ORI GI N AL ARTI CLE
Ex t r a - a n a t om ica l a r t e r ia l bypa ss of t h e a or t oilia c se gm e n t : 1 5 - ye a r
e x pe r ie n ce
Air t on D e ldu qu e Fr a n k in iI; Edu a r do Lich t e n fe lsI I; An ge lo Fr a n k in iI I I; Tia go Fr a n k in iI V IPhysician. Associat e pr ofessor , Angiology and Vascular Sur ger y, Fundação Faculdade Federal de Ciências Médicas de Por t o Alegr e ( FFFCMPA) , Port o Alegr e, RS, Brazil. Vascular and endovascular surgeon, I r m andade Sant a Casa de Miser icór dia de Por t o Alegr e ( I SCMPA) , Por t o Alegr e, RS, Br azil. Mem ber, SBACV.
I IVascular sur geon, I SCMPA and Hospit al Moinhos de Vent o ( HMV) , Por t o Alegr e, RS, Br azil. Graduat e st udent , Pr ogr am of Pat hology, FFFCMPA, Por t o Alegr e, RS, Br azil.
I I IResident in Gener al Sur ger y, FFFCMPA, Port o Alegr e, RS, Brazil. I VMedical st udent , FFFCMPA, Port o Alegr e, RS, Brazil.
Correspondence
J Vasc Bras. 2007; 6( 3) : 204- 10.
ABSTRACT
Ba ck gr ou n d: Ext ra- anat om ical bypass, w hich is an alt er nat ive pr ocedur e t o classical surgery, aim s at sim plifying a com plex pr ocedur e such as aort oiliac r econst r uct ion.
Obj e ct ive s: To analyze long- t erm out com es of ext ra- anat om ical by pass of t he aort oiliac segm ent . M e t h ods: Longit udinal ret rospect ive st udy including 79 ext ra- anat om ical bypasses of t he aort oiliac segm ent , per for m ed in 75 pat ient s bet w een Decem ber 1991 and Decem ber 2006.
Re su lt s: Mean age w as 64.2 year s, and m ale gender w as pr edom inant ( 64% ) . Cr it ical ischem ia account ed for m ost indicat ions for surgery ( 86.1% ) ; cr ossover iliofem oral by pass represent ed 41.8% of all pr ocedur es. Mor t alit y, pat ency and lim b salvage r at es w er e 28, 70.3 and 67.6% , respect ively, at five year s.
Con clu sion s: Ext ra- anat om ical bypasses should rem ain as alt ernat ive pr ocedur es because of t heir low er pat ency r at es in com par ison t o anat om ic procedures and consider able m or bidit y and
m or t alit y r at es. How ever , t hey are im port ant procedures w hen anat om ic revascularizat ion cannot be accom plished due t o clinical and local lim it at ions. Cr ossover bypasses dem onst r at ed bet t er pat ency rat es t han axillofem or al bypasses, and cr ossover iliofem oral bypasses show ed t he best pat ency rat es of all ( 77.3% at five year s) .
RESUM O
Con t e x t o: As derivações ext r a- anat ôm icas, sendo pr ocedim ent os cirúrgicos alt er nat ivos à cirurgia clássica, t êm com o principal obj et ivo sim plificar um pr ocedim ent o de gr ande port e com o a
rest auração aort o- fem or al.
Obj e t ivos: Analisar os r esult ados a longo pr azo das derivações ext ra- anat ôm icas no segm ent o aort o- ilíaco.
M é t odos:Est udo longit udinal ret rospect ivo envolvendo 79 der ivações ext ra- anat ôm icas no segm ent o aort o- ilíaco, realizadas em 75 pacient es, no per íodo de dezem br o de 1991 a dezem br o de 2006.
Re su lt a dos:Média de idade foi 64,2 anos, com predom inância pelo gêner o m asculino ( 64% ) . A isquem ia cr ít ica foi a r esponsável pela m aior ia das indicações cir úr gicas ( 86,1% ) e a derivação ilíaco- fem or al cruzada represent ou 41,8% dos casos. Em cinco anos, as t axas de m or t alidade geral, per viedade e salvam ent o do m em br o for am , r espect ivam ent e, de 28% ; 70,3% e 67,6% em cinco anos.
