Descending thoracic aorta to femoral bypass grafting for total abdominal aortic occlusion | |
DOI: 10.5606/e-cvsi.2016.478 | |
Olgar Bayserke1, Yavuz Beşoğul2 | |
1Department of Cardiovascular Surgery, Medical Faculty of Maltepe University, İstanbul, Turkey 2Department of Cardiovascular Surgery, Medicana Hospital, İstanbul, Turkey |
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Keywords: Abdominal aortic occlusion; aortofemoral bypass; descending thoracic | |
Descending thoracic aorta to femoral bypass graft is an alternative procedure for revascularization of the lower extremities to conventional
techniques, when the abdominal aorta is complete obstructed. In general, this technique is performed by surgeons, when abdomen is
unable to be opened due to the presence of an abdominal infection, fistulas, or hostile abdomen. In this article, we present our four-year
outcomes of descending thoracic aorta to femoral bypass with cross-femoral bypass in four patients. There was no mortality and all grafts
were patent. Descending thoracic aorta to femoral bypass grafting has excellent overall long-term results. |
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The thoracic aorta to femoral bypass grafting is an
ideal procedure for a small subgroup of patients,
comprising those with an occluded old aorta to femoral
bypass graft, those with a lead-pipe calcified infrarenal
aorta which is unsuitable as an inflow source, and those
with a hostile abdomen (i.e., ileal conduit, ileostomy
or colostomy or a previous aortic graft infection).
Complete obstruction of the abdominal aorta at the
renal artery level is often a surgical challenge in
case of a long-standing thrombosis, short suprarenal
aortic space, and extensive periarterial inflammatory
reaction. Therefore, a descending thoracic aorta to
femoral bypass graft is used as an alternative for
revascularization. Herein, we present our four-year
outcomes of descending thoracic aorta to femoral
bypass grafting with cross-femoral bypass in four
patients.
SURGICAL TECHNIQUE Figure 1: Preoperatively angiography of 60-year-old male patient. A written informed consent was obtained from each patient. Selective intubation with double-lumen tubes were performed under fentanyl anesthesia. The patients were positioned to position the hip flat; however, the torso was slightly rotated to the right. Four incisions were made: a left posterolateral thoracotomy, two groin incisions, and a lateral abdominal incision. The descending thoracic aorta was approached through the thoracotomy at the level of the sixth-seventh intercostal space. The left lung was decompressed by selective intubation, and the aorta was cleanly dissected. Common femoral arteries were obtained via two groin incisions. The psoas were reached through the lateral abdominal incisions and with an extra-peritoneal approach. A retroperitoneal tunnel was, then, fashioned for the passage of the graft. Once an 8 mm silver, INTERGARD collagencoated knitted polyester vascular prosthesis graft was carried from this tunnel, the patient underwent systemic heparinization (100 U/kg). The proximal end of the graft was reached the through the aortic hiatus at the diaphragm level. When the blood pressure was reduced by vasodilators, the descending thoracic aorta was controlled with side-clamp, and an end-to-side anastomosis was performed. The distal end of the graft was fashioned with an endto- side anastomosis to the left common femoral artery. An 8 mm INTERGARD collagen-coated knitted polyester vascular prosthesis graft was, then, performed through the left femoral to the right femoral crossover bypass. The side-aortic clamp was removed and the grafts were visualized with pulsing. Finally, after the bleeding was controlled, the lung was re-inflated, and the chest was closed in a standard fashion over a chest tube. There was no postoperative mortality. Except one patient, all were extubated in the operation room without a need for respiratory support. However, one patient required respiratory support for six hours. There were no pleural effusion; however, two patients had pulmonary atelectasis for four days. Oral antiaggregant (acetylsalicylic acid) treatment was started in the postoperative third day, following prophylaxis of lowmolecular- weight heparin in the postoperative early period. The mean length of intensive care and hospital stays was two days and eight days, respectively. Distal pulses of the lower extremities were sensed at discharge. The graft failure was not seen within the first month of follow-up. Computed tomography (CT) angiography revealed that all grafts were patent at four years (Figure 2). |
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Bypass grafting which originate from the descending
thoracic aorta to femoral arteries are well-described,
although they are not commonly used in the first-line
setting. The descending thoracic aorta to femoral
bypass grafting was first described in 1961 in two
cases.[1] The thoracic aorta is a good inflow option, as its
exposure is relatively straight forward and this segment
is usually free of significant atherosclerosis.[2] Most
authors have suggested that the use of the descending
thoracic aorta with a retroperitoneal tunnel yields
more acceptable operative risks and patency rates. Five
year patency rates of the procedure has been reported
as 86% in the literature.[3] Axillobifemoral bypass is the most common first choice as an alternative to aortofemoral incomplete obstruction of the abdominal aorta at the level of renal arteries.[4] However, the long-term patency is lower, due to the longer graft length with potential compression along the superficial course.[1] In our technique, we used the descending thoracic aorta, rather than the axillary artery. In most reports, the bifurcated graft is favored to thoracofemoral and femorofemoral crossover grafts.[5,6] We used this graft in only one patient. Furthermore, thoracic aorta is controlled either with a side-biting clamp or with two completely occluding aortic clamps placed in close proximity to each other. One of the disadvantages of completely occluding clamping is that renal circulation can be impaired, if the time of proximal anastomosis to aorta is hold over, and spinal cord and mesenteric ischemia can develop. Partial aortic control with sideclamping is successful in most cases, although it is not recommended, when the aorta is heavily diseased and calcified. Additionally, it makes the anastomosis more difficult, as the margins of aortotomy become closely opposed.[1] A partial side-clamp was placed in our patients, and it did not complicate the anastomosis. Baird et al.[6] described ascending aorta to femoral bypass grafting through a median sternotomy. The advantage of this technique is that concomitant coronary revascularization can be performed, when indicated. One of our patients who had coronary artery disease underwent offpump coronary artery bypass grafting three months before thoracofemoral grafting. Subsequently, we performed revascularization of the lower extremities by descending thoracic aorta to femoral and femorofemoral crossover bypass grafting. In the present study, all patients were eligible descending thoracic aorta to femoral bypass grafting with excellent overall long-term results. Despite pulmonary difficulties, we believe that this procedure is a satisfactory alternative for the treatment of juxtarenal complete abdominal aortic occlusions, as the thoracic aorta is no more atherosclerotic, and there is high blood flow in this segment to the axillary artery. In conclusion, endovascular treatment of infrarenal aortic occlusions is feasible in most cases with favorable midterm patency rates. However, due to relatively high procedurally-related complication rates, cautious selection of the patients and taking appropriate preventive measures are necessary to improve the immediate outcomes.[7]
Declaration of conflicting interests
Funding |
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