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References
239
References
1. Chew DKW, Owens CD, Belkin M, Donaldson MC,
et al. Bypass in the absence of ipsilateral greater
saphenous vein: safety and superiority of the contralateral greater saphenous vein. J Vasc Surg.
2002;35:1085–92.
2. Conte HS, Belkin M, Upchurch GR, Mannick JA,
etal. Impact on increasing comorbidity on infrainguinal reconstruction: a 20-year prospective. Ann Surg.
2001;233(3):445–52.
3. Ambur V, Park P, Gaugher JP, Golarz S, et al. The
impact of chronic kidney disease on lower extremity
bypass outcomes in patients with critical limb ischemia. J Vasc Surg. 2019;69(2):491–6.
Fig. 54.3 Postoperative CTA showing patent femoral-
peroneal bypass
Femoral-Peroneal Bypass
forSevere Calcic Disease Using
Tourniquet Occlusion
55
Physical Examination andHistory
A 78-year-old male was admitted to the hospital
for infected ulcer of the right fourth toe. X-ray of
the foot showed osteomyelitis, and he was started
on intravenous Zosyn and vancomycin. Doppler
arterial study showed severe bilateral supercial
femoral artery occlusive disease as well as with
infrapopliteal occlusions. Medical comorbidities
included ischemic cardiomyopathy (coronary
stent), atrial brillation, severe bilateral carotid
stenosis, hypertension, and nicotine abuse (80
pack years). Past surgical history included amputation of the right second toe and a right femoral
artery repair following coronary intervention 10
years ago due to malfunction of the closure
device. Arteriography showed right proximal and
midsegment popliteal artery occlusion and near
occlusion of the tibial-peroneal trunk and runoff
with peroneal artery, posterior tibial artery, and
anterior tibial artery were occluded. There was
heavy calcication in all the arteries extending
from the abdominal aorta to the feet (Fig.55.1).
Patient underwent right femoral to midsegment
peroneal in situ bypass using tourniquet occlusion with healing of the ulcer (Fig. 55.2).
Postoperative arteriogram showed patent right
femoral-peroneal bypass with a small retained
arteriovenous stula in the mid-thigh with faint
lling of the supercial femoral vein (Fig.55.3).
Postoperative duplex imaging showed patent
graft without demonstration of the stula and
with excellent distal ow.
In December 2019 patient was admitted with
ischemic gangrene of the toes of the left foot and
underwent arteriography which showed patent
right femoral-peroneal in situ bypass with thrombosis of the residual AV stula. Patient underwent left common femoral endarterectomy with
bovine pericardial patch for near occlusion with
severely calcied plaque involving the left common femoral artery. Patient had signicant
improvement in the ischemic lesions of the left
foot and was discharged home after 10days stay
in the hospital.
Discussion
In patients undergoing femoral-infrapopliteal
arterial bypass with severe calcications of the
arteries, clamp application to small arteries may
result in dissection of the artery and difculty in
occluding the target artery with micro bulldog
clamps. Tourniquet occlusion in the thigh prior to
the performance of distal anastomosis results in
better visualization of the operative eld and less
dissection of the target runoff arteries in the calf.
Since clamp application to the calcied and brittle arteries is avoided, the early failure may be
improved [1, 2]. Tourniquet time of less than an
hour has not shown any adverse effect on the
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_55
241
242
Fig. 55.1 Showing preoperative popliteal artery occlusion and severe stenosis of the tibio-peroneal trunk and runoff
with peroneal artery
55 Femoral-Peroneal Bypass forSevere Calcic Disease Using Tourniquet Occlusion
Fig. 55.2 Operative pictures showing right femoral to peroneal bypass using tourniquet occlusion
muscle biopsy specimens [1]. Bergamini et al.
reported on 361 consecutive in situ saphenous
vein bypasses and reported 6-year primary
patency of 63% and a secondary patency of 87%
[3]. They revised 86 (24%) venous conduits
because of a technical failure or inadequate vein
segment. In the follow-up period, 95 (26%)
bypasses were revised because of thrombus or
hemodynamic failure. Retained valve reex (N6)
and stula ligation (N4) were required by careful
duplex ultrasound imaging assessment during the
operation and during follow-up period.
