Axillo-femoral and Axillo-Bifemoral grafts

Axillo-femoral grafts: Improved results
in the modern era
Russell H. Samson MD, FACS, RVT
Clinical Professor of Surgery Florida State University
Medical School
Mote Vascular Foundation Inc.
Sarasota Vascular Specialists
Axillo-femoral Bypass grafts: a History
Louw JH, Splenic-to-femoral and Axillary-to-femoral
bypass grafts in diffuse atherosclerotic occlusive disease.
Lancet 1401-2 , 1963
Axillo-femoral Bypass grafts: a History
Blaisdell FW, Hall AD. Axillary-femoral artery bypass for
lower extremity ischemia Surgery. 1963 Oct;54:563–568.
1977 Retrospective
Axillo-bilateral femoral graft, although performed in an older population and
more frequently for limb salvage, has a lower operative mortality than
conventional aortic bypass surgery with similar patency (76%) and survival
(67%) at five years.
However, axillo femoral grafting requires more frequent remedial surgery to
obtain long term patency.
Axillo-unifemoral grafts had a 5 year patency of just 37%
–
Ann Surg 1977 Aug;186(2):123-9.Is axillo-bilateral femoral graft an effective substitute for aortic-bilateral iliac/femoral graft?: an analysis of ten years
Johnson WC, Logerfo, FW, Vollman RW, Corson JD, O’Hara ET, Mannick JA,
Nasbeth DC
experience.
Inferior Results
Five-year patency rates for Axillo-unifemoral bypasses
was 44% and 50% for Axillo-bifemoral grafts (p >0.5)
– Comparison of axillounifemoral and axillobifemoral bypass
operations. Surgery. 1985 Feb;97(2):169-75.Ascer E, Veith FJ,
Gupta SK, Scher LA, Samson RH
Inferior Results
Primary patency at 3 years was 63% for AxFB
versus 85% for AoFB (p = 0.032)
–
J Vasc Surg 1992 Jun;15(6):952-62; discussion 962-3.Axillofemoral bypass: outcome and hemodynamic results
in high-risk patients. Scneider JR, McDaniel MD, Walsh DB, Zwolak RM and Cronenwett JL
Axillo-femoral bypass is an acceptable but
hemodynamically inferior alternative to AoFB
More Bad Results
5 year primary patency rates for AxBFB
67.7%
– Cardiovasc Surg (Torino) 2000 Dec;41(6):905-10.Multivariate
analysis of long-term results after an axillobifemoral and
aortobifemoral bypass in patients with aortoiliac occlusive
Onohara et
Primary patency rates at 1, 3, and 5 years
were 86%, 72%, and 63%, respectively
– Am J Surg 2000 Aug;180(2):100-3.Axillofemoral bypass
for aortoiliac occlusive disease. Martin D, Katz SG
Sixty percent of graft occlusions occurred in
the femorofemoral limb with continued
patency of the axillofemoral limb
Poor Survival
Survival rates were at 64% and 41% at 1 and 5 years
–
World J Surg 2009 Nov;33(11):2490-6. doi: 10.1007/s00268-009-0189-x.The outcome of the axillofemoral bypass: a retrospective analysis of 45 patients. Liedenbaum MH,
et al
Inferior results
DeLaurentis: “If indeed this operation is designed for
poor risk cardiopulmonary patients threatened with
loss of limb and a short life expectancy rate, we
should not expect to see reports of patients with
long term survival rates.”
–
Surg Gynecol Obstet 1978 Dec;147(6):881-7.Twelve year experience with axillofemoral and
femorofemoral bypass operations.DeLaurentis DA, Sala LE, Russell E, McCombs PR
Externally supported
“Rendering the noncrimped porous Dacron
prosthesis kink and compression resistant
by an external support coil appears to
increase its potential for successful use,
especially in 8 mm axillofemoral and 6 mm
femoropopliteal bypasses.”
–
Ann vasc Surg 1986 Sep;1(2):214-24.A five- to seven-year experience with externallysupported Dacron prostheses in axillofemoral and femoropopliteal bypass. Schultz GA,
Sauvage LR et al
More Positive Reviews
Life-table primary patency and survival rates at 5 years were
71% and 52%, respectively
– Axillo-femoral grafting with externally supported polytetrafluoroethylene. Taylor LM
Jr, Moneta GL, McConnell D, Yeager RA, Edwards JM, Porter JM. Arch
Surg1994 Jun;129(6):588-94
“Axillofemoral grafting using polytetrafluoroethylene are
equivalent to those achieved with other accepted methods
including balloon angioplasty, aortofemoral bypass, and
infrainguinal bypass.”
“Axillofemoral bypass is an appropriate technique that is
deserving of more widespread use.”
–.
Passman
“Five-year life-table primary patency was 74% for
AXFBG and 80% for AOFBG.
