Descending Thoracic Aorta as an Inflow Source for Late Occlusive Failures Following Aortoiliac Reconstruction Alain Branchereau, MD, Hugo Espinoza, MD, Philippe Rudondy, MD, Pierre-Edouard Magnan, MD, Jean Reboul, MD, Marseille, France

From November 1984 to March 1990, 10 descending thoracic aorta-to-femoral artery bypass procedures were performed after failure of one or several aortoiliofemoral reconstructions. All patients were men, mean age 60 years. Indications included noninfected false aneurysm of an infrarenal end-to-side aortoprosthetic anastomosis in one case; one occlusion of an axillofemoral bypass; degradation of an aortobifemoral prosthetic graft; two occlusions of aortofemoral bypass; and five occlusions of aortobiiliac or aortobifemoral bypasses. Eight bifurcated grafts, one aortoprosthetic tube graft, and one aortopopliteal tube graft were inserted. One patient died 23 days postoperatively of multiple organ failure. Three patients underwent a successful secondary lower limb reconstruction procedure (prosthetic limb thrombectomy, embolectomy, femoral bifurcation angioplasty in one case each). Mean survival time was 14 months (range 3-48 months). Two patients were lost to follow-up, and one died of myocardial infarction six months postoperatively with a patent bypass. Graft thrombosis occurred in two patients. One was treated by thrombectomy at five months, the other was treated by in-situ thrombolysis at 15 months. Both of these patients had patent grafts at 12 and 21 months, respectively. The four other patients had patent grafts at 48 months. Primary patency was 55.5% (5/9 survivors) and secondary patency was 100% (9/9). This is a relatively simple method for constructing an extraanatomic aortofemoral or aortobifemoral bypass in late failures of aortoiliofemoral reconstructive surgery without having to re-enter the abdomen. (Ann Vasc Surg 1991 ;5:8-15). KEY WORDS: Thoracic aorta; occlusive disease; aortoiliac disease; aortofemoral bypass; aortoiliofemoral reconstruction.

Revascularization of the lower limbs with a prosthetic graft originating from the descending thoracic aorta was described for the first time by Stevenson From the Service de Chirurgie Vasculaire, des Hopitaux, Sud Marseille, France. Presented at the Annual Meeting of the Socidt~ de Chirurgie Vasculaire de Langue Franfaise, May 18-19, 1990, Nancy, France. Reprint requests: A. Branchereau, MD, Service de Chirurgie Vasculaire, Hopital Sainte-Marguerite 13274 Marseille Cedex9, France.

and associates [1] in 1961, and then by Blaisdell and colleagues [2] before the latter group of authors described the axillofemoral bypass technique [3] whose use is presently much more widespread. During these last years, however, descending thoracic aorta-to-femoral artery bypass has been suggested as an alternative to axillofemoral bypass because it is associated with fewer complications and better hemodynamics [4-23]. Repeat revascularization of the lower limbs represents one of the most obvious indications for this technique. The objectives of this study were to describe and report

VOLUME 5 No

1 -

1991

DESCENDING THORACIC AORTA AS I N F L O W SOURCE

9

Fig. 1. Position of Patient and Skin incisions.

our experience with descending thoracic aorta-tofemoral bypass as we and others [4,5,9,11,23] perform it in this setting.

SURGICAL TECHNIQUE The patient is positioned to allow simultaneous lateral thoracotomy and access to both femoral bifurcations (Fig. 1). Monitoring procedures are as usual, but clamping of the thoracic aorta requires the placement of a Swan-Ganz catheter. On the other hand, selective tracheal intubation with exclusion of the left lung can be dispensed with. The left lateral border of the descending thoracic aorta is dissected through a left lateral thoracotomy in the seventh or eighth interspace. A horizontal incision is made posteriorly in the left lumbar fossa approximately halfway between the twelfth rib and iliac crest. Through this short incision, the retroperitoneum is opened behind the kidney from the diaphragm to the retropubic space in order to guide the exterior placement of the graft. The prevesical space is opened through a vertical suprapubic approach allowing construction of a relay from the right limb of the prosthesis to the right femoral triangle, as required. The femoral bifurcations are approached as usual. For this procedure, we use albumin-coated bifurcated prosthetic grafts [24]. The stem is preserved entirely, and the right limb of the graft is extended by a prosthetic tube w h e n e v e r necessary. The proximal anastomosis is performed after cross-clamping the aorta and peripheral hypotension is controlled using sodium nitroprusside. The

