Iliofemoral Bypass

In cases of isolated iliac or proximal common femoral artery occlusive disease, several options exist when patients present with symptoms of claudication or, less commonly, limb-threatening ischemia (eg, nonhealing ulcers or gangrene; see the images below). Additional indications include isolated iliac aneurysm and proximal common femoral aneurysm.

Pressure ulcer of the heel exacerbated by arterial occlusive disease.

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Cyanosis of the first toe and dependent rubor of the foot characteristic of arterial insufficiency.

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Peripheral interventions, including angioplasty and stenting, ^[1] remain the mainstay of treatment. However, when these measures are unsuccessful or inadvisable, operative treatment is indicated.

Surgical procedures performed in this setting include femorofemoral bypass, aortic bifemoral bypass, unilateral axillofemoral bypass, and isolated unilateral iliofemoral bypass. ^{[2, 3, 4]}  Although femorofemoral bypass has been a more popular option than iliofemoral bypass, some studies have found iliofemoral bypass grafting to yield better patency, a finding that may justify more widespread use of this procedure. ^[5]

Iliofemoral bypass may be considered in cases of isolated iliac or proximal common femoral artery occlusive disease, provided that the aorta and the proximal ipsilateral common iliac artery are free of severe occlusive disease. ^{[2, 6]}  In addition, iliofemoral bypass is preferred in certain scenarios where femorofemoral bypass is contraindicated—for example, when the contralateral donor iliac artery may not provide adequate inflow because of proximal disease, or when there is heavy scarring or infection in the contralateral femoral region.

All methods of iliofemoral revascularization may be combined with other procedures, such as profundaplasty or distal bypass. Iliofemoral and associated distal bypass or iliodistal bypass may be indicated when a surgeon wishes to limit the extent of the procedure and to avoid approaching the contralateral femoral artery in the setting of multilevel unilateral disease. ^[7]

Contraindications for iliofemoral bypass include severe aortic or proximal ipsilateral common iliac artery occlusive disease. ^[2]

The morbidity and mortality of iliofemoral bypass are low, provided that the patient is from a low-risk group. In one study, the patency rate for this procedure was approximately 96% at 1 year and 92% at 3 years. ^[2]  For the subgroup of patients whose operative indication was limb salvage (those with rest pain, ulcer, or gangrene), the salvage rate was 86% at 1 year and 76% at 3 years.

A subsequent study of iliofemoral bypass in 40 patients with unilateral aortoiliac occlusive disease found that this procedure achieved excellent technical and functional outcomes, particularly in patients treated for vasculogenic claudication. ^[8]  Secondary patency was 97.5% at 1 year and 93.3% at 5 years. The limb salvage rate in patients with critical limb ischemia was 85.1% at 1 year and 79.1% at 5 years. Limb amputation was performed because of infection in two patients and because of failed iliofemoral bypass in two patients.

A study by Ultee et al found that when iliofemoral bypass was performed concomitantly with endovascular aneurysm repair for abdominal aortic aneurysm, it was associated with an increased risk of deteriorating renal function. ^[9]