Total Laparoscopic Aortofemoral Bypass as a Routine Procedure for the Treatment of Aortoiliac Occlusive Disease

Judith C. Lin, MD, Ralf Kolvenbach, MD, PhD; Elisabeth Schwierz MD; Sergej Wassiljew MD


Vascular. 2005;13(2):80-83. 

In This Article


Total laparoscopic aortofemoral bypass was performed in 68 consecutive patients admitted in two hospitals from 2002 to January 2004. Among 68 patients, there were 50 men and 18 women, with a mean age of 68.4 ± 9 years. The mean body mass index (BMI) was 28 ± 1 kg/m2. Indication for surgery was disabling claudication with a walking distance of less than 30 meters in 30 patients and necrosis or gangrene in 38 patients. The majority of the patients (51 of 68) were heavy smokers until the day of the operation.

Preoperative angiographic results showed the following TransAtlantic Inter-Society Consensus (TASC) classification[11]: 4 TASC B, 7 TASC C, and 57 TASC D lesions. Among the 68 patients, 51 (75%) patients had undergone interventional procedures, including subintimal angioplasty and/or multiple stent placements, prior to their surgical intervention. Laparoscopy and suturing were performed by one of three surgeons who were trained in these procedures. In eight cases, surgery was performed without prior attempts to use angioplasty and stent placement. The mean operating time was 199 minutes, with a mean cross-clamp time of 85 minutes; the length of time depends not only on the time required for the aortic anastomosis but also on the complexity of the reconstruction in the groin (see Table 1 ).

There were five major complications (7.3%). One patient died after a massive myocardial infarction. Another patient with Leriche's syndrome, who underwent an end-to-end anastomosis with an aortic cross-clamp time of 34 minutes, developed paraplegia postoperatively. One patient had transient renal failure for 3 weeks after developing a compartment syndrome, which eventually resolved completely. One 82-year-old patient with forefoot gangrene remained in the intensive care unit for more than 5 days because of pneumonia. Another patient developed limb ischemia owing to graft thrombosis and underwent graft thrombectomy and profundaplasty.

Limb salvage was achieved in 68 patients. During a mean follow-up period of 47 months, additional procedures, such as distal bypass or peripheral angioplasty, were performed in 16 patients because of the large number of cases involving critical limb ischemia and requiring a staged multilevel revascularization. An end-to-end anastomosis was performed in 21 cases and an end-to-side anastomosis in 47 cases. An end-to-end anastomosis was routinely performed in patients with concomitant small aneurysms (< 5 cm) and occlusive disease and in those cases with Leriche's syndrome. Conversion to a minilaparotomy was required in three cases, in one case because of difficult exposure and in two cases because of severe calcification of the aorta, which did not permit safe clamping. In two patients, the suprarenal aortic segment was clamped, and thromboendarterectomy of the juxtarenal aorta was performed prior to completing the proximal anastomosis.