Femorofemoral Crossover Bypass for Noninfective Complications of Aortoiliac Surgery Fabrice Frangois, MD, Eric Picard, MD, Philippe Nicaud, MD, Bernard Albat, MD, Andr6 Thdvenet, MD, Montpellier, France
Between 1973 and 1989, 39 femorofemoral crossover bypasses were performed to treat unilateral noninfective complications of aortoiliac surgery. The initial revascuiarization procedure, performed an average of 79.5 months previously, was an aortobifemoral bypass in 29 cases, an aorto- or iliofemoral bypass in six cases, an inlay graft for abdominal aortic aneurysm and aortoiliac endarterectomy in two cases each, The indications for femorofemoral crossover bypass included prosthetic occlusion in 35 cases, thrombosed false aneurysm in two, and further degradation after endarterectomy (lilac stenosis and occlusion in one case each). There was no operative mortality. One patient with acute ischemia upon admission and another with distal gangrene required below-knee and forefoot amputations, respectively. No amputations were required during the rest of the follow-up period. Three repeat aortobifemoral bypasses were performed because of occurrence of aortic or inflow vessel lesions. Primary and secondary actuarial five year patency rates for femorofemoral crossover bypasses were 59.7% and 78.4%, respectively. Femorofemoral crossover bypass can extend the benefits derived from direct aortoiliac surgery with low mortality and morbidity in the absence of associated aortic pathology (false aneurysm at the aortic implantation site or severe obstructive lesions). (Ann Vasc Surg 1991:5:46-49). KEY WORDS: Extraanatomic bypass; crossover bypass; surgical complications; aortoiliac disease; graft occlusion.
Since the first report by Oudot in 1953 [1] and the first series published by Vetto in 1962 [2], the efficacy and simplicity of the femorofemoral crossover bypass has stood the test of time [3-12]. Secondary unilateral thrombosis after aortoiliac or aortofemoral surgery is due to degradation of runoff
vessels or anastomotic stenosis in the majority of cases [13-15]. When the thrombosed prosthetic or vascular conduit cannot be cleared by thrombectomy, femorofemoral crossover bypass appears to be an attractive alternative to direct redo aortic surgery. The objective of this study was to verify the foundations of this policy based on our experience with 39 cases.
From the Service de Chirurgie Thoracique et CardioVasculaire, CHR Aiguelongue, Montpellier, France. Presented at the Annual Meeting of the Socidtd de Chirurgie Vasculaire de Langue Fran~'aise, May 18-19, 1990, Nancy, France. Reprint requests: F. Franfois, MD, Service de Chirurgie Thoracique et Cardio-Vasculaire, CHR Aiguelongue, 34059 Montpellier Cddex, France.
MATERIAL AND METHODS From January 1973 to December 1989, 170 femorofemoral crossover bypasses were performed. Thirty-nine (23%) were performed to treat a nonin46
VOLUME 5 No 1 1991
FEMOROFEMORAL CROSSOVER BYPASS
-
TABLE I.--Risk factors and patient status
Heavy tobacco consumption Coronary artery disease Hyperlipidemia Hypertension Cerebral arterial disease Diabetes
Number of patients 35
Percent 90
11 10 5 5 2
28 26 13 13 5
fective complication occurring after aortoiliac or aortofemoral reconstruction. There were 37 men and two women whose mean age was 61.7 years (range 47 to 75 years). The risk factors and status of these patients are indicated in Table I. Persistent tobacco consumption was found in 90% of patients. Initial aortoiliac or aortofemoral reconstructions were performed on an average of 79.5 months before (range one to 264 months). The type of initial surgery, dominated by aortobifemoral bypass, is indicated in Table I1. Femorofemoral bypass was performed for prosthetic occlusion in 35 patients (90%), a thrombosed false aneurysm in two cases, and degradation of the lilac artery (stenosis and occlusion in one case each) after endarterectomy. Clinical symptoms associated with these complications are indicated in Table Ill. Seventeen patients (43%) presented with severe lower limb ischemia. The preoperative workup included a velocimetric Doppler study and arteriograms. Arteriograms were not obtained for five patients, two of whom had severe ischemia. Computed tomography (CT) was performed for the 10 most recent patients in this series. All patients were operated on under general anesthesia and had prophylactic antibiotics starting at
TABLE II.--Initial surgical procedures
