Results of Lower Limb Revascularization from the Descending Thoracic Aorta

Results of Lower Limb Revascularization from the Descending Thoracic Aorta Pierre-Edouard Magnan, MD, Bertrand Ede, MD, Andrea Ascoli Marchetti, MD, Euge´nio Rosset, MD, Jean-Pierre Mathieu, MD, and Alain Branchereau, MD, Marseilles, France

The aim of this retrospective study was to substantiate our results of lower limb revascularizations from the descending thoracic aorta. From November 1984 to November 1994, we used bypass grafting from the descending thoracic aorta to revascularize 69 lower limbs in 36 patients, 34 men and 2 women, whose mean age was 61.8 years. Patients were divided into two groups. Group I (primary indications) included 10 patients who had not had any prior lower limb arterial reconstruction. Group II (secondary indications) consisted of 26 patients who had had a prior arterial reconstruction that was either occluded or complicated. There were three early graft occlusions, all of them successfully treated. Complete flaccid, paraplegia occurred in one patient. Five patients presented with one or several late graft occlusions. Two patients had to undergo below-knee amputation, bilateral in one patient. Routine late control of the repair was performed by CT scanning, at a mean interval of 50.8 months. The good results recorded for bypasses revascularizing lower limbs from the descending thoracic aorta make this technique a satisfactory alternative when the abdominal aorta cannot be used. (Ann Vasc Surg 2000;14:567-576.) DOI: 10.1007/s100169910105

INTRODUCTION The first bypass graft from the descending thoracic aorta was carried out in 1956 to remedy an occluded aortobiiliac bypass graft. This report appeared in 1961 by Stevenson et al.,1 the same year that Blaisdell et al.2 reported another case, 2 years before describing the technique of axillofemoral bypass grafting.3 In the following years, the latter operation was a major success with surgeons whenever it was deemed impossible to use the infrarenal aorta to revascularize lower limbs. Meanwhile, only anecdotal observations or short series of bypasses from the descending thoracic aorta were reported.4-16

From the Service de Chirurgie Vasculaire, Hoˆpital de la Timone, Marseilles, France. Presented at the Annual Meeting of the French Society for Vascular Surgery, Nice, France, June 11-14, 1997. Correspondence to: A. Branchereau, MD, Service de Chirurgie Vasculaire, Hoˆpital de la Timone, Marseille, France.

In 1985 the first series including more than 15 patients was reported,17 we have found a mere 215 cases in the entire literature up until now1,2,4-36 (Table I). The aim of this study is to evaluate our shortand long-term results of lower limb revascularizations using bypass grafting from the descending thoracic aorta.

PATIENTS AND METHODS Population From November 1984 to November 1994, we revascularized 69 lower limbs in 36 patients, using the descending thoracic aorta as the source of inflow. Two patients had undergone unilateral amputation, and one had a prior unilateral revascularization following unilateral acute ischemia. There were 34 men and 2 women with a mean age of 61.8 years (range, 41 to 79 years). All patients but three smoked more than 20 cigarettes a day on a regular 567

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Table I. Revascularization from the thoracic aorta: literature review References

Year

Period

Cases

Primary reconstructionsa

Secondary reconstructions

Postoperative deaths

Stevenson et al.1 Blaisdell et al.2 Robicsek et al.4 Reichle et al.5 Nunn and Kamal6 Froysaker et al.7 Finseth and Abbott8 Jarret et al.9 Cevese and Galluci10 Buxton et al.11 Lakner and Lukacs12 Reilly et al.13 Haas et al.14 Enon et al.15 Feldhaus et al. and Schultz et al.17,19 Schellack et al.21 Hussain22 Bradham et al.23 Bowes et al.24 O’Brien et al.25 Costantino28 Kalman et al.29 DeLaurentis30 McCarthy et al.33 Carrel et al.34 Criado and Keagy35 Mitchell et al.36 Present study Total

1961 1961 1967 1970 1972 1973 1974 1975 1975 1976 1983 1984 1985 1985 1985-86 1988 1988 1989 1990 1991 1991 1991 1991 1993 1994 1994 1995 2000

— — — — — 1966-1972 — — — — 1978-1979 — — 1983-1984 1972-1985 1984-1985 1982-1986 — 1976-1988 — — 1986-1990 1975-1989 1982-1992 — 1982-1993 — 1984-1994

