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Despite recent advancements in endovascular technology and the proven durability of open surgery, extensive thoracoabdominal aortoiliac occlusive disease (AIOD) remains challenging to treat. In the present report, we have described the case of a 58-year-old woman with AIOD and multiple medical comorbidities. She successfully underwent a novel intraoperative transesophageal echocardiography-guided combined treatment with concurrent descending thoracic aorta to bilateral femoral artery bypass and thoracic endovascular aortic repair. We have shown that this approach, which combines descending thoracic aorta to bilateral femoral artery bypass with thoracic endovascular aortic repair, is an effective treatment alternative for future cases of complex AIOD.

A 77-year-old man visited our hospital due to bilateral painful inguinal swellings. He had a history of femoral-femoral artery bypass surgery for peripheral artery disease and took ethyl icosapentate. Additionally, he had a previous history of open left colectomy for descending colon cancer and had a median incision reaching the lower abdomen. With a diagnosis of bilateral direct inguinal hernias after femoral-femoral artery bypass surgery, he underwent single-incision laparoscopic surgery for totally extraperitoneal repair, continuing on ethyl icosapentate. During surgery, the preperitoneal space was safely and easily dissected, avoiding a subcutaneous vascular graft. No perioperative complications or hernia recurrence have been observed at 3 months follow-up.

Objective: Aortic arch replacement in acute type A aortic dissection patients remains a most challenging cardiovascular operation. This article aims to show our Modified Y-Graft Technique using the Femoral Artery Bypass (FAB) and the One Minute Systemic Circulatory Arrest (OSCA) Technique and assess the short-term outcomes of the patients. Methods: Between February 2015 and November 2017, 51 patients with acute type A aortic dissection underwent aortic arch replacement. Among them, 23 patients' procedure used FAB and 28 patients utilized both FAB and OSCA. The intraoperative data and postoperative follow-up data were recorded. The follow-up data of patients with traditional Y-graft technique were collected from previous reported studies. Results: In FAB group, two patients died for pulmonary infection (30-day survival rate 91.3%), and two patients paralyzed from the waist down. The hemodialysis was performed for five patients (21.7%) before hospital discharge. Fifteen patients (65.2%) received more than 2-day's respiratory support and 8 patients (34.8%) received more than 5-day's respiratory support. These follow-up data are basically flat or precede to the patients with traditional Y-graft technique. Furthermore, compared to the FAB Group, the morbidity of the neurologic dysfunction and the acute renal failure was significantly reduced in FAB+OSCA Group. Besides, the respiratory support, the length of the postoperative stay and the ICU stay were shortened. Conclusions: This study clarified the feasibility of FAB and OSCA technique in modifying Y-graft technique. The acute type A aortic dissection patients tend to have less surgical complications and favorable short-term outcomes by this surgery. Funding Statement: The study has no funding. Declaration of Interests: The authors declare no conflict of interest. Ethics Approval Statement: All procedures performed in studies involving human participants were approved by the Ethics Committee of Qilu Hospital of Shandong University.

While competing in an obstacle course race, a 57-year-old male athlete developed left groin and leg pain. Several days later, infrarenal aortic dissection with clinically worsening left leg ischemia was diagnosed. An emergent repair was performed and consisted of an aorto-uni-iliac endovascular stent graft, an occluder in the left iliac artery, and a right-to-left femoral-femoral artery bypass. To the authors’ knowledge, the present report is the first case of a spontaneous infrarenal aortic dissection in a competitive athlete associated with participation in an extreme athletic event.

The case of a patient with an actively bleeding pseudoaneurysm associated with remnants of a polytetrafluoroethylene femoral bypass graft in his transfemoral residual limb is described. Initial graft placement was due to peripheral arterial disease. During subsequent transfemoral amputation, remnants of the nonpatent graft were retained in the residuum. After 4 yrs of lower limb prosthesis use, a proximal anastomosis pseudoaneurysm developed (with avulsion of graft remnants). The patient presented to clinic with a 5-day history of increased left groin fullness and largely nonradiating pain (rated 10/10). He was diagnosed with a pseudoaneurysm (1.9 cm) originating from the left common femoral artery and an associated hematoma (8 cm) on computed tomography; this required emergent reoperation. This case highlights the importance surrounding the decision to leave or explant neovascularization materials, which may carry significant risk for infection or physical disruption complications in residual limbs.

