“Lower Limbs Revascularization from Supraceliac and Thoracic Aorta”

‘‘Lower Limbs Revascularization from Supraceliac and Thoracic Aorta’’ Mariel Riedemann Wistuba, Manuel Alonso-Perez, Amer Zanabili Al-Sibbai, Mario Gonz alez-Gay, Francisco Alvarez Marcos, Lino A. Camblor, and Jose Manuel Llaneza-Coto, Oviedo, Spain

Revascularization of femoral arteries from descending thoracic or supraceliac aorta is an uncommon procedure, in part because of the popularization of the technically easier extraanatomic bypasses. However, using those aortic levels as the source of the bypass inflow is a useful alternative in selected patients with aortoiliac disease, with excellent results. We report long-term results in 4 patients with revascularization from thoracic aorta and another 2 cases from aorta at supraceliac level. This technique should be considered as a good alternative in patients with adverse abdominal conditions or with a severely diseased infrarenal aorta due to heavy calcification.

INTRODUCTION

MATERIALS AND METHODS

The use of thoracic descending or supraceliac aorta as an inflow source for bypasses in aortoiliac disease is uncommon; its place taken by extra-anatomic axillofemoral bypasses, technically easier. Although lower limb revascularization from these aortic levels has been usually described as a second line procedure, its role is still relevant in patients with unfavorable conditions for transabdominal approach and severe aortoiliac atherosclerosis.1 Results reported with this technique show comparable long-term patency and mortality rates to extra-anatomic bypasses.2 The aim of this article was to present our experience in 4 cases of lower limb revascularization from descending thoracic aorta and 2 from supraceliac aorta, with excellent outcomes.

During a 12-year period (2002e2014), 6 atypical revascularization procedures from aorta have been performed at the Central University Hospital of Asturias: 4 aortobi-femoral bypasses from descending thoracic aorta and 2 from supraceliac aorta. Data regarding medical history, clinical course, and patients’ follow-up were obtained retrospectively from hospital records. Age, cardiovascular risk factors, symptoms present at the time of surgical indication, preoperative work-up, intraoperative events, surgical technique, postsurgical complications, length of stay, and postoperative intensive care were collected. Information from diagnostic imaging studies and cause for surgical indication was obtained in each case, as well as follow-up time and clinical stage at the end of this period.

Department of Vascular Surgery, Hospital Universitario Central de Asturias, Oviedo, Spain.

RESULTS

Correspondence to: Mariel Riedemann Wistuba, Hospital Universitario Central de Asturias, Julian Claverı´a s/n. Oviedo-Asturias 30066, Spain; E-mail: [email protected] Ann Vasc Surg 2015; 29: 1035–1039 http://dx.doi.org/10.1016/j.avsg.2015.02.002 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: April 22, 2014; manuscript accepted: February 5, 2015; published online: March 12, 2015.

Medical features and cardiovascular risk factors are summarized in Table I. Preoperative work-up consisted of blood analysis (complete blood count, coagulation, creatinine, glucose, urea, and plasmatic electrolytes), electrocardiogram (ECG), chest radiography, and spirometry for each 1035

4.5 0 Intermittent claudication II Male 54

Male 63

Male

6

5

Descending thoracic aortaebifemoral Descending thoracic aortaebifemoral Descending thoracic aortaebifemoral 4

66

Male Descending thoracic aortaebifemoral 3

64

Male Supraceliacebifemoral 2

56

Supraceliacebifemoral 1

ASA, American Society of Anesthesiologists; UB, unit of blood.

Thrombosis of previous aortobi-femoral bypass

4.5 1 Rest pain II Hostile abdomen

4 1 Rest pain II Aortic calcifications

4 3 II Aortic calcifications

Intermittent claudication

3 0 Intermittent claudication II Aortic calcifications

5 2 Intermittent claudication II Aortic calcifications

Smoker, diabetes mellitus, obesity Ex-smoker, arterial hypertension Arterial hypertension, diabetes mellitus, hypercholesterolemia, coronary disease Smoker, arterial hypertension Ex-smoker, arterial hypertension Arterial hypertension Male

Type of bypass

66

Unfavorable conditions Comorbidities Gender

Annals of Vascular Surgery

Case

Age, years

Table I. Demographic and clinical characteristics of patients and intraoperative parameters

ASA score

Symptoms

Blood transfusion (UB)

Duration of surgery (hr)