1 1 1 1 3 6 1 2 6 1 2 5 3 3 21 3 8 2 26 1 1 6 13 21 8 32 1 36 215

0 0 0 1 1 (1) 6 (4) 1 1 6 (6) 0 2 (2) 0 3 (1) 3 3 0 6 2 (1) 16 (8) 1 0 0 2 3 1 19 0 10 87/40.5%

1 1 1 0 2 0 0 1 0 1 0 5 0 0 18 3 2 0 10 0 1 6 11 18 7 13 1 26 128/59.5%

0 1 0 0 0 0 0 1 0 0 0 0 1 0 1 0 0 0 1 0 0 0 0 0 0 2 0 4 11/5.11%

a

Numbers in parentheses are number of indications of reconstruction for aortic occlusive disease.

basis. Seven patients presented with stable coronary heart disease, 7 with respiratory insufficiency, 4 with diabetes mellitus, and 11 with hypertension. Indications Patients were divided into two groups: group I, which included patients having all the indications of primary revascularization and who had undergone no prior revascularization of the lower limbs (10 patients), and group II, which included patients with indications of secondary revascularization and who were being operated on for replacement of an occluded or complicated bypass graft (26 patients). Among the 10 group I patients (Table II), 9 had aortoiliac occlusive lesions that caused intermittent claudication in 4 patients, chronic critical ischemia in 4 patients, and acute ischemia in 1 patient. Bypass grafting from the descending thoracic aorta was preferred because of chylous ascites in one pa-

Table II. Indications of bypass grafting from the thoracic aorta in group of primary revascularizations (group I = 10 patients) Aortoiliac occlusive lesions Chylous ascites Hepatic cirrhosis Evisceration History of laparotomy and calcified aorta Calcified aorta Digestive fistula Abdominal aorta infection

9 1 1 1 4 1 1 1

tient, portal hypertension from hepatic cirrhosis in one patient, obesity associated with a large incisional hernia in one patient, calcified abdominal aorta associated with prior laparotomy for septic bowel lesions in four patients, isolated calcified abdominal aorta in one patient, and rhabdomyosar-

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Lower limb revascularization from thoracic aorta 569

Table III. Indications of bypass grafting from the thoracic aorta in group of secondary revascularizations (group II = 26 patients) Aortic pseudoaneurysm Bypass infection Aortoduodenal fistula Aortobifemoral bypass Axillobifemoral bypass Bypass obstruction

3 9 4 4 1 14

Table IV. Approach routes and surgical procedures for bypasses from the thoracic aorta Thoracotomy Aortobifemoral bypass Aortofemoral + crossover bypass Suprapubic Perineal Unilateral aortofemoral bypass Thoracophrenolaparotomy

33 21 10 7 3 2 3

coma associated with an intestinal fistula in one patient. The last patient from group I had infection of the abdominal aorta following urologic surgery and was treated by ligation of the infrarenal aorta. Among the 26 patients making up group II (Table III), 3 presented with a false aneurysm of the proximal anastomosis of an aortobifemoral bypass, 9 had infection of an earlier lower limb revascularization, and 14 had occlusion of the bypass graft revascularizing their lower limbs, which determined acute ischemia in 5 patients, claudication in 5 patients, and chronic critical ischemia in 4 patients. Among these 14 patients, 4 presented with unilateral occlusion of an aortobifemoral bypass and a history of multiple laparotomy for digestive pathology; 3 had an occluded aortobifemoral bypass that had previously been repaired in situ (2 patients) or was associated with retroperitoneal fibrosis (one patient); 3 had presented with repeated occlusions of a crossover femorofemoral bypass; 3 had occlusions of an axillofemoral or axillobifemoral bypass; and 1 had occlusion of an aortofemoral bypass associated with an obstruction of the contralateral iliac artery.

