In the Current Era of Endovascular Surgery, What is the Role of Axillofemoral Bypass?

Introduction: Nowadays, axillofemoral bypass is viewed as an end-of-line solution for lower limb revascularization, owing to its classically described poor long-term patency, and recent advances in endovascular options for patients with complex aortoiliac anatomy not suitable for open reconstruction. There is a marked difference in patient profiles in published series of axillofemoral bypass, reflecting changing procedures indications due to technical innovations. The objective of this study is to determine the contemporary profile of patients treated with axillofemoral bypass and their outcome.

Methods: Patients who underwent axillofemoral bypass surgery in a tertiary hospital from April 2011 to September 2017 were identified. Surgical indication, patency, amputation and death rates were recorded. Patients were grouped in axillouni vs axillobifemoral, 1st revascularization procedure vs reintervention, and primary aortoiliac occlusive disease vs primary aneurysmal disease, and were compared using Kaplan-Meier survival analysis.

Results: 54 patients were included. 80% underwent an axillobifemoral bypass. Median age was 67 years; 96% were male. The most prevalent cardiovascular risk factors were HTA (81%) and history of smoking (76%). Primary vascular disease was aneurysmal in 24% of patients. The remaining group had peripheral occlusive arterial disease. In 53%, axillofemoral bypass was the first revascularization performed (naif group). On these, indications for this procedure were aorto-iliac occlusive disease (89%) and AA thrombosis (19%). In patients previously submitted to revascularization (47%), the most common first procedures were aortobifemoral bypass (56%), femoro-femoral bypass (44%) and EVAR (36%). Indications for axillofemoral bypass on this group were: prosthesis thrombosis (64%), secondary aorto-enteric fistulae (28%) and prosthesis infection (8%). Primary patency of axillofemoral bypass was 93% at 1 month and 80% at 5 years (Graphic 1). Differences were not significant regardless the vascular surgery status (naif vs reintervention), but axillobifemoral bypass and aneurysmal disease groups had a higher patency than axillounifemoral bypass and occlusive disease groups, respectively. No patient with aneurysmal disease required amputation over a 5-year follow-up. In primary occlusive disease group, 88% of patients were free-of-amputation at 1 month and 83% at 5 years. Patients who underwent this procedure had a survival rate of 78% at 1 month and 59% at 5 years (Graphic 2). No major difference was recorded between study groups.

Conclusion: Axillofemoral bypass, although being an increasingly uncommon procedure, still allows acceptable rates of patency and limb salvage. As patients with aortoiliac disease usually have multiple comorbidities and a short life- -expectancy, axillofemoral bypass is attractive owing to its less invasive character.