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252
57 Autogenous Composite Vein Bypass forRedo Infrainguinal Arterial Reconstruction
construct a conduit of sufcient length has been
performed for years and continues to confer an
advantage over the non-autogenous counterparts.
Studies have demonstrated that spliced arm vein
grafts provide durable lower extremity revascularization outcomes with favorable patency and limb
preservation rates over prosthetic grafts [4–6].
Aggressive endovascular interventions for
patients without adequate length autogenous conduits have also become more popular and appear
to offer benet without adversely affecting future
outcomes, in particular in those patients that
underwent spliced vein bypasses strategy rst [7].
The case presented is an important reminder
that the goal of aggressive redo lower extremity
arterial reconstruction is to de-escalate the
patient’s symptom complex by eliminating rest
pain and the consequent morbidity of tissue loss
and major limb amputation. It is imperative that
we remain aggressive in this endeavor and continue to use autogenous composite conduits
whenever possible, and as many spliced segments as necessary, because truly, arms (veins)
save legs!
References
1. DeFrang RD, Edward JM, Moneta GL, Yeager RA,
etal. Repeat leg bypasses after multiple prior bypass
failures. J Vasc Surg. 1994;19:268–77.
2. Biancari F, Railio M, Lundin J, Alback A. Redo
bypass surgery to the infrapopliteal artery for
critical leg ischemia. Eur J Vasc Endovasc Surg.
2001;2(21):137–42.
3. Conrad MF, Shepard AD, Rubinfeld IS, Burke
MW. Long term results of catheter-directed thrombolysis to treat infrainguinal bypass graft occlusion:
the urokinase era. J Vasc Surg. 2003;37(5):1009–16.
4. Vauclair F, Haller C, Marques-Vidal P, Déglise S,
Haesler E, Corpataux JM, Saucy F. Infrainguinal
bypass for peripheral arterial occlusive disease:
when arms save legs. Eur J Vasc Endovasc Surg.
2012;43:48–53.
5. Arvela E, Söderström M, Albäck A, Aho PS, Venermo
M, Lepäntalo M.Arm vein conduit vs prosthetic graft
in infrainguinal revascularization for critical leg ischemia. J Vasc Surg. 2010;52:616–23.
6. McGinigle KL, Pascarella L, Shortell CK, Cox MW,
McCann RL, Mureebe L.Spliced arm vein grafts are
a durable conduit for lower extremity bypass. Ann
Vasc Surg. 2015;29:716–21.
7. Ramdon A, Lee D, Hnath JC, Chang B, Feustel PJ,
Darling RC 3rd., Ramdon etal. Effects of endovascular rst strategy on spliced vein bypass outcomes. J
Vasc Surg. 2019:pii: S0741–5214(19)31733–1.
Repeat Femoral Posterior Tibial Bypass Using Spliced Cephalic Vein
58
History andPhysical Examination
A 56-year-old male presented to the outpatient
clinic with complaints of severe pain in the right
foot in August 2019. Medical comorbidities
included hypertension, nicotine abuse (60 pack
years), and alcohol abuse. Past surgical history
included right distal supercial femoral to mid
posterior tibial bypass with ipsilateral nonreversed greater saphenous vein in March 2017.
Patient was lost to follow-up but had two percutaneous interventions in the interim by another surgeon. Patient had easily palpable right femoral
pulse, but no pulses were palpable below that
level. Noninvasive arterial Doppler study revealed
an ankle brachial index of 0.26 on the right and
1.0 on the left. Arteriography showed occlusion of
the right femoral to posterior tibial bypass; right
supercial femoral artery at its junction with a
popliteal artery was patent. There was occlusion
of the right popliteal artery, and the runoff was
with posterior tibial artery, and the site of previously placed distal anastomosis to the midsegment posterior tibial artery can be seen by slight
angulation of the posterior tibial artery (Fig.58.1).
Procedure
Following venous mapping of the left upper
extremity, patient underwent distal right supercial femoral artery to distal posterior tibial artery
bypass with cephalic vein. There were two
cephalic veins from below the elbow to the middle upper arm and which joined to form a larger
cephalic vein. Both branches were preserved;
vein was harvested from the shoulder to just
below the elbow (Fig.58.2). These veins were
then anastomosed in an end-to-end fashion to
obtain an adequate length for the bypass. The
veins were used in a non-reversed fashion, and
after proximal anastomosis to the distal supercial femoral artery just above the abductor, magnus was performed. The valve leaets were
incised by retrograde valvulotome; distal posterior tibial artery was exposed 3–4cm inferior to
the previously placed anastomosis. Dissection
was difcult because of scar tissue formation.
