Extra Anatomic Aorto-Iliac Revascularization Using Descending Thoracic Aorta to Bifemoral Bypass in Selected Cases


      • Most aorto-iliac occlusive lesions are accessible to endovascular treatment or open surgery.
      • However, some patients present with highly challenging lesions for both endovascular treatment and direct open abdominal aortic reconstruction.
      • Thoracic aorta to bifemoral bypass may be offered to patients in such situation.
      • This work reports indication, technical aspects, and outcomes of this technique.


      When best medical treatment fails to relieve symptoms of aorto-iliac occlusive disease, endovascular treatment or conventional open surgery are the remaining options depending on lesions and patients’ characteristics. However, in certain situations both endovascular tools and abdominal aorta to bifemoral bypass (TFB) are not an option and the use of the descending thoracic aorta may be considered as an inflow site for revascularization.


      This work is a single-center retrospective study. Between 2008 and 2020, 27 patients were identified who were treated with descending thoracic aorta to TFB for severe aorto-iliac occlusive disease. Primary end point was 30-day postoperative mortality and major cardiovascular events. Secondary end points were primary patency, secondary patency, and all-cause mortality.


      The mean age of patients was 68 years and the majority (88.9%) presented with severe claudication. Eighteen patients underwent isolated TFB and 9 had TFB and concomitant visceral vessel revascularization. The mean length of stay was 14 days and there was no postoperative death. Complications, mainly pulmonary, occurred in 29.8% of the cases. After a mean of 26 months of follow-up, survival rate was 95% and primary and secondary patency rates were 92.6% and 96.3%, respectively. Mean Rutherford index shifted from 3.1 to 1.2 (P < 0.001).


