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Use of descending thoracic aorta for lower limb revascularisation
Eur J VascSurg 6, 255-262 (1992)
Use of Descending Thoracic Aorta for Lower Limb Revascularisation Alain Branchereau, Pierre-Edouard Magnan, Philippe Moracchini, Hugo Espinoza, Jean-Pierre Mathieu Service de Chirurgie Vasculaire des Hfipitaux Sud, H6pital Sainte Marguerite BP 29, Universit~ Aix-Marseille II, 13274 Marseille Cedex 9, France From November 1984 to May 1991, descending thoracic aorta to femoral artery bypass was used to revascularise 51 lower limbs in 27 patients. There were 25 men and 2 women with a mean age of 60.2 years. There were four primary indications because of inability to use the abdominal aorta, and 23 secondary indications for late failure of a previous lower limb revascularisation: two aorto-prosthetic false aneurysms, nine infected aorto-bifemoraI bypasses and 12 occluded grafts. Three deaths and one paraplegia occurred during the postoperative period, and three prosthetic occlusions and one popliteal embolism were successfully treated. During follow up (6-72 months)five deaths and three graft occlusions were observed; at 5 years, the cumulative life expectancy was 61.8 + 26.8%, and the cumulative secondary graft patency was 72.6 ++_24.7%. One prosthetic infection and one ureteric fistula occurred and both were successfully treated. Thoracic aorta to femoral artery bypass is a simple extra-anatomic technique which can be used in cases of failure of a previous aorta to lower limb reconstruction. The haemodynamic results are good, and late results are better than axillo-femoral or bifemoral bypass. Key Words: Thoracic aorta to femoral artery bypass; Thoracic aorta; Aorto-femoral bypass; Aorto-ilio-femoral reconstruction; Aorto-iliac disease; Occlusive disease.
Introduction
Surgical Technique
Descending thoracic aorta to femoral artery bypass was described by both Stevenson et al. 1 and Blaisdell et al. 2, in 1961. Two years later, Blaisdell described axillo-femoral bypass (AFB)3 which was to become the more popular of the procedures. In recent years, encouraging results have been published with descending thoracic aorta to femoral artery bypass 4-9 whereas AFB has been criticised because of poor long-term results. 10,11 The aim of this study is to present the technique of bypass from descending thoracic aorta for lower limb revascularisation, and the short- and long-term results we have obtained. Based on our experience and a review of the literature, the place of this technique in the armamentarium of vascular surgery must be re-evaluated.
The patient is rotated so that his shoulders are turned 60° and his pelvis 30° with respect to the table. This position allows a simultaneous approach to the thorax and both femoral arteries. Intra-operative monitoring includes central venous and direct arterial pressure measurements, continuous electrocardiography, and the use of a Swan-Ganz catheter. Selective tracheal intubation is not required. The procedure requires five cutaneous and one diaphragmatic incision (Figs 1 and 2). A short left lateral thoracotomy in the 7th or 8th intercostal space allows access to the distal thoracic aorta, a vertical incision in the groin is used for the femoral arteries, a 10-12cm horizontal incision, centred on the midaxillary line half-way between the iliac crest and the 12th rib, is used to tunnel the prosthetic graft behind the left kidney and a 5 cm vertical suprapubic incision allows the right limb of the graft to be tunnelled through the prevesical space to the right femoral triangle.
Please address all correspondence to: A. Branchereau, Servicede Chirurgie Vasculaire des H6pitauxsud, H6pitaI Sainte Marguerite BP 29, 13274MarseilleCedex9, France. 0950-821X/92/030255+08 $03.00/0© 1992Grune &StrattonLtd.
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Fig. 3. Proximalanastomosis: a single clamp is used to interrupt blood flowand to present the edges of the arteriotomy.
Fig. 1. Patient position and skin incisions for thoracic aorta to femoral artery bypass.
Fig. 2. Blindtunneling,through diaphragm, fromthe thoraxto the retroperitoneal area.
The diaphragm is incised in the posterior phrenicocostal sinus, at a point near the vertebral body, at the level of the accessory crux or the medial lumbocostal arch. This incision is made blindly with scissors through the thorax, guided by a hand introduced behind the left kidney through the lumbar incision (Fig. 2). The incision involves the pleura but the muscular fibres of the diaphragm are only separated. After dividing the pleura we limit dissection of the aorta to the left anterior margin. A single SatinskyEur J Vasc Surg Vol 6, May 1992
type clamp is used to cross-clamp the aorta and to allow an end-to-side anastomosis to be made (Fig. 3). Systemic hypotension is achieved with sodium nitroprussiate during aortic cross-clamping. We use albumin-coated Dacron grafts without shortening the main stem. 12 The graft is cut obliquely in order to implant it on the left lateral aspect of the aorta and to provide a lateral and slightly posterior direction passing through the diaphragmatic incision without kinking (Fig. 4). The two limbs of the graft are placed in the sagittal plane and tunnelled from the thorax to the lumbar incision in the retro-peritoneal area behind the kidney (Fig. 5). The anterior limb is placed extraperitoneally, from posterior to anterior, and from left to right, to the suprapubic incision then to the right femoral triangle. The posterior limb is run directly to the left femoral triangle. The distal anastomoses are constructed as usual. Several variants of this basic technique have been used. When a patent femoro-femoral bypass is available, a thoracic aorta to left femoral artery bypass is performed and the cross-over bypass attached to it. When both femoral triangles are infected, the aorta to left femoral artery bypass is made lateral to the infected area and revascularisation of the right lower limb is achieved by a cross-over perineal bypass 13 (Fig. 6). When the indication is a false aneurysm, a thoraco-phreno-laparotomy is made through the 9th intercostal space. The area of the false aneurysm and the distal thoracic aorta are approached extraperitoneally after partial division of the diaphragm. After clamping the aorta, the false aneurysm is opened, the old graft is freed, and temporarily occluded by bal-
Descending Thoracic Aorta to Femoral Artery Bypass
257
Fig. 4. Post-operative arteriogram of a thoracic aorta to bifemoral bypass using the basic technique. Fig. 5. Post-operative CT scan showing the route of the prosthesis. (a) Just below the proximal anastomosis; (b) behind the left kidney; (c) the two limbs are in a sagittal plane behind the left kidney. loon catheters. The native aorta is closed either b y suture just b e l o w the renal arteries w h e n the previous a n a s t o m o s i s was e n d - t o - e n d , or b y a prosthetic patch w h e n the p r e v i o u s a n a s t o m o s i s w a s side-toend in order to p r e s e r v e flow t h r o u g h the internal iliac arteries. After end-to-side a n a s t o m o s i s to the thoracic aorta, the n e w graft is c o n n e c t e d to the old graft end-to-end.