Aortobifemoral bypass Aorto- or iliofemoral bypass Inlay aortobiiliac graft Aortoiliac endarterectomy
Number of patients 29 6 2 2
Percent 74 15 5 5
TABLE IIl.--Symptoms
Intermittent claudication Resting pain Trophic disorders Acute ischemia
Number of patients 22 11 4 2
Percent 56.4 28.2 10.3 5.1
47
anesthetic induction and for 48 hours, postoperatively. The prosthetic graft was placed subfascially in all cases. The inflow conduit was a prosthetic limb in 31 (79%) cases. The common femoral artery was used in eight (20%) cases. The distal implantation site of the graft was the c o m m o n femoral artery in 17 cases, the profunda femoris artery in 18 cases, the superficial femoral artery in one case, the above-knee popliteal artery in two cases, and a femoropopliteal bypass in one case. Runoff vessel thromboendarterectomy of the femoral bifurcation and profunda femoris angioplasty were required in seven and three cases, respectively. No surgical procedures were performed on the inflow vessels. Polytetrafluoroethylene and Dacron grafts were used in 32 and seven cases, respectively. The prosthetic graft diameter ranged from 6 to 8 mm. Doppler investigation was performed in all patients before discharge and during follow-up, the mean follow-up period being 72 months. Primary and secondary patency was calculated according to the actuarial method. Patent but infected grafts requiring ablation without reconstruction were considered as thromboses.
RESULTS Early results
There were no intraoperative deaths. Thrombosis occurred in two cases, one and three days postoperatively. The first patient was a woman admitted for acute ischemia with a sensory motor deficit. The femorofemoral bypass failed to maintain femoropopliteal bypass patency, and below-knee amputation was required two days postoperatively. In the second patient, arteriograms obtained after the thrombotic event showed kinking of the inflow prosthetic limb requiring repeat aortobifemoral bypass. Three patients had suprapubic hematoma diffusing to the scrotum, spontaneously reversible within a few days. A forefoot amputation was required at one month in a patient admitted with distal gangrene although his femorofemoral crossover bypass was patent. Late results
Eight patients died in the late follow-up period. Four patients died of myocardial infarction between 10 and 107 months postoperatively: two had carcinoma, one had acute aortic thrombosis with paraplegia 13 months postoperatively, and one had intestinal hemorrhage due to aortoduodenal fistula at 32 months. Two patients were lost to follow-up. Two patients underwent reoperation for nonthrombosed false
48
Patenc
FEMOROFEMORAL CROSSOVER B Y P A S S
ANNALS OF
VASCULAR SURGERY
in primary and secondary patency rates reported herein. Several reports [3-12] in addition to ours have I00 57 33 31 shown that femorofemoral crossover bypass is associated with low mortality and morbidity. The 90 benefits obtained with this type of bypass seem better than those obtained with axillofemoral by60 7fl,4~ pass [16-18]. The use of femorofemoral crossover bypass in 70. the treatment of complications of direct aortoiliac surgery, and particularly, unilateral prosthetic thrombosis has been reported by several authors 60. i 59,7~g [4,11,19,20]. Late occlusions of prosthetic limbs have been treated successfully in most cases by 15 12 thrombectomy combined with reconstruction of the femoral bifurcation (endarterectomy or angioplasty) [13-15]. When this technique fails, femorofemoral days months crossover bypass constitutes~ the extraanatomic reFig. 1. Primary (59.7%) and secondary (78.4%) pavascularization procedure of choice [20-21]. tency rates at five years. The rate of patency of femorofemoral crossover bypass in this series was markedly lower than that reported when this bypass is used initially [4,11,19]. anastomotic aneurysm. Ten femorofemoral cross- This is thought to be due to more advanced atherover bypasses occluded. Seven of these were oma in patients operated on previously. While Planthrombectomized successfully. Two patients were igan and associates [4] and Kalman and colleagues not revascularized because they were not threat- [11] obtained three year primary patency rates of 65 ened; one required an aortobifemoral bypass for and 47%, respectively, Devolfe and coworkers [19] aortic false aneurysm. Two patients had prosthetic noted only 38.1% patent conduits at five years. In infection requiring removal, 19 and 39 