In three patients, the descending thoracic aorta was approached by thoracophrenolaparotomy37 through the ninth intercostal space. These patients had a false aneurysm of the aortic anastomosis of a prior aortobifemoral bypass graft. Following the proximal anastomosis to the distal descending thoracic aorta, the new graft was anastomosed to the body of the previous infrarenal prosthetic graft in two patients, and to the origin of the left limb of the previous graft in one patient in whom right prosthetic limb occlusion had been followed by amputation. Angiographic control was carried out in all the patients who survived beyond 30 days. Secondary patency was ascertained by means of Duplex ultrasonography. Late graft control was conducted through enhanced CT scanning. Survival and patency were assessed according to the actuarial method and were expressed in terms of 95% confidence interval,38 whereas the results were compared by means of the log-rank test. Patients lost to follow-up were listed as “excluded during the interval or patent” at the date of their last follow-up visit.

Technique

RESULTS

In the usual technique,32 which we used in 33 cases (Table IV), the descending thoracic aorta was approached through a left thoracotomy in the seventh or eighth intercostal space. Tunneling of the prosthesis was made easier by complementary flank and suprapubic incisions. The groin was approached in the usual way. A bifurcated bypass graft was implanted in 21 patients. In 10 patients, unilateral bypass grafting from the descending thoracic aorta to the left femoral artery was combined with a crossover femorofemoral bypass. In seven patients the crossover bypass was a prosthetic femorofemoral suprapubic bypass, and in three cases, a perineal venous bypass. Two patients had unilateral left aortofemoral bypass grafting.

Early Results There were four postoperative deaths (11%). One patient died on the third day postoperatively after two re-interventions for acute ischemia of the right lower limb due to occlusion of a femorofemoral bypass. Two patients died of multiple organ failure on the 11th and 23rd days postoperatively. One patient died of pulmonary embolism on the 15th postoperative day. These four patients were from group II; the respective operative indications were occlusion of a prior reconstruction in one patient, graft infection in two patients, and an aortic false aneurysm in one patient. There were no postoperative deaths among group I patients. There were three early occlusions of prosthetic limbs, all occurring in group II

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Table V. Causes of long-term deaths

Multiple organ failure Cardiac Stroke Cancer Respiratory failure Dementia Surgical redo

n

Time lapse (months)

1 2 2 2 1 1 1

8 6, 32 41, 42 39, 72 78 14 102

patients, and all three were reoperated on successfully. The occlusions were due to poor run-off that was remedied by patch angioplasty of the deep femoral artery in one case, heparin-induced thrombocytopenia in one case, and platelet aggregation from prosthetic material used in one case. Two patients had a popliteal embolism that was successfully treated by embolectomy. One patient who was operated on for the occlusion of a previous aortobifemoral bypass manifested complete flaccid paraplegia, which did not recede. Four patients had postoperative pneumonia with prolonged assisted ventilation. One patient had an intraoperative splenic trauma, treated by splenectomy. Long-Term Results Four patients were lost to follow-up—two immediately following discharge from the hospital and two after 4 and 8 months follow-up. Long-term results were obtained for 28 patients who were followed up over a period of 6 to 108 months (mean duration, 46.4 months). Ten long-term deaths occured (Table V), two of which were in group I. The patient who had presented with postoperative paraplegia died of multiple organ failure when his repair occluded, 8 months after intervention. At the 102nd month of follow-up, one patient reoperated on for a late ureteric fistula died. The other deaths bore no direct relation to the surgery performed and occurred in patients whose bypasses were patent. The actuarial survival probability (Table VI) was 79.7 ± 13.5% at 2 years, 62.4 ± 18.4% at 5 years, and 48.5 ± 22.2% at 7 years (Fig. 1). Long-term complications are displayed in Table VII. Four group II patients, in addition to the one who died at the eighth month postoperatively, presented with one or several late occlusions of their revascularizations. In one case, repeated obstructions of the right prosthetic limb occured at 7, 16,