Patients B e t w e e n N o v e m b e r 1984 a n d M a y 1991, this technique w a s u s e d to revascularise 51 lower limbs in 27 patients. T w o patients h a d already u n d e r g o n e contralateral a m p u t a t i o n a n d one patient w a s revascularised for unilateral acute ischaemia. There w e r e Eur J Vasc Surg Vol 6, May 1992
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had unilateral thrombosis of the aorto-bifemoral prosthetic graft after having undergone one to three laparotomies for various intestinal disorders; two had already undergone a replacement of an aortobifemoral bypass; three patients had repeated failures of femoro-femoral cross-over bypass; two patients had an occluded axillo-femoral or axillo-bifemoral ~x~,-~ ,,~,bypass; one patient had an occluded aorto-femoral f:y./ bypass associated with occlusion of the contralateral iliac artery; and the last had an occluded aorto/ bifemoral bypass with rePro-peritoneal fibrosis. The basic technique, as described above was used in 16 cases. Fifteen of the grafts were diameter 14/7, and one was 16/8. A cross-over procedure was associated with a thoracic to left femoral artery Fig. 6. Perineal bypass associated with a thoracic aorta to left bypass in seven cases. In one case, a pre-existing femoralarterybypass. femoro-femoral bypass was used by reversing the direction of flow. In three cases a venous cross-over 25 males and two females with a mean age of 60.2 bypass was performed through the perineum, and in years (range 41-79 years). All patients except two three cases a subcutaneous femoro-femoral prosthetic were heavy cigarette smokers (>20g/day); five cross-over procedure was employed. Only the left patients had stable coronary artery disease; four were lower limb was revascularised in two cases. In one hypertensive, and four had chronic bronchopulmon- case, the right lower limb had already been amputated and in the other, the right lower limb was adary disease. Fifteen patients had ischaemia of the lower equately vascularised and two previous cross-over limbs. Ten had chronic ischaemia (seven claudica- procedures had failed. The thoraco-phreno-lapartion, three gangrene) and five had acute ischaemia. otomy approach through the 9th intercostal space Ten patients had septic lesions: four had aorto-enteric was used in two cases involving false aneurysms. The fistulae arising from an aorto-bifemoral bypass; four new graft was implanted on the old abdominal graft. had an infected aorto-bifemoral bypass; one had an In one case on the main stem and in the other case on infected axillo-bifemoral bypass; and one had an the origin of left limb since the right limb was already infected aorta following lymphadenectomy for tes- occluded. ticular cancer. Two asymptomatic patients had false Follow-up angiograms were obtained for all aneurysms at the proximal anastomosis of their aorto- patients surviving more than 30 days. Late patency was established by palpation of femoral pulses. Two bifemoral bypasses. There were four primary indications for patients patients were lost to follow-up after discharge and who had never undergone arterial reconstruction of one was lost to follow-up after 6 months. The proxitheir lower limbs, and 23 secondary indications for mal anastomosis was examined by computed tomopatients with occluded or complicated bypass. graphy (CT) scan in 12 patients. Fifteen patients did Among the primary indications, three patients had not undergo this investigation because of death (n = aorto-iliac occlusive disease. This technique was 8), loss to follow-up (n = 3), refusal (n = 1), and chosen because of obesity associated with a large in- follow-up of less than I year (n = 3). cisional hernia in one patient, chylous ascites in one patient, and calcification of the entire abdominal aorta in one patient who had undergone two preResults vious laparotomies for septic intestinal lesions. The last primary indication involved a patient with an Before the 30th postoperative day or discharge, three infected aorta requiring ligation. Of the 23 secondary indications, two were false deaths, one popliteal embolism, three prosthetic aneurysms occurring at the aorto-prosthetic anasto- thromboses, and one paraplegia were recorded. One mosis; nine were infected aorto-bifemoral bypasses patient died on the third postoperative day after two and 12 were occluded grafts after one to four arterial successive occlusions of a cross-over bypass with reconstruction procedures involving the infrarenal acute ischaemia, and two patients died of multiple aorta or axillary artery. Of these 12 patients, three organ failure 11 and 23 days after operation, respect....
Eur J VascSurgVol 6, May 1992
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Fig. 7. Cumulativelife expectancy. Two years: 74.2 + 18.2%; 5 years, 61.8 + 26.8%. * Patients at risk.
Fig. 8. Cumulativesecondarypatency. Two years: 72.6 + 21.7%. * Reconstructionsat risk.
ively. Three graft thromboses were operated on with success. In the first case, a poor outflow was treated by profundoplasty. In the second, the patient presented a heparin-induced thrombopenia. In the third, the patient had platelet hyperaggregability potentiated by the prosthetic material. In the last two cases, patency was maintained with appropriate medical treatment associated with thrombectomy. Popliteal embolism occurred in one patient, and was treated successfully on day 2. One patient had paraplegia. He had undergone aortic cross-clamping associated with dissection of a large intercostal artery. Late results were available for 22 patients followed for 3-72 months (mean: 26.3 months). Five late deaths were observed. One patient died 8 months after operation due to thrombosis of the bypass; the other four deaths occurred in patients with patent grafts. The causes included myocardial infarction at 6 months, senile dementia at 14 months, prostate cancer at 39 months, and bladder cancer at 72 months. The cumulative life expectancy was 74.2 + 18.2% at 2 years and 61.8 + 26.8% at 5 years (Fig. 7). In addition to the patient who died with thrombosis at 8 months, two patients had late thrombosis. One patient had three episodes of thrombosis involving the right limb of the graft at 7, 16 and 21 months. The first two episodes w e r e managed by thrombolysis and thrombectomy respectively, the last episode required amputation. The other patient had thrombosis of a thoracic aorta to left femoral artery bypass at 10 months and 24 months; the first episode was successfully treated by thrombectomy but the second required amputation. The cumulative secondary patency rate was 72.6 + 24.7% at 5 years (Fig. 8). In one patient with a primary indication infection occurred at the right femoral anastomosis of a suprapubic cross-over prosthetic bypass 2 months after discharge. This patient was treated by ablation
of the suprapubic bypass and revascularisation by a perineal venous bypass. The graft was patent and non-infected at 65 months (Fig. 9). One patient developed a left ureteric fistula and was reoperated on 3 months later when a ureteric plasty was performed; this patient was without further problems at 66 months. None of the 12 patients who had CT scans had any evidence of false aneurysm.
