title: Temporary axillobifemoral bypass during fenestrated aortic aneurysm repair.
abstract: OBJECTIVE
  Fenestrated endovascular aortic aneurysm repair (f-EVAR) of juxtarenal aneurysms requiring cannulation of the superior mesenteric artery and renal arteries is technically challenging, has a long operating time, and requires bilateral large-caliber sheath insertion into the femoral arteries. Consequently, the risk of lower limb ischemia and subsequent reperfusion injury is increased. We describe the use of an adjunct temporary axillobifemoral bypass graft (TABFBG) for f-EVAR and propose that it be used as a strategy to avoid ischemia-reperfusion injury in patients anticipated as being at increased risk.
  
  
  METHODS
  Consecutive patients from a tertiary referral center undergoing f-EVAR, between October 2008 and August 2011, were retrospectively analyzed. Patients with lower limb arterial occlusive disease and those with difficult anatomy had an adjunct TABFBG.
  
  
  RESULTS
  All patients presenting with a juxtarenal aortic aneurysm were treated endovascularly, regardless of aneurysm anatomy and technical difficulties. There were 37 patients without TABFBG (group 1) and 27 with TABFBG (group 2). No patients required open conversion. Sex and age were not significantly different between the groups. The median ankle-brachial pressure index was significantly higher in group 1 (P=.0001). The groups had similar median blood loss, percentage of target vessel cannulation, and median stay in the intensive therapy unit. Morbidities were similar in both groups. There were no significant differences in cardiac, renal, or respiratory complications between the groups. The 30-day mortality was 10.8% (n=4) in group 1 and 0% in group 2 (P=.046).
  
  
  CONCLUSIONS
  Our series has demonstrated a significant reduction in mortality (10.8% absolute risk reduction) and no increase in morbidity with the use of a TABFBG for fenestrated grafts. This is likely a result of the reduction in ischemia and ischemia-reperfusion injury in these patients. We therefore recommend the use of TABFBG in patients with proximal severe stenotic or occlusive disease and those in whom an operative time of >4 hours is predicted (typically those for whom three or more target fenestrations is planned).
authors.affiliation: Multidisciplinary Endovascular Team, University College, London Hospital, London, United Kingdom. constantinoujason@hotmail.com
authors.forename: Jason
authors.initials: J
authors.lastname: Constantinou
authors.forename: Argyrios
authors.initials: A
authors.lastname: Giannopoulos
authors.forename: Jane
authors.initials: J
authors.lastname: Cross
authors.forename: Luke
authors.initials: L
authors.lastname: Morgan-Rowe
authors.forename: Obiekezie
authors.initials: O
authors.lastname: Agu
authors.forename: Krassi
authors.initials: K
authors.lastname: Ivancev
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000601:surgery*; D001366:Axillary Artery / Q000601:surgery; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000379:methods*; D057510:Endovascular Procedures / Q000009:adverse effects / Q000379:methods*; D005260:Female; D005263:Femoral Artery / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D011474:Prosthesis Design; D015427:Reperfusion Injury / Q000517:prevention & control*; D012189:Retrospective Studies; D015607:Stents; D016896:Treatment Outcome