Surg Today (2005) 35:785–788DOI 10.1007/s00595-005-2997-4

Primary Bypass Surgery from the Descending Aorta to the IliacArteries for a Severely Calcified Aorta: Report of Two Cases

Osamu Sato, Hiroyuki Okamoto, Harunobu Matsumoto, Kouji Ogata, and Keisuke Kondoh

Department of Surgery, Saitama Medical Center, 1981 Kamoda, Kawagoe 350-8550, Japan

artery bypass was performed as a primary procedure inorder to avoid clamping the severely calcified aorta.

Case Reports

Case 1

The patient was a 49-year-old Japanese man. He hadbeen on chronic hemodialysis for 17 years for chronicglomerulonephritis. He gradually experienced bilateralcalf claudication, which significantly limited his dailyactivity. He could barely walk 100m when he visited us.Lower extremity pulsations were not palpable belowthe fermoral arteries, and the ankle-brachial pressureindices (ABI) were 0.46 on the right and 0.51 on theleft. Angiography revealed severe aortic stenosis belowthe renal arteries and complete occlusion at the mid-abdomen (Fig. 1). A plain abdominal film disclosedcircumferential aortic calcification (lead aorta) belowthe celiac axis (Fig. 2).

In order to avoid any hazardous clamping of the leadaorta, we selected the descending aorta as the inflow sitefor the bypass to the bilateral iliac arteries. The patientwas placed in the right semilateral position. Both exter-nal iliac arteries were approached retroperitoneallythrough separate suprainguinal oblique incisions. Ananterolateral incision was made through the seventh leftintercostal space, and a tape was passed around thedescending aorta. After systemic heparinization, thedescending aorta was totally clamped and an 8-mmcollagen-coated polyester vascular graft (Hemashield,Meadox, Oakland, NJ, USA) was sewn to it. The aorticclamping time was 11min. A blunt dissection was madebehind the left kidney, and a small hole was made in thediaphragm near the aortic hiatus through which thegraft was guided to the retroperitoneal space. A sidearm was attached to the graft, and each end was thensutured to the bilateral external iliac arteries. The cross-

AbstractWe herein report two patients with end-stage renalfailure who complained of disabling claudication dueto abdominal aortic atherosclerosis. Both were onchronic hemodialysis for more than 15 years, and theirabdominal aorta was densely calcified. We elected toperform a descending aorta to iliac artery bypass inorder to avoid hazardous clamping of the calcifiedaorta. Hemodialyisis was able to be resumed on thefirst postoperative day. They tolerated the operationwell and their symptoms disappeared. This operativeprocedure is therefore considered to be a useful optionfor patients with a porcelain aorta who are on chronichemodialysis.

Key words End-stage renal failure · Aortic calcinosis ·Revascularization · Aortoiliac occlusive disease ·Hemodialysis

Introduction

The use of the descending aorta in an iliac artery bypassfor aortoiliac occlusive disease was first advocated in1956 as a secondary procedure after a failed aortoiliacbypass.1 Some authors later adopted this operation as aprimary bypass procedure for patients with hostile ab-domen.2–4 However, the application of this procedurefor a severely calcified aorta has not hitherto been re-ported. We herein report two cases with end-stage renaldisease (ESRD) in which a descending aorta to iliac

Reprint requests to: O. SatoReceived: March 19, 2004 / Accepted: November 16, 2004

786 O. Sato et al.: Descending Aorta to Iliac Artery Bypass

over arm of the graft was passed through thepreperitoneal space just cranial to the urinary bladder(Retzius’s space). The operation time was 233 min.

The postoperative course was uneventful. The pa-tient received hemodialysis on the first postoperativeday, resumed oral feeding on the second day, and wasdischarged on the 15th day. His claudication dis-appeared (Fig. 3).

Case 2

The patient was a 54-year-old Japanese man. He hadbeen on chronic hemodialysis for 18 years becauseof polycystic kidneys. His bilateral claudication hadworsened over time, and he could walk only 30m whenadmitted to our institution. Lower extremity pulsationswere not palpable, and the ABI was 0.45 on the rightand 0.24 on the left. Angiography demonstratedsevere aortic stenosis below the renal arteries.Extensive calcification was observed from the aorticarch to both common iliac arteries, but there was a“window” of calcification just above the diaphragmwhere only half-circumferential saucerlike calcificationwas observed. We decided to construct a bypass fromthere.

The clamping of the aorta was not very easy, andclamping had to be attempted several times at differentlocations. The rest of the procedure was essentially thesame as in case 1. The aortic clamping time was about15 min, but it was not precisely recorded; the operationtime was 300 min.

