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Thoracofemoral Bypass Through A Transdiaphragmatic, Retronephric Tunnel With Concomitant Tibial Bypass For Limb Salvage
Benjamin Keyser, DO1, Melissa Obmann, DO2, Shivprasad Nikam, MD2, David Mariner, MD2.
1Geisinger Medical Center, Danville, PA, USA, 2Department of Vascular and Endovascular Surgery - Geisinger Wyoming Valley, Wilkes Barre, PA, USA.

Objectives: Thoracofemoral bypass has been a well described but infrequently utilized procedure for aortoiliac occlusive disease. Peri-operative morbidity and mortality is comparable to aortofemoral bypass with equivalent long term patency. Although extra-anatomic bypass is often utilized after failed aortofemoral bypass, we would suggest thoracofemoral bypass may be a better alternative for patients who are active and otherwise good surgical candidates. We would like to present a case in which a thoracofemoral bypass using a transdiaphragmatic, retronephric tunnel was combined with lower extremity bypass for limb salvage.
Methods: A 54 year old male auto mechanic with a prior high above knee amputation, previous failed aortofemoral, axillary to profunda, and femoral to popliteal artery bypasses presented with severe rest pain and sensory loss. He underwent descending thoracic aorta to profunda femoral artery bypass through an 8th interspace thoracotomy with an 8mm Dacron graft tunneled in a transdiaphragmatic, retronephric tunnel. He also underwent a profunda to distal posterior tibial bypass with saphenous vein graft to provide direct inflow to the foot. He was discharged on post operative day 10 after an uneventful post operative course on aspirin and Coumadin.
Results: At three months follow up the patient was without rest pain or clinical evidence of limb ischemia. Routine one month follow up imaging confirmed widely patent thoraco-profunda and profunda-tibial bypasses. His physical exam was notable for a palpable posterior tibial pulse. The ankle brachial index, previously undetectable, had also returned to normal.
Conclusion: Thoracofemoral bypass is a technically feasible operation with acceptable peri-operative morbidity and mortality with excellent long term patency and limb salvage results. The case described here is an opportunity to review the technique of thoracic aorta to femoral bypass utilizing a retroperitoneal, retronephric tunnel. We believe this approach to be ideal for the hostile abdomen, failed aortofemoral bypass, and active patients who are good surgical candidates in an effort to avoid the subcutaneous tunnel of extra-anatomic bypass.


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