Discussion
This technique of thoracic aorta to femoral artery bypass that we and others 4-7' 14-16 use, seems simpler and less aggressive than the one proposed by McCarthy et al. 8 or by Ochsner. 17 The latter technique involves dividing the diaphragm and placing the graft anterior to the kidney, and is more invasive, takes longer to perform and is more haemorrhagic. Conversely, the presence of a false aneurysm requires an extended approach from the thoracic aorta to the aneurysm with division of the dia L phragm. Exposure of the aorta and false aneurysm is easier when the kidney is retracted anteriorly with the viscera. When both femoral arteries require revascularisation, if possible we use a bifurcated graft whose main stem is left at its original length. The main stem of the graft has to be tailored in order to place the prothesis in a sagittal position. In this manner, the course of the graft is more trouble-free than with an aorto-femoral tube associated with a femoro-femoral bypass (Fig. 4). If the femoral triangles are infected, neither the basic technique nor thoracic aorta to left femoral artery bypass associated with suprapubic femoro-femoral cross-over bypass can avoid the infected areas. In our opinion the best solution is a maximally lateralised thoracic aorta to left femoral Eur J Vasc SurgVol 6, May 1992
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Fig. 9, Post-operative arteriogram of a thoracic aorta to femoral artery bypass associatedwith a perineal bypass.
bypass with a perineal femoro-femoral bypass 13 (Figs 6 and 9). Postoperative paraplegia occurred in one patient and we are aware of other unpublished cases of spinal cord ischaemia in this setting. In our patient, a large:~ intercostal artery had been dissected and clamped together with the aorta. In our opinion, paraplegia was due to dissection and trauma to the intercostal artery rather than to clamping of the aorta Eur J Vasc SurgVol 6, May 1992
itself. Since this accident, we limit the dissection of the aorta as previously described. The place of this technique must be discussed in relation to alternative solutions. Late failure of aortoilio-femoral reconstruction is the most frequent indication. This was the case for 14 of our 27 patients and in 57 of the 121 patients reported in the literature (Table 1). When failure occurs and when thrombectomy is unsuccessful or unwarranted, descending thoracic aorta to femoral artery bypass must be considered. Re-do direct reconstruction of the previously operated site requires a long and haemorrhagic operation and carries an increased risk of infection. Although it is certainly less aggressive, axillo-femoral or bifemoral bypass also poses high immediate and long-term risks. This technique is associated with a higher rate of infection than deeply placed grafts and has a great risk of secondary thrombosis because of unfavourable local and haemodynamic conditions, especially when it is performed after failure of a previous reconstruction. 1°'11"31 Coeliac aorta bypass by the anterior transperitoneal approach is an aggressive and timeconsuming technique; moreover, use of the retroperitoneal route for placement of the second prothesis in cases of re-do surgery is hazardous. 32 As with axillofemoral bypass, revascularisation by a descending thoracic aorta to lower limb procedure is simple and expedient because it precludes the need for repeat dissection. The graft length is shorter and the route more direct. Implantation is performed on a highflow vessel. Because it is located deeply, this bypass provides more favourable haemodynamic conditions and carries less risk of infection than an axillo-femoral bypass. In cases of infection, another choice is axillo-bifemoral bypass before or after removal of the infected graft. The advantages of descending thoracic aorta to femoral artery bypass are described above. The chronology of treatment depends on the arterial circulation distal to the aortic anastomosis. If collateral flow through the internal iliac arteries is adequate, the infected graft is removed in the first stage and a reconstruction from the descending thoracic aorta is performed in the second stage (1 month and 3 months in this series). When the upper anastomosis of the infected graft is end-to-end and/or when collateral flow is poor distal to the aortic anastomosis, reconstruction from the descending thoracic aorta must be done during the same intervention either after or before removing the infected graft. It is difficult to evaluate the results of this technique as only 121 observations have been published, most as case reports. Only five series include 10 or more
Descending Thoracic Aorta to Femoral Artery Bypass
261
Table 1. Descending thoracic aorta to femoral artery bypass: review of literature Number of cases
Indications for late occlusion
Post-operative complications
Post-operative mortality
I amputation
0
0
1
1
0
0
3
2
0
0
1973
6
--
0
0
Finseth 21
1974
1
--
0
0
C e v e s e 22
1975
6
--
0
0
Jarrett 23
1975
2
--
0
1
Buxton 24
1976
1
--
1 pneumonia
0
Lakner 25
1983
2
--
0
0
Reilly26
1984
5
--
0
0
H a s s 27
1985
3
--
1 haemothorax
1
Bowes 4
1985
12
6
0
1
Feldhaus s
1985
18
12
1 myocardial infarction + 2 pneumonia
1
Enon 16
1985
3
2
0
0
Rosenfeld 6
1986
10
8
- - not available
0
Schultz 7
1986
15
15
1 thrombosis
0
McCarthy 8
1986
13
5
1 haemothorax + 1 atelectasis
0
Di Marzo 28
1987
5
--
0
1
Schellack29
1988
3
3
0
0
Hussain TM
1988
8
2
0
0
Bradham 3°
1989
2
--
0
0
1st author
Year
Stevenson ~
1961
1
1
BlaisdelI2
1961
1
--
Robicsek TM
1967
1
Nunn 19
1972
Froysaker 2°
c a s e s ( T a b l e 1). P o s t o p e r a t i v e m o r t a l i t y w a s 1 1 . 1 % i n t h i s s e r i e s a n d six o u t o f 121 c a s e s i n t h e l i t e r a t u r e . Mortality seems to be related to patient status rather t h a n t h e t e c h n i q u e i t s e l f w h i c h is i l l u s t r a t e d b y t h e h i g h l a t e m o r t a l i t y r a t e (Fig. 7). L a t e s e c o n d a r y p a t e n c y w a s 7 2 . 6 + 2 1 . 7 % a t 2 a n d 5 y e a r s (Fig. 8); these figures as well as those reported in the literat u r e ( T a b l e 2) a r e s a t i s f a c t o r y , c o n s i d e r i n g t h e u s u a l indications. Based on these results thoracic aorta to femoral bypass can be considered as an alternative to AFB. In f a c t it p r o v i d e s better haemodynamic conditions without higher morbidity or mortality particularly for l a t e f a i l u r e o f a o r t o - f e m o r a l r e c o n s t r u c t i o n . 10,11, 31
