Axillo-bifemoral bypass is a surgical procedure designed to restore blood flow to the legs when the main arteries in the abdomen, particularly the aorta or iliac arteries, are blocked or severely narrowed. Unlike the traditional aorto-bifemoral bypass, this approach avoids opening the abdomen and instead uses an artery from the chest (the axillary artery) as the blood supply.
This operation is especially valuable for patients who are not candidates for open abdominal surgery due to age, medical conditions, or previous surgeries. By providing an alternative blood supply, axillo-bifemoral bypass improves circulation, relieves symptoms of leg ischemia, and can prevent limb loss.
The aorta is the body’s main artery, carrying blood from the heart to the rest of the body. At the lower abdomen, it divides into the iliac arteries, which further branch into the femoral arteries supplying the legs.
In some cases, these arteries become severely blocked by atherosclerosis (plaque buildup), leading to reduced blood supply to the lower limbs. The axillary artery, located under the collarbone in the chest, provides an alternative route. In axillo-bifemoral bypass, a graft is tunneled under the skin from the axillary artery down to both femoral arteries, bypassing the diseased aorta and iliac arteries.
The primary cause of severe aorto-iliac blockages requiring bypass is peripheral arterial disease (PAD), most often due to:
Atherosclerosis: Plaque buildup in arterial walls causing narrowing or occlusion.
Smoking: Strongly accelerates vascular disease.
Diabetes mellitus: Increases risk of arterial narrowing.
High blood pressure (hypertension): Damages arterial walls over time.
High cholesterol: Contributes to plaque formation.
Age and genetics: Older individuals or those with a family history are at higher risk.
In rare cases, trauma, prior vascular surgery, or radiation injury may also damage these arteries.
Patients with severe aorto-iliac disease may experience:
Claudication: Pain in the thighs, buttocks, or calves while walking.
Rest pain: Pain in the feet or legs even when not moving, often worse at night.
Coldness or color change in the legs/feet.
Non-healing wounds or ulcers on the lower limbs.
Gangrene: In severe cases, tissue death due to lack of blood supply.
These symptoms usually progress gradually but can become limb-threatening if not treated.
Diagnosis involves a combination of clinical assessment and imaging tests:
Physical examination: Checking pulses in the legs, skin changes, and wounds.
Ankle-Brachial Index (ABI): A simple test comparing blood pressure in the ankle with the arm.
Doppler ultrasound: Assesses blood flow in arteries.
CT angiography or MR angiography: Provides detailed imaging of arterial blockages.
Conventional angiography: In some cases, used for both diagnosis and planning surgery.
Not all patients require surgery immediately. Treatment depends on severity:
Lifestyle changes: Smoking cessation, exercise programs, diet modification.
Medications: To control cholesterol, blood pressure, and diabetes, and to prevent clotting.
Endovascular therapy: Angioplasty and stenting to open narrowed arteries, if suitable.
Aorto-bifemoral bypass: The gold standard when patients are fit for abdominal surgery.
Axillo-bifemoral bypass: An alternative for high-risk patients unable to tolerate open abdominal surgery.
Axillo-bifemoral bypass is performed under general or regional anesthesia. The typical steps include:
Incision in the chest/shoulder area to access the axillary artery.
Incisions in the groin to expose both femoral arteries.
Insertion of a synthetic graft (commonly made of Dacron or PTFE).
Tunneling the graft under the skin from the axillary artery down to each femoral artery.
Connecting the graft to the arteries using sutures to establish a new blood flow pathway.
Closure of incisions after ensuring proper circulation through the graft.
The procedure typically takes 3–5 hours.
After surgery, patients are monitored in the hospital for several days:
Pain management and wound care.
Blood thinning medications (antiplatelet or anticoagulants) to prevent graft clotting.
Monitoring of leg circulation with pulse checks and Doppler studies.
Gradual mobilization to reduce the risk of blood clots and improve recovery.
Long-term care involves lifestyle changes, continued medical therapy, and regular follow-ups to assess graft function.
As with any major surgery, risks exist, particularly since many patients undergoing this operation have other health problems. Potential complications include:
Graft infection.
Graft thrombosis (clotting).
Bleeding or hematoma.
Wound complications.
Heart or lung issues in high-risk patients.
Stroke (rare but possible).
Axillo-bifemoral bypass provides significant relief of symptoms and limb salvage in many patients. However, compared with aorto-bifemoral bypass, long-term graft patency (keeping the graft open) is lower. Success rates improve with careful patient selection, control of risk factors, and adherence to medical therapy.
With proper management, many patients regain mobility, avoid amputation, and enjoy improved quality of life.
Seek medical attention if you experience:
Severe leg pain while walking or at rest.
Non-healing wounds on the legs or feet.
Color changes (pale, bluish, or black skin).
Sudden worsening of leg pain or coldness, which may indicate acute blockage.
Early diagnosis and treatment significantly reduce the risk of serious complications.
Axillo-bifemoral bypass is an important surgical option for patients with severe aorto-iliac artery disease who cannot undergo open abdominal surgery. By rerouting blood flow from the axillary artery to the femoral arteries, this procedure restores circulation to the legs, relieves pain, and helps prevent limb loss.
Although it carries some risks and its long-term durability is less than the aorto-bifemoral approach, it remains a lifesaving alternative for high-risk patients. Anyone experiencing symptoms of poor circulation in the legs should consult a vascular specialist to explore the best treatment options.
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