Saphenous vein grafts (SVGs) are frequently used for multi-vessel coronary artery bypass grafting and peripheral arterial bypasses; however, the estimated 40% failure rate within the first 5 y due to intimal hyperplasia (IH) and the subsequent failure rate of 2%-4% per year pose a significant clinical problem. Here, we report a surgical model in sheep intended to study IH development in SVGs, which can also be used for the evaluation of potential alternative treatments.Autologous bilateral SVGs were implanted as femoral artery interposition grafts using end-to-side anastomoses in adult sheep (n = 23), which were survived for 30 (n = 6), 90 (n = 7), 180 (n = 7), or 365 (n = 3) days. Post-implant, mid-term, and pretermination angiograms were quantified, and harvested SVGs were evaluated using quantitative histomorphometry.We describe a peripheral arterial surgical technique that models the progression of SVG pathology. Angiographic analysis showed a progressive dilation of SVGs leading to worsening diametrical matching to the target artery and reduced blood flow; and histomorphometry data showed an increase in IH over time. Multivariable regression analysis suggested that statistically significant (P 0.05) time-dependent relationships exist between SVG dilation and both reduction in blood flow and IH development.Bilateral SVGs implanted onto the femoral arteries of sheep produced, controlled and consistent angiographic and histomorphometric results for which direct correlations could be made. This preclinical investigation model can be used as a robust tool to evaluate therapies intended for cardiovascular pathologies such as occlusive IH in SVGs.

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.

The development of disease at sites where a bypass graft is attached to an artery is a major cause of graft failure. Localisation of this disease suggests that it may be promoted by the local disturbed flow field. Computational Fluid Dynamics (CFD) simulations of the pulsatile, non-Newtonian flow of blood through a life-like femoral artery bypass configuration have been performed in order to further the understanding of bypass flows, and to identify aspects of the flow which encourage the progression of disease. It may then be possible to develop more effective bypass systems. The graft/artery junction flow is characterised by extensive recirculation, flow separation and reversal, complicated flow paths, elevated fluid particle residence times, and an unusual wall shear stress distribution. It is believed that the occurrence of disease is related to high particle residence times and the unnatural shear stresses acting on the artery wall.

Descending thoracic aorta to femoral artery bypass has been used as a remedial operation after aortic or axillofemoral graft failure or graft infection and other intra-abdominal pathologies not amenable to standard aortofemoral revascularization. It can avoid abdomen approach and has been known as a durable procedure with excellent long-term patency. We reported descending thoracic aorta to femoral artery bypass grafting for primary revascularization in a 55-year-old male with hostile abdominal conditions.

This study assesses the patency of superficial femoral vein used as a crossover femoral artery bypass conduit in patients presenting either with localized groin sepsis, generalized sepsis or in patients with occluded or heavily diseased superficial femoral artery outflow. Twenty patients were followed prospectively with femoral crossover grafts constructed of superficial femoral vein. Twelve patients presented with sepsis and 8 with chronic ischemia from iliac artery occlusion and severely diseased superficial femoral artery outflow. Graft patency was assessed with regular duplex ultrasound examination. There was one perioperative death. Six patients died during the follow-up period. Mean follow-up time was 24.3 months. No graft occluded or required revision. There was no limb loss, graft infection, or graft hemorrhage. Superficial femoral vein offers an effective femoral crossover bypass graft in patients with either localized/generalized sepsis or disadvantaged outflow tracts.

The present paper presents the steps taken by the authors in the first stage of an experimental program within a larger national research project whose objective is to characterize the flow through a femoral artery bypass with a view to finding solutions for its optimization. The objective of the stage is to investigate by means of the PIV method the stationary flow through a bypass model with an idealized geometry. A bypass assembly which reunites the idealized geometry models of the proximal and distal anastomoses, and which respects the lengths of a femoral artery bypass was constructed on the basis of data for a real patient provided by medical investigations. With the aim of testing the model and the established experimental set-up with regard to their suitability for the assessment of the velocity field associated to the steady flow through the bypass, three zones that can restore the whole distal anastomosis were PIV investigated. The measurements were taken in the conditions of maintained inflow at the bypass entry of 0.9 l / min (Re = 600). The article presents comparatively the flow spectra and the velocity fields for each zone obtained in two situations: with the femoral artery completely occluded and completely open.

