The role of extraanatomic bypass in the management of bilateral aortoiliac occlusive disease.

Axillofemoral bypass is a hemodynamically inferior reconstruction that should be performed only in high-risk patients. In view of the apparent inferior patency and hemodynamic performance when compared with aortofemoral bypass, axillofemoral bypass should not be performed for claudication except in truly disabled, low-risk patients whose contraindication to aortofemoral bypass is a "hostile abdomen." Some of these patients might be candidates for extraperitoneal iliofemoral bypass, thoracofemoral bypass, or other procedures that would probably provide hemodynamically superior results. Axillofemoral bypass produces acceptable hemodynamic results, patency, and limb salvage in high-risk patients with limb-threatening ischemia and limited life-expectancy. Despite overall inferior results, relief of initial symptoms is nearly always achieved and few patients require amputation before death. Axillofemoral bypass will remain an important option in such patients. In general, we continue to favor axillobifemoral reconstructions when symptoms are significantly bilateral. However, we do not hesitate to perform axillounifemoral bypass when symptoms and disease are unilateral and alternative unilateral inflow operations are not appropriate. Outcome of operations is clearly influenced by patient selection, and this must be considered when interpreting published results. It is likely that axillofemoral bypass will continue to be a critical tool for vascular surgeons faced with desperately ill patients at risk of limb loss due to bilateral aortoiliac inflow disease. As the operative risk of aortofemoral and iliofemoral bypass continues to decrease, the admonition that a significant number of long-term survivors should prompt the surgeon to ask whether she or he is performing axillofemoral bypass when another procedure might be more appropriate is probably more true today than when DeLaurentis et al first made the following statement: If indeed this operation is designed for poor risk cardiopulmonary patients threatened with loss of limb and a short life expectancy rate, we should not expect to see reports of patients with long term survival rates.