Background
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. [1] 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. [2, 3, 4]
Bypass patency rates have been estimated to be in the range of 40-80% at 5 years. [5, 6, 7, 8, 9] A study by Samson et al cited a slightly higher figure of 83.7% overall (85.5% for unilateral bypass, 81.8% for bilateral bypass). [10] Patency rates are influenced by the characteristics of the patients; claudicants generally have better patency than patients with critical limb-threatening ischemia (CLTI). Bilateral reconstructions appear to be comparable to unilateral reconstructions with regard to patency. [11]
Indications
Indications for axillobifemoral bypass include the following:
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Symptomatic lower-extremity ischemia (disabling claudication, rest pain, tissue loss), acute (thrombosed aortoiliac system) or chronic
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Infected aortic grafts or prosthetics
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Aortoenteric fistulae
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Patients without endovascular options for management of their ischemic symptoms
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High-risk patients with significant comorbidities that preclude inline reconstruction with inflow from the aorta (cardiopulmonary disease, multiple prior abdominal operations, prior radiation therapy to the abdomen, abdominal stoma)
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Aortic coarctation
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). [12]
Contraindications
Contraindications for axillofemoral bypass include the following:
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Diseased axillary or subclavian arteries
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Extreme medical risks for surgery (eg, nonsurvivable acidosis in the setting of acute ischemia)
Technical Considerations
Complication prevention
The importance of 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 during the course of 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.
Outcomes
A retrospective analysis by Levin et al (N = 3261) assessed the outcomes of axillofemoral bypass (AxFB; n = 436) performed for intermittent claudication in comparison with those of aortofemoral bypass (AoFB; n = 2825). [13] Patients in the AxFB group had a shorter postoperative length of stay and fewer perioperative pulmonary and renal complications but required more perioperative ipsilateral major amputations. At 1 year, the AxFB cohort had higher rates of death; of graft occlusion or death; of ipsilateral major amputation or death; and of reintervention, amputation, or death. On multivariable analysis, AxFB was independently associated with an increased risk of 1-year reintervention, amputation, or death.
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Tunneling of the axillofemoral bypass (bifemoral configuration shown).
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Axillary anastomosis.
