Clinical Outcomes of Iliofemoral Bypasses for Isolated ......•Fem-fem bypass graft. 0 20 40 60 80...

Clinical Outcomes of Iliofemoral

Bypasses for Isolated Unilateral

Iliac Occlusive Disease:

A Review

Mohammed M. Moursi, MD

Professor, Vascular Surgery

Division Chief, UAMS Vascular and Endovascular Surgery

Chief, Vascular Surgery, Little Rock VA

Georgia Vascular Society

6th Annual Scientific Sessions

September 14 – 16, 2018

Ritz-Carlton Reynolds, Lake Oconee

Greensboro, GA

15 -Year10 -Year

Nothing to disclose

Iliac occlusive disease

• TASC II committee for the management

of peripheral artery disease

recommended an endovascular approach

over surgery as the preferred treatment

of TASC A and B aortoiliac lesions

• 60-80% 5 year patency

Iliac occlusive disease

• Recommendation for surgical treatment

of TASC C and D lesions in the iliac

system

Arkansas experience

• Excellent atherosclerotic population

• Tended towards operative repair of

isolated severe iliac stenosis and occlusion

via a unilateral retroperitoneal approach

• Including flush occlusions of the common

iliac artery

Patient population

• January 2003 till January 2018

• Single surgeon, single institution

• 102 pts underwent iliofem bypass for

occlusive disease

• Routine follow up consists of ABI every 6

months

• Aneurysmal disease, trauma etc. were

excluded

Follow –up

• 41 month average follow up

Demographics

Factor Value

Age (years) 61

Gender – male (%) 95

BMI 24

Smoking (%) 84

Diabetes (%) 22

Hypertension (%) 84

CAD (%) 23

COPD (%) 32

HPLD (%) 52

Indication %Claudication 58

Rest pain 33

Tissue loss 9

Indications

Previous vascular procedures

Ipsilateral leg

• 23% had previous procedures

• Iliac stents

• Fem endartectomy

• Fem-fem bypass

Concomitant outflow

procedures

• 12%

• Fem pop – above and below knee

• Profunda pop

• SFA thrombectomy/atherectomy

• Gracilis flap

Post-op Complications

• 24% typical types for this population

• Most were wounds

• 2% MI

• 2% Afib

• 2% pneumonia

Patency

• 4 grafts thrombosed within 30 days -

94% patency

• Thrombectomized and remained patent

• 5 additional grafts thrombosed within

one year - 89% one year patency

• 80% three year patency

• 75% five year patency

Patency

• 20 grafts failed in the cohort - several

multiple times

• 16 pts lower ext were revascularized

• thrombectomy of graft – adjunct procedures

• Fem-fem bypass

• 4 pts had thrombosed grafts and were not

revascularized

Patency

• 8 pts were identified with a decreased

ABI and underwent proximal or distal

repair prior to thrombosis

• Regained ABI

Patency – secondary

• Open thrombectomy

• Most will not have a “stump” of contrast

• Flush occlusion

• Will not be able to achieve a good

proximal “endpoint” with fogarty

• Will need proximal stenting

• Protect the contralateral side

Patency – secondary

• Relining the graft with covered stent

graft

• Removal of intimal hyperplasia and

patch angioplasty of distal anastomosis

• Removal of 2 infected grafts and

replacement with deep femoral vein

• Fem-fem bypass graft

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Patency

ABI

• Average increase in ABI was 91%

Mortality

• 2% 30 day mortality

• One year – 93%

• Three year – 75%

• Five year – 60%

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Technique

• General anesthesia

• Transplant (hockey stick) incision

• Proper dissection can expose the distal aorta

• Segmented ring fixed retractor

Iliofemoral bypass – conduit

• 8 mm ringed PTFE

Proximal control

• Aortic clamp 22%

• Aortic balloon occlusion via contralateral

femoral 17%

• Remaining – clamp placed on common

iliac

Iliofemoral procedure

proximal anastomosis• Proximal take off site endarterectomized

in nearly all cases

• Common iliac circumferential plaque

removal

• Anterior common iliac longitudinal

arteriotomy with patch angioplasty down to

internal iliac

• Patch

• Hood the graft as patch

• Aortic bifurcation plaque

Iliofemoral bypass

distal endpoint

• Common fem and profunda endarterectomy

• Separate patch

• Hood the graft

• Patch onto the profunda

Iliofemoral bypass

• Excellent option for extensive iliac

disease

• Can treat flush occlusions with aortic

control

• Good patency

• Acceptable morbidity and mortality

Acknowledgments

• Nawar Hudefi

• David Soni

• Victoria Ly

Thank you