Iliofemoral Bypass
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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.
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] 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. [4]
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, 5] 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. [6]
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. [7] 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. [8]
Mehta M, Zhou Y, Paty PS, Teymouri M, Jafree K, Bakhtawar H, et al. Percutaneous common femoral artery interventions using angioplasty, atherectomy, and stenting. J Vasc Surg. 2016 Aug. 64 (2):369-379. [Medline].
Kalman PG, Hosang M, Johnston KW, Walker PM. Unilateral iliac disease: the role of iliofemoral bypass. J Vasc Surg. 1987 Aug. 6(2):139-43. [Medline].
Nazzal MMS. Iliofemoral bypass. Hoballah JJ, Scott-Conner CEH, Chong HS, eds. Operative Dictations in General and Vascular Surgery. 3rd ed. Cham, Switzerland: Springer; 2017. 719-20.
Perler BA, Burdick JF, Williams GM. Femoro-femoral or ilio-femoral bypass for unilateral inflow reconstruction?. Am J Surg. 1991 Apr. 161(4):426-30. [Medline].
Ricco JB, Thanh Phong L, Belmonte R, Schneider F, Valagier A, Illuminati G, et al. Open surgery for chronic limb ischemia: a review. J Cardiovasc Surg (Torino). 2013 Dec. 54 (6):719-27. [Medline].
Aortoiliac disease. Rutherford RB, ed. Rutherford’s Vascular Surgery. 6th ed. Philadelphia: WB Saunders; 2005.
Carsten CG 3rd, Kalbaugh CA, Langan EM 3rd, Cass AL, Cull DL, Snyder BA, et al. Contemporary outcomes of iliofemoral bypass grafting for unilateral aortoiliac occlusive disease: a 10-year experience. Am Surg. 2008 Jun. 74(6):555-9; discussion 559-60. [Medline].
Ultee KH, Zettervall SL, Soden PA, Darling J, Siracuse JJ, Alef MJ, et al. The impact of concomitant procedures during endovascular abdominal aortic aneurysm repair on perioperative outcomes. J Vasc Surg. 2016 Jun. 63 (6):1411-1419.e2. [Medline].
[Guideline] Zierler RE, Jordan WD, Lal BK, Mussa F, Leers S, Fulton J, et al. The Society for Vascular Surgery practice guidelines on follow-up after vascular surgery arterial procedures. J Vasc Surg. 2018 Jul. 68 (1):256-284. [Medline]. [Full Text].
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.
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 Surgical Association, Pacific Coast Surgical Association, Society for Clinical Vascular Surgery, Society for Vascular Surgery, Western Vascular Society
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Iliofemoral Bypass
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