Con clu sõe s: As derivações ext r a- anat ôm icas devem per m anecer com o cirurgias alt er nat ivas, pois apr esent am t axas de perviedade inferiores aos pr ocedim ent os que seguem as vias anat ôm icas nat urais além de m or bim or t alidade considerável. Ent ret ant o, são pr ocedim ent os im port ant es nos casos em que a lim it ação de ordem clínica ou de nat ureza local t or na difícil ou im pede a
revascularização por via anat ôm ica. As der ivações cr uzadas apr esent ar am per viedade super ior às derivações axilo- fem orais e as ilíaco- fem orais cr uzadas r evelar am a m aior perviedade ent re t odas ( 77,3% em cinco anos) .
Pa la vr a s- ch a ve : Cirurgia, aort a abdom inal, pr ót ese vascular , am put ação, m ort alidade.
I n t r odu ct ion
Ext ra- anat om ical bypasses are surgical procedures per for m ed at sit es t hat do not correspond t o t he nat ur al anat om y. The m ain obj ect ive of ext ra- anat om ical by pass is t o sim plify a large surgical procedure, such as aort ofem oral reconst ruct ion, allow ing a higher num ber of pat ient s t o be revascularized.1 - 1 2
The crit eria for indicat ing such procedures ar e gener ally t he sam e cur r ent ly adopt ed for classical revascularizat ions: cr it ical ischem ia ( ischem ic pain at r est and/ or ulcer at ions) and incapacit at ing claudicat ion, w hose conservat ive t r eat m ent is not successful. On t he ot her hand, candidat es t o revascularizat ion due t o any of t hese alt ernat ive t echniques are pat ient s consider ed as high risk for t he classical procedure, w het her due t o increased anest het ic rest rict ions, or due t o cardiac
lim it at ions t hat w ould m ake aort ic clam ping a high risk procedure. Ther e is also a gr oup of pat ient s t hat offer s local difficult ies t o perform aort ofem oral reconst ruct ion, r elat ed t o fem or al anast om oses or due t o pr esence of infect ion in t he inguinal region of pr evious aor t ofem or al graft . Result s of ext ra- anat om ical bypasses r ange accor ding t o pr ocedur e and pat ient s' gener al condit ions.8 - 1 2
Classical aor t oiliac r evascular izat ion surgery has w ell know n r esult s. Pr im ar y pat ency is 87.5% in 5 year s and 81.8% in 10 year s, w it h operat ive m or t alit y rat e of 3.3% .1 3
from per cut aneous t r anslum inal angioplast y, w it h and w it hout st ent ing.1 3 - 2 0 I liac art ery angioplast ies have show n t he best result s regarding pat ency and clinical out com es, w it h low com plicat ion r at es, alt hough w it h high cost s com par ed w it h ext r a- anat om ical by pass surgery. I n large ser ies, balloon angioplast y pat ency r anges bet w een 77- 96% at t he end of t he first year of follow- up and bet w een 34- 85% in 5 year s.1 3 - 1 9 These rat es are ev en bet t er w hen st ent placem ent is consider ed: 81- 95% at 1- year follow - up and 63- 72% in 5 year s.1 3 , 1 6 - 2 3
This st udy aim s at analyzing long- t erm out com es of 15- year exper ience in ext r a- anat om ical aort oiliac bypasses.