anastomosis is made end-to-side on the left border of the aorta. The graft is positioned so that the right limb is placed anterior to the left. A short incision is made in the left paramedial portion of the phrenicocostal sinus at the level of the accessory crux or the medial lumbocostal arch. This incision is guided by the left hand of the operator which mobilizes the left kidney and the retroperitoneum through the lumbar incision. (Figs. 2, 3). The prosthetic graft is tunneled through the retroperitoneum from the thoracic cavity to the femoral bifurcations. The left limb is kept vertical and posterior and directed toward the left femoral bifurcation. The right limb is placed anteriorly and crosses the prevesical space to the right femoral bifurcation (Figs. 4, 5). The femoral anastomoses are made as usual.

PATIENTS Between N o v e m b e r 1984 and March 1990, we performed 23 lower limb revascularizations originating from the descending thoracic aorta. Ten were for late failures of aortoiliofemoral reconstructions and form the basis of this study (Table i). All patients were male, aged from 49 to 65 years (mean 60 years). A total of 19 lower limbs were revascularized; one patient had an unilateral amputation. All patients were heavy cigarette smokers; two were chronic alcoholics. Two patients had coronary artery disease, two others were hypertensive, and three had chronic bronchopulmonary dis-

10

D E S C E N D I N G THORACIC AORTA A S I N F L O W SOURCE

ANNALS OF VASCULAR SURGERY

Fig. 2. Aorta cross-clamping and opening of the costophrenic angle. ease. Indications for initial surgery were intermittent claudication in nine patients and infrarenal aortic aneurysm in one patient. Initial treatment was aortobifemoral bypass in six cases, aortobiiliac bypass in two, and aortofemoral bypass in two cases. Several redo operations had already been required: five taparotomies, five crossover bypasses, one change of aortobifemoral prosthetic graft, and one axillofemoral bypass for infected aortobifemoral bypass. The delay between initial reconstruction and the revascularization using the descending thoracic aorta ranged from 24 to 132 months (mean 69 months). The indications for thoracic aorta-to-femoral bypass were acute ischemia in four cases, chronic ischemia in five cases, and a painful, false, infrarenal, noninfected aneurysm of the aorta in one case. Anatomic lesions included: noninfected false aneurysm occurring after end-to-side prosthetic replacement in one case; repeat occlusion of the axillofemoral bypass to the only lower limb in an amputee having undergone direct reconstruction

originating from the infrarenal aorta; progressive degradation of an aortobifemoral bypass associated with retroperitoneal fibrosis in one case; occlusion of aortofemoral bypass in two cases, one of which was associated with redo iliofemoral crossover bypass and the other with three repeat laparotomies; occlusion of aortobiiliac or bifemoral prosthetic grafts in five cases, one of which had already undergone a change of graft, two others repeat laparotomies, and two further patients having had repeat crossover bypasses because of previous occlusion of the contralaterat limb of the bifurcated graft. The above-described technique was used in nine patients without entering the peritoneal cavity or dividing the diaphragm. For the patient with the false aortic aneurysm, the thoracic approach was extended by an extraperitoneal phrenolaparotomy in order to expose the false aneurysm and the original graft. Graft material included eight bifurcated albumin-coated Dacron grafts implanted distally on the femoral arteries, one Dacron aortoprosthetic tube graft, and one Dacron tube graft implanted on the distal poptiteal artery with a relay on the profunda femoris artery.

RESULTS

Immediate outcomes

Fig. 3. Tunneling of the prosthesis through the diaphram.