months post- our experience, three and five year patency rates operatively. One of these patients had an axillofem- were 68.2 and 59.7%, respectively. These differences may be explained by the fact that infective oral bypass. One patient, operated on successfully for throm- complications of aortoiliac surgery were excluded bosis of his femorofemoral bypass at 19 months, from this series. During the same time interval, five had repeat thrombosis at 72 months. This was due year primary and secondary patency rates for 131 to an aortic false aneurysm which required repeat other femorofemoral crossover bypasses performed in our institution were 76.7 and 83.7%, respectively. aortobifemoral bypass. Femorofemoral crossover bypass allows preserPrimary patency was 87%, 68.2%, and 59.7% at one, three, and five years, respectively. Successful vation of the benefits obtained by previous aortoilreoperations allowed us to obtain secondary pa- iac reconstruction. Secondary patency rates of this tency rates of 89.6%, 86.6%, and 78.4%, at one, bypass are similar to overall patency rates for three, and five years, respectively (Fig. 1). The aortoiliac reconstruction. Our rate of 78.4% at five longest follow-up without reoperation, was twelve years compares favorably with the 76.6% rate reyears (two patients). Overall, of 14 patients who ported by Szilagyi after aortobifemoral reconstruchad thrombosis of their femorofemoral bypass, tion. Furthermore, our series shows that certain failpatent bypasses were obtained in six cases after thrombectomy. Of the eight remaining patients, ures of femorofemoral revascularization procedures four (50%) required a revascularization procedure are related to lesions of the aorta or inflow conduit. Two aortic anastomotic false aneurysms on an (three aortobifemoral and one axillofemoral bypass). aortobifemoral bypass and kinking of the inflow prosthetic limb in another case led to repeat aortobifemoral bypass. This justifies full work-up when DISCUSSION complications occur after aortoiliac reconstruction. Our experience shows that femorofemoral cross- Whereas conventional arteriograms are sufficient over bypass can extend the benefits obtained by for the diagnosis of occlusive lesions, CT is useful previous reconstructive surgery. Although this se- for early detection of proximal (aortic) false aneuries is small, the mean follow-up period was long (72 rysm. The discovery of such a lesion contraindimonths). Thrombosis is the principal complication cates performing a femorofemoral crossover bypass in this type of surgery. Successful thrombectomy and should prompt repeat direct aortoiliac reconfor this complication explains the marked difference struction.
VOLUME 5 No 1 - 1991
FEMOROFEMORAL CROSSOVER BYPASS
Although femorofemoral crossover bypass is certainly attractive because of its technical simplicity and satisfactory results, it would be of interest to study the respective values of thrombectomy, crossover bypass, and direct repeat reconstruction in the treatment of unilateral prosthetic occlusions in a large series to determine the most appropriate treatment in these settings.
11.
12.
13.
14.
REFERENCES l. OUDOT J, BEACONSPIELD D. Thrombosis of the aortic bifurcation treated by resection and homograft replacement. Arch Sur~ 1953;66:365-374. 2. PETTO RM. The treatment of unilateral lilac artery obstructive with a transabdominal subcutaneous, femorofemoral graft. Surgery 1962;52:342-345. 3. MANNICK JA, MINI BS. Femorofemoral grafting: indica tions and late results. Am J SurL, 1978;136:190-192. 4. FLANIGAN DP, PRATT DG, GOODREAU J J, et al. Hemodynamic and angiographic guidelines in selection of patients for femorofemoral bypass. Arch Sur~ 1978:113: 1257-1262. 5. MC DONALD PT, RICH NM, COLLINS GJ, et aL Femorofemoral grafts: the role of concomitant extended profundaplasty. Am J Sur~ 1978;136:622-628. 6. DICK LS, BIREF DK, ALPERT J, et al. 12-year experience with femorofemoral crossover grafts. Arch Surg 1980:115: 1359-1365. 7. HARRIS JP, FLINN WR, RUDO ND, et al. Assessment of donor limb hemodynamics in femorofemoral bypass for claudication. Surgeliv 1981 ;90:764-773. 8. MOSLEY JG, MARSTON A. Long term results of 66 femoral-to-femoral by-pass grafts: a 9-year folIow-up. Br J Sur~ 1983 ;70:631-634. 9. PLECHA FR, PLECHA FM. Femorofemoral bypass grafts: ten-year experience. J Vase Sury 1984:1:555-561. 10. BROUWER MHJ, BLEMANS RGM, DONDERS HPC.
m m m
15.
16.
17.
18.
19. 20. 21.
22.