Posterior tibial artery was small in caliber; distal
anastomosis was performed with a continuous
7-0 cardiovascular polypropylene suture as a
parachute stitch at the start of the anastomosis
(Fig.58.2). Patient had excellent posterior tibial
Doppler signal at the ankle. Twelve hours after
the arterial bypass the graft thrombosed. Patient
was re-explored; thrombus was removed. The
probable cause of thrombus was retained anterior
valve reex just above the distal anastomosis.
The anastomosis was opened at its hood; a
number two Fogarty catheter was passed distally.
After revision of this anastomosis, patient had a
palpable posterior tibial pulse. Patient had satisfactory healing of the incisions but developed
hematoma/seroma in the lower thigh 2 weeks
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_58
253
254
58 Repeat Femoral Posterior Tibial Bypass Using Spliced Cephalic Vein
Fig. 58.1 Preoperative arteriography showing right popliteal artery occlusion with runoff with posterior tibial artery
and peroneal artery
abc
de f
Fig. 58.2 (a) Harvesting of duplicate cephalic vein in the
left upper arm. (b) Exposure of distal supercial artery/
proximal popliteal artery. (c) Proximal anastomosis. (d)
Exposure of distal posterior tibial artery with silastic
loops. A small micro bulldog clamp is at the distal end of
cephalic vein. Skin markers on the supercial surface of
the vein for proper orientation. (e) Competed distal anastomosis. (f) Skin closure
References
Fig. 58.3 Postoperative duplex imaging showing patent
graft
later requiring aspiration three separate times.
Patient was last seen in October 2019 with duplex
imaging showing patent bypass to the distal posterior tibial artery (Fig.58.3).
Discussion
An arm vein was rst reported as a vascular conduit by Kakkar in 1969 [1]. Since that time, there
have been a number of large case series reported
by investigators about the use of arm vein for
lower extremity arterial bypass as ipsilateral
greater saphenous vein is either inadequate or
unavailable [2–4]. Varcoe et al. reported 37
infrainguinal arterial reconstructions using arm
255
veins with almost half were formed for redo
operations. They reported 5-year patency of
37±9% and secondary patency of 76±8% and a
limb salvage of 91±5% [2]. Faries etal. reported
153 lower extremity revascularizations between
1990 and 1998 [4]. The grafts were composed of
spliced arm vein segments with venovenostomy
in 122 and of composite prosthetic-autogenous
conduit in 31. They used intraoperative angioscopy for valve lysis and identication of luminal
abnormalities in 47.7% of cases. Reported 5-year
primary patency in their series was 53.8±8.7%
with secondary patency of 57.7±8% when arm
veins were used. They concluded that arm veins
are conduit of choice when an adequate greater
saphenous vein is not available [4].
References
1. Kakkar VV.The cephalic vein as a preferred vascular
graft. Surg Gyn Ecol Obstet. 1969;128:351–6.
2. Varcoe RL, Chee W, Subramaniam P, Roach DM.Arm
vein as a last autogenous option for an infrainguinal bypass surgery: it is worth the effort. Eur J Vasc
Endovasc Surg. 2007;33:737–41.
3. Andros G, Haris RW, Salles-Cunha S, Dulawa LB,
et al. Arm veins for arterial revascularization of the
leg: arteriographic and clinic observations. J Vasc
Surg. 1986;4:416–27.
4. Faries PL, Arora S, Pomposelli FB Jr, Pulling MC,
etal. The use of arm vein for lower extremity revascularization: results of 520 procedures performed in
eight years. J Vasc Surg. 2000;31(1):50–9.
Part XIV
Adventitial Cystic Disease
of the Popliteal Artery
Management ofaPatient
withComplicated Adventitial
Cystic Disease ofthePopliteal
Artery
59
Physical Examination
A 77-year-old male was seen in the outpatient
clinic with symptoms of left calf claudication on
walking 50 yards in October 2011. Medical
comorbidities included degenerative arthritis and
hyperlipidemia. All the pulses were normal in the
right lower extremity. Examination of the arterial
pulses in the left lower extremity revealed easily
palpable left femoral pulse, but no pulses were
palpable below that level. Noninvasive Doppler
arterial study showed an ankle brachial index of
1.0 on the right and 0.71 on the left. CTA of lower
extremities showed thrombosis of popliteal artery
with adjoining adventitial cyst (Fig.59.1). Patient
underwent arteriography which showed stenosis
of the popliteal artery in its proximal portion and
complete occlusion in its midsegment just above
the knee suggestive of adventitial cystic disease
(Fig.59.2). The length of the occlusion was about
3 centimeters long. Patient was scheduled for
revascularization of the left popliteal artery with
autogenous vein.