Purpose To report on the occlusion of a femoral artery bypass, an unusual complication of primary total hip replacement. Clinical case A 74-year-old male with a femoro-femoral implant and a Dacron graft suffered arterial ischemia resulting from thrombosis of the vascular graft further to total hip replacement. We present a brief bibliographical review of arterial complications following total hip arthroplasty. Discussion As the patient was operated through a posterolateral approach, we thought that the complication was caused by the limb adduction and internal rotation maneuvers that are required in such procedures, which Could have bent the graft thereby causing a thrombus to be formed. Conclusions In addition to a careful preoperative vascular assessment, care must be taken in these cases with the maneuvers carried out on the limb during femoral preparation. As it is advisable to avoid the extreme flexion, adduction and internal rotation maneuvers necessary for the posterolateral approach, the anterior approach should be selected.

Failed abdominal aortic reconstructions, because of infection or intraabdominal catastrophe, have necessitated the use of bypasses that would avoid the infrarenal aorta. Such was the case in the first two separate descriptions of bypass from the descending thoracic aorta to the femoral arteries by Stevenson' and Blaisdell' in 1961. Shortly after, the 1963 Blaisdell3 described for the first time the axillofemoral graft as a simple technique to bypass the aortoiliac segment. Because of its technical ease, axillofemoral bypass rapidly became the extraanatomical bypass of choice when avoidance of a transabdominal aortic reconstruction was advisable. For that reason, bypass from the descending thoracic aorta to the femoral arteries was rarely used. During the last 10 years, a few series of extraanatomical bypasses using the descending thoracic aorta as an inflow source have clarified the indications and documented excellent results despite the challenging situations in which such bypasses were employed. The most important features of the bypass from the descending thoracic aorta to the femoral arteries are avoidance of the peritoneal cavity, use of a superb inflow source, and placement of the graft in a deep lateral retroperitoneal position remote from the peritoneal cavity.

We experienced a rare case of acute ischemia of the lower extremity due to embolism caused by an occluded prosthetic graft late after axillary-femoral artery bypass. A 67-year-old woman developed acute right lower extremity ischemia 7 years after axillary-femoral artery bypass, which had been performed for lower limb ischemia as a complication of acute aortic dissection (Stanford B). The graft was occluded, and the native vessel had re-canalized by the time of the present admission. She was successfully treated by disconnection of the graft followed by revascularization.

Use of the descending thoracic aorta as an inflow source for treatment of aortoiliac occlusive disease was first described in 1961 (Blaisdell 1961; Sevenson et al. 1961). These initial reports were attempts to find an alternative inflow supply when conditions prohibited use of the infrarenal aorta. Upon the heels of these publications, the use of the less complex axillofemoral bypass for extra-anatomic aortoiliac reconstruction was developed and popularized, diminishing interest in the use of the thoracic aorta. During recent years, experience has accumulated and the indications, surgical technique, and excellent results of descending thoracic aorta to femoral artery bypass have been characterized.

Femoral or femoropopliteal artery bypass graft junctions have a predilection for failure due to restenosis. It has been clinically proven that vascular reconstructions tend to restenose within a short period of time [1]. Extensive studies have cited wall shear stresses as being primarily responsible and definite correlations between hydrodynamic stresses in the arterial wall and arterial disease have been shown [2,3]. However intensive investigations into wall shear stresses have lead to conflicting arguments on the proliferation and propagation of stenoses. It was concluded by Freidman [4] that the intima at sites exposed to relatively high or unidirectional shears thickened initially, but as time progressed the greatest thicknesses were ultimately achieved at sites exposed to lower or more oscillatory shear environments. A contradicting view was expressed by Nazemi [5] that low wall shear stress contributed to the onset of atherosclerotic plaque formation, whilst high wall shear stress encouraging plaque growth. A number of studies have however established a statistically significant correlation between pressure and intimal hyperplasia and concluded that blood pressure and not blood flow is the primary factor responsible for the localization of atherosclerosis [6–8].