49
Long-term results of 44 cross-over bypasses. J Cardiovasc Surg 1988;29:290-295. KALMAN PG, HOSANG M, JOHNSTON KW, el al. The current role for femorofemoral bypass. J Vasc Surg 1987:6: 71-76. FAHAL AH, Mc DONALD AM, MARSTON A. Femorofemoral bypass in unilateral iliac artery occlusion. Br J Surg 1989:76:22-25. THEVENET A. Les oblit6rations apr6s chirurgie reconstructrice aorto-iliaque. In: NATALI J (ed), Les Art6riopathies des Membres lnf4rieurs. Association Fran~:aise de Chimrgie, Paris, 1982, pp 157-160. NAYLOR AR, AH-SEE AK, ENGESET J. Graft occlusion following aortofemoral bypass for peripheral ischaemia. Br Y Surg 1989:76:572-575. NEVELSTEEN A. SUY R. DAENEN W, et al. Aortofemoral grafting: factors influencing late results. SurgeJJ' 1980; 88:642-653. EUGENE J, GOLDSTONE EJ, MOORE WS. Fifteen year experience with subcutaneous bypass grafts for lower extremity ischemia. Ann Suro 1977;186:177-183. I,IVESAY JJ, ATK1NSON JB, BAKER JD, et al. Late results of extra-anatomic bypass. Arch Surg 1979:1/4:12601267. GRAHAM JC, CAMERON AEP, 1SMAIL HI, et al. Axillofemoral and femorofemoral grafts: a 6 year experience with emphasis on the relationship of peroperative flow measurement to graft survival. Br J Sur# 1983;70:326-331. DEVOLFE C, ADELEINE P, HENRIE M, et al. Iliofemoral and femoro-femoral crossover grafting. J Cardiovase S,r~ 1983:24:634-640. CRAWFORD FA, SETHI GK, SCOTT SM, et al. Femorofemoral grafl: for unilateral occlusion of aortic bifurcation grafts. Sur;~eo' 1975;77:150-153. BENHAMOU M. Les pontages crois6s femoro-femoraux. In: NATALI J (ed) Les Arteriopathies des Membres Infdrieurs. Association Frangaise de Chirurgie, Paris, 1982, pp 123-130. SZILAGYI DE. ELLIOTT JP, SMITH RF, et al. A thirtyyear survey of the reconstructive surgical treatment of aortoiliac occlusive disease. J Vase Surg 1986;3:421436.
Between 1973 and 1989, 39 femorofemoral crossover bypasses were performed to treat unilateral noninfective complications of aortoiliac surgery. The initial revascuiarization procedure, performed an average of 79.5 months previously, was an aortobifemoral bypass in 29 cases, an aorto- or iliofemoral bypass in six cases, an inlay graft for abdominal aortic aneurysm and aortoiliac endarterectomy in two cases each, The indications for femorofemoral crossover bypass included prosthetic occlusion in 35 cases, thrombosed false aneurysm in two, and further degradation after endarterectomy (lilac stenosis and occlusion in one case each). There was no operative mortality. One patient with acute ischemia upon admission and another with distal gangrene required below-knee and forefoot amputations, respectively. No amputations were required during the rest of the follow-up period. Three repeat aortobifemoral bypasses were performed because of occurrence of aortic or inflow vessel lesions. Primary and secondary actuarial five year patency rates for femorofemoral crossover bypasses were 59.7% and 78.4%, respectively. Femorofemoral crossover bypass can extend the benefits derived from direct aortoiliac surgery with low mortality and morbidity in the absence of associated aortic pathology (false aneurysm at the aortic implantation site or severe obstructive lesions). (Ann Vasc Surg 1991:5:46-49). KEY WORDS: Extraanatomic bypass; crossover bypass; surgical complications; aortoiliac disease; graft occlusion.
Since the first report by Oudot in 1953 [1] and the first series published by Vetto in 1962 [2], the efficacy and simplicity of the femorofemoral crossover bypass has stood the test of time [3-12]. Secondary unilateral thrombosis after aortoiliac or aortofemoral surgery is due to degradation of runoff
vessels or anastomotic stenosis in the majority of cases [13-15]. When the thrombosed prosthetic or vascular conduit cannot be cleared by thrombectomy, femorofemoral crossover bypass appears to be an attractive alternative to direct redo aortic surgery. The objective of this study was to verify the foundations of this policy based on our experience with 39 cases.