1036 Wistuba et al.

patient. All cases had an American Society of Anesthesiologists (ASA) II score. In case of prior heart disease or ECG anomalies, a cardiology assessment was required. Symptoms present at the time of surgical indication corresponded to stage III in Fontain’s classification in 2 patients and to stage IIB (disabling intermittent claudication) in the remaining cases. The preoperative imaging study was either arteriography or angio computed tomographies (TCs), in equal numbers. Coincidentally, all angio TCs were performed in the latest interventions. All patients had some unfavorable conditions for conventional surgery: severe abdominal aortic calcification in 4 cases, 1 case of hostile abdomen due to several previous procedures (a global aortoiliac endartherectomy, 2 aortomesenteric bypasses, and bowel resection secondary to ischemia), and 1 case of thrombosis of previous aortobi-femoral prosthetic bypass (1 year evolution). In the 4 cases of severe calcification, selection of aortic level (descending thoracic or supraceliac) was based on the possibility of having a healthy zone for graft’s suture, being feasible above celiac trunk in 2 cases and on distal descending thoracic aorta in the other 2. For patients with hostile abdomen and graft thrombosis, descending thoracic aorta was the direct choice. There was no perioperative mortality. For those bypasses from supraceliac aorta, the average intervention time was 4 hr (not including the time for anesthetic induction), and only 1 patient required blood transfusion. The bypasses from thoracic descending aorta required an average surgical time of 4.2 hr, and blood transfusions were required in 3 cases (Table I). One patient with an aortobi-femoral bypass from supraceliac artery experienced a subsegmental lung collapse (left lower lobe) in the immediately postoperative period, without clinical consequences. In the group of revascularization from thoracic aorta, one of the patients experienced a minimal right lung collapse and a small seroma in right groin, which were resolved by means of chest physiotherapy and wound care, respectively; 1 patient was diagnosed with postoperative acalculous cholecystitis and small left pleural effusion. Medium hospital stay after surgery was 11 days (±3.5 days). Average stay in intensive care unit after surgery was 4.5 days (±2.8 days). Patients’ follow-up covered a medical review 3 months after discharge, and annually from then, and included clinical assessment and ankle-brachial index (Table II). Follow-up was possible in all patients, ranging between 7 and

Vol. 29, No. 5, July 2015

Lower limbs revascularization 1037

Table II. Postoperative outcomes and follow-up

Case

ICU stay (days)

Postsurgery hospital stay (days)

1 2

2 2

8 11

3

7

10

4 5

4 9

10 18

6

3

9

Postoperative complications

Follow-up (months)

Postsurgery Fontain’s stage

Postsurgery ankle-brachial index

No Minimal right lung collapse Groin seroma, minimal collapse right lung No Cholecystitis, left pleural effusion No

7 115

IIA I

RL, 0.68; LL, 0.62 RL > 1; LL, 0.99

I

RL > 1; LL > 1

58 100

I IIA

RL, 0.7; LL, 0.69 RL, 0.47; LL, 0.69

63

IIA

RL, 0.98; LL, 0.89

44

ICU, intensive care unit; RL, right leg; LL, left leg.

Fig. 1. Postoperative computerized angiotomography reconstruction of a supraceliac bypass (case 1).

115 months (median, 61 months). All patients remain in Fontain stage I or IIA, with patent bypass grafts.

(Fig. 1). In the other one, we used a standard bifurcated 12  7-mm Dacron graft. Side-to-end anastomosis at this level was performed after aortic cross-clamping above the celiac trunk. From this point, the bypass follows the left ventral side of the aorta in a retropancreatic position, reaching the pelvis and tunneled after the iliac arteries to the groins in a standard fashion, with end-to-side distal suture on the common femoral arteries. To obtain inflow from the descending thoracic aorta, a single endotracheal intubation was performed without collapsing the left lung, making a small left thoracotomy through the seventh or eighth intercostal space and allowing adequate exposure of the distal descending thoracic aorta. A bifurcated 16  8 mm-Dacron graft was sutured side-to-end in a suitable area of the distal descending thoracic aorta, performing a partial aortic clamping. A cross-over tunnel was then created from the left thoracic cavity into the retroperitoneal space through a small lateral diaphragmatic incision. The tunneling continued distally after a left retroperitoneal route, with the help of a complementary left flank incision. The right branch of the bypass gained access to the groin through the Retzius space and was anastomosed on the common femoral artery in a standard end-to-side fashion. The left branch continues through the retroperitoneum, passing under the inguinal ligament to reach the left common femoral artery (Fig. 2).