M e t h ods
A longit udinal, obser vat ional and r et r ospect ive st udy w as carried out in 75 pat ient s subm it t ed t o 79 ext ra- anat om ical aor t oiliac bypasses for art erial revascularizat ion of t he low er lim bs from
Decem ber 1991 t o Decem ber 2006. All bypasses w er e perform ed by t he first aut hor at t hree large hospit als in Port o Alegr e, Brazil ( I rm andade Sant a Casa de Port o Alegr e, Hospit al Nossa Senhora da Conceição and Hospit al Moinhos de Vent o) . Pat ient s included in t he st udy did not have adequat e clinical or local condit ions t o be subm it t ed t o classical aort ofem oral bypass surgery ( anat om ical posit ion) . Follow- up w as per for m ed at a privat e office and in out pat ient clinics of t he hospit als. All bypasses w er e per for m ed using a Dacr on graft . Assessed out com es w er e bypass pat ency, lim b salvage ( low er lim b am put at ion) and m or t alit y, besides t he follow ing var iables: gender , age, surgical indicat ion, associat ed com or bidit ies and t ype of bypass perform ed. Thir t y- day follow - up w as considered operat ive; fr om 30 days t o 12 m ont hs, shor t t er m ; and fr om 12 t o 60 m ont hs, long t erm .
Bypass pat ency w as assessed by pr esence of pulsat ion in t he graft and recipient art ery dur ing physical exam inat ion. Doppler vascular ult rasound w as used in cases of difficult graft palpat ion. Lim b am put at ion ( t r anst ibial or t ransfem oral) w as consider ed as out com e w hen relat ed t o init ial pat hology and t o t he surgery per for m ed. Deat hs due t o varied clinical causes w er e included, not necessar ily relat ed t o t he procedure. Deat hs r esult ing from ext ernal causes w er e excluded. Deat hs occurring w it hin t he first 30 days aft er t he surgery w er e considered as oper at ive m or t alit y.
Out com e analysis w as perform ed using t he calculat ion of pr evalence and Kaplan- Meier cur ve. Result s for all bypasses w er e obt ained as a group and fem orofem oral and iliofem oral bypasses w er e individually crossed. For int ragroup com parison, chi- square t est w it h Fisher 's correct ion w as used. Confidence int er val w as set in 95% . Each pr ocedur e ( bypass) account ed for a single case for st at ist ical pur poses.
Re su lt s
Fr om Decem ber 1991 t o Decem ber 2006 79 ext r a- anat om ical bypasses w er e per for m ed in 75 pat ient s. Mean age w as 64.2 year s ( st andar d deviat ion = 9.6) . Male pat ient s account ed for 64% ( n = 48) .
Diagnosis of cr it ical ischem ia w as r esponsible for m ost sur gical indicat ions, being present in 86.1% ( n = 68/ 79) of cases. I ncapacit at ing claudicat ion at a dist ance short er t han 20 m account ed for 8.9% ( n = 7/ 79) of indicat ions. Sever e infect ion at t he operat ive w ound of a pr evious gr aft w as t he indicat ion in 5.1% ( n = 4/ 79) of cases. The m ost fr equent associat ed com orbidit ies w er e
pulm onary disease, 31.6% ; diabet es m ellit us, 22.8% ; obesit y, 16.5% ; cer ebr ovascular disease, 10.1% ; and neoplasm , 7.6% . I n 81.3% ( n = 61/ 75) of pat ient s, t her e w er e m ult iple com orbidit ies ( t w o or m ore) .
Crossover iliofem oral bypass w as t he m ost fr equent ly perform ed sur ger y, account ing for 33 cases ( 41.8% ) ( Table 1) . I nfect ion rat e of ext r a- anat om ical bypasses w as 3.8% ( n = 3/ 79) over t he first 30 days, and t her e w er e no furt her addit ional cases of infect ion. All cases of infect ion occur r ed in axillofem oral bypasses and at inguinal sit e w it h pr evious surgery. Five pat ient s ( 6.3% ) w er e subm it t ed t o associat ed infr ainguinal bypass for low er lim b revascularizat ion.
Lim b salvage rat e w as 67.6% ( n = 25/ 37) in 5 years. Tot al am put at ion rat e at t he end of follow- up w as 24% ( n = 19/ 79) ( Figure 3) .
am put at ion rat e of 37.5 v s. 22.7% ( p = 0.6) in 5 year s. Pat ency rat e of cr ossover iliofem oral bypass w as significant ly higher t han t hat of cr ossover fem or ofem or al bypass. Pat ient s subm it t ed t o crossover fem or ofem or al and iliofem oral bypasses had, r espect ively, t he follow ing associat ed fact ors: pr evious inguinal sur ger y, four and eight cases; and fem or opoplit eal obst r uct ion, one and four cases.