Retained valve leaets may result in early
thrombosis. In a large diameter vein, the graft
may not thrombose, but an intimal hyperplastic
stenosis threatening the patency of the bypass
may occur during follow-up. Residual arteriovenous stula, if small (either no lling or very
poor lling of the deep veins), may thrombose
spontaneously as occurred in the patient described
in the report. However large arteriovenous stula
may threaten the patency of the graft. Long-term
patency of in situ bypass is dependent on the
quality of the conduit and atherosclerotic disease
in the inow arteries. Careful intraoperative and
postoperative surveillance by duplex imaging
helps prevent the thrombosis of the graft by correcting the hemodynamic failure due to graft
References
243
Fig. 55.3 Showing patent right femoral-peroneal bypass with residual arteriovenous stula in the upper thigh with
minimal lling of the deep vein
stenosis by angioplasty or open surgical revision.
Residual arteriovenous stulas can be treated
with coil embolization or ligation.
References
1. Cierro A, Dardik H, Quin F, Silvestri F, etal. The tourniquet revisited as an attempt to lower limb revascularization. J Vasc Surg. 2000;31(3):436–42.
2. Wagner WH, Trieman RL, Cosman DV, Cohen J, etal.
Tourniquet occlusion for tibial artery construction. J
Vasc Surg. 1993;18:637–47.
3. Bergamini TM, Town JB, Bandyk DF, Seabrook
GR. Experience within situ saphenous vein bypass
during 1981–1989. Detrimental factors of long-term
patency. J Vasc Surg. 1991;13(1):137–49.
Femoral Distal Posterior Tibial
Bypass forEstablished Gangrene
Physical Examination
A 70-year-old male was admitted to the hospital
with gangrene of the toes of the left foot
(Fig.56.1). He was started on intravenous Zosyn
and vancomycin. He underwent noninvasive
Doppler arterial study and arteriography.
Arteriography showed left supercial femoral
artery and popliteal artery occlusion with runoff
with peroneal artery and posterior tibial artery.
Posterior tibial artery was occluded in the rst
few centimeters; plantar arch was incomplete
(Fig.56.2).
56
Procedure
On September 13, 2016, patient underwent left
femoral to distal posterior tibial in situ bypass
with amputation of the left second, third, fourth,
and fth toe at trans-metatarsal level. Through an
oblique left groin incision, common femoral
supercial and deep femoral arteries were
exposed. Thrombus was removed from the supercial femoral artery at its origin, and proximal
anastomosis of greater saphenous vein was done
end to end to the proximal supercial femoral
artery. A retrograde valvulotome was introduced,
and valve leaets were incised to obtain a pulsatile ow. In the distal portion of the calf, dissection was deepened down between the tibialis
posterior tendon and exor digitalis longus, and
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_56
Fig. 56.1 Gangrene toes of the left foot
posterior tibial artery was exposed, and distal
anastomosis was performed with 7-0 cardiovascular polypropylene in an end-to-side fashion.
Patient was prepped and draped again after
wound closure, and amputation of the second,
third, fourth, and fth toe was performed just
245
246
Fig. 56.2 Preoperative arteriography showing left supercial femoral and left popliteal artery occlusion with runoff via
posterior tibial and peroneal artery
56 Femoral Distal Posterior Tibial Bypass forEstablished Gangrene
3 years (last follow-up October 2019) with patent
graft. He wears specially made orthotics for
ambulation.
Fig. 56.3 Healing of amputation site (toes)
proximal to metatarsal heads. Patient had an
uneventful postoperative course and amputation
site healed in 6 weeks’ time (Fig. 56.3).
