Long Term Outcomes of Femorofemoral Crossover Bypass Grafts

PURPOSE: Femorofemoral crossover bypass (FCB) is a good procedure for patients with unilateral iliac artery disease. There are many articles about the results of FCB, but most of them were limited to 5 years follow-up. The purpose of our study was to analysis the results of FCB with a 10-year follow-up period. MATERIALS AND METHODS: Between January 1995 and December 2010, 133 patients were operated in Samsung Medical Center (median follow-up: 58.8 months). We retrospectively analysed patient characteristics, the preoperative treatment, the operative procedure, and material used. RESULTS: The indications for FCB were claudication in 110 and critical limb ischemia in 23 patients. Three patients were died due to myocardiac infarction, intracranial hemorrhage, and acute respiratory failure within 30 days after surgery. The one-year primary and secondary patency rates were 89% and 97%, the 5-year primary and secondary patency rates were 70% and 85%, and the 10-year primary and secondary patency rates were 31% and 67%. The 5-year and 10-year limb salvage rates were 97% and 95%, respectively. CONCLUSION: Our long term analysis suggests that FCB might be a valuable alternative treatment modality in patients with unilateral iliac artery disease.

Cross Pubic Femoro-femoral Artery Bypass with Great Saphenous Vein / 대한혈관외과학회지

PURPOSE: The purpose of this study was to evaluate the great saphenous vein (GSV) as a conduit for crossover femoro-femoral bypass. Generally the conduit for crossover femoro-femoral bypass is a synthetic material because of the acceptable long-term patency and low complication rates. But, as the average life expectancy becomes extended, a better patency rate becomes more important. In this study, we compared the patency rates and hemodynamic results between crossover femoro-femoral bypass operations with GSVs and those with synthetic grafts. METHODS: From 1998 to 2008, 119 femoro-femoral bypass operations were done. Among them, 38 femoro-femoral bypass used GSV as a conduit (group I) and 79 operations used expanded polytetrafluoroethylene (group II). Two cases used arm veins and we excluded those cases. RESULTS: The 3 year primary patency rate of total cases was 75.1%, 93.7% in group I and 66.1% in group II. There were no statistical differences in hemodynamic results such as peak systolic velocity, volume flow and ankle/brachial systolic pressure index between the two groups. CONCLUSION: The 3 year primary patency rate of group I was better than that of group II. However there were no differences in hemodynamic changes. So GSV is recommended as a conduit for crossover femoro-femoral bypass especially in young patients who are eager to have longer patency rates after surgery instead of less invasive endovascular therapy.

Femoro-femoral Cardiopulmonary Bypass during Tracheal Reconstruction Surgery: A case report / 대한마취과학회지

A 45 year-old-women with tracheal stenosis due to an endotracheal tumor was scheduled for tracheal reconstruction surgery. The stenotic lesion was located 1 cm above the carina, and was length of 4 cm and had a narrowest internal diameter of 0.4 cm. The length of such a stenotic segment and its narrowest internal diameter may pose lung ventilation problems before or during tumor resection, which may preclude a successful outcome. Thus, during tracheal reconstruction surgery a femoro-femoral partial cardiopulmonary bypass, self respiration, and pulmonary artery ligation were used. These measures improved oxygenation and cardiovascular stability, and tracheal reconstruction was successfully performed without complication.

Femorofemoral Cardiopulmonary Bypass in the Management of Severe Airway Obstruction by Thyroid Cancer: A Case Report / 대한마취과학회지

Severe upper airway obstruction due to thyroid cancer is often related severe hypoxia and hypercarbia during anesthesia induction. Attempts to insert an endotracheal tube or a bronchoscope may cause complete immediate airway obstruction. We anesthetized two patients. One had a large mediastinal thyroid mass which compressed trachea and caused near complete obstruction, and the other patient had a large papillary thyroid cancer, which had invaded larynx and compressed the upper trachea. Patients were sedated with fentanyl 150microgram i.v. and a target controlled infusion (TCI, 1.8microgram/ml) of propofol. A femorofemoral cardiopulmonary bypass was performed under local anesthesia. After bypass, the propofol TCI concentration was increased to 3.5microgram/ml, and fentanyl 500microgram and vecuronium 6 mg were injected. Ventilation was performed using a laryngeal mask in one patient, and a laryngeal tube in the other. After removing the tumor mass, the airway was secured, and the cardiopulmonary bypass discontinued. All patients recovered uneventfully and were discharged. We discuss the management of severe upper airway obstruction and the usefulness of cardiopulmonary bypass.

Patency Rates of Femoro-Femoral Bypass Graft

PURPOSE AND METHOD: To access the value and results of femoro-femoral bypass for the treatment of unilateral iliac artery occlusion, the clinical data of 53 patients who underwent femoro-femoral bypass graft at Yeungnam University Hospital between January 1994 to December 2000 were analyzed retrospectively. The influence of several variables (such as, age, sex, preoperative symptom, risk factors and associated medical illness, status of distal artery, preoperative ABI) on the long term patency was evaluated by univariate statistical analysis. RESULT: The patients were 47 males and 6 females ranging from 37 to 84 years of age. The mean age was 65, with the highest incidence among people in their 60s, followed by those in their 70s and then in their 50s. Associated diseases were hypertension in 28 cases (52.8%), diabetes mellitus in 10 cases (18.8%), cardiac disease in 19 cases (32.0%) and cerebrovascular disease in 4 cases (7.5%). History of smoking was noted in 77.4% of the cases. Focal stenosis of donor site iliac artery has been found in 2 cases and combined distal outflow occlusion has been found in 21 cases. 2 donor site iliac artery ballon angioplasty was performed preoperatively and 14 adjuvant procedures (9 femoro-popliteal bypass, 2 femoro-tibial bypass, 3 profundoplasty) was performed simultaneously during the operation. Cumulative 1, 3, 5,-year primary and secondary patency rates of all femoro-femoral bypass were 87.0%, 76.6%, 68.1% and 91.7%, 85.7%, 73.5%. There was no operative mortality and major perioperative complications. Univariate analysis showed that the patients without distal arterial occlusion had significantly better 1-, 3- and 5-year primary patency rates (93.0%, 89.0% and 74.2% versus 76.6%, 45.9% and 45.9%, P=0.02) compared with the patients with distal arterial occlusion. No significant effect was exerted by all other variables on long term results. CONCLUSION: These results suggest that femoro-femoral bypass is a safe and durable operation that results in good patency in a good runoff.

Combined Angioplasty and Femorofemoral Bypass in the Treatment of Unilateral Iliac Arterial Occlusive Disease

PURPOSE: The purpose of this article is to analyze the results of combined agioplasity and femorofemoral bypass in patients with unilateral iliac arterial occlusive disease. METHOD: During the 11-year period from 1990 to 2000, 44 patients with iliac artery occlusion and a hemodynamically significant contralateral iliac artery stenosis were treated by using a combination of percutaneous transluminal angioplasity (PTA) and femorofemoral bypass (n=18) as well as aortobifemoral bypass (n=12) and iliofemoral bypass (n=14) at Korea university medical center. PTA was performed if the lesions in the donor iliac artery were less than 3 cm in length with no more than one well-localized lesion in either the common or external iliac artery, or both. Stent was deployed for suboptimal PTAs. The femorofemoral bypass was done within 3 to 5 days after PTA or stenting. RESULT: The mean age was 61.2 years. The Indications of femorofemoral bypass were hypertension, ischemic heart disease, chronic obstructive lung disease, old age (>75), cancer, and previous abdominal operation. The complication rate of the combination treatment was lower than that of the others. Primary patency rate at 1 and 3 years were 89%, 78% for aortobifemoral bypass, 83%, 66% for iliofemoral bypass, and 77%, 65% for femorofemoral bypass, respectively. CONCLUSION: The combination of PTA with or without stent deployment and femorofemoral bypass can be a useful option for treating iliac occlusion and contralateral iliac stenosis in patients with severe comorbid illness, advanced age, and intra-abdominal pathology. Angioplasity can allow more widespread use of femorofemoral bypass in these patients.