From the Service de Chirurgie Thoracique et CardioVasculaire, CHR Aiguelongue, Montpellier, France. Presented at the Annual Meeting of the Socidtd de Chirurgie Vasculaire de Langue Fran~'aise, May 18-19, 1990, Nancy, France. Reprint requests: F. Franfois, MD, Service de Chirurgie Thoracique et Cardio-Vasculaire, CHR Aiguelongue, 34059 Montpellier Cddex, France.
MATERIAL AND METHODS From January 1973 to December 1989, 170 femorofemoral crossover bypasses were performed. Thirty-nine (23%) were performed to treat a nonin46
VOLUME 5 No 1 1991
FEMOROFEMORAL CROSSOVER BYPASS
-
TABLE I.--Risk factors and patient status
Heavy tobacco consumption Coronary artery disease Hyperlipidemia Hypertension Cerebral arterial disease Diabetes
Number of patients 35
Percent 90
11 10 5 5 2
28 26 13 13 5
fective complication occurring after aortoiliac or aortofemoral reconstruction. There were 37 men and two women whose mean age was 61.7 years (range 47 to 75 years). The risk factors and status of these patients are indicated in Table I. Persistent tobacco consumption was found in 90% of patients. Initial aortoiliac or aortofemoral reconstructions were performed on an average of 79.5 months before (range one to 264 months). The type of initial surgery, dominated by aortobifemoral bypass, is indicated in Table I1. Femorofemoral bypass was performed for prosthetic occlusion in 35 patients (90%), a thrombosed false aneurysm in two cases, and degradation of the lilac artery (stenosis and occlusion in one case each) after endarterectomy. Clinical symptoms associated with these complications are indicated in Table Ill. Seventeen patients (43%) presented with severe lower limb ischemia. The preoperative workup included a velocimetric Doppler study and arteriograms. Arteriograms were not obtained for five patients, two of whom had severe ischemia. Computed tomography (CT) was performed for the 10 most recent patients in this series. All patients were operated on under general anesthesia and had prophylactic antibiotics starting at
TABLE II.--Initial surgical procedures
Aortobifemoral bypass Aorto- or iliofemoral bypass Inlay aortobiiliac graft Aortoiliac endarterectomy
Number of patients 29 6 2 2
Percent 74 15 5 5
TABLE IIl.--Symptoms
Intermittent claudication Resting pain Trophic disorders Acute ischemia
Number of patients 22 11 4 2
Percent 56.4 28.2 10.3 5.1
47
anesthetic induction and for 48 hours, postoperatively. The prosthetic graft was placed subfascially in all cases. The inflow conduit was a prosthetic limb in 31 (79%) cases. The common femoral artery was used in eight (20%) cases. The distal implantation site of the graft was the c o m m o n femoral artery in 17 cases, the profunda femoris artery in 18 cases, the superficial femoral artery in one case, the above-knee popliteal artery in two cases, and a femoropopliteal bypass in one case. Runoff vessel thromboendarterectomy of the femoral bifurcation and profunda femoris angioplasty were required in seven and three cases, respectively. No surgical procedures were performed on the inflow vessels. Polytetrafluoroethylene and Dacron grafts were used in 32 and seven cases, respectively. The prosthetic graft diameter ranged from 6 to 8 mm. Doppler investigation was performed in all patients before discharge and during follow-up, the mean follow-up period being 72 months. Primary and secondary patency was calculated according to the actuarial method. Patent but infected grafts requiring ablation without reconstruction were considered as thromboses.
