- Author: Dale K Mueller, MD; Chief Editor: Vincent Lopez Rowe, MD more...
The typical treatment for aortoiliac occlusive disease is an aortofemoral bypass graft, with patency rates of approximately 83-92% at 5 years. Thoracofemoral bypass is an alternative surgical bypass that is indicated for aortoiliac occlusive disease when aortobifemoral bypass is contraindicated. These conditions occur when performing a transabdominal or retroperitoneal abdominal procedure such as with prior abdominal radiation, multiple abdominal interventions, colostomy, proximal aortic disease in close proximity or above the renal arteries, and failure or infection of previous abdominal aortic surgery is difficult or impossible.
Some surgeons currently advocate thoracofemoral bypass as a primary treatment for isolated aortoiliac occlusive disease, at least when the disease is in close proximity to the visceral and/or renal arteries of the aorta. Reported patency rates for thoracofemoral bypass rival the traditional aortofemoral bypass at approximately 81% at 5 years.
The indications for thoracofemoral bypass include aortic graft failure, graft infection, hostile abdomen, occlusive disease in close proximity to the visceral and/or renal arteries, and other intra-abdominal pathologies not amenable to standard aortofemoral revascularization. Although some advocate its use as a primary procedure, most surgeons consider it as a secondary procedure with the previous indications.
The contraindications to a thoracofemoral bypass graft include severe pulmonary insufficiency in a patient who is hence unable to tolerate a thoracotomy and an unapproachable thoracic aorta. A limiting factor includes a prior thoracic operation precluding or complicating the approach to the descending aorta.
The thoracofemoral bypass requires general anesthesia and most prefer left lung isolation, although the procedure can be conducted with a left lung ventilation and appropriate retraction. Epidural anesthesia for postoperative pain control is also helpful. An arterial line and often central line are also useful for the procedure.
See the list below:
Double lumen endotracheal tube and bronchial blocker/Univent
Ability to perform on table angiography
Bean bag, pillows, and cushions to allow for positioning
The patient is placed in a posterolateral thoracotomy position with the left chest at approximately 45 º off the horizontal and with the pelvis in a horizontal position. The left arm is kept anteriorly and supported.
A left thoracotomy (except with sinus invertus) is performed through the seventh, eighth, or ninth rib space. The inferior pulmonary ligament is taken down and left lower lobe retracted to expose the distal descending thoracic aorta. Standard exposure is done for the femoral vessels. Most tunnel the graft through a small incision in the diaphragm and pass the graft retroperitoneally to the left femoral vessel.
A standard femoral-femoral tunnel for the right femoral artery is otherwise performed if necessary, or this portion of the graft can also be placed preperitoneally due to the potential for kinking if passed from the left groin to the right. Some authors recommend carrying the intercostals incision across the costal margin or even a thoracoabdominal incision.[1, 3] Most tunnel the graft posteriorly to the kidney, but a technique has been described to tunnel the graft anterior to the left kidney, although blind tunneling posterior to the left kidney appears to be the simplest approach to the author.
The descending thoracic aortic anastomosis is performed end-to-side, usually with a side biting clamp although proximal and distal clamping of the descending aorta may be necessary. The graft is angled to be directed to the previously created tunnel and clamped after releasing the thoracic aortic clamps. Standard femoral anastomoses are then conducted. A thoracoscopic method has also been described by stapling the thoracic anastomosis.
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