Aortoiliac occlusive disease is a common problem among patients with peripheral vascular disease. Clinically, patients often present with proximal muscle group claudication which can be debilitating. The combination of proximal muscle claudication, leg muscle atrophy, impotence and lack of femoral pulses was first described by René Leriche and is a presentation unique to aortoiliac occlusive disease. Though rarely an acute limb-threatening problem in itself, if combined with femoral–popliteal disease, patients can present with critical limb ischemia. The typical patient with aortoiliac occlusive disease has a history of tobacco use, hypertension, hyperlipidemia, and advanced age.

Common indications for intervention in patients with aortoiliac occlusive disease include life-style limiting claudication, critical limb ischemia, or nonhealing ischemic ulceration.

The diagnosis and extent of aortoiliac occlusive disease is made by either CT angiogram, magnetic resonance angiography, or standard digital subtraction angiography. Duplex ultrasonography is limited in its ability to characterize the proximal vasculature beyond the distal external iliac artery in most patients. While noninvasive studies may suggest aortoiliac disease by dampened waveforms on pulse volume recordings (PVR) or diminished ankle–brachial index (ABI) values, axial imaging is the modality of choice for diagnosis and treatment planning.

The Trans-Atlantic Inter Society Consensus (TASC) statement gave stratification for disease based on morphology and length. As endovascular techniques have improved, many patients with aortoiliac disease are being treated with angioplasty and stenting. Patients with TASC A, B, and even some C lesions have been successfully treated by endovascular means. The TASC D classified lesions are routinely addressed by open surgical means.

The typical open treatment of choice for patients with aortoiliac occlusive disease is an aortobifemoral bypass (ABF). This remains the most straightforward and durable repair but requires a laparotomy. Though most patients can be treated with a standard ABF, certain situations preclude the standard transabdominal approach and an extra-anatomic reconstruction must be considered.

Patients with a previous aortic graft failure, a hostile abdomen from multiple interventions, a horseshoe kidney, or an infected aortic reconstruction are the most common indications for an extra-anatomic approach. Patients with colostomy or urostomy, a history of abdominal irradiation or proximal aortic disease above the renal arteries may force surgeons to consider extra-anatomic bypass options as well. The first choice extra-anatomic bypass for most vascular surgeons is an axillobifemoral bypass. However, questions remain about issues with patency and need for reintervention. The utilization of a thoracobifemoral bypass as a primary procedure has been controversial. There is a paucity of published studies and case series with long-term patency and results of thoracobifemoral bypass because the vast majority of patients are being treated with an ABF or axillo-bifemoral bypass as the usual extra-anatomic option.

The use of the descending thoracic aorta as an alternative inflow source was first described by Dr. Blaisdale in 1961. A key advantage to the thoracobifemoral bypass is the use of the descending thoracic aorta as inflow. This is typically spared of atherosclerotic disease and is readily accessed through a small left thoracotomy. The specific considerations for the operation are detailed below.

Patients with poor pulmonary reserve that cannot tolerate a thoracotomy have a contraindication for thoracobifemoral bypass. Patients with a previous left thoracotomy may not be candidates. Significant calcific descending aortic atherosclerosis is also a relative contraindication. Though distal outflow through the common femoral is ideal, the procedure can be combined with more distal targets as long as the outflow is not prohibitively limited.

Risk factor modification is the first step in preoperative preparation for all vascular interventions. Patients should undergo intensive smoking cessation programs, monitored exercise programs, and medical optimization. The benefits of aspirin, statin, and glucose control have been well demonstrated in the vascular surgery population. Additionally, preoperative cardiac and pulmonary evaluations are imperative. Candidates should undergo formal pulmonary function tests to ensure the ability to tolerate a thoracotomy.

A preoperative IV contrast enhanced CT scan of the abdomen and pelvis is required for evaluation of the aorta, femoral vessels, and distal run-off. Patients may be evaluated by MRI/MRA but this is limited by the ability to differentiate calcific atherosclerosis of the vessel. Likewise digital subtraction angiography can be used but gives only luminal data and does not characterize the atherosclerotic disease. Patient should also undergo baseline ABI measurements and PVR which can be compared to postoperative studies.

Patients should receive preoperative antibiotics which cover skin flora as an implant will be used (first generation cephalosporin). Preoperative subcutaneous heparin is usually omitted as the patient will be fully anticoagulated during the procedure. General endotracheal anesthesia is typically with a single lumen tube though some groups may prefer a double lumen tube for single lung ventilation with a bronchoscopy to confirm placement. A baseline activated clotting time is recorded and cross-matched blood should be available.