Is an artery bypass graft with redo bilateral groin exposure medically indicated for a patient with peripheral artery disease, presenting with rest pain, non-palpable pedal pulses, and occlusion of the infrarenal abdominal aorta, including the renal artery?

Arterial Bypass Graft is Medically Indicated for This Patient

This patient with critical limb ischemia (CLI) presenting with rest pain and extensive aortoiliac occlusive disease requires urgent revascularization, and arterial bypass grafting with bilateral groin exposure is the appropriate surgical intervention to prevent limb loss and improve quality of life. 1

Clinical Justification for Intervention

Critical Limb Ischemia Diagnosis

• This patient meets criteria for CLI with rest pain, severely limited walking distance, non-palpable pedal pulses, and symptoms of cold intolerance, numbness, and paresthesias 1
• Revascularization should be considered the primary approach for CLI patients unless survival is very limited, independent ambulation is unlikely due to tissue necrosis/flexion contracture, or general medical condition is poor 1
• The absence of wounds is favorable, as this patient does not have significant necrosis of weight-bearing foot portions that would indicate primary amputation 1
• Major amputation carries 4-30% 30-day mortality and 20-37% morbidity risk (MI, stroke, infection), with devastating impact on quality of life and independence, making revascularization strongly preferred 1

Anatomic Pattern Requiring Surgical Intervention

The imaging demonstrates combined inflow and outflow disease requiring staged or simultaneous correction:

• Infrarenal aortic occlusion beginning at the renal artery takeoff with apparent renal artery involvement 1
• Occlusive disease in common iliac arteries with collateralization and reconstitution at internal/external iliac level 1
• Mild disease in common femoral and profunda femoris arteries 1
• Moderate mixed plaque in mid-superficial femoral artery 1
• Diffuse moderate disease in below-knee vessels (anterior tibial, posterior tibial, peroneal) 1

Surgical Approach Selection

For this extensive aortoiliac occlusive disease with CLI, aortobifemoral bypass is the Class I recommended procedure:

• Aortobifemoral bypass is recommended (Class I, Level of Evidence A) for patients with symptomatic, hemodynamically significant aorto-bi-iliac disease requiring intervention 1
• The bypass is constructed by sewing a bifurcated graft end-to-end to the aorta immediately below the renal artery origins, with distal limbs sewn to common femoral or profunda femoris arteries 1
• Aortobifemoral bypass achieves excellent outcomes: 87.5% limb-based 5-year patency, 80.4% patient-based 5-year patency, with minimal decline at 10 years (81.8% and 72.1% respectively) 1
• Operative mortality is 3.3% with 8.3% morbidity, primarily MI (0.8-5.2%) or renal failure (0-4.6%) 1

Addressing Combined Disease

The principle of treating inflow before outflow is critical:

• In patients with combined inflow and outflow disease with CLI, inflow lesions should be addressed first (Class I, Level of Evidence B) 1
• If CLI symptoms or infection persist after inflow revascularization, an outflow revascularization procedure should be performed (Class I, Level of Evidence B) 1
• The planned bilateral groin exposure allows assessment of femoral vessels and potential for staged distal bypass if needed 1

Critical Caveat: Renal Artery Involvement

The imaging description stating "renal artery is not visible and appears to be occluded" requires urgent attention:

• If the renal artery is truly occluded, this patient may require simultaneous aortorenal bypass or alternative renal revascularization to preserve renal function 1
• Aortorenal bypass is commonly performed using reversed saphenous vein when multiple vessel reconstructions are needed 1
• The risk of surgery increases significantly in patients requiring concomitant aortic and renal reconstruction, with renal failure occurring in 0-4.6% of cases 1
• Preoperative assessment of renal function and consideration of nephrology consultation is essential 1

Alternative Approaches if Patient is High-Risk

If this patient has prohibitive surgical risk:

• Axillofemoral-femoral bypass is indicated (Class I, Level of Evidence B) for CLI patients with extensive aortoiliac disease who are not candidates for other interventions 1
• However, axillofemoral bypass has significantly inferior patency (50-76% at 5 years for axillobifemoral) compared to aortobifemoral bypass 1
• Endovascular therapy could be considered for high-risk patients, though the extensive nature of occlusive disease (infrarenal aorta, common iliacs, multilevel disease) makes complete endovascular treatment challenging 2, 3

Superiority Over Amputation

The mortality and quality of life data strongly favor revascularization:

• Distal arterial reconstruction mortality: 0-6% 1
• Major amputation mortality: 4-30% with 20-37% major morbidity 1
• Rehabilitation difficulties and inability to ambulate with prosthesis in older patients severely impact independence 1
• This patient has no contraindications to revascularization (no significant tissue necrosis, no flexion contracture, no paresis) 1

Conclusion on Medical Necessity

The proposed arterial bypass graft with redo bilateral groin exposure is medically indicated and represents standard-of-care treatment for this patient's CLI with extensive aortoiliac occlusive disease. The procedure addresses life-threatening limb ischemia, has superior outcomes compared to amputation, and follows Class I guideline recommendations. 1, 2