Causes of Recurrent Leg Ischemia and Graft Occlusion after Crossover Femoro-femoral Bypasses (FFBs)

With increasing number of high-risk, advanced atherosclerotic patients, crossover femoro-femoral bypass (FFB) became commonly chosen extra-anatomic bypass for symptomatic iliac artery occlusive disease. But the causes FFB graft failure have not been clarified yet. PURPOSE: We aimed to investigate the natural course of native artery disease, the causes of graft occlusion and recurrent leg ischemia after FFBs. METHOD: Among 162 primary FFBs for atherosclerotic iliac occlusive disease, 45 patients who underwent follow-up arteriography for recurrent ischemic symptom were enrolled. We investigated the interval changes between initial preoperative and follow-up angiograms and categorized them as inflow, outflow and/or graft lesions. The significant changes between 2 angiograms was arbitrarily defined as progression of lesion into stenosis >50% or occlusion. And the patients were divided into 2 groups as patent FFB group and occluded FFB group. We compared interval changes on angiograms between patient and occluded FFB groups to find out any difference and tried to determine the ultimate causes of recurrent leg ischemia considering not only the interval changes but the preexisting, untreated leg arterial lesions. RESULT: The follow-up angiography was most commonly performed within 1 year after FFB with mean interval of 21.2 +/- 21.6 months. Interval changes between 2 angiograms were 24 (53.3%) FFB grafts occlusion, 8 (17.8%) inflow iliac disease progression, and 26 (57.8%) ouflow arterial occlusion. Comparing the interval changes between patent and occluded FFB groups, the significantly higher frequency of outflow occlusion was noted in occluded FFB group (75% vs 38.1%, P=0.012). The most common finding on follow-up angiongram responsible for the recurrent ischemia was also outflow arterial occlusion even in patent FFB group. CONCLUSION: The most common cause of graft occlusion and recurrent leg ischemia was outflow arterial occlusion after FFB.

Analysis of Graft Patency and Risk Factors Influencing Graft Failure in Femorofemoral Crossover Bypass

PURPOSE: Femorofemoral crossover bypass is commonly employed to treat unilateral iliac artery occlusion in chronic limb ischemic patients. We retrospectively analysed the risk factors related to postoperative graft failure and primary patency. METHODS: We reviewed 33 iliac artery occlusion patients who visited Samsung Medical Center between March 1995 and July 2000 and underwent femorofemoral bypass surgery. 33 cases were employed 6 mm or 7 mm PTFE (polytetrafluoroethylene). The average age of the patients was 63.3 year-old, and all of them were male. The indication of surgery were claudication (19 cases, 57.6%), resting pain (9 cases, 27.3%), and lower limb ulceration or gangrene (5 cases, 15.2%) in preoperatively. RESULTS: The average ankle-brachial index (ABI) was 0.34 preoperatively and 0.837 postoperatively. Graft failure after 30 days (late graft failure) was found in 7 cases (21.3%). The primary patency rates were 80.1% for 1 year and 60.1% for 2 years. According to the cross table analysis of the risk factors, smoking, diabetes mellitus, cardiac status, distal run-off score, and cerebrovascular disease related with carotid stenosis showed significantly high rate graft failure. A univariate analysis of risk factors showed that preoperative smoking, diabetes mellitus, hypertension, distal run-off score, cardiac status, and cerebrovascular diseases related with carotid stenosis were significantly related with primary patency. However, according to multivariate analysis, these risk factors did not show any significant relationship with primary patency, with the exception of the distal run-off score (p= 0.0018). CONCLUSION: Continuous and close care of patients through postoperative long-term follow up would improve graft patency in patients with risk factors, such as diabetes mellitus, carotid stenosis, cardiac status, and smoking. Examination of the preopertive distal run off artery will predict the prognosis of the postoperative graft patency.