One patient operated on for acute ischemia of the lower limbs died on the twenty-third postoperative day of multiple organ failure. He had right pneumothorax, acute postoperative pulmonary infection, and had undergone above-knee amputation with a patent prosthetic graft. One other patient had

VOLUME 5 No

1 -

1991

DESCENDING THORACIC AORTA AS I N F L O W SOURCE

11

Late outcomes

Nine patients have been followed for three to 48 months (mean 14 months). Two patients with patent grafts were lost to follow-up after three months. One patient died of myocardial infarction with a patent graft at six months. Two late graft thromboses were observed: one at five months was treated by thrombectomy; the other at 15 months was treated by in situ thrombolysis. Both patients had patent grafts 12 and 21 months postoperatively. The four remaining patients had patent grafts 12, 17, 24, and 48 months postoperatively, respectively. Primary patency was 55.5% (5/9 surviving patients) and secondary patency was I00% (9/9).

DISCUSSION

?

S

Fig. 4. Postoperative arteriogram.

prosthetic limb occlusion several days after operation. This patient had platelet hyperaggregability aggravated by his prosthetic material. Patency was obtained following thrombectomy and antiaggregant therapy. Popliteal embolism occurred in one patient and was treated successfully two days postoperatively. Another patient had a successful profundaplasty twelve days postoperatively, in one further case, acute postoperative pulmonary infection required prolonged mechanical ventilation.

Late failure of aortoiliofemoral reconstruction procedures is one of the principal indications for lower limb revascularization by descending thoracic aorta-to-femoral bypass. This technique was indicated in nearly half of our cases (10/23) and in 57 of 120 cases reported in the literature (Table I1). When failure occurs, and when simple thrombectomy is unsuccessful or unwarranted, descending thoracic aorta-to-femoral artery bypass must be considered and discussed along with other therapeutic options such as direct reconstruction of the previously operated site, axillofemoral or axillobifemoral bypass. Redo direct reconstructions are associated with maximal operative difficulties, generally requiring a long and hemorrhagic operation. The infective risk is obviously important and increased by the duration of operation and the repeated dissection. Although axillofemoral bypass is assuredly simpler and less aggressive, the patient remains exposed to immediate and long-term risks. Axillofemoral bypass is associated with a higher infection risk than are deeply placed grafts and with a greater risk of secondary thrombosis because of unfavorable local and hemodynamic conditions, especially when axillofemoral bypass is performed because of previously complicated surgery [26] (Table 11i). As with axillofemoral bypass, revascularization by a descending aorta-to-lower limb procedure is simple, expedient, and precludes the need for repeat dissection. The length of necessary graft, however, is shorter and the course more direct. Implantation is performed in a high-flow vessel. Because of its deep location, descending thoracic aorta-to-femoral bypass is associated with more favorable hemodynamics and less risk of infection than with the axillofemoral bypass. McCarthy and co-workers [17], as others [13,18,19,25], prefer to perform a thoracophreno-

12

DESCENDING THORACIC AORTA AS I N F L O W SOURCE

ANNALS OF VASCULAR SURGERY

Fig. 5. Postoperative CT-scan showing the location of the prosthesis. laparotomy and to approach the lower thoracic and thoracoabdominal aorta through a prerenal route and then to place the graft in this prerenal position. The technique that we use, along with other authors [4,5,9,11,23], is much simpler, more expedient, and certainly less invasive. The graft can be inserted retroperitoneally between the thoracic aorta and the femoral bifurcations through a simple lateral thorac o t o m y without dividing the diaphragm. A thoracophrenolaparotomy was required in only one patient with a false anastomotic aneurysm. Direct access to the lesion allowed us to close the aorta with a patch to preserve infrarenal flow to the internal iliac arteries and then to perform an aortoprosthetic bypass to revascularize the lower limbs.