SURGICAL TECHNIQUE Surgical technique for aortic bypass from supraceliac aorta consisted of a transperitoneal approach by xifo-pubic midline laparotomy, exposing the suprarenal aorta. In one case, a handmade bifurcated prosthesis was created suturing a straight 8-mm Dacron graft as a limb on a 10-mm straight Dacron

DISCUSSION Literature regarding lower limb revascularization from the descending thoracic or supraceliac aorta is limited, and current series include a small number of patients or isolated cases. The first report of a

1038 Wistuba et al.

Annals of Vascular Surgery

Fig. 2. Pre and postoperative computerized angiotomography reconstruction of a thoracicebifemoral bypass (case 5).

thoracic femoral bypass was published in 1961 by Stevenson et al.,3 and afterward, a series of 50 patients published by Passman et al.4 in 1999 has been the most extensive so far. In 1986, the first case of lower limb revascularization from supraceliac aorta was reported by Barral et al.,5 who described this procedure in 10 patients in whom infrar-renal aorta was unsuitable for direct reconstruction. Most of these interventions were performed in patients whose conditions contraindicated or discouraged a transabdominal approach, including previous failure of abdominal grafts due to thrombosis or infection and obstruction of previous extra-anatomic subcutaneous grafts. However, an important number of reconstructions have been primarily performed in aortoiliac disease with hostile abdomen or severe aortic calcification, when an aortic clamping at a lower level is not possible or carries a high risk.6e8 In our report, the main

indication for this technique was aortic atheromatosis with severe calcification, preventing safe cross-clamping and hampering graft anastomosis. Our case number 5 (Table I), shows a patient with hostile abdomen due to multiple previous abdominal interventions, with an important degree of peritoneal fibrosis. Moreover, our patients’ mean age was 62 years, all classified as ASA II, which makes the axillobi-femoral bypass a less appealing choice, considering that superficial tunneling and a more precarious hemodynamic condition are responsible for a higher susceptibility to infections and premature thrombosis, with reported patency ranging from 10% to 75% at 5 years.9 In the literature, perioperative mortality for bypass from the descending thoracic aorta varies from 0% to 11%,4,10 mainly because of surgical reinterventions. In our cases, there were no serious immediate postoperative complications, except a

Vol. 29, No. 5, July 2015

cholecystitis that required intervention by the general surgery department, prolonging the hospital stay. For these procedures a high level of expertise is required because of potential technical difficulties, which may limit widespread application. Despite this, and the fact that there is often an important degree of systemic atherosclerosis affecting other target organs and therefore increasing the surgical risk in these patients, the immediate and long-term results are comparable with those obtained by aortobi-femoral bypasses in conventional aortoiliac surgery, with primary patency rates of 73e86% at 5 years and secondary patency rates of 85.6e100% at 5 years.4,11

CONCLUSIONS Although our series report a small number of patients, we have achieved satisfactory results, with low perioperative mortality, morbidity, and good long-term patency rates. Based on our experience, we can conclude that the use of this technique as an alternative procedure for primary revascularization in patients with hostile abdomen or severe aortic calcification represents a valuable option in selected patients.

Lower limbs revascularization 1039

REFERENCES 1. Criado E, Johnson G, Burnham SJ, et al. Descending thoracic aorta-to-iliofemoral artery bypass as an alternative to aortoiliac reconstruction. J Vasc Surg 1992;15:550e7. 2. Passman MA, Farber MA, Criado E, et al. Descending thoracic aorta to iliofemoral artery bypass grafting: a role for primary revascularization for aortoiliac occlusive disease? J Vasc Surg 1999;29:249e58. 3. Stevenson JK, Sauvage LR, Harkins HN. A bypass homograft from thoracic aorta to femoral arteries for occlusive vascular disease. Am Surg 1961;27:632e7. 4. Magnan PE, Ede B, Marchetti AA, et al. Results of lower limb revascularization from the descending thoracic aorta. Ann Vasc Surg 2000;14:567e76. 5. Barral X, Youvarlakis P, Boissier C, et al. Supraceliac aorta-tolower extremity arterial bypass. Ann Vasc Surg 1986;1:30e5. 6. Martins C, Rosa A, Evangelista A, et al. Lower limbs revascularization originated in the descending thoracic aorta. Rev Port Cir Cardiotorac Vasc 2004;11:91e6. 7. Koksal C, Kocamaz O, Aksoy E, et al. Thoracic aortobifemoral bypass in treatment of juxtarenal Leriche syndrome (midterm results). Ann Vasc Surg 2012;26:1085e92. 8. Nevelsteen A, Suy R. Supraceliac aorta-to-femoral artery bypass: a case report. Acta Chir Belg 1991;91:137e9. 9. Passman MA, Taylor LM Jr, Moneta GL, et al. Comparison of axillofemoral and aortofemoral bypass for aortoiliac occlusive disease. J Vasc Surg 1996;23:263e71. 10. McCarthy WJ, Mesh CL, McMillan WD, et al. Descending thoracic aorta-to-femoral artery bypass: ten years’ experience with a durable procedure. J Vasc Surg 1993;17:336e48. 11. Criado E, Keagy BA. Use of the descending thoracic aorta as an inflow source in aortoiliac reconstruction: indications and long-term results. Ann Vasc Surg 1994;8:38e47.