Original Article

Femorofemoral Crossover Bypass Graft Has Excellent Patency When Performed with EVAR for AAA with UIOD

Authors: Akinfemi A. Akingboye, MBBS, MD(Res), Bijendra Patel, MBBS, MS, Frank W. Cross, MBBS, MS


Objectives: To compare the durability of the crossover femorofemoral bypass graft (CFFBG) in combination with aorto-uni-iliac stent graft (AUIS) for abdominal aortic aneurysm with the durability of CFFBG used in the treatment of unilateral iliac occlusive disease (UIOD).

Methods: We analyzed the clinical records of 69 patients who underwent CFFBG from 1992 until 2010. Group I consisted of 34 patients who received CFFBGs in combination with AUIS. Group II consisted of 35 patients treated with CFFBG for UIOD. The mean period of follow up was 2.7 years. Outcomes analyzed included primary graft patency, secondary graft patency, and postoperative morbidity and mortality.

Results: There was one death in each group. Wound infection complicated 11.4% of CFFBGs performed as a sole procedure for UIOD and 5.8% of cases in combination with AUIS (P = 0.673). Primary graft patency was 96.5% and 96.5% at 2 and 5 years in group I, compared with 76.6% and 53.7% in group II (P = 0.046, 0.009). Secondary graft patency at 5 years was 100% and 92.9% for groups I and II, respectively. No variables independently influenced primary graft patency. Patients in group I experienced complications that could be linked to the bypass graft in 20.5% of cases, after long-term follow-up.

Conclusions: The CFFBG possesses superior long-term durability and patency when implemented in combination with aorto-uni-iliac stent grafts and does not seem to compromise the endpoint success of endovascular treatment.