Arterial bypass from the descending thoracic aorta to the femoral artery provides successful perfusion to the lower extremity when a transabdominal approach to the abdominal aorta is undesirable. The first reported operation was performed in 1956 by Stevenson et al.1. Several years later, in 1961, Blaisdell et al. used this type of bypass around an infected abdominal aortic prosthesis2. Since then, fewer than 160 cases have been reported in the world literature3–5. In patients with good surgical risk this procedure provides an alternative inflow source for femoral artery reconstruction with a long-term patency rate superior to the traditional axillofemoral bypass.

Peripheral vascular disease (PVD) is a significant cause of cardiovascular morbidity. We hypothesised that there would be significant alterations of thrombogenesis, platelet activation and endothelial damage, which could be associated with abnormal oxidative stress during femoral artery bypass surgery for PVD, where the femoral artery is cross-clamped (causing acute ischaemia) and reperfused (following revascularisation). To test this hypothesis, we measured sequential changes in von Willebrand factor (vWF, and index of endothelial damage/dysfunction), tissue factor (TF, an index of thrombogenesis) and soluble P-selectin (sP-sel, an index of platelet activation) as well as lipid hydroperoxides (LPO, an index of oxidative stress) in 28 consecutive patients undergoing elective peripheral artery bypass surgery. Mean baseline vWF and sP-sel levels in PVD patients (before clamping) were significantly higher compared with age- and sex-matched controls (unpaired t test, both p < 0.05), but there were no significant differences in TF and LPO levels. There was a correlation between TF and vWF (Spearman’s, r = 0.374, p = 0.05), as well as between sP-sel and vWF at the start of surgery (r = 0.467, p = 0.012). The patients undergoing peripheral artery bypass surgery had a mean femoral artery clamp time of 28 min (standard deviation 14 min; range 11–65 min). There were no significant overall changes in sP-sel, vWF, TF and LPO with femoral artery cross-clamping and reperfusion (repeated measures ANOVA, p = NS). In conclusion, we found that during ischaemia-reperfusion during peripheral arterial bypass surgery, thrombogenesis (as measured by plasma TF) and oxidative damage (as measured by LPO) within the affected leg does not increase in the immediate perioperative period. Further studies are required to assess the mechanism(s) of ischaemia-reperfusion injury in PVD, and the contributory role(s) of the endothelium and platelets.

We present a novel technique for aorto-profunda femoral artery bypass using both the obturator foramen and the direct medial thigh approach to the profunda femoral artery in a patient with an infected femoral graft and limb-threatening ischemia. This patient has undergone multiple bypass grafts to salvage function of his lower extremities, but these standard anatomic and extra-anatomic bypasses had failed because of graft infections. The technique as well as the surgical anatomy are described. The combination of the transobturator aorto-profunda femoral artery bypass and the direct medial approach to the profunda femoral artery is technically feasible, provides adequate outflow for limb salvage in selected patients with good collateral arteries, offers acceptable long-term patency, and is particularly useful when the groin is hostile to dissection or graft material and the superficial femoral and popliteal arteries are occluded.

The rupture of vulnerable atherosclerotic plaque accounts for the majority of clinically significant acute cardiovascular events. Because stability of these culprit lesions is directly related to chemical and morphological composition, Raman spectroscopy may be a use- ful technique for their study. Recent developments in optical fiber probe technology have allowed for the real-time in vivo Raman spec- troscopic characterization of human atherosclerotic plaque demon- strated in this work. We spectroscopically examine 74 sites during carotid endarterectomy and femoral artery bypass surgeries. Of these, 34 are surgically biopsied and examined histologically. Excellent signal-to-noise ratio spectra are obtained in only 1s and fit with an established model, demonstrating accurate tissue characterization. We also report the first evidence that Raman spectroscopy has the potential to identify vulnerable plaque, achieving a sensitivity and specificity of 79 and 85%, respectively. These initial findings indicate that Raman spectroscopy has the potential to be a clinically relevant diagnostic tool for studying cardiovascular disease. © 2006 Society of Photo