When both femoral arteries require revascularization, we have always been able to use a bifurcated graft whose main stem is left at its original length. Whenever necessary, the right limb may be prolonged. The main stem of the graft has to be tailored in order to place the graft in a sagittal position with the right limb anterior to the left. Placed in this manner, the course of the graft is more trouble-free than in an aortofemoral tube graft associated with a femorofemoral crossover bypass (Fig. 4). Postoperative paraplegia occurred in one patient not included in this series (Table II), and we are aware of other unpublished cases of medullary compromise in this setting. In one patient, a large

VOLUME 5 N o 1 - 1991

D E S C E N D I N G THORACIC AORTA AS I N F L O W SOURCE

13

TABLE I.--Summary of personal experience with 10 cases

Patient

Initial procedure

1

Aortobifem

2 3

Aortobifem Aortobifem

Secondary procedure None Axfem Ablation aortobifem Amputation Thrombectomy axfem (2) Femfem (2) Thrombectomy aortofem Replacement aortobifem Gastrectomy Femfem (2) Gastrectomy Incisional hernia Lumbar sympathectomy Femfem (2) Acute pancreatitis

Aortobifem Aortobifem Aortobifem Aortofemorat Aortofemoral

9

Aortobiiliac Aortobiiliac

10

Indication for thoracic aortic bypass False aneurysm Proximal anastomosis Retroperitoneal fibrosis Occlusion axfem

Occlusion aortofem Occlusion (acute) Occlusion Occlusion (acute) Occlusion (acute) Occlusion Occlusion

Aortobifem--Aortobifernoralbypass Axfem--Axillofemoralbypass Femfem--Femorofemoralbypass Aortofem--Aortofemoralbypass

intercostal artery had been isolated by dissection before being 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 itself. Since this accident, we avoid complete dissection and mobilization of the

aorta. We limit the dissection to the left anterior margin then cross-clamp the aorta and its branches with a Satinsky-type clamp. (Fig. 2). Results of revascularization procedures using the descending thoracic aorta as a runoff vessel are difficult to judge presently because only 120 cases

TABLE ft.--Thoracic aorta-to-femoral artery bypass: review of literature and personal experience

Number of cases

Indications for late occlusion

First author

Year

Stevenson [1] Blaisdell [2] Robicsek [20] Nunn [18] Froysaker [13] Cevese [8] Jarrett [15] Buxton [6]

1961 1961 1967 1972 1973 1975 1975 1976

1 1 1 3 6 6 2 1

1 -1 2 --i --

Lakner [16] Reilly [19] Haas [14] Bowes [5] Feldhaus [12]

1983 1984 1985 1985 1985

2 5 3 12 18

---6 12

Enon [11] De Laurentis [9,21] Schultz [23] McCarthy [17]

1985 1986 1986 1986

3 10 15 13

2 8 15 5

DiMarzo [10] Schellack [22] Hussain [4] Bradham [7] Personal experience

1987 1988 1988 1989 1990

5 3 8 2 23

-3 2 -10

Postoperative complications 1 amputation 0 0 0 0 0 0 1 pulmonary pathology 0 0 1 hemothorax 0 1 myocardial infarction + 2 pulmonary pathologies 0 Not Available 1 thrombosis 1 hemothorax 4- 1 atelectasis 0 0 0 0 1 paraplegia 4- 2 thromboses

Postoperative mortality 0 1 0 0 0 0 1 0 0 0 1 1 1

0 0 0 0 1 0 0 0 2

DESCENDING THORACIC AORTA AS I N F L O W SOURCE

14

ANNALS OF VASCULARSURGERY

TABLE III.--Results of axillofemoral bypass First author Oblath [26]

Year 1978

Number of cases 22*

Postoperative mortality 9 (41%)

Broome [27]

1980

61

5 (8%)

Ascer [28]

1985

56

3 (5.3%)

Donaldson [29]

1986

100

Cina [30]

1988

41

8 (8%)

2 (4.8%)

Postoperative complications Thrombosis (15%) Infection (11%) Thrombosis (13%) Infection (7%) Amputation (5%) Thrombosis (1.7%)

Patency 1 year: SP 47%

3 years: SP 75% 5 years: PP 47% SP 75% 3 years: PP 54% SP 72%

Thrombosis (14%) Amputation (3%) Late nonlethal complications (57%) Thrombosis (7%) Miscellaneous nonlethal complications (21%)