At t he end of 60 m ont hs, w e r egist er ed follow- up loss of 20 cases ( 25.3% ) , m ost of t hem due t o change in addr ess and im possibilit y of cont act .
D iscu ssion
Most st udies involving ext ra- anat om ical bypasses w er e published around one decade ago.2 4 - 3 2 Now adays, w it h t he developm ent of endovascular sur ger y, due t o enhancem ent in t echnique and equipm ent , im pr ovem ent in clinical and anest het ic m anagem ent of pat ient s w ho are able t o perform classical surgery and w it h bet t er cont rol of infect ions, ext ra- anat om ical by pass has becom e an except ion surgery. Despit e it s indicat ion having becom e m or e rest rict ed, it is st ill a t echnique of gr eat value in our count r y, especially due t o econom ic r est r ict ions of endovascular procedures used and incr easingly higher num ber of pat ient s w it h older age and m ult iple
com or bidit ies. I n addit ion, it also has a very specific indicat ion r elat ed t o t reat m ent of pr evious infect ed graft s.
This st udy show ed high m ean age ( 64.2 year s) of pat ient s subm it t ed t o ext ra- anat om ical
bypasses. Pr evalent m ale gender follow s t he higher pr evalence of at her oscler ot ic disease in m en.9 -1 2
According t o m ost aut hors, indicat ions for ext r a- anat om ical by pass are t he sam e of convent ional surgery.9 - 1 2 , 2 6 , 2 7 I n our st udy w e dem onst r at ed a pr edom inance of indicat ion due t o cr it ical ischem ia ( 86.1% of cases) , incapacit at ing claudicat ion being t he indicat ion in 8.9% of cases. Only 5.1% of pat ient s w er e subm it t ed t o by pass due t o inguinal infect ion in pr evious graft . Ther efor e, t he dat a show t hat cont r aindicat ion t o anat om ical sur ger y w as one of t he m ost im por t ant fact ors in indicat ion, local fact or being t he least im por t ant , despit e it s precise indicat ion in cases of
infect ion.3 3 - 4 0
Associat ed com or bidit ies in pat ient s subm it t ed t o ext ra- anat om ical bypasses are frequent ly
m ult iple, severe and det er m inant t o indicat e t he pr ocedur e.9 , 1 1 , 1 2 , 2 6 , 2 7 I n t his st udy, w e found high prevalence rat es of hypert ension, sm oking, ischem ic car diopat hy, chronic obst r uct ive pulm onar y disease and diabet es; 81.3% of pat ient s had t w o or m or e com or bidit ies.
The m ost frequent ly perform ed surgery in t his st udy w as cr ossover iliofem or al bypass, account ing for 41.8% of all pr ocedur es. Crossover fem or ofem or al and iliofem oral bypasses w er e perform ed in 24 and 21.5% of cases, r espect ively. Axillar y- unifem oral bypass w as perform ed in six cases, and axillopoplit eal in only t w o cases ( Table 1) .