Table 2. Late results of descending thoracic aorta to femoral artery bypass: review of literature Number of cases
1st author
Year
Late patency
Cevese 22
1975
6
30 months: PP 100%
Feldhaus 5
1985
18
60 months: SP 85%
Rosenfeld 6
1986
10
44 months: PP 90%
Schultz 7
1986
15
60 months: SP 80%
McCarthy s
1986
13
22 months: PP 100%
Hussain 14
1988
8
36 months: SP 100%
PP: primary patency; SP: secondary patency. Eur J Vasc Surg Vol 6, May 1992
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A. Branchereau et aL
References
17 OCHSNER JL. Use of thoracic aorta in revascularization of the lower extremity. In: BERGAN JJ, YAO JST, eds. Evaluation and
Treatment of Upper and Lower Extremity Circulatory Disorders. 1 STEVENSONJK, SAUVAGELR, HARKINS HN. A bypass homograft from thoracic aorta to femoral arteries for occlusive vascular disease. Ann Surg 1961; 27: 632-637. 2 BLAISDELLFW, DEMATTEI GA, GAUDER PJ. Extraperitoneal thoracic aorta to femoral bypass graft as replacement for an infected aortic bifurcation prosthesis. Am J Surg 1961; 102: 583585. 3 BLAlSDELL FW, HALL AD. Axillary femoral artery bypass for lower extremity ischemia. Surgery 1963; 54: 563-568. 4 BOWESDE, KEAGYBA, BENOIT CH, PHARR WF. Descending thoracic aortobifemoral bypass for occluded abdominal aorta: retroperitoneal route without an abdominal incision. J Cardiovasc Surg (Torino) 1985; 26: 41-45. 5 FELDHAUSRJ, STERPETTIAV, SCHULTZRD, PEETZDJ JR. Thoracic aorta-femoral artery bypass: indications, technique and late results. Ann Thorac Surg 1985; 40: 588-592. 6 ROSENFELDJC, SAVARESERP, DE LAURENTIS DA. Distal thoracic aorta to femoral artery bypass a surgical alternative. ] Vasc Surg 1985; 2: 747-750. 7 SCHULTZ RD, STERPETTI AM, FELDHAUS RJ. Thoracic aorta as source of inflow in reoperation for occluded aortoiliac reconstruction. Surgery 1986; 100: 635-645. 8 McCARTHY WJ, RUBINJR, FLINN WR, WILLIAMS LR, BERGANJJ, YAO JS. Descending thoracic aorta to femoral bypass. Arch Surg 1986; 121: 681-688. 9 BRANCHEREAUA, ESPINOZAH, RUDONDYP, MAGNANPE, REBOUL J. Descending thoracic aorta as an inflow source for late occlusive failures following aortoiliac reconstruction. Ann Vasc Surg 1991; 5: 8-15. 10 OBLATHRW, GREENRaN'l,DE WEESEJA, ROB CG. Extra-anatomic bypass of the abdominal aorta management of postoperative thrombosis. Ann Surg 1978; 187: 647-652. 11 DONALDSON MC, LOURAS JC, BUCKNAM CA. Axillofemoral bypass: a tool with a limited role. J Vasc Surg 1986; 3: 757-763. 12 BRANCHEREAUA, RUDONDY P, GOURNIER JP, ESPINOZAH. The albumin-coated knitted dacron aortic prosthesis: a clinical study. Ann Vasc Surg 1990; 4: 138-142. 13 BRANCHEREAU A, CIosI G, BORDEAUXJ, LASELVE L, DEVIN R. Fernorofemoral bypass through the perineum for infection complicating arterial revascularization of the lower limb. Ann Vasc Surg 1988; 2: 43-49. 14 HUSSAIN SA. Descending thoracic aorta to bifemoral bypass graft without laparotomy. Int Surg 1988; 73: 260-263. 15 DE LAURENTISDA. The descending thoracic aorta in reoperative aortic surgery. In: BERGANJJ, YAO JST, eds. Reoperative Arterial Surgery. Orlando: Grune & Stratton, 1986; 195-203. 16 ENON B, CHEVALIERJM, MOREAU P, LESCALIE F, PILLET J, Revascularisation des membres inf6rieurs h partir de l'aorte thoracique descendante. J Chir 1985; 122: 539-543.
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Orlando: Grune & Stratton, 1984; 361-368. 18 ROBICSEKF, McCALL MM, SANGERPW, DAUGHERTYHK. Recurrent aneurysm of the abdominal aorta. Ann Thorac Surg 1967; 3: 549-552. 19 NUNN DB, KAI MA. Bypass grafting from the thoracic aorta to femoral arteries for high aorto-iliac occlusive disease. Surgery 1972; 72: 749-755. 20 FROYSAKER T, SKAGSETH E, DUNDAS P, HALL KV. Bypass procedures in the treatment of obstructions of the abdominal aorta. J Cardiovasc Surg 1973; 14: 317-321. 21 FINSETHF, ABBOTTWM. One stage operative therapy for Salmonella mycotic abdominal aortic aneurysm. Ann Surg 1974; 179: 8-11. 22 CEVESE PG, GALLUCCI V. Thoracic aorta to femoral artery bypass. J Cardiovasc Surg 1975; 16: 432-438. 23 JARRETT F, DARLING RC, MUNDTH ED, AUSTEN G. Experience with infected aneurysms of the abdominal aorta. Arch Surg 1975; 110: 1281-1286. 24 BUXTONB, SIMPSON L, JOHNSON N, MYERS K. Descending thoracic aortofemoral bypass for distal aortic reconstruction after removal of an infected dacron prosthesis. Med J Aust 1976; 2: 133-136. 25 LAKNER G, LUKACSL. High aortoiliac occlusion" treatment with thoracic aorta to femoral arterial bypass. ] Cardiovasc Surg 1983; 24: 532-534. 26 REILLYLM, EHRENFELD WK, STONEYRJ. Delayed aortic prosthetic reconstruction after removal of an infected graft. Am J Surg 1984; 148: 234-239. 27 HAss KL, MOULDERPV, KERSTEINMD. Use of thoracic aortobifemoral artery grafting as an alternative procedure for occlusive aortoilliac disease. Ann Surg 1985; 51: 573-576. 28 DI MARZO L, FELDHAUS RJ, SCHULTZ RD. Surgical treatment of infected aortofernoral grafts: a fifteen year experience. Vasc Surg 1987; 21: 229-236. 29 SCHELLACKJ, FULENWIDERJT, SMITH RB III. Descending thoracic aortofemoral-femoral bypass a remedial alternative for the failed aortobifemoral bypass. J Cardiovasc Surg 1988; 29: 201204. 30 BRADHAMRR, LOCKLAIR PR JR, GRIMBALL A. Descending thoracic aorta to femoral artery bypass. J SC Med Assoc 1989; 85: 283-286. 31 BROOME A, CHRISTENSON JT, EKLOF B, NORGREN L. Axillofemoral bypass reconstructions in sixty-one patients with leg ischemia. Surgery 1980; 88: 673-676. 32 ]3ARRALX, YOUVARLAKISP, BOISSIER G, CAVALLO G. Revascularisation des membres inf6rieurs h partir de l'aorte supracoeliaque. Ann Chir Vasc 1986; 1: 30-35.