and 21 months postoperatively, and were respectively treated by thrombolysis, thrombectomy, and amputation. In one case, a bypass from the thoracic aorta to the left femoral artery occluded at 10 then at 24 months. The first episode was treated by thrombectomy, the second one required amputation. In one case, thrombosis of a pseudoaneurysm of the right prosthetic limb at 62 months postoperatively was addressed by thrombolysis and followed by resection and grafting. In one case, the left limb of the graft occluded twice, at 48 and 88 months, and benefitted both times from thrombectomy. Primary patency was 81.8 ± 13.4% at 2 years and 72.7 ± 20.6% at 5 years. Secondary patency was 85.6 ± 13.3% at 2 and 5 years (Fig. 2). Patency according to indication is displayed in Table VIII. No late obstruction occured in group I patients. The lowest patency was observed among group II and occluded redo patients. This was significantly lower than that noted for group I (p < 0.05). One patient in group I presented with infection at the level of the right femoral anastomosis of a suprapubic prosthetic crossover bypass 2 months after intervention. The infection was remedied by excision of the crossover bypass, and revascularization was ensured by a venous perineal bypass. This was still patent and infection-free at 65 months postoperatively. One group II patient, operated on for an aortoduodenal fistula, presented at the third month after intervention with a left ureteric fistula, which was treated by ureteroplasty. After a 68-month follow-up, the patient developed a fistula exteriorized at the left flank. His death at the 102nd month of follow-up was followed an urological intervention meant to address this latter complication. The proximal anastomosis at the level of the thoracic aorta was controlled by CT scanning in 19 patients, with a mean follow-up of 50.8 months (range, 17 to 94 months). Seventeen patients did not undergo CT scanning because they were either lost to follow-up (n = 4) or dead (n = 13). In 18 cases, this survey did not show any dilatation of the thoracic aorta or of the prosthesis. In one case, a thoracic aorta aneurysm at the level of the proximal anastomosis of the bypass was detected at the 53rd month of follow-up in a patient who had undergone surgery for graft infection (Fig. 3). This aneurysm was treated by graft replacement of the thoracic aorta and transposition of the bypass in the new graft. There were three leg amputations during the follow-up, all three in group II patients. One patient underwent amputation of his right leg at the 21st postoperative month upon occlusion of the right

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Lower limb revascularization from thoracic aorta 571

Table VI. Survival according to indicationa Survival (%) Indication

2 years

5 years

Group I (n = 10) Group II (n = 26) Bypass obstruction (n = 14) Bypass infection (n = 9) Global series (n = 36)

100 71.5 ± 18.0 75.0 ± 24.8 77.8 ± 27.2 79.7 ± 13.5

68.6 ± 36.5 60.5 ± 20.7 50.0 ± 32.7 77.8 ± 27.2 62.4 ± 18.4

a

In group II, survival was not assessed for the subgroup of three patients presenting with an aortic pseudoaneurysm.

Fig. 1. Actuarial survival curve.

Fig. 2. Primary and secondary patency actuarial curves.

limb of his prosthesis, and amputation of his left leg at the 60th postoperative month because of deterioration of its runoff. One patient who had already had his right leg amputated underwent amputation of his left leg at the 24th postoperative month when his bypass graft occluded. The rate of limb salvage was 95.6 ± 6% at 2 years, and 91 ± 10.4% at 6 and 7 years.

described by Enon et al.15 or by McCarthy et al.,20 in which the prosthesis crosses the diaphragm laterally along the anterior axillary line. Similarly, the approach through thoracophrenolaparotomy, which Ochsner37 describes, is more aggressive, and we have used it only when treating a pseudoaneurysm of the proximal anastomosis of an aortobifemoral bypass graft. Whenever feasible, we revascularize the right lower limb by a direct bypass from a bifurcated prosthesis. We reserve the suprapubic crossover bypass, the patency of which is lower,39 for use in cases where a prior crossover bypass can be transposed in the left aortofemoral bypass and in cases where the retroperitoneal tunneling of the right prosthetic limb might be hampered by the sequelae of a previous intervention. The choice of this technique over alternative procedures of extraanatomical bypass grafting must be examined according to each patient’s indications. In the context of occlusive aortoiliac lesions, primary indications have risen proportionally in number over the most recent years of our experience. These were chiefly cases in which multiple prior digestive interventions had rendered the abdomen hostile,

DISCUSSION Revascularization of lower limbs using the thoracic aorta as a donor has not been used very much since it was described in 1961.1,2 There are few reported cases, and relatively lengthy enrolling periods were required to complete the 6 series of more than 10 cases each (Table I). The technique we use, in which sectioning of the diaphragm is avoided while the prosthesis follows a retrorenal tunneling, is advocated by most authors.10,16-18,31 A prosthesis route that crosses the diaphragm at the level of the crux and then passes dorsal to the kidney in the peritoneum (Fig. 4) seems more compatible and more direct than those