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1. Volodos NL, Karpovich IP, Troyan VI, et al. Clinical experience of the use of self-fixing synthetic prostheses for remote endoprosthetics of the thoracic and the abdominal aorta and iliac arteries through the femoral artery and as intraoperative endoprosthesis for aorta reconstruction. Vasa Suppl 1991;33:93-95.
2. Parodi JC, Criado FJ, Barone HD, et al. Endoluminal aortic aneurysm repair using a balloon-expandable stent-graft device: a progress report. Ann Vasc Surg 1994;8:523-529.
3. Greenhalgh RM, Brown LC, Kwong GP, et al. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet 2004;364:843-848.
4. Blankensteijn JD, de Jong SE, Prinssen M, et al. Two-year outcomes after conventional or endovascular repair of abdominal aortic aneurysms. N Engl J Med 2005;352:2398-2405.
5. Arko FR, Filis KA, Seidel SA, et al. How many patients with infrarenal aneurysms are candidates for endovascular repair? The Northern California experience. J Endovasc Ther 2004;11:33-40.
6. Carpenter JP, Baum RA, Barker CF, et al. Impact of exclusion criteria on patient selection for endovascular abdominal aortic aneurysm repair. J Vasc Surg 2001;34:1050-1054.
7. Walker SR, Braithwaite B, Tennant WG, et al. Early complications of femorofemoral crossover bypass grafts after aorta uni-iliac endovascular repair of abdominal aortic aneurysms. J Vasc Surg 1998;28:647-650.
8. Vetto RM. The treatment of unilateral iliac artery obstruction with a transabdominal, subcutaneous, femorofemoral graft. Surgery 1962;52:343-345.
9. Capoccia L, Riambau V, da Rocha M. Is femorofemoral crossover bypass an option in claudication? Ann Vasc Surg 2010;24:828-832.
10. Rowe VL, Lee W, Weaver FA, et al. Patterns of treatment for peripheral arterial disease in the United States: 1996-2005. J Vasc Surg 2009;49:910-917.
11. Goodney PP, Beck AW, Nagle J, et al. National trends in lower extremity bypass surgery, endovascular interventions, and major amputations. J Vasc Surg 2009;50:54-60.
12. Scurr J, How T, Vallabhaneni SR, et al. EVAR in iliac occlusion. J Endovasc Ther 2007;14:59-61.
13. Rehring TF, Brewster DC, Cambria RP, et al. Utility and reliability of endovascular aortouniiliac with femorofemoral crossover graft for aortoiliac aneurysmal disease. J Vasc Surg 2000;31:1135-1141.
14. Heredero AF, Stefanov S, del Moral LR, et al. Long-term results of femoro-femoral crossover bypass after endovascular aortouniiliac repair of abdominal aortic and aortoiliac aneurysms. Vasc Endovascular Surg 2008;42:420-426.
15. Chaikof EL, Blankensteijn JD, Harris PL, et al. Reporting standards for endovascular aortic aneurysm repair. J Vasc Surg 2002;35:1048-1060.
16. Rutherford RB, Baker JD, Ernst C, et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg 1997;26:517-538.
17. Brewster DC, Jones JE, Chung TK, et al. Long-term outcomes after endovascular abdominal aortic aneurysm repair: the first decade. Ann Surg 2006;244:426-438.
18. United Kingdom EVAR Trial Investigators, Greenhalgh RM, Brown LC, et al. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 2010;362:1863-1871.
19. De Bruin JL, Baas AF, Buth J, et al. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med 2010;362:1881-1889.
20. Cotroneo AR, Iezzi R, Giancristofaro D, et al. Endovascular abdominal aortic aneurysm repair: how many patients are eligible for endovascular repair? Radiol Med 2006;111:597-606.
21. Armon MP, Yusuf SW, Latief K, et al. Anatomical suitability of abdominal aortic aneurysms for endovascular repair. Br J Surg 1997;84:178-180.
22. Clouse WD, Brewster DC, Marone LK, et al. Durability of aortouniiliac endografting with femorofemoral crossover: 4-year experience in the Evt/Guidant trials. J Vasc Surg 2003;37:1142-1149.
23. Onohara T, Takano T, Takai M, et al. Long-term results of reconstructive surgery for the unilateral aortoiliac occlusive disease and future risks of contralateral iliac events. Ann Vasc Dis 2010;3:60-67.
24. Yilmaz LP, Abraham CZ, Reilly LM, et al. Is cross-femoral bypass grafting a disadvantage of aortomonoiliac endovascular aortic aneurysm repair? J Vasc Surg 2003;38:753-757.
25. Lipsitz EC, Ohki T, Veith FJ, et al. Patency rates of femorofemoral bypasses associated with endovascular aneurysm repair surpass those performed for occlusive disease. J Endovasc Ther 2003;10:1061-1065.
26. Hinchliffe RJ, Alric P, Wenham PW, et al. Durability of femorofemoral bypass grafting after aortouniiliac endovascular aneurysm repair. J Vasc Surg 2003;38:498-503.
27. Saratzis N, Melas N, Lazaridis J, et al. Endovascular AAA repair with the aortomonoiliac EndoFit stent-graft: two years' experience. J Endovasc Ther 2005;12:280-287.
28. Mingoli A, Sapienza P, Feldhaus RJ, et al. Comparison of femorofemoral and aortofemoral bypass for aortoiliac occlusive disease. J Cardiovasc Surg (Torino) 2001;42:381-387.
29. Ng RL, Gillies TE, Davies AH, et al. Iliofemoral versus femorofemoral bypass: a 6-year audit. Br J Surg 1992;79:1011-1013.
30. Rutherford RB, Patt A, Pearce WH. Extra-anatomic bypass: a closer view. J Vasc Surg 1987;6:437-446.
31. Piotrowski JJ, Pearce WH, Jones DN, et al. Aortobifemoral bypass: the operation of choice for unilateral iliac occlusion? J Vasc Surg 1988;8:211-218.
32. Mingoli A, Sapienza P, Feldhaus RJ, et al. Femorofemoral bypass grafts: factors influencing long-term patency rate and outcome. Surgery 2001;129:451-458.
33. Mii S, Eguchi D, Takenaka T, et al. Role of femorofemoral crossover bypass grafting for unilateral iliac atherosclerotic disease: a comparative evaluation with anatomic bypass. Surg Today 2005;35:453-458.
34. Kim YW, Lee JH, Kim HG, et al. Factors affecting the long-term patency of crossover femorofemoral bypass graft. Eur J Vasc Endovasc Surg 2005;30:376-380.
35. Elkassaby M, Alawy M, Ali MZ, et al. Aorto-uni-iliac stent grafts with and without crossover femorofemoral bypass for treatment of abdominal aortic aneurysms: a parallel observational comparative study. Int J Vasc Med 2015;2015:962078.
36. Nicoloff AD, Taylor LM, Jr McLafferty RB, et al. Patient recovery after infrainguinal bypass grafting for limb salvage. J Vasc Surg 1998;27:256-266.
37. Brewster DC. Do current results of endovascular abdominal aortic aneurysm repair justify more widespread use? Surgery 2002;131:363-367.
38. Patel R, Sweeting MJ, Powell JT, et al. Endovascular versus open repair of abdominal aortic aneurysm in 15-years&#x2019 follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial. Lancet 2016;388:2366-2374.