RESULTS Early results
There were no intraoperative deaths. Thrombosis occurred in two cases, one and three days postoperatively. The first patient was a woman admitted for acute ischemia with a sensory motor deficit. The femorofemoral bypass failed to maintain femoropopliteal bypass patency, and below-knee amputation was required two days postoperatively. In the second patient, arteriograms obtained after the thrombotic event showed kinking of the inflow prosthetic limb requiring repeat aortobifemoral bypass. Three patients had suprapubic hematoma diffusing to the scrotum, spontaneously reversible within a few days. A forefoot amputation was required at one month in a patient admitted with distal gangrene although his femorofemoral crossover bypass was patent. Late results
Eight patients died in the late follow-up period. Four patients died of myocardial infarction between 10 and 107 months postoperatively: two had carcinoma, one had acute aortic thrombosis with paraplegia 13 months postoperatively, and one had intestinal hemorrhage due to aortoduodenal fistula at 32 months. Two patients were lost to follow-up. Two patients underwent reoperation for nonthrombosed false
48
Patenc
FEMOROFEMORAL CROSSOVER B Y P A S S
ANNALS OF
VASCULAR SURGERY
in primary and secondary patency rates reported herein. Several reports [3-12] in addition to ours have I00 57 33 31 shown that femorofemoral crossover bypass is associated with low mortality and morbidity. The 90 benefits obtained with this type of bypass seem better than those obtained with axillofemoral by60 7fl,4~ pass [16-18]. The use of femorofemoral crossover bypass in 70. the treatment of complications of direct aortoiliac surgery, and particularly, unilateral prosthetic thrombosis has been reported by several authors 60. i 59,7~g [4,11,19,20]. Late occlusions of prosthetic limbs have been treated successfully in most cases by 15 12 thrombectomy combined with reconstruction of the femoral bifurcation (endarterectomy or angioplasty) [13-15]. When this technique fails, femorofemoral days months crossover bypass constitutes~ the extraanatomic reFig. 1. Primary (59.7%) and secondary (78.4%) pavascularization procedure of choice [20-21]. tency rates at five years. The rate of patency of femorofemoral crossover bypass in this series was markedly lower than that reported when this bypass is used initially [4,11,19]. anastomotic aneurysm. Ten femorofemoral cross- This is thought to be due to more advanced atherover bypasses occluded. Seven of these were oma in patients operated on previously. While Planthrombectomized successfully. Two patients were igan and associates [4] and Kalman and colleagues not revascularized because they were not threat- [11] obtained three year primary patency rates of 65 ened; one required an aortobifemoral bypass for and 47%, respectively, Devolfe and coworkers [19] aortic false aneurysm. Two patients had prosthetic noted only 38.1% patent conduits at five years. In infection requiring removal, 19 and 39 months post- our experience, three and five year patency rates operatively. One of these patients had an axillofem- were 68.2 and 59.7%, respectively. These differences may be explained by the fact that infective oral bypass. One patient, operated on successfully for throm- complications of aortoiliac surgery were excluded bosis of his femorofemoral bypass at 19 months, from this series. During the same time interval, five had repeat thrombosis at 72 months. This was due year primary and secondary patency rates for 131 to an aortic false aneurysm which required repeat other femorofemoral crossover bypasses performed in our institution were 76.7 and 83.7%, respectively. aortobifemoral bypass. Femorofemoral crossover bypass allows preserPrimary patency was 87%, 68.2%, and 59.7% at one, three, and five years, respectively. Successful vation of the benefits obtained by previous aortoilreoperations allowed us to obtain secondary pa- iac reconstruction. Secondary patency rates of this tency rates of 89.6%, 86.6%, and 78.4%, at one, bypass are similar to overall patency rates for three, and five years, respectively (Fig. 1). The aortoiliac reconstruction. Our rate of 78.4% at five longest follow-up without reoperation, was twelve years compares favorably with the 76.6% rate reyears (two patients). Overall, of 14 patients who ported by Szilagyi after aortobifemoral reconstruchad thrombosis of their femorofemoral bypass, tion. Furthermore, our series shows that certain failpatent bypasses were obtained in six cases after thrombectomy. Of the eight remaining patients, ures of femorofemoral revascularization procedures four (50%) required a revascularization procedure are related to lesions of the aorta or inflow conduit. Two aortic anastomotic false aneurysms on an (three aortobifemoral and one axillofemoral bypass). aortobifemoral bypass and kinking of the inflow prosthetic limb in another case led to repeat aortobifemoral bypass. This justifies full work-up when DISCUSSION complications occur after aortoiliac reconstruction. Our experience shows that femorofemoral cross- Whereas conventional arteriograms are sufficient over bypass can extend the benefits obtained by for the diagnosis of occlusive lesions, CT is useful previous reconstructive surgery. Although this se- for early detection of proximal (aortic) false aneuries is small, the mean follow-up period was long (72 rysm. The discovery of such a lesion contraindimonths). Thrombosis is the principal complication cates performing a femorofemoral crossover bypass in this type of surgery. Successful thrombectomy and should prompt repeat direct aortoiliac reconfor this complication explains the marked difference struction.
VOLUME 5 No 1 - 1991
FEMOROFEMORAL CROSSOVER BYPASS
Although femorofemoral crossover bypass is certainly attractive because of its technical simplicity and satisfactory results, it would be of interest to study the respective values of thrombectomy, crossover bypass, and direct repeat reconstruction in the treatment of unilateral prosthetic occlusions in a large series to determine the most appropriate treatment in these settings.