5 years: PP 69% SP 72%

*All patients were operated for failed aortofemoral reconstructions PP--Primary patency; SP--Secondary patency

have been published to date and only five series report 10 cases or more (Table II). Early mortality and morbidity are low and when they do occur, they are essentially due to the fact that this operation is performed for debilitated, multiple operated patients with complex arterial problems. Under these conditions, mortality, which is just under I0%, is similar to that observed with axillofemoral bypass, especially if one considers only those patients operated on for late thrombosis or infected grafts. Late results available in the literature are listed in Table IV. Excepting underlying arterial pathology, !ong-term patency is good. Other indications for descending aorta-to-femoral artery revascularization procedures include periprosthetic infection, abdominal lesions (previous laparotomies, large incisional hernias), radiation lesions [31], arterial lesions such as coarctation or extensive medical calcinosis of the infrarenal aorta. Descending aorta-to-femoral bypass is indicated for these pathologic conditions in nearly the same proportion as for late occlusion of aortoiliofemoral reconstruction.

CONCLUSION Revascularization by a descending thoracic aorta-to-femoral bypass is a nonaggressive technique which allows construction of an extraanatomic bypass to the lower limbs with good hemodynamics. It represents a simple solution to the complex situation of late failure of aortoiliofemoral reconstruction.

REFERENCES I. STEVENSON JK, SAUVAGE LR, HARKINS HN. A bypass homograft from thoracic aorta to femoral arteries for occlusive vascular disease. Ann Surg 1961;27:632-637. 2. BLAISDELL FW, DEMATTEI GA, GAUDER PJ. Extraperitoneal thoracic aorta to femoral bypass graft as replacement for an infected aortic bifurcation prosthesis. Am J Surg 1961 ;102:583-585. 3. BLAISDELL FW, HALL AD. Axillary femoral artery bypass for lower extremity ischemia. Surgery 1963;54:563568. 4. AMJAD HUSSAIN S. Descending thoracic aorta to bifemoral bypass graft without laparotomy, lnt Surg 1988;73:260263.

TABLE IV.--Late results: review of literature and personal experience First author Cevese [8] Feldhaus [12] DeLaurentis [9,21] Schultz [23] McCarthy [17] A. Hussain [4] Personal experience

Year 1975 1985 1986 1986 1986 1988 1990

* Number of cases operated for failed aortofemoral reconstruction PP--Primary patency SP--Secondary patency

Number of cases 6 18 (12)* 10 (8)* 15* 13 (5)* 8 (2)* 10*

30 60 44 60 22 36 14

Late patency months: PP 100% months: SP 85% months: PP 90% months: SP 80.2% months: PP 100% months: SP 100% months: SP 100%

VOLUME 5 No 1 - 1991

DESCENDING THORACIC AORTA AS INFLOW SOURCE

5. B O W E S DE, K E A G Y BA, B E N O I T G H , et al. Descending thoracic aortobifemoral bypass for occluded abdominal aorta retroperitoneal route without an abdominal incision. J Cardiovasc Surg 1985;26:41M5. 6. B U X T O N B, S I M P S O N L, J O H N S O N N, et ah Descending thoracic aortofemoral bypass for distal aortic reconstruction after removal of an infected dacron prosthesis. Med J Attst 1976;2:133-136. 7. B R A D H A M RR, L O C K L A I R PR Jr, G R I M B A L L A. Descending thoracic aorta to femoral artery bypass. J S C Med Assoc 1989;85:283-286. 8. C E V E S E PG, G A L L U C C 1 V. Thoracic aorta to femoral artery bypass. J Cardiovase Surg 1975:16:432~38. 9. DE L A U R E N T 1 S DA. The descending thoracic aorta in reoperative aortic surgery. In: B E R G A N J J, YAO JST (eds). Reoperative Arterial Surgery. Orlando, Grune & Stratton 1986; pp 195-203. 10. DI M A R Z O L, F E L D H A U S RJ, S C H U L T Z RD. Surgical treatment of infected aortofemoral grafts: a fifteen year experience. Vase Surg 1987;21:229-236. 11. E N O N B, C H E V A L I E R JM. M O R E A U P. et ah Revascularization des m e m b r e s infdrieurs fl partir de I'aorte thora cique d e s c e n d a n t e . . I Chit 1985:122:539-543. 12. F E L D H A U S RJ. S T E R P E T T I AV, S C H U L T Z RD, et al. Thoracic aorta-femoral artery bypass indications, technique, and late results. Ann Thorac Surg 1985:40:588-592. 13. F R O Y S A K E R T, S K A G S E T H E, D U N D A S P, et al. Bypass procedures in the treatment of obstructions of the abdominal aorta. J Cardiovase Surg 1973:14:317-321. 14. H A S S K L , M O U L D E R PV, KERSTE1N MD. Use of thoracic aortobifemoral artery grafting as an alternative procedure for occlusive aortoiliac disease. Am7 Sure 1985: 51:573-576. 15. J A R R E T T F, D A R L I N G RC, M U N D T H ED, et al. Experience with infected a n e u r y s m s of the abdominal aorta. Arch Surg 1975;110:1281-1286. 16. L A K N E R G, L U K A C S L. High aortoiliac occlusion: treatment with thoracic aorta to femoral arterial bypass. J Cardiovasc Surg 1983:24:532-534. 17. M C C A R T H Y WJ, R U B I N JR. FL1NN WR, et al. Descending thoracic aorto to femoral bypass. Arch Surg 1986:121: 681-688. 18. N U N N DB, KA1 MA. Bypass grafting from the thoracic

