Thoracic aorta as source of inflow in reoperation for occluded aortoiliac reconstruction.

We reviewed our experience with reoperations for recurrent obstruction occurring after aortoiliac or aortofemoral reconstruction. Patients who underwent successful transfemoral thrombectomy of the aortofemoral graft or femorofemoral crossover graft were excluded from the study. A more proximal source of inflow to revascularize the ischemic limbs was required in the remaining 35 patients. Bilateral reconstruction was performed in 22 patients. Operative indication was rest pain or necrosis in 36 limbs and severe claudication in 21 limbs. Preoperative ankle/brachial pressure index (API) ranged from 0.05 to 0.61. Thirteen patients (21 limbs, group I) underwent transabdominal reoperation. Since the transabdominal approach was considered hazardous because of multiple previous operations, the remaining patients underwent retroperitoneal descending thoracic aorta-femoral artery bypass (15 patients, 25 limbs; group II) or axillofemoral bypass graft (7 patients, 11 limbs; group III). No statistically significant difference was present between the three groups in regard to the operative indication, API, and angiographically determined outflow (analysis of variance, p greater than 0.2). Axillofemoral bypass was preferred in patients with severe chronic pulmonary disease. Postoperative deaths (2 of 35 patients) and morbidity (6 of 35 patients) had a similar incidence in the three groups (p greater than 0.2). Follow-up ranged from 3 to 120 months (mean 37 months). The 5-year actuarial patency rate was 80.5% for group I and 80.2% for group II. In group III it was statistically lower (32.9%, p less than 0.05). Serial measurement showed a significant decrease of API in group III compared with group I and group II. We conclude that retroperitoneal descending thoracic aorta-femoral artery bypass is a valid alternative to transabdominal reoperation when exposure or availability of the abdominal aorta poses a specific hazard and is preferable to axillofemoral bypass in terms of long-term patency and hemodynamic results.