      TFB is an invasive procedure which provides high clinical improvement and patency rates. This procedure should remain part of the vascular surgeon portfolio.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Annals of Vascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Aboyans V.
        • Ricco J.-B.
        • Bartelink M.-L.E.L.
        • et al.
        2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European society for vascular surgery (ESVS): document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European stroke organization (ESO)the task force for the diagnosis and treatment of peripheral arterial diseases of the European society of cardiology (ESC) and of the European society for vascular surgery (ESVS).
        Eur Heart J. 2018; 39: 763-816
        • Jongkind V.
        • Akkersdijk G.J.M.
        • Yeung K.K.
        • et al.
        A systematic review of endovascular treatment of extensive aortoiliac occlusive disease.
        J Vasc Surg. 2010; 52: 1376-1383
        • Grimme F.a.B.
        • Goverde P.C.J.M.
        • Verbruggen P.J.E.M.
        • et al.
        Editor’s choice--first results of the covered endovascular reconstruction of the aortic bifurcation (CERAB) technique for aortoiliac occlusive disease.
        J Eur Soc Vasc Surg. 2015; 50: 638-647
        • Rocha-Neves J.
        • Ferreira A.
        • Sousa J.
        • et al.
        Endovascular approach versus aortobifemoral bypass grafting: outcomes in extensive aortoiliac occlusive disease.
        Vasc Endovascular Surg. 2020; 54: 102-110
        • Indes J.E.
        • Mandawat A.
        • Tuggle C.T.
        • et al.
        Endovascular procedures for aorto-iliac occlusive disease are associated with superior short-term clinical and economic outcomes compared with open surgery in the inpatient population.
        J Vasc Surg. 2010; 52: 1173-1179.e1
        • Kashyap V.S.
        • Pavkov M.L.
        • Bena J.F.
        • et al.
        The management of severe aortoiliac occlusive disease: endovascular therapy rivals open reconstruction.
        J Vasc Surg. 2008; 48: 1451-1457.e1-3
        • Clair D.G.
        • Beach J.M.
        Strategies for managing aortoiliac occlusions: access, treatment and outcomes.
        Expert Rev Cardiovasc Ther. 2015; 13: 551-563
        • Criado E.
        • Johnson G.
        • Burnham S.J.
        • et al.
        Descending thoracic aorta-to-iliofemoral artery bypass as an alternative to aortoiliac reconstruction.
        J Vasc Surg. 1992; 15: 550-557
        • Carrel T.
        • Pasic M.
        • Niederhäuser U.
        • et al.
        [Extra-anatomic thoraco-bifemoral bypass: an excellent alternative to in-situ reconstruction for repeat revascularization of the lower limbs].
        Schweiz Med Wochenschr. 1994; 124: 961-965
        • McCarthy W.J.
        • Mesh C.L.
        • McMillan W.D.
        • et al.
        Descending thoracic aorta-to-femoral artery bypass: ten years’ experience with a durable procedure.
        J Vasc Surg. 1993; 17 (discussion 347-348): 336-347
        • Sapienza P.
        • Mingoli A.
        • Feldhaus R.J.
        • et al.
        Descending thoracic aorta-to-femoral artery bypass grafts.
        Am J Surg. 1997; 174: 662-666
        • Schultz R.D.
        • Sterpetti A.V.
        • Feldhaus R.J.
        Thoracic aorta as source of inflow in reoperation for occluded aortoiliac reconstruction.
        Surgery. 1986; 100: 635-645
        • Frazier O.H.
        • Oalmann M.C.
        • Strong J.P.
        • et al.
        Clinical applications of the supraceliac aorta: anatomical and pathologic observations.
        J Thorac Cardiovasc Surg. 1987; 93: 631-633
        • Passman M.A.
        • Farber M.A.
        • Criado E.
        • et al.
        Descending thoracic aorta to iliofemoral artery bypass grafting: a role for primary revascularization for aortoiliac occlusive disease?.
        J Vasc Surg. 1999; 29: 249-258
        • Chiu K.W.H.
        • Davies R.S.M.
        • Nightingale P.G.
        • et al.
        Review of direct anatomical open surgical management of atherosclerotic aorto-iliac occlusive disease.
        Eur J Vasc Endovasc Surg. 2010; 39: 460-471
        • Crawford J.D.
        • Scali S.T.
        • Giles K.A.
        • et al.
        Contemporary outcomes of thoracofemoral bypass.
        J Vasc Surg. 2019; 69: 1150-1159.e1
        • Norgren L.
        • Hiatt W.R.
        • Dormandy J.A.
        • et al.
        Inter-society consensus for the management of peripheral arterial disease (TASC II).
        J Vasc Surg. 2007; 45: S5-S67
        • Rutherford R.B.
        • Baker J.D.
        • Ernst C.
        • et al.
        Recommended standards for reports dealing with lower extremity ischemia: revised version.
        J Vasc Surg. 1997; 26: 517-538
        • Kondov S.
        • Rylski B.
        • Kari F.A.
        • et al.
        Descendo-bifemoral bypass grafting and renal artery revascularization to treat complex obliterative arteriopathy.
        Interact Cardiovasc Thorac Surg. 2017; 24: 655-658
        • Koksal C.
        • Kocamaz O.
        • Aksoy E.
        • et al.
        Thoracic aortobifemoral bypass in treatment of juxtarenal Leriche syndrome (midterm results).
        Ann Vasc Surg. 2012; 26: 1085-1092
        • West C.A.
        • Johnson L.W.
        • Doucet L.
        • et al.
        A contemporary experience of open aortic reconstruction in patients with chronic atherosclerotic occlusion of the abdominal aorta.
        J Vasc Surg. 2010; 52: 1164-1172
        • Nevelsteen A.
        • Wouters L.
        • Suy R.
        Long-term patency of the aortofemoral Dacron graft. A graft limb related study over a 25-years period.
        J Cardiovasc Surg (Torino). 1991; 32: 174-180
        • Szilagyi D.E.
        • Elliott J.P.
        • Smith R.F.
        • et al.
        A thirty-year survey of the reconstructive surgical treatment of aortoiliac occlusive disease.
        J Vasc Surg. 1986; 3: 421-436
        • Bowes D.E.
        • Youkey J.R.
        • Pharr W.P.
        • et al.
        Long term follow-up of descending thoracic aorto-iliac/femoral bypass.
        J Cardiovasc Surg (Torino). 1990; 31: 430-437
        • Landry G.
        • Lau I.
        • Liem T.
        • et al.
        Open abdominal aortic aneurysm repair in the endovascular era: effect of clamp site on outcomes.
        Arch Surg. 2009; 144: 811-816
        • Ligush J.
        • Criado E.
        • Burnham S.J.
        • et al.
        Management and outcome of chronic atherosclerotic infrarenal aortic occlusion.
        J Vasc Surg. 1996; 24 (discussion 404-405): 394-404
        • Reilly L.M.
        • Sauer L.
        • Weinstein E.S.
        • et al.
        Infrarenal aortic occlusion: does it threaten renal perfusion or function?.
        J Vasc Surg. 1990; 11 (discussion 224-225): 216-224
        • Scali S.T.
        • Schmit B.M.
        • Feezor R.J.
        • et al.
        Outcomes after redo aortobifemoral bypass for aortoiliac occlusive disease.
        J Vasc Surg. 2014; 60: 346-355.e1
        • Kearney D.J.
        • Lee T.H.
        • Reilly J.J.
        • et al.
        Assessment of operative risk in patients undergoing lung resection. Importance of predicted pulmonary function.
        Chest. 1994; 105: 753-759
        • Schneider J.R.
        • Golan J.F.
        The role of extraanatomic bypass in the management of bilateral aortoiliac occlusive disease.
        Semin Vasc Surg. 1994; 7: 35-44
        • Samson R.H.
        • Showalter D.P.
        • Lepore M.R.
        • et al.
        Improved patency after axillofemoral bypass for aortoiliac occlusive disease.
        J Vasc Surg. 2018; 68: 1430-1437
        • Jebara V.A.
        • Fabiani J.N.
        • Acar C.
        • et al.
        Combined coronary and femoral revascularization using an ascending aorta to bifemoral bypass.
        Arch Surg. 1994; 129: 275-279
        • Kieffer E.
        • Sabatier J.
        • Koskas F.
        • et al.
        Atherosclerotic innominate artery occlusive disease: early and long-term results of surgical reconstruction.
        J Vasc Surg. 1995; 21: 326-337
        • Ye W.
        • Liu C.-W.
        • Ricco J.-B.
        • et al.
        Early and late outcomes of percutaneous treatment of TransAtlantic Inter-Society Consensus class C and D aorto-iliac lesions.
        J Vasc Surg. 2011; 53: 1728-1737
        • Premaratne S.
        • Newman J.
        • Hobbs S.
        • et al.
        Meta-analysis of direct surgical versus endovascular revascularization for aortoiliac occlusive disease.
        J Vasc Surg. 2020; 72: 726-737