Postoperative arteriography 1 year later showed
patent left femoral posterior tibial bypass
(Fig.56.4). Patient has been followed for the past
Discussion
Femoral distal tibial bypass for established gangrene presents a challenging problem. In patients
with gangrene of the toes (tissue necrosis) with
patency of posterior tibial and peroneal artery, the
preferential site of distal anastomosis is posterior
tibial artery to provide maximal pulsatile ow to
the foot. Perimalleolar bypasses (distal peroneal
artery, distal posterior tibial artery, lateral plantar
artery, and dorsalis pedis artery) are an important
subset of infragenicular bypasses in patients with
diabetes mellitus and renal failure. Autogenous
vein should be used as the results with use of synthetic bypasses are poor. Patent ipsilateral supercial femoral arteries/popliteal arteries without any
signicant stenosis on arteriography are a satisfactory choice for proximal anastomosis as they permit the construction of a short bypass. Incidence
of surgical site infection after lower extremity
bypass has been reported to be between 4.8% and
18% [1–3]. Preoperative chlorhexidine showers,
transverse groin incisions, and skip incisions (skin
References
Fig. 56.4 Follow-up arteriogram 1 year later with patent left femoral to posterior tibial in situ bypass
247
bridges) have a result in lower incidence of surgical site infection. Other independent of surgical
site infection include an ankle brachial index of
less than 0.35, transfusion of more than two units
of packed cells, and operative time of more than
220minutes [3]. Wiseman etal. from NSQIP data
(2005–2012) reported incidence of surgical site
infection of 2.1% in the hospital and incidence of
6.9% after discharge [1]. In patients with infected
gangrene limited to distal portion of the foot (toes),
we prefer amputation of the infected portion of the
foot and perform arterial bypass a few days later.
In patients with dry gangrene, arterial bypass and
partial amputation of the foot/toes can be performed at the same setting.
References
1. Wiseman JT, Fernandes-Taylor S, Barnes ML,
Saunders RS.Predictors of surgical site infection after
hospital discharge in patients undergoing major vascular surgery. J Vasc Surg. 2015;62(4):1023–31.
2. Kalish JA, Farber A, Homa K.Factors associated with
surgical site infection after lower extremity bypass in
the society for vascular surgery, quality initiative. J
Vasc Surg. 2014;60(5):1238–46.
3. Heckman KE, Michael E, Blay E, Helenowski IB,
etal. Evidence based intervention for reducing surgical site infection in lower extremity vascular bypass
predictors. JACS. 2019;226(1):44–53.
Autogenous Composite Vein
Bypass forRedo Infrainguinal
Arterial Reconstruction
57
History andPhysical Examination
A 61-year-old female presented to the clinic in
April 2018 with severe ischemic rest pain and
night pain for the past 3 months. Medical comorbidities included hypertension, hyperlipidemia,
and nicotine abuse (80 pack years). Past surgical
history included right femoral-popliteal in situ
bypass (below the knee) for ischemic rest pain in
January 2017 at an outside hospital. She also
underwent left external iliac stent placement and
a left femoral popliteal in situ bypass for symp-
toms of intermittent claudication in September
2017. In situ bypass occluded within 2 months of
its performance. She underwent thrombolysis
with TPA and a balloon angioplasty of the distal
anastomosis.
In April 2018, patient underwent arteriography
which revealed occluded left femoral- popliteal
bypass, occlusion of the left supercial femoral
and popliteal artery, with runoff with peroneal
artery and anterior tibial artery supplying the left
foot with a short segment stenosis of the anterior
tibial artery in the proximal third (Fig.57.1).
Fig. 57.1 Preoperative arteriography showing occluded left femoral popliteal bypass with occlusion of left supercial
femoral and popliteal artery with runoff with anterior tibial and peroneal artery
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_57
249
250
57 Autogenous Composite Vein Bypass forRedo Infrainguinal Arterial Reconstruction
Procedure
Following venous mapping she underwent left
common femoral endarterectomy and a left femoral to mid anterior tibial bypass on May 24,
2018 using three composite segments of the
vein. Initially patient was placed prone and both
lesser saphenous veins were harvested. Right
lesser saphenous vein in its entire length was
adequate, but the left lesser saphenous vein was
of adequate caliber in its distal segment only.
Both posterior calf incisions were closed.
Following this, with patient in supine position,
the right greater saphenous vein was harvested
from below the knee to the ankle. These three
venous segments were sutured end to end (venovenostomy). Proximal anastomosis was performed at the hood of the previously performed
femoral-popliteal in situ bypass (occluded). This
anastomosis was performed in an end-to-end
fashion to the most proximal segment of the in
situ bypass. The vein was kept in the subcutaneous plane through skip incisions on the medial
side, and tourniquet occlusion in the left thigh
was performed after the valve lysis was done by
passage of a retrograde valvulotome. Following
tourniquet occlusion, incision was made in the
mid anterolateral segment of the left lower leg,
and between tibialis anterior tendon and an
extensor hallucis longus tendon, anterior tibial
artery was exposed. A tunnel was made in
the interosseous membrane by crisscross incision with a scalpel, and the composite vein
bypass was brought through the interosseous
membrane, and distal anastomosis was performed with 7-0 cardiovascular polypropylene.