Accepted 14 October 1991
Use of Descending Thoracic Aorta for Lower Limb Revascularisation Alain Branchereau, Pierre-Edouard Magnan, Philippe Moracchini, Hugo Espinoza, Jean-Pierre Mathieu Service de Chirurgie Vasculaire des Hfipitaux Sud, H6pital Sainte Marguerite BP 29, Universit~ Aix-Marseille II, 13274 Marseille Cedex 9, France From November 1984 to May 1991, descending thoracic aorta to femoral artery bypass was used to revascularise 51 lower limbs in 27 patients. There were 25 men and 2 women with a mean age of 60.2 years. There were four primary indications because of inability to use the abdominal aorta, and 23 secondary indications for late failure of a previous lower limb revascularisation: two aorto-prosthetic false aneurysms, nine infected aorto-bifemoraI bypasses and 12 occluded grafts. Three deaths and one paraplegia occurred during the postoperative period, and three prosthetic occlusions and one popliteal embolism were successfully treated. During follow up (6-72 months)five deaths and three graft occlusions were observed; at 5 years, the cumulative life expectancy was 61.8 + 26.8%, and the cumulative secondary graft patency was 72.6 ++_24.7%. One prosthetic infection and one ureteric fistula occurred and both were successfully treated. Thoracic aorta to femoral artery bypass is a simple extra-anatomic technique which can be used in cases of failure of a previous aorta to lower limb reconstruction. The haemodynamic results are good, and late results are better than axillo-femoral or bifemoral bypass. Key Words: Thoracic aorta to femoral artery bypass; Thoracic aorta; Aorto-femoral bypass; Aorto-ilio-femoral reconstruction; Aorto-iliac disease; Occlusive disease.
Introduction
Surgical Technique
Descending thoracic aorta to femoral artery bypass was described by both Stevenson et al. 1 and Blaisdell et al. 2, in 1961. Two years later, Blaisdell described axillo-femoral bypass (AFB)3 which was to become the more popular of the procedures. In recent years, encouraging results have been published with descending thoracic aorta to femoral artery bypass 4-9 whereas AFB has been criticised because of poor long-term results. 10,11 The aim of this study is to present the technique of bypass from descending thoracic aorta for lower limb revascularisation, and the short- and long-term results we have obtained. Based on our experience and a review of the literature, the place of this technique in the armamentarium of vascular surgery must be re-evaluated.
The patient is rotated so that his shoulders are turned 60° and his pelvis 30° with respect to the table. This position allows a simultaneous approach to the thorax and both femoral arteries. Intra-operative monitoring includes central venous and direct arterial pressure measurements, continuous electrocardiography, and the use of a Swan-Ganz catheter. Selective tracheal intubation is not required. The procedure requires five cutaneous and one diaphragmatic incision (Figs 1 and 2). A short left lateral thoracotomy in the 7th or 8th intercostal space allows access to the distal thoracic aorta, a vertical incision in the groin is used for the femoral arteries, a 10-12cm horizontal incision, centred on the midaxillary line half-way between the iliac crest and the 12th rib, is used to tunnel the prosthetic graft behind the left kidney and a 5 cm vertical suprapubic incision allows the right limb of the graft to be tunnelled through the prevesical space to the right femoral triangle.
Please address all correspondence to: A. Branchereau, Servicede Chirurgie Vasculaire des H6pitauxsud, H6pitaI Sainte Marguerite BP 29, 13274MarseilleCedex9, France. 0950-821X/92/030255+08 $03.00/0© 1992Grune &StrattonLtd.
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Fig. 3. Proximalanastomosis: a single clamp is used to interrupt blood flowand to present the edges of the arteriotomy.
Fig. 1. Patient position and skin incisions for thoracic aorta to femoral artery bypass.
Fig. 2. Blindtunneling,through diaphragm, fromthe thoraxto the retroperitoneal area.
The diaphragm is incised in the posterior phrenicocostal sinus, at a point near the vertebral body, at the level of the accessory crux or the medial lumbocostal arch. This incision is made blindly with scissors through the thorax, guided by a hand introduced behind the left kidney through the lumbar incision (Fig. 2). The incision involves the pleura but the muscular fibres of the diaphragm are only separated. After dividing the pleura we limit dissection of the aorta to the left anterior margin. A single SatinskyEur J Vasc Surg Vol 6, May 1992
type clamp is used to cross-clamp the aorta and to allow an end-to-side anastomosis to be made (Fig. 3). Systemic hypotension is achieved with sodium nitroprussiate during aortic cross-clamping. We use albumin-coated Dacron grafts without shortening the main stem. 12 The graft is cut obliquely in order to implant it on the left lateral aspect of the aorta and to provide a lateral and slightly posterior direction passing through the diaphragmatic incision without kinking (Fig. 4). The two limbs of the graft are placed in the sagittal plane and tunnelled from the thorax to the lumbar incision in the retro-peritoneal area behind the kidney (Fig. 5). The anterior limb is placed extraperitoneally, from posterior to anterior, and from left to right, to the suprapubic incision then to the right femoral triangle. The posterior limb is run directly to the left femoral triangle. The distal anastomoses are constructed as usual. Several variants of this basic technique have been used. When a patent femoro-femoral bypass is available, a thoracic aorta to left femoral artery bypass is performed and the cross-over bypass attached to it. When both femoral triangles are infected, the aorta to left femoral artery bypass is made lateral to the infected area and revascularisation of the right lower limb is achieved by a cross-over perineal bypass 13 (Fig. 6). When the indication is a false aneurysm, a thoraco-phreno-laparotomy is made through the 9th intercostal space. The area of the false aneurysm and the distal thoracic aorta are approached extraperitoneally after partial division of the diaphragm. After clamping the aorta, the false aneurysm is opened, the old graft is freed, and temporarily occluded by bal-
Descending Thoracic Aorta to Femoral Artery Bypass
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Fig. 4. Post-operative arteriogram of a thoracic aorta to bifemoral bypass using the basic technique. Fig. 5. Post-operative CT scan showing the route of the prosthesis. (a) Just below the proximal anastomosis; (b) behind the left kidney; (c) the two limbs are in a sagittal plane behind the left kidney. loon catheters. The native aorta is closed either b y suture just b e l o w the renal arteries w h e n the previous a n a s t o m o s i s was e n d - t o - e n d , or b y a prosthetic patch w h e n the p r e v i o u s a n a s t o m o s i s w a s side-toend in order to p r e s e r v e flow t h r o u g h the internal iliac arteries. After end-to-side a n a s t o m o s i s to the thoracic aorta, the n e w graft is c o n n e c t e d to the old graft end-to-end.