11.
12.
13.
14.
REFERENCES l. OUDOT J, BEACONSPIELD D. Thrombosis of the aortic bifurcation treated by resection and homograft replacement. Arch Sur~ 1953;66:365-374. 2. PETTO RM. The treatment of unilateral lilac artery obstructive with a transabdominal subcutaneous, femorofemoral graft. Surgery 1962;52:342-345. 3. MANNICK JA, MINI BS. Femorofemoral grafting: indica tions and late results. Am J SurL, 1978;136:190-192. 4. FLANIGAN DP, PRATT DG, GOODREAU J J, et al. Hemodynamic and angiographic guidelines in selection of patients for femorofemoral bypass. Arch Sur~ 1978:113: 1257-1262. 5. MC DONALD PT, RICH NM, COLLINS GJ, et aL Femorofemoral grafts: the role of concomitant extended profundaplasty. Am J Sur~ 1978;136:622-628. 6. DICK LS, BIREF DK, ALPERT J, et al. 12-year experience with femorofemoral crossover grafts. Arch Surg 1980:115: 1359-1365. 7. HARRIS JP, FLINN WR, RUDO ND, et al. Assessment of donor limb hemodynamics in femorofemoral bypass for claudication. Surgeliv 1981 ;90:764-773. 8. MOSLEY JG, MARSTON A. Long term results of 66 femoral-to-femoral by-pass grafts: a 9-year folIow-up. Br J Sur~ 1983 ;70:631-634. 9. PLECHA FR, PLECHA FM. Femorofemoral bypass grafts: ten-year experience. J Vase Sury 1984:1:555-561. 10. BROUWER MHJ, BLEMANS RGM, DONDERS HPC.
m m m
15.
16.
17.
18.
19. 20. 21.
22.
49
Long-term results of 44 cross-over bypasses. J Cardiovasc Surg 1988;29:290-295. KALMAN PG, HOSANG M, JOHNSTON KW, el al. The current role for femorofemoral bypass. J Vasc Surg 1987:6: 71-76. FAHAL AH, Mc DONALD AM, MARSTON A. Femorofemoral bypass in unilateral iliac artery occlusion. Br J Surg 1989:76:22-25. THEVENET A. Les oblit6rations apr6s chirurgie reconstructrice aorto-iliaque. In: NATALI J (ed), Les Art6riopathies des Membres lnf4rieurs. Association Fran~:aise de Chimrgie, Paris, 1982, pp 157-160. NAYLOR AR, AH-SEE AK, ENGESET J. Graft occlusion following aortofemoral bypass for peripheral ischaemia. Br Y Surg 1989:76:572-575. NEVELSTEEN A. SUY R. DAENEN W, et al. Aortofemoral grafting: factors influencing late results. SurgeJJ' 1980; 88:642-653. EUGENE J, GOLDSTONE EJ, MOORE WS. Fifteen year experience with subcutaneous bypass grafts for lower extremity ischemia. Ann Suro 1977;186:177-183. I,IVESAY JJ, ATK1NSON JB, BAKER JD, et al. Late results of extra-anatomic bypass. Arch Surg 1979:1/4:12601267. GRAHAM JC, CAMERON AEP, 1SMAIL HI, et al. Axillofemoral and femorofemoral grafts: a 6 year experience with emphasis on the relationship of peroperative flow measurement to graft survival. Br J Sur# 1983;70:326-331. DEVOLFE C, ADELEINE P, HENRIE M, et al. Iliofemoral and femoro-femoral crossover grafting. J Cardiovase S,r~ 1983:24:634-640. CRAWFORD FA, SETHI GK, SCOTT SM, et al. Femorofemoral grafl: for unilateral occlusion of aortic bifurcation grafts. Sur;~eo' 1975;77:150-153. BENHAMOU M. Les pontages crois6s femoro-femoraux. In: NATALI J (ed) Les Arteriopathies des Membres Infdrieurs. Association Frangaise de Chirurgie, Paris, 1982, pp 123-130. SZILAGYI DE. ELLIOTT JP, SMITH RF, et al. A thirtyyear survey of the reconstructive surgical treatment of aortoiliac occlusive disease. J Vase Surg 1986;3:421436.
