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Thoracofemoral Bypass

  • Author: Dale K Mueller, MD; Chief Editor: Vincent Lopez Rowe, MD  more...
 
Updated: Jun 07, 2013
 

Overview

The typical treatment for aortoiliac occlusive disease is an aortofemoral bypass graft, with patency rates of approximately 83-92% at 5 years.[1] 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.[2] Reported patency rates for thoracofemoral bypass rival the traditional aortofemoral bypass at approximately 81% at 5 years.[1]

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Preparation

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.[2]

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Contraindications

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.

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Anesthesia

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.

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Equipment

See the list below:

  • Operative table
  • Vascular tray
  • Thoracotomy tray
  • Double lumen endotracheal tube and bronchial blocker/Univent
  • Ability to perform on table angiography
  • Bean bag, pillows, and cushions to allow for positioning
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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.[1]

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Technique

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.[1]

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.[1] A thoracoscopic method has also been described by stapling the thoracic anastomosis.[4]

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Complications

See the list below:

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Contributor Information and Disclosures
Author

Dale K Mueller, MD Co-Medical Director of Thoracic Center of Excellence, Chairman, Department of Cardiovascular Medicine and Surgery, OSF Saint Francis Medical Center; Cardiovascular and Thoracic Surgeon, HeartCare Midwest, Ltd, A Subsidiary of OSF Saint Francis Medical Center; Section Chief, Department of Surgery, University of Illinois at Peoria College of Medicine

Dale K Mueller, MD is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, American Medical Association, Chicago Medical Society, Illinois State Medical Society, International Society for Heart and Lung Transplantation, Society of Thoracic Surgeons, Rush Surgical Society

Disclosure: Received consulting fee from Provation Medical for writing.

Chief Editor

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Society for Vascular Surgery, Vascular and Endovascular Surgery Society, Society for Clinical Vascular Surgery, Pacific Coast Surgical Association, Western Vascular Society

Disclosure: Nothing to disclose.

References
  1. Schneider JR. Extra-Anotomic Bypass. Cronenwett JL, Johnston KW. Ruther ford’s Vascular Surgery. 7th ed. Philadelphia, PA: WB Saunders; 2010. 1137-1153.

  2. Aortoiliac Disease: Extra-anatomical bypass. Cronenwett JL, Johnston KW. Rutherford’s Vascular Surgery. 7th ed. Philadelphia, PA: WB Saunders; 2010.

  3. McCarthy WJ, Mesh CL, McMillan WD, Flinn WR, Pearce WH, Yao JS. Descending thoracic aorta-to-femoral artery bypass: ten years' experience with a durable procedure. J Vasc Surg. 1993 Feb. 17(2):336-47; discussion 347-8. [Medline].

  4. McMillan WD, McCarthy WJ. Minimally invasive thoracoscopic thoraco-femoral bypass: a case report. Cardiovasc Surg. 1999 Mar. 7(2):251-4. [Medline].

  5. Raju S, Owen S Jr, Neglen P. The clinical impact of iliac venous stents in the management of chronic venous insufficiency. J Vasc Surg. 2002 Jan. 35(1):8-15. [Medline].

  6. Schillinger M, Sabeti S, Loewe C, et al. Balloon angioplasty versus implantation of nitinol stents in the superficial femoral artery. N Engl J Med. 2006 May 4. 354(18):1879-88. [Medline].

  7. Sumi M, Ohki T. "Technique: Endovascular Therapeutic.". Cronenwett JL, Johnston KW. Rutherford’s Vascular Surgery. 7th ed. Philadelphia, PA: WB Saunders; 2010. 1277-94.

 
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