Patients B e t w e e n N o v e m b e r 1984 a n d M a y 1991, this technique w a s u s e d to revascularise 51 lower limbs in 27 patients. T w o patients h a d already u n d e r g o n e contralateral a m p u t a t i o n a n d one patient w a s revascularised for unilateral acute ischaemia. There w e r e Eur J Vasc Surg Vol 6, May 1992
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had unilateral thrombosis of the aorto-bifemoral prosthetic graft after having undergone one to three laparotomies for various intestinal disorders; two had already undergone a replacement of an aortobifemoral bypass; three patients had repeated failures of femoro-femoral cross-over bypass; two patients had an occluded axillo-femoral or axillo-bifemoral ~x~,-~ ,,~,bypass; one patient had an occluded aorto-femoral f:y./ bypass associated with occlusion of the contralateral iliac artery; and the last had an occluded aorto/ bifemoral bypass with rePro-peritoneal fibrosis. The basic technique, as described above was used in 16 cases. Fifteen of the grafts were diameter 14/7, and one was 16/8. A cross-over procedure was associated with a thoracic to left femoral artery Fig. 6. Perineal bypass associated with a thoracic aorta to left bypass in seven cases. In one case, a pre-existing femoralarterybypass. femoro-femoral bypass was used by reversing the direction of flow. In three cases a venous cross-over 25 males and two females with a mean age of 60.2 bypass was performed through the perineum, and in years (range 41-79 years). All patients except two three cases a subcutaneous femoro-femoral prosthetic were heavy cigarette smokers (>20g/day); five cross-over procedure was employed. Only the left patients had stable coronary artery disease; four were lower limb was revascularised in two cases. In one hypertensive, and four had chronic bronchopulmon- case, the right lower limb had already been amputated and in the other, the right lower limb was adary disease. Fifteen patients had ischaemia of the lower equately vascularised and two previous cross-over limbs. Ten had chronic ischaemia (seven claudica- procedures had failed. The thoraco-phreno-lapartion, three gangrene) and five had acute ischaemia. otomy approach through the 9th intercostal space Ten patients had septic lesions: four had aorto-enteric was used in two cases involving false aneurysms. The fistulae arising from an aorto-bifemoral bypass; four new graft was implanted on the old abdominal graft. had an infected aorto-bifemoral bypass; one had an In one case on the main stem and in the other case on infected axillo-bifemoral bypass; and one had an the origin of left limb since the right limb was already infected aorta following lymphadenectomy for tes- occluded. ticular cancer. Two asymptomatic patients had false Follow-up angiograms were obtained for all aneurysms at the proximal anastomosis of their aorto- patients surviving more than 30 days. Late patency was established by palpation of femoral pulses. Two bifemoral bypasses. There were four primary indications for patients patients were lost to follow-up after discharge and who had never undergone arterial reconstruction of one was lost to follow-up after 6 months. The proxitheir lower limbs, and 23 secondary indications for mal anastomosis was examined by computed tomopatients with occluded or complicated bypass. graphy (CT) scan in 12 patients. Fifteen patients did Among the primary indications, three patients had not undergo this investigation because of death (n = aorto-iliac occlusive disease. This technique was 8), loss to follow-up (n = 3), refusal (n = 1), and chosen because of obesity associated with a large in- follow-up of less than I year (n = 3). cisional hernia in one patient, chylous ascites in one patient, and calcification of the entire abdominal aorta in one patient who had undergone two preResults vious laparotomies for septic intestinal lesions. The last primary indication involved a patient with an Before the 30th postoperative day or discharge, three infected aorta requiring ligation. Of the 23 secondary indications, two were false deaths, one popliteal embolism, three prosthetic aneurysms occurring at the aorto-prosthetic anasto- thromboses, and one paraplegia were recorded. One mosis; nine were infected aorto-bifemoral bypasses patient died on the third postoperative day after two and 12 were occluded grafts after one to four arterial successive occlusions of a cross-over bypass with reconstruction procedures involving the infrarenal acute ischaemia, and two patients died of multiple aorta or axillary artery. Of these 12 patients, three organ failure 11 and 23 days after operation, respect....
Eur J VascSurgVol 6, May 1992
Descending
Thoracic
Aorta
,oo
to Femoral
Artery
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Bypass
259
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., 60
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3 5
50
T 20* I 0
6
I
12
I
18
12"
]
I
I
I
24 30 56 42 TTme (months)
4*
I
48
I
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4*
I
60
20* 0
I
6
I
12
I
IS
I1" I
I
7*
I
I
24 50 36 42 ,Time (months)
I
48
I
54
4*
I
60
Fig. 7. Cumulativelife expectancy. Two years: 74.2 + 18.2%; 5 years, 61.8 + 26.8%. * Patients at risk.
Fig. 8. Cumulativesecondarypatency. Two years: 72.6 + 21.7%. * Reconstructionsat risk.
ively. Three graft thromboses were operated on with success. In the first case, a poor outflow was treated by profundoplasty. In the second, the patient presented a heparin-induced thrombopenia. In the third, the patient had platelet hyperaggregability potentiated by the prosthetic material. In the last two cases, patency was maintained with appropriate medical treatment associated with thrombectomy. Popliteal embolism occurred in one patient, and was treated successfully on day 2. One patient had paraplegia. He had undergone aortic cross-clamping associated with dissection of a large intercostal artery. Late results were available for 22 patients followed for 3-72 months (mean: 26.3 months). Five late deaths were observed. One patient died 8 months after operation due to thrombosis of the bypass; the other four deaths occurred in patients with patent grafts. The causes included myocardial infarction at 6 months, senile dementia at 14 months, prostate cancer at 39 months, and bladder cancer at 72 months. The cumulative life expectancy was 74.2 + 18.2% at 2 years and 61.8 + 26.8% at 5 years (Fig. 7). In addition to the patient who died with thrombosis at 8 months, two patients had late thrombosis. One patient had three episodes of thrombosis involving the right limb of the graft at 7, 16 and 21 months. The first two episodes w e r e managed by thrombolysis and thrombectomy respectively, the last episode required amputation. The other patient had thrombosis of a thoracic aorta to left femoral artery bypass at 10 months and 24 months; the first episode was successfully treated by thrombectomy but the second required amputation. The cumulative secondary patency rate was 72.6 + 24.7% at 5 years (Fig. 8). In one patient with a primary indication infection occurred at the right femoral anastomosis of a suprapubic cross-over prosthetic bypass 2 months after discharge. This patient was treated by ablation
of the suprapubic bypass and revascularisation by a perineal venous bypass. The graft was patent and non-infected at 65 months (Fig. 9). One patient developed a left ureteric fistula and was reoperated on 3 months later when a ureteric plasty was performed; this patient was without further problems at 66 months. None of the 12 patients who had CT scans had any evidence of false aneurysm.
