title: Endovascular aortounifemoral grafts and femorofemoral bypass for bilateral limb-threatening ischemia.
abstract: OBJECTIVE
  Although axillobifemoral bypass procedures have a lower mortality rate than aortobifemoral bypass procedures, they are limited by decreased patency, moderate hemodynamic improvement, and the need for general anesthesia. This report describes an alternative approach to bilateral aortoiliac occlusive disease using unilateral endovascular aortofemoral bypass procedures in combination with standard femorofemoral reconstructions.
  
  
  METHODS
  Seven patients who had bilateral critical ischemia and tissue necrosis in association with severe comorbid medical illnesses underwent implantation of unilateral aortofemoral endovascular grafts, which were inserted into predilated, recanalized iliac arteries. The proximal end of the endovascular graft was fixed to the distal aorta or common iliac artery with a Palmaz stent. The distal end of the graft was suture-anastomosed to the ipsilateral patent outflow vessel, and a femorofemoral bypass procedure was then performed.
  
  
  RESULTS
  All endovascular grafts were successfully inserted through five occluded and two diffusely stenotic iliac arteries under either local (1), epidural (5), or general anesthesia (1). The mean thigh pulse volume recording amplitudes increased from 9 +/- 3 mm to 30 +/- 7 mm and from 6 +/- 2 mm to 26 +/- 4 mm ipsilateral and contralateral to the aortofemoral graft insertion, respectively. In all cases the symptoms completely resolved. Procedural complications were limited to one local wound hematoma. No graft thromboses occurred during follow-up to 28 months (mean, 17 months).
  
  
  CONCLUSIONS
  Endovascular iliac grafts in combination with standard femorofemoral bypass grafts may be an effective alternative to axillobifemoral bypass in high-risk patients who have diffuse aortoiliac occlusive disease, particularly when bilateral axillary-subclavian disease is present.
authors.affiliation: Department of Surgery, Montefiore Medical Center, University Hospital, Albert Einstein College of Medicine, New York, NY 10467, USA.
authors.forename: T
authors.initials: T
authors.lastname: Ohki
authors.forename: M L
authors.initials: ML
authors.lastname: Marin
authors.forename: F J
authors.initials: FJ
authors.lastname: Veith
authors.forename: R T
authors.initials: RT
authors.lastname: Lyon
authors.forename: L A
authors.initials: LA
authors.lastname: Sanchez
authors.forename: W D
authors.initials: WD
authors.lastname: Suggs
authors.forename: J G
authors.initials: JG
authors.lastname: Yuan
authors.forename: R A
authors.initials: RA
authors.lastname: Wain
authors.forename: R E
authors.initials: RE
authors.lastname: Parsons
authors.forename: A
authors.initials: A
authors.lastname: Patel
authors.forename: S P
authors.initials: SP
authors.lastname: Rivers
authors.forename: J
authors.initials: J
authors.lastname: Cynamon
authors.forename: C W
authors.initials: CW
authors.lastname: Bakal
mesh_terms: D000368:Aged; D001012:Aorta, Abdominal / Q000601:surgery*; D001157:Arterial Occlusive Diseases / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D015897:Comorbidity; D005260:Female; D005263:Femoral Artery / Q000601:surgery*; D005500:Follow-Up Studies; D006801:Humans; D007083:Iliac Artery / Q000601:surgery*; D007511:Ischemia / Q000601:surgery*; D007866:Leg / Q000098:blood supply*; D008297:Male; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome