Eleven-year experience with tibiotibial bypass: An unusual but effective solution to distal tibial artery occlusive disease and limited autologous vein (original) (raw)
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Direct approaches to the distal portions of the deep femoral artery for limb salvage bypasses
Journal of vascular …, 1988
This study describes a technique that facilitates lower extremity "redo" revascularizations and that may increase the number of patients who can be revascularized. By using the distal deep femoral artery for bypass outflow or inflow, we were able to revascularize patients with no other accessible patent major thigh artery, to increase the use o f autologous vein for infrapopliteal bypasses, and to avoid difficult groin reoperations. Thirtyseven patients (23 men) had various distal deep femoral revascularizations for limb salvage indications only (rest pain, ischemic ulcers, and/or gangrene). Techniques to expose the distal deep femoral artery directly are described and their uses discussed. We found that the type o f bypass performed (e.g., axiUofemoral or aortofemoral) determined the patency rate o f the reconstruction. Placement o f the origin or termination o f the graft in the deep femoral artery did not appear to affect the results adversely.
Journal of Vascular Surgery, 1993
Purpose: It is believed that secondary operations involving the inguinal region are associated with a significant morbidity that includes infection, lymphatic obstruction, lymphorrhea, and neurovascular injury. To prevent these potentially important complications we have avoided a redo groin incision in 38 patients with severely symptomatic disease who had primary (23 cases) or secondary (15 cases) femoropopliteal bypass thrombosis during the past 3 years. Methods: All patients were candidates for prosthetic bypasses because of lack of a suitable vein. Twenty-nine external iliac-to-popliteal bypasses (18 above-knee; 11 below-knee) and nine external iliac-to-infrapopliteal bypasses (five anterior tibial; two posterior tibial; two peroneal) were performed with 6 mm polytetrafluoroethylene r.inged grafts in 38 patients. Adjunctive distal arteriovenous fistulas were constructed in all infrapopliteal bypasses. The external iliac artery was exposed via a retroperitoneal approach. The second incision was placed just below the scarred area and deepened to the level of the medial border of the sartorius muscle. A tunnel that connected both incisions was easily created by blunt dissection alongside the anterolateral border of the femoral artery. Results: Four popliteal bypasses occluded at 4, 6, 10, and 28 months after operation. The remaining 25 grafts are patent (mean 14 months). Three of the infrapopliteal bypasses occluded at 0, 2, and 3 months after operation. The remaining six grafts are patent with follow-up from 4 to 18 months (mean 12 months). Only one patient had a superficial wound infection at the below-knee popliteal incision, which healed with local treatment. All other patients had an uneventful postoperative course. Conclusions: Thus we believe this approach to be simple, safe, and durable and should be used preferentially to avoid the difficult and hazardous dissection of a previously operated groin. (J VAsc SURG 1993;18:234-41.) An aggressive approach at reoperations for recurrence of severe lower limb ischemia has been shown to be worthwhile in providing extended periods of graft patency and limb salvage. ~4 In general, however, these procedures are more technically demanding and require more expertise and judgment than the primary operation. Fewer options for a bypass entirely constructed with autogenous vein, a more distal recipient artery, and a difficult dissection through scarred tissue are some of the problems From
Value of the Deep Femoral Artery as Alternative Inflow Source in Infrainguinal Bypass Surgery
Annals of Vascular Surgery, 2014
Background: The purpose of this study was to analyze the long-term results of infrainguinal bypass surgery using the deep femoral artery (DFA) as the inflow source. Methods: Between 1998 and 2011, 88 bypasses of the lower limb were placed in 86 patients (mean age 71 years) using the deep femoral artery as inflow. Patients' records were retrieved from a computerized database and analyzed retrospectively. Results: Critical limb ischemia (rest pain/tissue loss) was the indication in the majority (87.5%) of cases. The distal anastomosis of the bypass grafts was located at the popliteal level in 32 cases and the tibial (pedal) level in 52 cases, respectively, with the autologous vein as conduit in 94% of cases. Perioperative mortality was 2.3% and 77 patients (79 limbs) were followed over a mean period of 48 months. Overall primary, primary assisted, and secondary patency rates of 64.2%, 74.9%, and 92.3% were noted at 60 months, respectively. The limb salvage rate was 97%, with an overall survival of 48.7% at 60 months. Conclusions: The deep femoral artery can serve as reliable inflow source for infrainguinal bypass surgery in difficult situations like redo groin surgery, limited conduit length, and circumferential nonobstructive calcification of the common femoral artery.