Discussion
This technique of thoracic aorta to femoral artery bypass that we and others 4-7' 14-16 use, seems simpler and less aggressive than the one proposed by McCarthy et al. 8 or by Ochsner. 17 The latter technique involves dividing the diaphragm and placing the graft anterior to the kidney, and is more invasive, takes longer to perform and is more haemorrhagic. Conversely, the presence of a false aneurysm requires an extended approach from the thoracic aorta to the aneurysm with division of the dia L phragm. Exposure of the aorta and false aneurysm is easier when the kidney is retracted anteriorly with the viscera. When both femoral arteries require revascularisation, if possible we use a bifurcated graft whose main stem is left at its original length. The main stem of the graft has to be tailored in order to place the prothesis in a sagittal position. In this manner, the course of the graft is more trouble-free than with an aorto-femoral tube associated with a femoro-femoral bypass (Fig. 4). If the femoral triangles are infected, neither the basic technique nor thoracic aorta to left femoral artery bypass associated with suprapubic femoro-femoral cross-over bypass can avoid the infected areas. In our opinion the best solution is a maximally lateralised thoracic aorta to left femoral Eur J Vasc SurgVol 6, May 1992
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Fig. 9, Post-operative arteriogram of a thoracic aorta to femoral artery bypass associatedwith a perineal bypass.
bypass with a perineal femoro-femoral bypass 13 (Figs 6 and 9). Postoperative paraplegia occurred in one patient and we are aware of other unpublished cases of spinal cord ischaemia in this setting. In our patient, a large:~ intercostal artery had been dissected and clamped together with the aorta. In our opinion, paraplegia was due to dissection and trauma to the intercostal artery rather than to clamping of the aorta Eur J Vasc SurgVol 6, May 1992
itself. Since this accident, we limit the dissection of the aorta as previously described. The place of this technique must be discussed in relation to alternative solutions. Late failure of aortoilio-femoral reconstruction is the most frequent indication. This was the case for 14 of our 27 patients and in 57 of the 121 patients reported in the literature (Table 1). When failure occurs and when thrombectomy is unsuccessful or unwarranted, descending thoracic aorta to femoral artery bypass must be considered. Re-do direct reconstruction of the previously operated site requires a long and haemorrhagic operation and carries an increased risk of infection. Although it is certainly less aggressive, axillo-femoral or bifemoral bypass also poses high immediate and long-term risks. This technique is associated with a higher rate of infection than deeply placed grafts and has a great risk of secondary thrombosis because of unfavourable local and haemodynamic conditions, especially when it is performed after failure of a previous reconstruction. 1°'11"31 Coeliac aorta bypass by the anterior transperitoneal approach is an aggressive and timeconsuming technique; moreover, use of the retroperitoneal route for placement of the second prothesis in cases of re-do surgery is hazardous. 32 As with axillofemoral bypass, revascularisation by a descending thoracic aorta to lower limb procedure is simple and expedient because it precludes the need for repeat dissection. The graft length is shorter and the route more direct. Implantation is performed on a highflow vessel. Because it is located deeply, this bypass provides more favourable haemodynamic conditions and carries less risk of infection than an axillo-femoral bypass. In cases of infection, another choice is axillo-bifemoral bypass before or after removal of the infected graft. The advantages of descending thoracic aorta to femoral artery bypass are described above. The chronology of treatment depends on the arterial circulation distal to the aortic anastomosis. If collateral flow through the internal iliac arteries is adequate, the infected graft is removed in the first stage and a reconstruction from the descending thoracic aorta is performed in the second stage (1 month and 3 months in this series). When the upper anastomosis of the infected graft is end-to-end and/or when collateral flow is poor distal to the aortic anastomosis, reconstruction from the descending thoracic aorta must be done during the same intervention either after or before removing the infected graft. It is difficult to evaluate the results of this technique as only 121 observations have been published, most as case reports. Only five series include 10 or more
Descending Thoracic Aorta to Femoral Artery Bypass
261
Table 1. Descending thoracic aorta to femoral artery bypass: review of literature Number of cases
Indications for late occlusion
Post-operative complications
Post-operative mortality
I amputation
0
0
1
1
0
0
3
2
0
0
1973
6
--
0
0
Finseth 21
1974
1
--
0
0
C e v e s e 22
1975
6
--
0
0
Jarrett 23
1975
2
--
0
1
Buxton 24
1976
1
--
1 pneumonia
0
Lakner 25
1983
2
--
0
0
Reilly26
1984
5
--
0
0
H a s s 27
1985
3
--
1 haemothorax
1
Bowes 4
1985
12
6
0
1
Feldhaus s
1985
18
12
1 myocardial infarction + 2 pneumonia
1
Enon 16
1985
3
2
0
0
Rosenfeld 6
1986
10
8
- - not available
0
Schultz 7
1986
15
15
1 thrombosis
0
McCarthy 8
1986
13
5
1 haemothorax + 1 atelectasis
0
Di Marzo 28
1987
5
--
0
1
Schellack29
1988
3
3
0
0
Hussain TM
1988
8
2
0
0
Bradham 3°
1989
2
--
0
0
1st author
Year
Stevenson ~
1961
1
1
BlaisdelI2
1961
1
--
Robicsek TM
1967
1
Nunn 19
1972
Froysaker 2°
c a s e s ( T a b l e 1). P o s t o p e r a t i v e m o r t a l i t y w a s 1 1 . 1 % i n t h i s s e r i e s a n d six o u t o f 121 c a s e s i n t h e l i t e r a t u r e . Mortality seems to be related to patient status rather t h a n t h e t e c h n i q u e i t s e l f w h i c h is i l l u s t r a t e d b y t h e h i g h l a t e m o r t a l i t y r a t e (Fig. 7). L a t e s e c o n d a r y p a t e n c y w a s 7 2 . 6 + 2 1 . 7 % a t 2 a n d 5 y e a r s (Fig. 8); these figures as well as those reported in the literat u r e ( T a b l e 2) a r e s a t i s f a c t o r y , c o n s i d e r i n g t h e u s u a l indications. Based on these results thoracic aorta to femoral bypass can be considered as an alternative to AFB. In f a c t it p r o v i d e s better haemodynamic conditions without higher morbidity or mortality particularly for l a t e f a i l u r e o f a o r t o - f e m o r a l r e c o n s t r u c t i o n . 10,11, 31