Result of ext r a- anat om ical bypasses is dependent on t ype of revascularizat ion and pat ient 's clinical st at us. Cr ossover fem or ofem or al bypass has m or t alit y rat e of up t o 6% in published series2 5 , 2 6 , 4 1 -4 7 and accum ulat ed pat ency in 5 y ear s r anging bet w een 56 and 82% .1 1 , 3 1 , 4 1 - 4 9 Axillofem oral and axillary - bifem oral bypasses, since t hey are a pr ocedur e in w hich t he gr aft is longer, have less sat isfact ory result s t han cr ossover fem or ofem or al gr aft s. Mort alit y r anges bet w een 2- 10% and is usually relat ed t o basal clinical disease.9 , 2 6 , 3 0 , 4 4 , 5 0 - 5 8 Result s in 5 year s r ange bet w een 30- 79% in axillofem oral bypasses4 4 , 5 1 , 5 2 , 5 4 , 5 6 , 5 9 and bet w een 33- 77% in axillar y- bifem oral
pat ency in 5 year s of 40% , w it h lim b salvage rat e of 58% .6 0 I t is im port ant t o st r ess t hat t he result s of ext ra- anat om ical bypasses are low er t han t hose obt ained w it h classical reconst ruct ions.1 3
I n t he pr esent st udy, gener al m or t alit y over t he first 30 days in pat ient s subm it t ed t o ext ra-anat om ical by pass w as 12% , w it h gener al cum ulat ive m or t alit y of 28% in 5 year s ( Figure 1) . Deat hs unr elat ed t o t he sur ger y w er e included, except for deat hs due t o ext er nal causes, t o dem onst rat e t he high ear ly and lat e general m or t alit y r at es of pat ient s w ho are subm it t ed t o t his t herapeut ic m odalit y.
Pat ency rat e of all bypasses, in t his st udy, w as 92.9% at t he end of t he first 30 days and 70.3% at t he end of a 5- year follow- up ( Figur e 2) . Decrease in pat ency rat e can be at t ribut ed t o sever it y of pat ient s subm it t ed t o surgeries and t o shor t er dur abilit y of t his t ype of bypass. Pat ency r at e of crossover iliofem or al bypass w as significant ly higher t han t hat of crossover fem or ofem or al bypass in 5 year s: 37.5 v s. 77.3% ( p = 0.02) . Ther e w as no difference bet w een t hese bypasses as t o pr esence of fact ors of w orse pr ognosis.
Tot al rat e of am put at ion w as 24% at t he end of follow- up in t his st udy, w it h lim b salvage rat e of 67.6% in 5 years. Such dat a reveal t he sever it y and lit t le favor able condit ions of pat ient s
subm it t ed t o ext ra- anat om ical bypasses. Maint enance of low er lim b t hroughout t im e is dem onst r at ed by t he cur ve in Figur e 3.
We conclude t hat ext r a- anat om ical by pass should r em ain as an alt ernat ive sur gical opt ion,
reserved for cases in w hich t he pat ient has ver y high sur gical risk or unfavor able local condit ions, such as gr aft infect ion in t he inguinal r egion. I n cases in w hich t he pat ient has favorable anat om ical condit ions, ev en at high sur gical risk, t he endovascular pr ocedur e should be chosen ( angioplast y w it h or w it hout st ent placem ent ) , if it is available due t o higher cost s. Now adays, in pat ient s in w hich ext ra- anat om ical by pass is indicat ed, w e choose bypasses in t he follow ing order: cr ossover iliofem oral, cr ossover fem or ofem or al, axillary- unifem oral or axillary- bifem oral. Whenever possible, we t ry t o per for m cr ossover bypasses, since t hey have longer dur abilit y because t hey are shor t er . I n addit ion, w it h frequent use of cr ossover iliofem oral procedure, descr ibed in det ails in anot her publicat ion,8 w e pr efer t his t ype of bypass, since it avoids approach t o t he fem or al art ery in at least one lim b, r educing r isk of infect ion w it hout com pr om ising pat ency.
Re fe r e n ce s
1. Oudot J. La gr effe vasculair e dans les t hr om boses du car r efour aor t ique. Press Med. 1951; 59: 234- 6.
2. Oudot J, Beaconsfield P. Throm bosis of t he aort ic bifur cat ion t r eat ed by r esect ion and hom ogr aft
replacem ent. AMA Arch Surg. 1953; 66: 365- 74.
3. Fr eem an NE, Leeds FH. Operat ions on large ar t er ies: applicat ion of recent advances. Calif Med. 1952; 77: 229- 33.
4. McCaughan JJ, Kahn SP. Cr oss- over gr aft for unilat eral occlusive disease of t he iliofem oral art eries. Ann Surg. 1960; 151: 26- 30.