The patient received hemodialysis on the first post-operative day, resumed oral feeding on the fourth day,and was discharged on the 11th day. The patient devel-oped left pleural effusion after discharge, but it wascorrected after the patient underwent thoracentesis twotimes on an outpatient basis. Thereafter, he did notexperience any further claudication.

Discussion

Extensive aortic medial calcification is often encoun-tered in patients with end-stage renal disease who areon chronic hemodialysis.5 The treatment of secondary

Fig. 1A,B. Preoperative angiogram of case 1. Theinfrarenal portion of the aorta is stenotic (A), andthe terminal aorta is completely occluded (B)

Fig. 2. Plain abdominal film of case 1. Dense calcification ofthe abdominal aorta is observed

787O. Sato et al.: Descending Aorta to Iliac Artery Bypass

hyperparathyroidism has not allowed us to avoid thiscomplication effectively. Calcification per se does notmean occlusion of the artery, but dense calcification is agreat challenge to vascular surgeons when they try tocontrol the aorta in order to construct a bypass from it.Sufficient control of the aorta may not be possible, andthe forceful crushing of the aorta between the clampjaws fractures the hard plaques, and penetration of theadventitia by such shattered plaque can sometimesresult in troublesome bleeding.

We have learned by experience that calcificationtends to be severest in the abdominal portion of theaorta, often extending into the internal iliac arteries,while the external iliac arteries are often spared. Inmany cases, calcification is milder in the supradiaphrag-matic portion of the descending aorta.

The use of the descending aorta to perform an iliacartery bypass was first advocated as a secondary proce-dure for a failed aortoiliac (or femoral) bypass graft.1 Itwas later adopted as a primary procedure for patientswith a hostile abdomen.2–4 However, the application ofthis operation as a primary procedure for the calcifiedaorta has not yet been reported. Such reluctance to usethis procedure probably stems from a hesitancy to per-form open-chest surgery on patients with a renal im-pairment. For most patients with aortoiliac occlusivedisease who are on chronic hemodialysis, the recom-mended procedure is an extraanatomic bypass. How-ever, the axillofemoral bypass is an imperfect procedurethat has only a 50% primary patency at the end of thethird year and a 57% graft-related complication rate,including graft infection in 11% of the patients.6,7 Wefound five reports dealing with the patency of anaxilofemoral bypass graft since 19998–12 (Table 1). Thesefigures show that, even today, the 5-year patency of this

procedure is around 50%. Musicant et al.13 also hasreported a 12.2% graft infection rate during an average25-month follow-up period. Rutherford14 asserts in hisreview article that an axillofemoral bypass should belimited to patients demonstrating a prohibitive opera-tive risk or hostile abdominal conditions. Therefore, wethink that this procedure should be avoided in youngerpatients with a longer life expectancy and high dailyactivity level.

There have been several reports dealing with meth-ods of anastomosis to the porcelain aorta. Brewster15

advocated that removal of the calcified intima whileperforming reinforced anastomosis to the adventitia.Several surgeons also drill suture holes in the calcifiedaortic wall.16–17 Sasajima et al.,18 in accordance withour contention, denounces the axillofemoral bypassand uses an air drill to remove the calcified intima inorder to suture to the reinforced aorta. However, theseprocedures are all tedious and also risk a loss of aorticcontrol.

Fig. 3A,B. Postoperative angiogram of case 1. Aproximal anastomosis is made in the descendingaorta (A), and a side arm is passed through Retzius’sspace to the left external artery (B)

Table 1. Reported five-year primary patency of axillofemoralgrafts

Firstauthor (ref. no.) No. of cases Patency (%)

Onohara (8) 25 67.7Martin (9) 60 63Seeger (10) 36 64Jamsen (11) 84 56.7Johnson (12)

Dacron 30 51.1PTFE 33 34.2

PTFE, polytetrafluoroethylene

788 O. Sato et al.: Descending Aorta to Iliac Artery Bypass

The presented cases demonstrated that exposure ofthe descending aorta and iliac arteries can be accom-plished expeditiously, even faster than for ordinaryaortoiliac bypass procedures. These patients toleratedwell the surgery and could soon after resume their rou-tine dialysis protocol. Most authors advocate a partialclamping of the descending aorta,3,19–22 but we consid-ered that a partial clamping of the smaller aorta of thesepatients might cause difficulties during anastomosis.23

Total clamping enabled us to perform secure anastomo-sis within 15 min, and there was no adverse effect result-ing from total aortic control.

This procedure is thus considered and option foryounger patients, if they are found to be at high risk forregular operative treatment, and this surgical modalityis also preferable to less durable procedures.

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