Axillofemoral bypass with local anesthesia: a way forward to enable limb salvage in high-risk patients

Abstract

For an active, ambulant patient with critical, lower limb ischemia, amputation can lead to a poor quality of life. A small group of older people with critical limb ischemia are considered at high risk for revascularization under conventional anesthesia owing to their comorbid conditions. In these cases, when endovascular therapy is not an option, the decision to amputate or revascularize presents a dilemma, especially in ambulant patients. In this article, we present 2 cases in which the individuals had diabetic foot gangrene, rest pain, and multiple comorbidities, and were unfit to undergo conventional anesthesia. In addition, they had severe aortoiliac occlusive disease, which cannot be managed by endovascular methods. Both patients were living independently and were ambulant before their foot ulcer and ischemia. They underwent an axillofemoral bypass under local anesthesia. The postoperative course was uneventful. After a 3-year follow-up, both patients continue to be ambulant and have no complaints. With selective use of local anesthetic techniques, surgical teamwork to shorten the procedure time, and close meticulous postoperative care, an axillofemoral bypass can enable limb salvage for ambulant patients who are considered unfit for conventional anesthesia.

An axillofemoral bypass graft transgressing the chest wall

“…This has provided an alternate limb salvage option for elderly patients where endovascular recanalization is anatomically not feasible or their cardiorespiratory fitness is of concern. Al‐Wahbi reported the successful revascularization of an ischemia foot in an octogenarian with an axillofemoral bypass graft under local anesthesia. Cappello et al .…”

Axillobifemoral Bypass: A Brief Surgical and Historical Review

“…In one of the patients, AXFBG was performed using only local anesthesia, highlighting the utility of AXFBG in patients who could not tolerate general anesthesia. Further, AXFBG provided a major advantage over other procedures by avoiding abdominal incision and cross-clamping of the aorta, both of which entail significant physiologic stress to the patient (Blaisdell and Hall, 1963; Al Wahbi, 2010). …”

“…The AXbiFBG procedure has been described in the literature several times with slight variations related to the surgeon’s preference (Blaisdell and Hall, 1963; Sauvage and Wood, 1966; Mannick and Nabseth, 1968; Al-Wahbi, 2010; Slovut and Lipsitz, 2012; Jun and Lopez, 2015). The procedure is typically performed with the patient under general anesthesia, but can be performed with local anesthetic, with or without sedation, according to the needs of the patient (Al-Wahbi, 2010).…”

“…The procedure is typically performed with the patient under general anesthesia, but can be performed with local anesthetic, with or without sedation, according to the needs of the patient (Al-Wahbi, 2010). …”

Surgical Intervention for Peripheral Arterial Disease

“…58,59 Typically, the right axillary artery is used as a source of inflow, as the left subclavian artery is athero-prone; however, a simple blood pressure measurement is sufficient to determine laterality ( Figure 3). As with all aortoiliac reconstructions, optimizing the outflow is key to maintaining the durability of the procedure.…”