m m m

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

15

aorta to femoral arteries for high aorto-iliac occlusive disease. Suroery 1972:72:749-755. R E I L L Y LM, E H R E N F E L D W K . S T O N E Y RJ. Delayed aortic prosthetic reconstruction after removal of an infected graft. Am ,I Sur~" 1984:148:234-239. R O B I C S E K F, MC C A L L MM, S A N G E R PW, et al. Recurrent a n e u r y s m of the abdominal aorta. Ann Thorac Surg 1967:3:549-552. R O S E N F E L D JC, S A V A R E S E RP, DE L A U R E N T I S DA. Distal thoracic aorta to femoral artery bypass a surgical alternative. J Vase Surg 1985;2:747-750. S C H E L L A C K J, F U L E N W I D E R JT, SMITH RB III. Descending thoracic aortofemoral-femoral bypass a remedial alternative for the failed aortobifemoral bypass. J Cardiovase Surg 1988:29:201-204. S C H U L T Z RD, S T E R P E T T I AV, F E L D H A U S RJ. Thoracic aorta as source of inflow in reoperation for occluded aortoiliac reconstruction. Surgeo' 1986;100:635-645. B R A N C H E R E A U A, R U D O N D Y PH, G O U R N I E R JP, et ah The albumin-coated knitted dacron aortic prosthesis: a clinical study. Ann Vasc Sur~ 1990:4:138-142. O C H S N E R JL. Use of thoracic aorta in revascularization of the lower extremity. In: B E R G A N J J, Y A O JST (eds). Evaluation and Treatment of Upper and Lower Extremity Circulatory DLsorders. Orlando, Grune & Stratton, 1984; pp 361-368. O B L A T H RW, G R E E N RM, DE W E E S E JA, el al. Extraanatomic bypass of the abdominal aorta m a n a g e m e n t of postoperative thrombosis. Ann Surg 1978;187:647-652. B R O O M E A, C H R I S T E N S O N JT, E K L O F B, et al. AxilIofemoral bypass reconstructions in sixty-one patients with leg ischemia. Sm'geO' 1980:88:673-676. A S C E R E, VE1TH FJ. G U P T A SK, et ah Comparison of axillounifemoral and axillobifemoral bypass operations. SurgeO' 1985:97:169-175. D O N A L D S O N MC, L O U R A S JC, B U C K A M CA. AxilIofemoral bypass: a tool with a limited role. ,I Vase Surg 1986:3:757-763. C I N A C. AMEL1 FM, K A L M A N P, et al. Indications et intdr6t du pontage axillo-f6moral chez les malades fl haut risque. Ann Chit Vase 1988:2:237-241. P I L L E T J, C H E V A L I E R JM, E N O N B, et ah Art6rites post-radiques propos de 9 observations. Ann Chit 1984:9:645-650.