Femorofemoral Bypass for Aortoiliac Occlusive Disease

General Principles and Patient Selection

The primary indication for performing a femorofemoral bypass is the presence of symptomatic unilateral iliac artery occlusive disease. A more recent indication is completing a reconstruction after an aorto-uni-iliac endovascular graft placement for abdominal aortic aneurysm. The threshold for high risk and the decision to choose a femorofemoral bypass over an AFB are certainly not well defined, and criteria are likely to be somewhat different from surgeon to surgeon. The less satisfactory patency and hemodynamic performance of a femorofemoral bypass compared to an AFB makes the author much less likely to recommend its use in claudicants, who are generally lower risk and likely to live longer than those with critical limb ischemia.

A femorofemoral bypass depends on the ability of one iliac artery to supply adequate blood for both legs without causing a decline in flow to the donor leg. The surgical literature has confirmed that this concept is correct, at least when the patient is at rest as long as there is no significant disease in the donor iliac arterial system. If needed, a suboptimal donor iliac artery can often be improved using endovascular techniques to make it satisfactory for use as a donor vessel. Thus the primary considerations from an anatomic standpoint are: Does the patient have ipsilateral iliac artery disease that does not appear favorable for endovascular treatment? Is the contralateral iliac arterial system free of hemodynamically significant disease, and if not, can it be improved with endovascular techniques to make it a suitable donor artery? Is there reasonable common, deep, and/or superficial femoral artery target runoff on the ipsilateral side?

Preoperative Evaluation

A lower extremity segmental arterial noninvasive examination should be performed to calibrate the severity of disease and to serve as a baseline to which post-reconstruction studies may be compared. A good-quality CT angiogram may be sufficient for determining suitability for a femorofemoral bypass and operative planning. However, resolution might not be adequate to determine the level of disease in the common and external iliac arteries, particularly if there is significant calcification, which significantly degrades resolution. In such cases, a conventional transfemoral angiogram is preferred. In some cases it may be useful to perform a vasodilator (papaverine)-enhanced measurement of the pressure gradient between the aorta and the donor side femoral artery to determine the physiologic significance of any suspect donor iliac arterial lesion. Significant occlusive disease of the aorta itself is unusual in the face of at least one patent common iliac artery, but if the aorta is occluded, the occlusion must be addressed (endovascular in many cases) or another procedure must be considered.