Table 2. Late results of descending thoracic aorta to femoral artery bypass: review of literature Number of cases
1st author
Year
Late patency
Cevese 22
1975
6
30 months: PP 100%
Feldhaus 5
1985
18
60 months: SP 85%
Rosenfeld 6
1986
10
44 months: PP 90%
Schultz 7
1986
15
60 months: SP 80%
McCarthy s
1986
13
22 months: PP 100%
Hussain 14
1988
8
36 months: SP 100%
PP: primary patency; SP: secondary patency. Eur J Vasc Surg Vol 6, May 1992
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A. Branchereau et aL
References
17 OCHSNER JL. Use of thoracic aorta in revascularization of the lower extremity. In: BERGAN JJ, YAO JST, eds. Evaluation and
Treatment of Upper and Lower Extremity Circulatory Disorders. 1 STEVENSONJK, SAUVAGELR, HARKINS HN. A bypass homograft from thoracic aorta to femoral arteries for occlusive vascular disease. Ann Surg 1961; 27: 632-637. 2 BLAISDELLFW, DEMATTEI GA, GAUDER PJ. Extraperitoneal thoracic aorta to femoral bypass graft as replacement for an infected aortic bifurcation prosthesis. Am J Surg 1961; 102: 583585. 3 BLAlSDELL FW, HALL AD. Axillary femoral artery bypass for lower extremity ischemia. Surgery 1963; 54: 563-568. 4 BOWESDE, KEAGYBA, BENOIT CH, PHARR WF. Descending thoracic aortobifemoral bypass for occluded abdominal aorta: retroperitoneal route without an abdominal incision. J Cardiovasc Surg (Torino) 1985; 26: 41-45. 5 FELDHAUSRJ, STERPETTIAV, SCHULTZRD, PEETZDJ JR. Thoracic aorta-femoral artery bypass: indications, technique and late results. Ann Thorac Surg 1985; 40: 588-592. 6 ROSENFELDJC, SAVARESERP, DE LAURENTIS DA. Distal thoracic aorta to femoral artery bypass a surgical alternative. ] Vasc Surg 1985; 2: 747-750. 7 SCHULTZ RD, STERPETTI AM, FELDHAUS RJ. Thoracic aorta as source of inflow in reoperation for occluded aortoiliac reconstruction. Surgery 1986; 100: 635-645. 8 McCARTHY WJ, RUBINJR, FLINN WR, WILLIAMS LR, BERGANJJ, YAO JS. Descending thoracic aorta to femoral bypass. Arch Surg 1986; 121: 681-688. 9 BRANCHEREAUA, ESPINOZAH, RUDONDYP, MAGNANPE, REBOUL J. Descending thoracic aorta as an inflow source for late occlusive failures following aortoiliac reconstruction. Ann Vasc Surg 1991; 5: 8-15. 10 OBLATHRW, GREENRaN'l,DE WEESEJA, ROB CG. Extra-anatomic bypass of the abdominal aorta management of postoperative thrombosis. Ann Surg 1978; 187: 647-652. 11 DONALDSON MC, LOURAS JC, BUCKNAM CA. Axillofemoral bypass: a tool with a limited role. J Vasc Surg 1986; 3: 757-763. 12 BRANCHEREAUA, RUDONDY P, GOURNIER JP, ESPINOZAH. The albumin-coated knitted dacron aortic prosthesis: a clinical study. Ann Vasc Surg 1990; 4: 138-142. 13 BRANCHEREAU A, CIosI G, BORDEAUXJ, LASELVE L, DEVIN R. Fernorofemoral bypass through the perineum for infection complicating arterial revascularization of the lower limb. Ann Vasc Surg 1988; 2: 43-49. 14 HUSSAIN SA. Descending thoracic aorta to bifemoral bypass graft without laparotomy. Int Surg 1988; 73: 260-263. 15 DE LAURENTISDA. The descending thoracic aorta in reoperative aortic surgery. In: BERGANJJ, YAO JST, eds. Reoperative Arterial Surgery. Orlando: Grune & Stratton, 1986; 195-203. 16 ENON B, CHEVALIERJM, MOREAU P, LESCALIE F, PILLET J, Revascularisation des membres inf6rieurs h partir de l'aorte thoracique descendante. J Chir 1985; 122: 539-543.
Eur J Vasc Surg Vol 6, May 1992
Orlando: Grune & Stratton, 1984; 361-368. 18 ROBICSEKF, McCALL MM, SANGERPW, DAUGHERTYHK. Recurrent aneurysm of the abdominal aorta. Ann Thorac Surg 1967; 3: 549-552. 19 NUNN DB, KAI MA. Bypass grafting from the thoracic aorta to femoral arteries for high aorto-iliac occlusive disease. Surgery 1972; 72: 749-755. 20 FROYSAKER T, SKAGSETH E, DUNDAS P, HALL KV. Bypass procedures in the treatment of obstructions of the abdominal aorta. J Cardiovasc Surg 1973; 14: 317-321. 21 FINSETHF, ABBOTTWM. One stage operative therapy for Salmonella mycotic abdominal aortic aneurysm. Ann Surg 1974; 179: 8-11. 22 CEVESE PG, GALLUCCI V. Thoracic aorta to femoral artery bypass. J Cardiovasc Surg 1975; 16: 432-438. 23 JARRETT F, DARLING RC, MUNDTH ED, AUSTEN G. Experience with infected aneurysms of the abdominal aorta. Arch Surg 1975; 110: 1281-1286. 24 BUXTONB, SIMPSON L, JOHNSON N, MYERS K. Descending thoracic aortofemoral bypass for distal aortic reconstruction after removal of an infected dacron prosthesis. Med J Aust 1976; 2: 133-136. 25 LAKNER G, LUKACSL. High aortoiliac occlusion" treatment with thoracic aorta to femoral arterial bypass. ] Cardiovasc Surg 1983; 24: 532-534. 26 REILLYLM, EHRENFELD WK, STONEYRJ. Delayed aortic prosthetic reconstruction after removal of an infected graft. Am J Surg 1984; 148: 234-239. 27 HAss KL, MOULDERPV, KERSTEINMD. Use of thoracic aortobifemoral artery grafting as an alternative procedure for occlusive aortoilliac disease. Ann Surg 1985; 51: 573-576. 28 DI MARZO L, FELDHAUS RJ, SCHULTZ RD. Surgical treatment of infected aortofernoral grafts: a fifteen year experience. Vasc Surg 1987; 21: 229-236. 29 SCHELLACKJ, FULENWIDERJT, SMITH RB III. Descending thoracic aortofemoral-femoral bypass a remedial alternative for the failed aortobifemoral bypass. J Cardiovasc Surg 1988; 29: 201204. 30 BRADHAMRR, LOCKLAIR PR JR, GRIMBALL A. Descending thoracic aorta to femoral artery bypass. J SC Med Assoc 1989; 85: 283-286. 31 BROOME A, CHRISTENSON JT, EKLOF B, NORGREN L. Axillofemoral bypass reconstructions in sixty-one patients with leg ischemia. Surgery 1980; 88: 673-676. 32 ]3ARRALX, YOUVARLAKISP, BOISSIER G, CAVALLO G. Revascularisation des membres inf6rieurs h partir de l'aorte supracoeliaque. Ann Chir Vasc 1986; 1: 30-35.
Accepted 14 October 1991