5. Blaisdell FW, Dem at t ei GA, Gauder PJ. Ext raperit oneal t hor acic aort a fem or al bypass gr aft as
replacem ent for an infect ed aort ic bifurcat ion pr ost hesis. Am J Surg. 1961; 102: 583- 5.
Surg. 1961;48:574-5.
7. O’Connor S, Andrew P, Batt M, Becquemin JP. A systematic review and meta-analysis of treatments for aortic graft infection. J Vasc Surg. 2006;44:38-45.
8. Bonamigo TP, Frankini AD, Lichtenfels E. Deriva•‚es extra-anatƒmicas no segmento aortoil„aco. In: Maffei FHA, editor. Doen•as vasculares perif…ricas. Rio de Janeiro: Medsi; 2001. p. 1059-69.
9. Ascer E, Veith FJ. Extra-anatomic bypasses. In: Haimovici H, editor. Vascular surgery: principles and techniques. 3nd ed. Norwalk: Appleton & Lange; 1989. p. 526-38.
10. Sitr†ngulo Jr. CJ, Langer B. Cirurgias alternativas. In: Bonamigo TP, Burihan E, Cinelli Jr M, Ristow AV, editors. Doen•as da aorta e seus ramos: diagn‡stico e tratamento. Sˆo Paulo: BYK; 1991. p. 238.
11. Whittemore AD, Belkin M, Donaldson MC, Mannick JA. Aortoiliac occlusive disease. In: Moore WS, editors. Vascular surgery: a comprehensive review. 5nd ed. Philadelphia: WB Saunders; 1998. p. 483-96.
12. Rutherford RB. Extra-anatomic bypass as alternative to direct arterial reconstruction in aorto-iliac occlusive disease. In: Rutherford RB, editor. Vascular surgery. 2nd ed. Philadelfia: WB Saunders; 1984. p. 586.
13. Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33 Suppl 1:S1-75.
14. Johnston KW. Iliac arteries: reanalysis of results of balloon angioplasty. Radiology. 1993;186:207-12.
15. Jorgensen B, Skovgaard N, Nordgard J, et al. Percutaneous transluminal angioplasty in 226 iliac artery stenosis: Role of the superficial femoral artery for clinical success. VASA. 1992;21:382-6.
16. Martin EC, Katzen BT, Benenati JF, et al. Multicenter trial of wallstent in the iliac and femoral arteries. J Vasc Interv Radiol. 1995;6:843-9.
17. Schneider PA, Rutherford RB. Endovascular interventions in the management of chronic lower extremity ischemia. In: Rutherford RB, editor. Vascular surgery. 5nd ed. Philadelphia: WB
Saunders.; 2000. p. 1035-69.
18. Stokes KR, Strunk HM, Campbell DR, Gibbons GW, Wheeler HG, Clouse ME. Five-year results of
iliac and femoropopliteal angioplasty in diabetic patients. Radiology. 1990;174(3 Pt 2):977-82.
19. Tegtmeyer CJ, Hartwell GD, Selby JB, Robertson R, Kron IL, Tribble CG. Results and complications of angioplasty in aortoiliac disease. Circulation. 1991;83(2 Suppl):I53-60.
20. Vorwerk D, Gunther RW, Schurmann K, Wendt G. Aortic and iliac stenoses: follow-up results of stent placement after insufficient balloon angioplasty in 118 cases. Radiology. 1996;198:45-8.
21. Reekers JA, Vorwerk D, Rousseau H, et al. Results of a European multicentre iliac stent trial with a flexible balloon expandable stent. Eur J Vasc Endovasc Surg. 2002;24:511-5.
lesions. J Vasc Surg. 2003; 38: 272- 8.
23. Kudo T, Chandr a FA, Ahn SS. Long- t erm out com es and predict ors of iliac angioplast y w it h
select ive st ent ing. J Vasc Surg. 2005; 42: 466- 75.
24. Gupt a SK, Veit h FJ, Kram HB, Wenger t er KA. Significance and m anagem ent of inflow gr adient s unexpect edly gener at ed aft er fem or ofem or al, fem or opoplit eal and fem or oinfr apoplit eal by pass
graft ing. J Vasc Surg. 1990; 12: 278- 83.