Fig. 59.1 CTA showing thrombosis of the left popliteal artery with adjoining adventitial cyst
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_59
259
260
Fig. 59.2 Arteriogram showing occlusion of the mid
popliteal artery
59 Management ofaPatient withComplicated Adventitial Cystic Disease ofthePopliteal Artery
Procedure
Patient was placed in supine position, and saphenous vein (10 cm long) was harvested from the
groin and upper thigh, and the wound was closed in
layers. The patient was then placed supine, and
popliteal artery was exposed through the posterior
approach. The proximal popliteal artery and the
distal popliteal artery were looped with vessel loop
after the fascia in the midline was divided. There
was inammatory reaction around the artery.
7500units of heparin were given by the anesthesia.
The adventitial cyst was carefully dissected from
the artery as it was rmly adherent to surrounding
structures. Proximal vascular clamp was applied to
the popliteal artery and distally to the popliteal
artery above its bifurcation. The artery was completely excised, cyst was opened, and there was
gelatinous uid in the cyst along with a thrombus in
the popliteal artery (Fig.59.3). The saphenous vein
was anastomosed to the popliteal artery in its proximal portion in a non- reversed fashion with continuous 5-0 cardiovascular polypropylene. Retrograde
valvulotome was introduced and anterior and posterior valve leaets were incised, and a distal anastomosis to the popliteal artery was done in an
end- to- end fashion. This anastomosis was spatulated, and 7-0 cardiovascular running polypropyl-
Fig. 59.3 Operative pictures of adventitial cyst and
thrombosis in the popliteal artery
ene suture was used. It is to be noted that the
diameter of its vein at its distal end was 3 mm.
Patient was discharged on the fth postoperative
day. Patient presented with symptoms of recurrent
claudication in June 2012 and underwent arteriography which showed occlusion of the bypass graft.
Patient underwent thrombolysis with TPA and with
24-hour infusion, establishing the patency of the
venous bypass. Since the vein was small in caliber, patient underwent balloon angioplasty and
placement of a covered stent GORE®VIABAHN®
Endoprosthesis (W.L.Gore, Newark, DE) 6mm
in diameter and 5cm long which was post-dilated
with a 6×4cm balloon (Fig.59.4). His postoperative course was uneventful, and he had a palpable
dorsalis pedis pulse. Noninvasive Doppler arterial
study showed normal dorsalis pedis pulse. Patient
Invited Commentary fromS.Keisin Wang, MD, andRaghu L.Motaganahalli, MD
medial layers. Popliteal artery adventitial cystic
disease typically presents in males (5:1) in their
early to mid-30s who complain of sudden onset of
short-distance claudication. The recovery time is
typically prolonged (= 20 mins) compared to
patients who have peripheral artery disease associated with symptoms of intermittent claudication. Conventional arteriography is the most
common imaging test performed; however, MRI
is an alternative noninvasive imaging modality.
The pathognomonic sign of adventitial cystic disease is scimitar sign [4–6]. However in one third
of cases, there is complete popliteal artery occlusion. Management of popliteal adventitial cyst
includes resection of the cystic segment with
autogenous graft. Resection with autogenous
Fig. 59.4 Following thrombolysis placement of covered
stent in the left popliteal artery
has been followed for the past 7 years without
any recurrence of symptoms. Patient has been
maintained on antiplatelet drugs (low-dose aspirin and clopidogrel).
Discussion
Popliteal artery adventitious cystic disease is a
non-atheromatous popliteal artery condition
which is rare but can cause symptoms ranging
from intermittent claudication to critical limb
ischemia. The disease is uncommon with more
recent articles citing approximately 600 cases.
Adventitious cystic disease was rst reported in
1947 involving the iliac artery; however, more
than 85% of the cases involve popliteal artery [1,
2]. Other arteries less commonly involved are the
external iliac and femoral, brachial, axillary, and
radial arteries. It is well established that this
pathology occurs in arteries lying adjacent to joint
space. Therefore, no unifying consensus on the
etiology of this disease process has been reached.
Many controversial hypotheses include repetitive
trauma theory, ganglion theory, systemic disorder
theory, and the developmental theory [3].
