Thoracobifemoral bypass as salvage after sequential failure of endovascular and open aortoiliac reconstruction

Descending thoracic aorta-to-bilateral femoral artery bypass (DTFB) is an established option when abdominal aortic reconstruction is hazardous. A 57-year-old man with chronic limb-threatening ischemia had complete juxtarenal aortic occlusion after failed bilateral iliac stenting and previous transperitoneal aortobifemoral bypass. He underwent DTFB with a concomitant left femoropopliteal bypass. Three years later, the left limb of the DTFB and femoropopliteal graft occluded, whereas the central conduit and right limb remained patent. Revascularization was achieved with a graft body to profunda femoris bypass, avoiding thoracic re-entry and abdominal aortic reconstruction. This report does not present thoracic inflow or concomitant infrainguinal bypass as novel. Its educational contribution is the longitudinal management of tertiary salvage, including selection of DTFB after sequential endovascular and open failure, the importance of diaphragmatic graft geometry and distal outflow, and the conditions under which a patent central conduit can serve as inflow for subsequent revision.