25. Kalm an PG, Hosang M, Johnst on KW, Walker PM. The current r ole for fem or ofem or al bypass. J Vasc Surg. 1987; 6: 71- 6.
26. Bellen BV, Zor n WGW, Br aga PEG. Derivações ar t er iais ext ra- anat ôm icas do segm ent o aort oilíaco. I ndicações e result ados. Cir Vasc Angiol. 1985; 1: 5- 11.
27. East cot t HHG. Fem orofem oral cr ossover gr aft ing. I n: Gr eenhalgh RM, edit or . I ndicat ions in vascular sur ger y. London: WB Saunder s; 1988. p. 429.
28. Cinelli Jr. M, Fer r onat o A, Cam haj i N, Puech- leão LE. Der ivações axilo- fem orais e fem or ofem or ais cr uzadas: im por t ant es alt er nat ivas t écnicas para r evascular izar m em br os inferiores. Rev Ass Med Brasil. 1977; 23: 66- 70.
29. Johnson WC, Lee KK. Com par at ive evaluat ion of ext er nally suppor t ed Dacr on and polyt et rafluoroet hylene pr ost het ic bypasses for fem or ofem or al and axillofem or al ar t er ial
r econst r uct ions. Vet er ans Affair s Cooper at ive St udy # 141. J Vasc Sur g. 1999; 30: 1077- 83.
30. Livesay JJ, At kinson JB, Baker JD, Busut t il RW, Barker WF, Machleder HI . Lat e result s of ext
ra-anat om ic bypass. Ar ch Sur g. 1979; 114: 1260- 7.
31. Rut her for d RB, Pat t A, Pearce WH. Ext ra- anat om ic bypass: a closer view. J Vasc Surg. 1987; 6: 437- 46.
32. Hepp W, de Jonge K, Pallua N. Lat e result s follow ing ext ra- anat om ic by pass procedures for
chronic aor t oiliac occlusive disease. J Car diovasc Surg ( Torino) . 1988; 29: 181- 5.
33. Bunt TJ. Vascular gr aft infect ions: a per sonal exper ience. Car diovasc Surg. 1993; 1: 489- 93.
34. Lehner t T, Gr uber HP, Maeder N, Allenberg JR. Managem ent of prim ary aort ic gr aft infect ion by
ext ra- anat om ic by pass reconst ruct ion. Eur J Vasc Surg. 1993; 7: 301- 7.
35. Quiñones- Baldrich WJ, Her nandez JJ, Moore WS. Long- t erm result s follow ing sur gical
m anagem ent of aort ic gr aft infect ion. Ar ch Sur g. 1991; 126: 507- 11.
36. Ricot t a JJ, Faggioli GL, St ella A, et al. Tot al excision and ext ra- anat om ic by pass for aort ic gr aft
infect ion. Am J Surg. 1991; 162: 145- 9.
37. Schm it t DD, Seabr ook GR, Bandyk DF, Tow ne JB. Graft excision and ext r a- anat om ic
revascularizat ion: t he t reat m ent of choice for t he sept ic aor t ic pr ost hesis. J Car diovasc Surg
( Torino) . 1990; 31: 327- 32.
38. Sharp WJ, Hoballah JJ, Mohan CR, et al. The m anagem ent of t he infect ed aort ic prost hesis: a
39. Yeager RA, Moneta GL, Taylor LM, Harris EJ, McConnell DB, Porter JM. Improving survival and limb salvage in patients with aortic graft infection. Am J Surg. 1990;159:466-9.
40. Smith RB, Perdue GD, Hyatt HC, Ansley JD. Management of the infected aortofemoral prosthesis including use of an axillopopliteal bypass. Am Surg. 1977;43:65-73.
41. Brief DK, Brener BJ, Alpert J, Parsonnet V. Crossover femorofemoral grafts followed up five years or more: an analysis. Arch Surg. 1975;110:1294-9.