Use of Femorofemoral Bypass for Life Saving before the Emergency Replacement of Thrombotic Prosthetic Mitral Valve / 대한구급학회지

Mechanical valves have generally good hemodynamic function and indefinite durability, but they have a higher thromboembolic potential and thus a requirement for permanent anticoagulation, because thrombotic occlusion is a potentially fatal complication of heart valve replacement surgery. We had experienced mitral valve replacement because of thrombosis around the replaced prosthetic valve. The patient's mechanical prosthetic valve was acutely obstructed by thrombosis, and it was a life threatening condition. We performed partial bypass through femorofemoral bypass for life saving. Femorofemoral bypass improved oxygenation and cardiovascular stability, and mitral valve replacement was successfully performed without complication.

Patency Rates of Femorofemoral Bypass: Effects of Concomitant Leg Arterial Bypass

Femorofemoral bypass was chosen as a primary(n=71) and redo (n=7) procedures for 78 patients with unilateral iliac artery occlusive disease during the period of 4 and a half years at the Department of Surgery, Kyungpook National University Hospital. The patients were categorized into 3 groups according to the patency of the superficial femoral artery on the recipient-side leg and the performance of concomitant leg arterial bypass: Group I (n=34), patent superficial femoral artery (SFA); Group II (n=19), occluded SFA left untreated; Group III (n=25), occluded SFA treated with leg arterial bypass. Adjuvant procedures during the femorofemoral bypasses included 16 femoral endarterectomies, 5 donor-side iliofemoral interposition grafts, and 4 donor-side iliac balloon angioplasties. The primary cumulative patency rates for all femorofemoral bypasses at 1, 2, 3, and 4 years were 96.3%, 84.7%, 84.7%, and 74.2%, respectively calculated by the life table method. The primary patency rates were 90.0%, 62.9%, 62.9%, 62.9% in Group II and 95.7%, 89.5%, 89.5%, 89.5% in Group III at 1, 2, 3, and 4 years after bypass grafting. The statistical analysis with log rank test to compare the patency rates between Group II and III revealed no significant (p=0.2425) differences. In summary, femorofemoral bypass was a durable bypass procedure for the patients with unilateral iliac artery occlusion. Further follow-up is required to confirm the effects of concomitant leg arterial bypass to the patency of femorofemoral bypass.

2 Cases of Aortoiliac Disease Treated with Strecker Stent Followed by Femoro-Femoral Bypass Graft

In the treatment of aortoiliac disease, two methods could be considered. One is percutaneous transluminal angioplasty, and the other is bypass graft. However sometimes two methods could be combined in high risk patients with a lengthy unilateral occlusion of one iliac artery and less extensive obstruction of the contralateral one, since higher risk aortofemoral bypass surgery may be obviated by femoro-femoral bypass graft after percutaneous treatment of the less diseased iliac artery. We report two cases of arortoiliac disease treated with Strecker stent followed by femoro-femoral bypass graft.

2 Cases of Aortoiliac Disease Treated with Strecker Stent Followed by Femoro-Femoral Bypass Graft

In the treatment of aortoiliac disease, two methods could be considered. One is percutaneous transluminal angioplasty, and the other is bypass graft. However sometimes two methods could be combined in high risk patients with a lengthy unilateral occlusion of one iliac artery and less extensive obstruction of the contralateral one, since higher risk aortofemoral bypass surgery may be obviated by femoro-femoral bypass graft after percutaneous treatment of the less diseased iliac artery. We report two cases of arortoiliac disease treated with Strecker stent followed by femoro-femoral bypass graft.

Anesthetic Management for Surgery of the Descending Aortic Aneurysm / 대한마취과학회지

The rupture of the aorta commonly follows major blunt truma to the thorax. It was markdly increased in recent years, paralleling the rising number of vehicular accidents, The patient underwent surgical repair with femoro-femoral partial bypass 40 days after injury. The anesthesia for descending aortic surgery presented problems involving large hemodynamic alterations during thoracic aortic cross-clamping, protection of the heart and brain from large increases in pressure occuring above the cross clamp, and prevention of spinal cord and renal ischemic damage below the cross-clamp. One lung ventilation was also employed with this anesthetic technique. A 23 years old male patient with traumatic aneurysm of descending thoracic aorta was treated successfully.