Completion arteriography showed narrowing
just beyond the distal anastomosis (Fig. 57.2).
However, patient had an excellent Doppler signals in the dorsalis pedis artery; the narrowing
was attributed to spasm.
Due to loss of signals in the foot, patient was
re-explored 6 hours following initial procedure,
and the distal anastomosis was disconnected,
incision was made in the groin, skip incisions
were opened, and thrombus was removed manually with progressive gentle pressure between the
thumb and forenger till pulsatile ow was
Fig. 57.2 Operative arteriogram showing distal portion
of the vein bypass through the interosseous membrane
and anastomosed to anterior tibial artery. Narrowing of
the artery just distal to the anastomosis
obtained. Since the vein was slightly redundant, a
new anastomosis distal to the previous anastomosis in the anterior tibial artery was constructed
with palpable pulses in the dorsalis pedis artery.
Postoperative CTA showed patent femoral anterior tibial bypass (Fig. 57.3). Patient developed
occlusion of the bypass in October 2018.
Thrombolysis of the graft was started and the
patency of the graft was established, but the
entire graft had become extremely narrow, and it
was felt that no further intervention should be
performed as patient had marked improvement in
her symptoms (relief of ischemic rest pain) and
her ankle brachial index is 0.4. Patient had
stopped nicotine abuse and is currently on lowdose aspirin and clopidogrel.
Discussion
Redo lower extremity arterial bypass of the
saphenous vein is the most effective method of
revascularization after failed primary bypass [1].
Endovascular intervention in anatomically suitable lesions is an acceptable alternative to bypass
in patients who would require synthetic conduit.
DeFrang et al. reported 85 arterial bypass
Invited Commentary fromNicolas J.Mouawad, MD MPH MBA FSVS FACS FRCS RPVI
Fig. 57.3 Postoperative CTA showing patent femoral anterior tibial artery bypass
251
procedures using arm vein (32%), spliced vein
(16%), lesser saphenous vein (2%), contralateral
greater saphenous vein (14%), prosthetic graft
(16%), and composite graft (prosthetic and vein,
5%). They reported mean time to failure from
the rst bypass of 24months. They observed primary patency at 4 years of 79.8% [1].
Biancari etal. reported 51 reconstructions to
the infrapopliteal arteries for critical limb ischemia and reported a primary patency of 44% at 1
year with vein graft and with prosthetic graft
plus arteriovenous stula of 67% and prosthetic
graft without arteriovenous stula of 17% [2].
Conrad et al. reported long-term results of
catheter- directed thrombolysis to treat acutely
occluded infrainguinal bypass graft occlusion in
69 patients (48 vein grafts, 21 prosthetic). They
reported successful lysis in 71% of cases. They
identied causative lesion and its treatment by
angioplasty or limited operative revision in 33
patients [3]. They observed (like the patient in
this report) diffuse intimal hyperplasia in few
patients and did not offer any further intervention in patients with diffuse intimal hyperplastic
lesions. It is possible that injury to the intima
during preparation of the composite graft, and
more likely from thrombectomy performed in
the immediate postoperative period, resulted in
diffuse hyperplasia.
Invited Commentary fromNicolas
J.Mouawad, MD MPH MBA FSVS
FACS FRCS RPVI
Lower extremity arterial reconstruction in the
absence of satisfactory single segment autogenous great saphenous vein remains very challenging in contemporary vascular surgical
practice. In fact, the high incidence of endovenous ablative procedures as well as continued
harvest for coronary artery bypass grafting in an
era of increasing prevalence of peripheral arterial
disease and reoperative infrainguinal bypass surgery really relegates the vascular surgeon to
novel, complicated (and time-consuming) options
of conduit creation.
Although prosthetic and biologic options are
available, autogenous solutions are always more
favorable, particularly for distal infrapopliteal targets in the setting of critical limb ischemia.
Harvesting of contralateral great saphenous, bilateral small saphenous, and even upper extremity
veins in addition to splicing multiple segments to