External Iliac Artery to Tibial Arteries Vein Graft for Inaccessible Femoral Artery
Annals of Vascular Surgery, 2019
Background: An endovascular-first approach to limb salvage and relief from lifestyle-limiting claudication is widely accepted. Stenosis or short occlusion of common, superficial femoral, and popliteal arteries can be corrected with percutaneous transluminal angioplasty (PTA) with stent positioning. Patency rates of these procedures are limited. We report our experience with external iliac artery to the infrapopliteal vessels vein grafts when the endovascular treatment fails. Methods: Between January 2013 and January 2019, 16 patients (16 limbs) were operated on for limb-threatening ischemia after the occlusion of PTA with stent positioning of the common, superficial femoral, and popliteal arteries. Three patients were treated at our hospital by interventional radiologists; the remaining were operated on elsewhere. An external iliac artery to the infrapopliteal vessels vein bypass graft was anatomically interposed to restore blood flow. End points of the study were death-related events, vein graft failure, and major (above-or below-knee amputation) or minor (foot or toe amputation) limb loss. Results: There were 12 men and 4 women. Mean age of patients was 68 years. Indication for the initial PTA with stent positioning of the common and superficial femoral artery was according to the Rutherford classification Grade I: Category 1, 11 patients (69%) and Category 2, 5 (31%) patients (Stage IIa and IIb according to Fontaine classification, respectively). Great saphenous vein was used in 14 (87%) cases and in 2 (13%) cases a composite graft with a segment of cephalic vein was required. The distal anastomoses were performed on the posterior tibial artery in 6 (37%) cases, anterior tibial artery in 4 (26%), and peroneal artery in 6 (37%). Four-year survival and primary patency rates were 71% (standard error [SE] ¼ 0.15) and 73% (SE ¼ 0.14), respectively. One graft occlusion required an above-knee amputation. Four-year limb salvage rate was 86% (SE ¼ 0.13). Discussion: We recommend the external iliac artery as source of inflow in patients in whom the vein bypass cannot originate from the common femoral or from a more distal inflow source because of previous PTA with stent positioning or it is deemed hazardous.
Preservation of the Ischemic Leg by Distal Vascular Bypass
Annals of Surgery, 1977
Autogenous saphenous vein bypass grafts to tibial or peroneal vessels have resulted in successful, long-term limb preservation in appropriately selected patients. This success appears to justify an aggressive approach to what has previously been considered "end-stage" distal vascular occlusive disease. This report describes the clinical management and long-term follow-up of 41 patients with tibial artery reconstruction.
Tibiotibial vein bypass grafts: A new operation for limb salvage
Journal of Vascular Surgery, 1985
Tibiotibial bypasses were performed with short (8 to 33 cm) segments of reversed autologous vein in 14 patients who did not have longer segments of usable vein. All patients faced imminent amputation unless they had an effective revascularization. Two patients died, one within 1 month of operation. One patient required below-knee amputation despite a patent bypass. Eleven patients (79%) have a patent bypass and a functional limb 6 to 50 months after operation. These good patency results even with several grafts inserted into isolated segments of tibial arteries, some with incomplete plantar arches, suggest that these short vein grafts may be superior to other vein grafts. Tibiotibial bypasses may improve limb salvage results in otherwise difficult circumstances. (J VAsc SURG 1985; 2:552-7.)