From my personal experience with a series of 227 extraanatomic bypasses, it is concluded that a high risk group of patients with multiple problems may have a reasonable alternative mode for limb salvage with extraanatomic bypass procedures. Axillo-bilateral femoral artery bypass grafts have a primary patency rate of 75 percent at the fifth year. With appropriate measures, net limb salvage can be accomplished in 84 percent of surviving patients at the fifth year. The result of a small group of patients with descending thoracic-aortofemoral artery bypass in this series was poor because of meager distal runoff and multiple previous operations. Axilloaxillary artery bypass grafts have shown an excellent long-term patency rate. A group of patients who underwent simultaneous axilloaxillary artery bypass and carotid endarterectomy have shown symptom-free long-term results with no subsequent stroke. This combined procedure showed no added neurologic morbidity. By proper application of extraanatomic bypass procedures, adequate palliation can be accomplished without major procedures in many patients who otherwise are high surgical risks.

Our experience indicates that the DTA-FA bypass is an acceptable alternative inflow procedure when more commonly used procedures are not feasible. In particular, it is suitable for patients who have undergone prior abdominal surgery or irradiation that makes additional abdominal surgery difficult or undesirable and for patients whose previous inflow operations have failed.

Nine patients with traumatic disruption of the thoracic aorta have been operated upon at the UCLA Medical Center. Left atrium to femoral artery bypass support was used to repair the lesion by either direct suture or insertion of a prosthetic graft. One patient died from renal failure two weeks postoperatively. The remaining eight patients have been followed up to eight years and are alive and well. Three cases are presented illustrating different clinical manifestations of this injury and their management.

Our experience with 36 cases of traumatic rupture of the aorta has prompted an aggressive investigative and surgical approach. Age range, mechanism of injury, and associated injuries are quite variable. Aortogram is essential for diagnosis and should be done with any evidence of mediastinal abnormality following a deceleration injury. The preferred method of repair is graft interposition for the transected aorta, using femoral vein to femoral artery bypass with an oxygenator in the system. The salvage rate is good if an aggressive surgical approach is used. Language: en

In three cases we have used a retrosternal and extraperitoneal approach to revascularize the lower extremities with a subclavian-femoral artery bypass. This technique is as easy technically as the conventional subcutaneous axillofemoral bypass and has the advantage of avoiding extrinsic compression, thus improving long-term patency.

Bovine arterial heterografts and autogenous veins were compared as femoral artery bypass grafts in 33 dogs observed from 1 to 39 weeks. The vein grafts had a patency rate of 97%. Glutaraldehyde and dialdehyde tanned bovine grafts had patency rates of 13% and 50%, respectively. The poor performance of the heterografts was associated with marked fibrous hyperplasia at the anastomoses. It was concluded that autogenous vein remains the material of choice for small vessel bypass procedures.

Traumatic aneurysms of the thoracic aorta differ from arteriosclerotic, luetic, and other aneurysms due to diffuse vascular disease, in important respects. Typically, the patient is young, healthy, and the aneurysm arises from a linear, transverse disruption of the intima and media with no significant loss of adjacent, normal vessel. These distinctive pathologic features form the basis for the therapeutic concept that traumatic aneurysm should usually be susceptible to excision with direct, graftless restoration of aortic continuity. The validity of this concept is apparent on pathologic grounds; its practical application has now been established by clinical usage. Based on experience with two cases so treated with the aid of left-atrial femoral artery bypass, the authors outline the steps of the operative procedure.

In this report a case is described where simultaneous myocardial revascularization and ascending to femoral bypass grafting was performed for severe coronary artery disease and impending gangrene of the foot.

• Expanded microporous polytetrafluoroethylene (PTFE) has been used experimentally and clinically for small-vessel bypass or replacement grafting; the results vary widely. This study assessed short (4-cm) femoral and carotid artery replacement PTFE grafts and longer (12-cm) femoral artery bypass PTFE grafts that crossed a flexion crease. Pore size at the blood-graft interface ranged from 10 to 30 μ. At the end of three months, overall patency rate was 22%. No long bypass grafts remained patent. The pore size and type of anastomosis did not affect patency. The occlusion was always thrombotic, associated with fibrin at the suture line. Nine of 20 short carotid grafts (45%) and five of 22 short femoral grafts (22%) remained patent. These poor results indicate that further experimental studies are needed before PTFE is used clinically when an alternative exists. ( Arch Surg 113:863-866, 1978)