42. Criado E, Burnham SJ, Tinsley EA, Johnson G, Keagy BA. Femorofemoral bypass graft: analysis of patency and factors influencing long-term outcome. J Vasc Surg. 1993;18:495-504.
43. Dick LS, Brief DK, Alpert J, Brener BJ, Goldenkranz R, Parsonnet V. A 12-year experience with femorofemoral crossover grafts. Arch Surg. 1980;115:1359-65.
44. Eugene J, Goldstone J, Moore WS. Fifteen year experience with subcutaneous bypass grafts for lower extremity ischaemia. Ann Surg. 1977;186:177-83.
45. Farber MA, Hollier LH, Eubanks R, Ochsner JL, Bowen JC. Femorofemoral bypass: a profile of graft failure. South Med J. 1990;83:1437-43.
46. Flanigan DP, Pratt DG, Goodreau JJ, Burnham SJ, Yao JS, Bergan JJ. Hemodynamic and angiographic guidelines in selection of patients for femorofemoral bypass. Arch Surg. 1978;113:1257-62.
47. Ng RL, Gillies TE, Davies AH, Baird RN, Horrocks M. Iliofemoral versus femorofemoral bypass: a 6 year audit. Br J Surg. 1992;79:1011-3.
48. Lamerton AJ, Nicolaides AN, Eastcott HH. The femorofemoral graft. Hemodynamic improvement and patency rate. Arch Surg. 1985;120:1274-8.
49. Mosley JG, Marston A. Long term results of 66 femoral-to-femoral by-pass grafts: a 9-year follow-up. Br J Surg. 1983;70:631-4.
50. Kalman PG, Hosang M, Cina C, et al. Current indications for axillounifemoral an axillobifemoral bypass grafts. J Vasc Surg. 1987;5:828-32.
51. LoGerfo FW, Johnson WC, Corson JD, et al. A comparison of the late patency rates of
axillobilateral femoral and axillo unilateral femoral grafts. Surgery. 1977;81:33-8; discussion 38-40.
52. Ray LI, O’Connor JB, Davis CC, et al. Axillofemoral bypass: a critical reappraisal of its redo in the management of aortoiliac occlusive disease. Am J Surg. 1979;138:117-8.
53. Burrell MJ, Wheeler JR, Gregory RT, Synder SO, Gayle RG, Mason MS. Axillofemoral bypass: a ten-year review. Ann Surg. 1982;195:796-9.
54. Johnson WC, Logerfo FW, Vollman RW, et al. Is axillo-bilateral femoral graft an effective substitute for aortic-bilateral iliac-femoral graft?: an analysis of ten years experience. Ann Surg. 1977;186:123-9.
56. el-Massry S, Saad E, Sauvage LR, et al. Axillofemoral bypass using externally-supported, knitted dacron grafts: a follow-up through twelve years. J Vasc Surg. 1993;17:107-14; discussion 114-5.
57. Harris EJ, Taylor LM, McConnell DB, Moneta GL, Yeager RA, Porter JM. Clinical results of axillobifemoral bypass using externally supported polytetrafluoroethylene. J Vasc Surg. 1990;12:416-20.
58. Passman MA, Taylor LM, Moneta GL, et al. Comparison of axillofemoral and aortofemoral bypass for aortoiliac occlusive disease. J Vasc Surg. 1996;23:263-9.
59. Naylor AR, Ah-See AK, Engeset J. Axillofemoral bypass as limb salvage procedure in high risk patients with aortoiliac disease. Br J Surg. 1990;77:659-61.
60. Ascer E, Veith FJ, Gupta S. Axillopopliteal bypass grafting: indications, late results and determinants of long-term patency. J Vasc Surg. 1989;10:285-91.
Cor r e spon de n ce :
Eduardo Lichtenfels
Rua Hon‡rio S. Dias, 1500/305
CEP 90540-070 – Porto Alegre, RS, Brazil Tel.: (51) 3325.5379
Email: elichtenfels@uol.com.br
This study was approved by the Research Ethics Committee at ISCMPA.