102 53 Infection Thoracic aortic aneurysm

Primary infection

Secondary infection Secondary infection

Left aortofemoral + suprapubic crossover Aortobifemoral Left aortofemoral

Left limb Proximal anatomosis

Infection

Secondary occlusion Aortobifemoral

Crossover bypass

Intervention Aortic grafting

Patent Patent Patent infectionfree Death Patent Left limb

Right limb

Pseudoaneurysm occlusion Occlusion Secondary infection Aortobifemoral

Occlusion Secondary occlusion Left aortofemoral

Bypass

48 88 2

Thrombolysis Thrombectomy — Trombectomy — Thrombolysis + resection and grafting Thrombectomy Thrombectomy Perineal bypass 8 7 16 21 10 24 62 Occlusion Occlusion Secondary occlusion Secondary occlusion Aortobifemoral Aortobifemoral

Complication Indication Type of bypass

Left limb Right limb

Treatment Time lapse (months) Site of complication

Table VII. Late complications

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Death Patent Patent Amputation Patent Amputation Patent

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and cases in which the difficulty of clamping a calcified infrarenal abdominal aorta was anticipated. In such cases, bypasses from the supraceliac aorta by an abdominal route40-42 and bypasses in which the axillary artery is used as a donor may be proposed. The approach to the supraceliac aorta, however, is more difficult and longer, notably in obese patients, and the prosthesis comes into direct contact with the viscera in its supramesocolic path. Axillofemoral bypasses, which are decidedly less aggressive, have been and still are widely used in these situations. Although a recent publication reported results similar to those recorded with aortofemoral bypasses,43 it seems that their more superficial tunneling and more precarious hemodynamic condition make them more prone to infection and to numerous extrinsic causes of thrombosis than more deeply tunneled bypasses.44-47 A few cases of infection of the infrarenal aorta, one of which was in our series, were treated by the association of an infrarenal aorta ligation with a bypass graft from the thoracic aorta.8,9 Currently, in situ repair by means of an arterial allograft is preferred.48 Other primary indications, such as occlusion of the infrarenal aorta,6,7,10,12,14,23,24 presence of a horseshoe kidney, and potential postoperative sexual disorders or radic arterial disease of the lower limb, have all been put forward,35,49 but they are not part of our experience. In the case of a prior lower limb revascularization becoming occluded, and when thrombectomy proves impracticable, direct redo surgery remains a possibility. This solution yields good results,50,51 but the intervention is more aggressive, lengthy, and hemorrhagic. As for bypasses arising from the supraceliac aorta, in addition to the previously mentioned drawbacks, it is difficult to achieve retroperitoneal tunneling in the patients concerned. The results of axillofemoral or bifemoral bypasses are still less satisfactory in this type of indication.44-47 When a prior aortoiliac reconstruction is infected, the technique classically resorted to is that involving ablation of infected material and an axillofemoral bypass, but it is beset with such considerable morbidity in terms of middle-term bypass infection and occlusion52 that we do not use it. Revascularization from the thoracic aorta enabled us to treat these patients and achieve a postoperative mortality rate of 22%, which is similar to that reported with the previous technique, without any recurrence of infection, as stated in McCarthy et al.’s series.33 However, we currently favor in situ repair by arterial allograft, which yields at least equivalent results, with a simpler and one-step procedure.53

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Lower limb revascularization from thoracic aorta 573

Table VIII. Patency rates according to indicationa Primary patency (%)

Secondary patency (%)

Indication

2 years

5 years

2 years

5 years

Group I (n = 10) Group II (n = 26) Bypass obstruction (n = 14) Bypass infection (n = 9) Global series (n = 36)

100 73.3 ± 18.9 52.4 ± 31.9 88.9 ± 20.5 81.8 ± 13.4

64.2 ± 23.6 52.4 ± 31.9 74.1 ± 31.6 72.7 ± 20.6

100 78.7 ± 18.9 63.5 ± 33.2 88.9 ± 20.5 85.6 ± 13.3

78.7 ± 18.9 63.5 ± 33.2 88.9 ± 20.5 85.6 ± 13.3

a

In group II, patency was not assessed for the subgroup of three patients who presented with an aortic pseudoaneurysm.