Surgical implications of early failed endovascular intervention of the superficial femoral artery
Journal of Vascular Surgery, 2008
Background: It is generally accepted that failed infrainguinal bypass with prosthetic material significantly compromises arterial run off, which may limit future revascularization. It is well known that the negative consequences of early vein graft thrombosis are limited, but the effect of failed peripheral angioplasty on the distal vasculature is poorly studied. The purpose of this study was to determine whether early failure after superficial femoral artery intervention influences subsequent revascularization options. Methods: Between July 1, 1998, and June 30, 2006, 276 patients underwent endovascular intervention of the superficial femoral artery. A prospective analysis of angiograms done before the intervention and after early failure (<200 days) was performed in a blinded fashion by three attending vascular surgeons to determine the optimal distal bypass site if an operation were to be performed. Inter-rater reliability of the angiogram scores was assessed using the Fleiss generalized for multiple raters. Potential distal anastomotic sites were classified as above knee popliteal, below knee popliteal, tibial, or no adequate site. A consensus classification was determined for each patient (2 of 3 raters). Results: Of the 276 patients who underwent endovascular intervention of the superficial femoral artery, early failure was noted in 24 limbs in 23 patients. Angiographic records were available for 21 limbs in 20 patients (60% men; mean age, 65.3 ؎ 11.3 years), of which 60% had critical limb ischemia, 40% had claudication, and 65% had diabetes. The distal bypass site was altered in six limbs (28.6%); four from popliteal to tibial and two from above knee to below knee popliteal. Inter-rater reliability was 0.54 (moderate/good). The procedures performed on these early failures were percutaneous transluminal angioplasty ؎ stent (n ؍ 14), infrainguinal bypass (n ؍ 5), and no treatment (n ؍ 1). Only 0.4% (1 of 276) of patients required major limb amputation due to early failure of a superficial femoral artery intervention.
Annals of Vascular Surgery, 2012
Background: The aim of the study was to describe and analyze the results of a technique in which the inflow for distal bypasses is provided by the proximal superficial femoral artery, reopened through an eversion endarterectomy, to avoid a ''difficult groin.'' Material and Methods: Twenty-one patients who underwent distal bypass for severe lowerlimb ischemia and in whom the proximal superficial femoral artery was reopened with an eversion endarterectomy to provide inflow for the bypass itself were included in the study. As a comparison group, 20 patients in whom the inflow for a distal bypass was obtained by the distal deep femoral artery were randomly selected. In all 41 patients, the groin was considered ''difficult'' because of multiple previous operations. Results: Five-year cumulative patency rates were 53% for femoropopliteal bypasses and 40% for femorotibial bypasses. Similar patency rates were obtained when the distal deep femoral artery was used as inflow. Conclusions: Eversion endarterectomy of the proximal superficial femoral artery provides a valid source of inflow for distal bypasses, and it should be kept in the armamentarium of the vascular surgeon, to be used in selected cases.
Journal of Surgical Research, 2012
Background. In selected patients, eversion endarterectomy of the proximal superficial femoral artery can represent a valid inflow for a distal bypass to avoid a ''hostile'' groin. Material and Methods. Patency rates and limb salvage rates were retrospectively analysed for 21 consecutive patients who underwent distal bypass for severe lower limb ischemia and in whom the proximal superficial femoral artery was reopened with an eversion endarterectomy. In all patients, this technique was used to avoid a hostile groin. Results. Five-year cumulative patency rates were 53% for femoropopliteal bypasses and 40% for femorotibial bypasses. Overall 5-y cumulative limb salvage was 72%. Conclusions. In case of hostile groin, eversion endarterectomy of the proximal superficial femoral artery is a valid solution to provide inflow for a distal bypass.
International Journal of Surgery Open, 2019
Background: Peripheral occlusive arterial disease (POAD) is a steadily increasing global epidemic. Femoropopliteal bypass (FPB) is the traditional therapeutic option whenever endovascular treatments failed or not indicated. We present our experience in lower limb revascularization. Patients and methods: Prospective observational cohort single center study included 158 patients with intermittent claudication (IC) or critical limb ischemia (CLI). The patients were placed in 7 Rutherford categories & their angiographic findings were graded according to Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) criteria. The ipsilateral great saphenous vein was used for revascularization. Results: male patients were 113 (71.5%); female were 45 (28.5%). Age ranged from 39 to 77 years, with a mean of 60.7 ± 7.8 years. About 79.1% of patients were in the 6th & 7th decades. Only 26 patients (16.5%) had severe IC & 83.5% had CLI. Almost all patients with Rutherford category 3e6 had an ankle brachial index (ABI) less than 0.70. Most Femoropopliteal lesions (n ¼ 115, 72.8%)near half infrapopliteal lesions (n ¼ 74, 46.8%) were of TASC II B & C types. Majority of patients received a vein graft. Distally, 100 grafts (66.7%) were sutured below the knees whereas the remainder were either behind (n ¼ 31) or above the knees (n ¼ 8). The follow up ranged from 1 month to 11 years. One & 5 year patency rates of vein grafts were 88.7% & 70.2% respectively. Conclusions: FPB using saphenous graft yield a very good graft patency, low rates of amputation, morbidity and mortality. Long-term patency is excellent.