Although the patient survival rate was statistically
lower with AXFBG, primary patency and limb salvage
rates did not differ when compared with AOFBG.”
– J Vasc Surg1996 Feb;23(2):263-9; discussion 26971.Comparison of axillofemoral and aortofemoral
bypass for aortoiliac occlusive disease. Pasmman MA,
Taylor LM, Moneta GL, Edwards JM, Yeager RA,
McConnell DB and Porter JM
Freischlag
“At our institution, the axillofemoral
bypass is now reserved almost
exclusively for the treatment of graft
infections and rarely for primary limb
ischemia. This evolution is a reflection
of the increase in interventional
techniques used to improve inflow in
high-risk patients who require
revascularization.”
Angle, Niren. Dorafshar, Amir H. Farooq, Michael M. Ahn, Samuel S. Gelabert, Hugh A. Quinones-Baldrich,
William J. Moore, Wesley S. Freischlag, JulieTiThe evolution of the axillofemoral bypass over two
decades.Annals of Vascular Surgery. 16(6):742-5, 2002 Nov.
This series
10 year evaluation with statistically significant data at 5 years
116 Axilla-to-femoral grafts
62, 53%
Axillo-bifemoral
54, 47%
Axillounifemoral
Prior Procedures
15 patients – 24 procedures
– 8 fem-fem
– 5 Aorto/iliac/femoral
– 4 Infrainguinal
– 4 iliac stents
– 1 iliac PTA
– 1 carotid subclavian bypass
Reasons
High risk
Hostile abdomen
Hostile aorta
NEJM 2011. 36: 1449
Reasons for Choosing Axillary Inflow
11
12
7
Hostile aorta
4
High risk
56
16
Failed prior
Aortic occlusion
Age
18
Infection
23
Hostile abdomen
Dissection
Obesity
Demographics
Indications %
[CATEGORY
NAME]
[CATEGORY
NAME]
[CATEGORY
NAME]
7
5
39
17
32
[CATEGOR
Y NAME]
[CATEGOR
Y NAME]
Patency definition continued
Graft failure if any limb occluded (6 Patients)
– Redo fem-fem crossover consider a failed graft
Treatment
– 3 new crossover fem-fem from vertical limb
– One new Ax-fem from contralateral Axilla
– One new Ax-bifem from contralateral Axilla
– One Aorto-bifemoral bypass
Patency definition
Primary patency and assisted patency were the
same :
– Three grafts required an inflow procedure to maintain
patency
One subclavian stent
One PTA of the proximal anastomosis
One carotid to vertical limb bypass
Axillo-Bifemoral and Axillo- Unifemoral Grafts
96.4%
86.4%
116
30
Axillo-bifemoral Grafts
98%
62
85.3%
13
Axillo-Unifemoral
94.5%
54
86.2%
17
Survival
No
operative
mortality
5 Years
10 Years
12 (10%) died in the
first year
116
45
54%
16
6
1
Hospital and ICU length of Stay
2 – 54 days Median 4 days
– 26% home in 2 days
27% went to the ICU postop ( Median no ICU!)
8 Patients died within 3 months all due to comorbid
conditions
Our concomitant experience with
Aortobifemoral Dacron grafts
5% year Patency 96.2%
What has happened in the “Modern Era”
Better anesthetic management
Board certified vascular surgeons
Antiplatelet agents and statins
CT angiograms to evaluate the aorta, donor and recipient arteries
Improved Duplex ultrasound to assess graft patency and possibly
predict graft failure
Endovascular techniques to prepare the donor artery
Endovascular techniques to prevent graft failure
Move from 6mm Dacron, to 6mm ePTFE, to 8mm ePTFE
Pre-constructed, ringed 8mm grafts with possibly improved flow
dynamics
Old literature - Failures
16% due to inflow
artery disease
60% failures in the
fem-fem crossover
Conclusions
Patency rate for Aortobifemoral bypass grafts remain
superior but have a greater morbidity, mortality and length
of stay
Axillo-unifemoral grafts have equal patency to Axillobifemoral and so Axillo-bifemoral grafts should be
reserved for bilateral indications
Conclusions
Axillo- femoral grafts should be considered as primary
interventions
– when endovascular procedures have failed or are unlikely to
offer long term success and:
high risk patients or for
those with short life expectancy or for
patients with anatomy that may endanger aortic surgery
Heparin Bonded ePTFE
Outperforms Standard ePTFE at
four years
Russell H. Samson MD FACS RVT
Clinical Professor of Surgery
Florida State University Medical School
Primary Patency AK and BK combined
If the Gore® Axillo-bifemoral graft had
heparin bonding?
Aorto-bifemoral 96%
Axillo-bifemoral 96%??????
Would we ever do another direct Aortic graft?