Fig. 3. Aneurysm at the level of the proximal anastomosis of a bypass arising from the thoracic aorta. A CT scan and B arteriogram show the aneurysm at 53-month follow-up.

Fig. 4. Normal CT scan microphotography of a bypass graft arising from the descending aorta, which shows the prosthesis route: A proximal anastomosis, B crossing of the diaphragm, C both graft limbs are tunneled dorsal to the kidney.

The results of bypasses running from the thoracic aorta cannot be as precisely appraised as those of bypasses from the infrarenal abdominal aorta or from the axillary artery. In the literature, the risk of perioperative mortality varies from 0 to 11%. The high rate of postoperative deaths observed in certain series, including ours, was connected to the

proportion of secondary indications. Indeed, out of the 11 postoperative deaths reported in the literature, 7 happened after redo surgery. The mean mortality risk is 5.1% for all reported cases, and 5.4% (8/149) if we only consider series of more than 10 cases. Long-term mortality was high in our series,

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Table IX. Literature review of series expressing rates of long-term patency of lower limb revascularization from the thoracic aorta Primary patency (%)

Secondary patency (%)

References

Period

Cases

2 years

5 years

2 years

5 years

Follow-up (months)

Hussain22 Bowes et al.24 McCarthy et al.33 Criado and Keagy35 Present series

1982-1986 1976-1988 1982-1992 1982-1993 1984-1994

8 26 21 32 36

73 91 100 85.9 81.8

— 79 86 75.8 72.7

100 — 100 — 85.6

— — 100 — 85.6

36 — 44 22 46

Table X. Literature review of long-term obstructions of bypasses from the thoracic aorta according to indication Indication References

Bypasses n

Occlusions n

Primary

Prothesis occlusion

Prosthesis infection

Not specified

Froysaker et al.7 Haas et al.14 Feldhaus et al. and Schultz et al.17,19 Hussain22 Bowes et al.24 DeLaurentis30 McCarthy et al.33 Criado and Keagy35 Present series

6 3 21 8 26 13 21 32 36

1 1 4 2 4 2 1 2 5

1 1 — 1 1 — — — —

— — 3 1 1 2 1 1 4

— — 1 — — — — 1 1

— — — — 2 — — — —

particularly for redo patients (Table VI). Criado and Keagy35 analyzed the collective experience available in 146 published and exploitable cases.12,14,15,17,21,22,24,32,33,35 They also found a survival probability of 67.5 ± 6.9% at 5 years and of 55.4 ± 9.9% at 7 years. Out of the 21 deaths registered, 19 occured in three series that included a high percentage of redo patients.20,24,32 Few long-term complications attributable to bypasses arising from the thoracic aorta have been reported. An aneurysmal growth at the level of the prosthetic implantation, an instance of which we observed, is not documented by other authors. Bowes et al. reported a case of renal insufficiency caused by a suprarenal extension of thrombosis in a patient who had an occluded infrarenal aorta.24 A case of medically treated re-infection of the whole bypass was also described.28 In those series in which patency is clearly expressed (Table IX), primary patency at 5 years varies from 72.7 to 86% and secondary patency at 5 years ranges from 85.6 to 100%. In an analysis of 146 published cases, Criado and Keagy35 also found probabilities of primary and secondary patencies at

5 years of 72.7% and 82.7%, respectively. These percentages are slightly lower than those reported for aortobifemoral bypasses through an abdominal route.54,55 In such a comparison, one must allow for the large proportion of secondary indications (59.5%) in the series of bypasses in which the thoracic aorta is used as a donor (Table I). In our series as well as in Criado and Keagy’s,35 no late occlusion was observed in the primary indication group. Among the 22 cases of long-term thrombosis found in the literature (Table X), only 4 occured after a primary revascularization, 16 happened in patients who had undergone surgery for a secondary indication, and in 2 cases the indication was not specified. Use of bypasses from the thoracic aorta makes it possible to revascularize lower limbs in satisfactory hemodynamic condition when the abdominal aorta is not available. The best results are obtained in patients who have not already had any aortoiliac reconstruction. Nevertheless, should a prior bypass fail, bypasses from the thoracic aorta are simpler to carry out than those from the supraceliac aorta by an abdominal route or than re-interventions at the

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