Axillofemoral bypass is a method of surgical revascularization used in the setting of symptomatic aortoiliac occlusive disease for patients who have no endovascular option or who cannot undergo an aortofemoral reconstruction. The bypass depends on a healthy axillary artery for adequate inflow to the ipsilateral arm and one or both legs. This extra-anatomic reconstructive method is one of the options for managing patients presenting with infected aortic grafts or aortoenteric fistulae. [1, 2, 3]
Bypass patency rates are estimated to be in the range of 40-80% at 5 years. [4, 5, 6, 7] Patency rates are influenced by the characteristics of the patients; claudicants generally have better patency than patients with critical limb ischemia (CLI).
Indications for axillobifemoral bypass include the following:
Symptomatic lower-extremity ischemia (disabling claudication, rest pain, tissue loss), acute (thrombosed aortoiliac system) or chronic
Infected aortic grafts or prosthetics
Patients without endovascular options for management of their ischemic symptoms
High-risk patients with significant comorbidities that preclude inline reconstruction with inflow from the aorta (cardiopulmonary, multiple prior abdominal operations, prior radiation therapy to the abdomen, abdominal stoma)
Monnot et al reported three cases in which a temporary axillofemoral bypass was performed to protect renal function in kidney transplant recipients undergoing open repair of an abdominal aortic aneurysm (AAA). 
Contraindications for axillofemoral bypass include the following:
Diseased axillary or subclavian arteries
Extreme medical risks for surgery (eg, nonsurvivable acidosis in the setting of acute ischemia)
A thorough preoperative assessment of the inflow vessel cannot be stressed enough.
Pay strict attention to sterile technique when handling prosthetic grafts. A wide sterile field is necessary to allow for a thoracotomy, sternotomy, or laparotomy to manage intraoperative bleeding or other unexpected complications that can arise while performing the revascularization procedure.
Place the axillary anastomosis as medially on the artery as possible (medial to the pectoralis minor) to avoid tension on the anastomosis when the arm is abducted. Tunnel the graft along the midaxillary line to prevent kinking of the graft with torso flexion.