Adventitial cysts are lled with gelatinous mucoid
material between arterial adventitia and the
graft bypass has a 1% risk of recurrence [1]. Other
treatment modalities include image guided cyst
aspiration and transluminal angioplasty [4]. Cyst
aspiration is associated with high incidence of
recurrence of the lesion. Transluminal angioplasty
should be avoided as the cyst is located between
the media and the adventitia. The patient reported
in this chapter had thrombosis of the vein graft
most likely secondary to inadequate size of the
greater saphenous vein. Covered stent graft
(GORE®VIABAHN® Endoprosthesis) has
remained patent for the past 7 years.
Invited Commentary fromS.Keisin
Wang, MD, andRaghu
L.Motaganahalli, MD
Adventitial cystic disease (ACD) of the popliteal
artery, the target of over 80% of all cases, was not
described until the 1950s by Ejrup [7]. ACD is a
form of non-atheromatous arterial disease which
tends to afict nonsmoking patients out of the age
and risk factor range of those with peripheral arterial disease. As such, this rare diagnosis (<0.1% of
claudicants) is often missed until referral to the
appropriate specialist [8]. No consensus on the
pathophysiology is available, and multiple genesis theories have been proposed and debated.
Diagnosis can be conrmed with a combination
of duplex, CTA, MRA, and/or DSA depending on
ease and availability to the clinician. While it is
261
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59 Management ofaPatient withComplicated Adventitial Cystic Disease ofthePopliteal Artery
important to emphasize the pathognomonic presence of eccentric (“scimitar” sign) or concentric
(“hourglass” sign) compression of the arterial
lumen on imaging, ACD is often diagnosed without visualization of these signs secondary to the
availability of noninvasive duplex imaging.
The author in this chapter describes a longitudinal clinical experience with a 77-year-old male
recently diagnosed with ACD.This presentation
is atypical as subjects tend to present at a younger
age. A revascularization was offered given severe
lifestyle-limiting claudication in this nonsmoker,
and cyst resection and arterial interposition were
performed, perhaps with a marginal vein.
Reintervention was required in follow-up, but
secondary patency was maintained via thrombolysis and covered stenting after bypass thrombosis
due to conduit quality.
Consensus treatment recommendations are
limited by the scarcity of this pathology in the real
world. Because cyst formation occurs between
the tunica media and adventitia, angioplasty ±
stenting is not durable secondary to aggressive
elastic recoil, often within the rst postoperative
day. Similarly, cyst evacuation by aspiration has
been plagued by poor ability to achieve technical
success and disease recurrence. Therefore, complete resection and arterial replacement have
become the treatment of choice [9]. Recently, we
published a contemporary ACD series within the
auspices of the VLFDC compiling 47 patients
between 14 institutions [5]. As expected, claudication (93%) was the most common presenting
symptom, and the popliteal artery was the artery
most often affected (87%). Ultimately, 41 patients
underwent surgical intervention consisting of a
combination of techniques. Reintervention rate
was 18% over a mean follow-up of 20 months
with complete resection and interposition bypass
most predictive of freedom from reintervention
(p= 0.04). However unlike the durability of the
open revascularization, endovascular therapy is
yet to demonstrate durability and efcacy.
References
1. Desy NM, Spinner RJ, Cambria RP.The etiology and
management of cystic adventitial disease. J Vasc Surg.
2014;60(1):235–45.
2. Allemang MT, Kashyup VS.Adventitial cystic disease
of the popliteal artery. J Vasc Surg. 2015;62(2):290.
3. Levien LJ, Benn CA.Adventitial cystic disease: a unifying hypothesis. J Vasc Surg. 1998;28(2):193–205.
4. Paravastu SC, Regi JM, Turner DR, Graines PA. A
contemporary review of cystic adventitial disease.
Vasc Endovasc Surg. 2012;46:5–14.
5. Motagnahalli RL, Smeds MR, Harlander-Locke MP,
Lawrence PF. A multi-institutional experience in
adventitial cystic disease. J Vasc Surg. 2017;65:157–61.
6. Lezotte J, Le QP, Slanley C, Hans S.Adventitial cystic disease: complicated and uncomplicated. Ann Vasc
Surg. 2018;46:370–2.
7. Ejrup B, Hiertonn T.Intermittent claudication; three
cases treated by free vein graft. Acta Chir Scand.
1954;108(2–3):217–30.
8. Hernandez Mateo MM, Serrano Hernando FJ,
Martinez Lopez I, etal. Cystic adventitial degeneration
of the popliteal artery: report on 3 cases and review of
the literature. Ann Vasc Surg. 2014;28(4):1062–9.
9. Desy NM, Spinner RJ. The etiology and management of cystic adventitial disease. J Vasc Surg.
2014;60(1):235–45, 245.e231–211
Part XV
Popliteal Venous Pseudoaneurysm
and Arteriovenous Fistula