinted with permission from J.B. Ricco et al. J Vasc Surg. 2008;47:45-53.)

73.2±10%, p=0.001]. Assisted primary patency and secondary patency at 5 years were also higher after direct bypass than crossover bypass [92.7±6.1% vs. 84.3±8.5%, p=0.04 and 97.0±3.0% vs. 89.8±7.1%, p=0.03 respectively]. Patency at 5 years after crossover bypass was significantly higher in patients presenting no or low-grade SFA stenosis than in patients presenting high-grade (³50%) stenosis or occlusion of the SFA [74.0±12% vs. 62.5±19%, p=0.04].Inbothtreatmentgroups,patencywascomparableusingPTFEandpolyestergrafts. Overall survival was 59.5±12% at 10 years. This study showed that late patency was higher after direct bypass than crossover bypass in good-risk patients with unilateral iliac occlusive disease not amenable to angioplasty. This randomized study shows that determination of the status of the donor iliac artery was a key element for successful crossover bypass (Fig.18.7). As early as 1973, Porter et al.16 acknowledged the frequency of some degree of contralateral iliac disease in patients with extensive unilateral iliac disease and became one of the first groups to recommend use of donor iliac angioplasty in combination with crossover bypass. Not surprisingly use of endovascular techniques that can provide excellent long-term results inselectediliacarterylesionshasimprovedtheoutcomeofcrossoverbypassinpatientswith a suboptimal donor iliac artery.17–20 The experience of several authors21,22 has supported this view. In non-randomized studies comparing crossover femoral grafts with or without donor iliac balloon angioplasty, both Perler et al.19 and Schneider et al.20 concluded that patency of the crossover bypass in patients who underwent preliminary stenting of the iliac artery was comparable to that of patients whose donor iliac artery was normal. These findings clearly