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Bypass to the Lateral Circumflex Femoral Artery
Bypass to the Lateral Circumflex Femoral Artery W a y n e S. G r a d m a n , M D , Los Angeles, California
Two patients with severe aortoiliac disease presented with total occlusion of all major femoral arteries, including the distal profunda femoris artery. Bypass to the lateral circumflex femoral artery, the most proximal branch of the profunda femoris artery, was successful in each patient. One patient had a bifurcated Dacron graft implanted from the aorta to the lateral circumflex femoral artery on each side. No sequential bypass to more distal vessels has since been necessary. The second patient underwent bypass to the lateral circumflex femoral artery from the contralateral femoral artery using saphenous vein. The procedure obviated the need to revise an above-knee amputation. The lateral circumflex femoral artery can provide suitable outflow in patients with thrombosis of the entire profunda femoris artery. (Ann Vasc Surg 1992; 6:344-346). KEY WORDS:
Femoral artery; bypass; aortoiliac disease.
profunda femoris artery. The left limb was anastomosed directly to the suprageniculate popliteal artery after a thorough exploration of the left groin revealed no vessel suitable for bypass. He was referred in 1985 with thrombosis of the right limb of the graft. At surgery the right proximal and distal profunda femoris arteries were calcified and occluded with organizing thrombus. A thrombectomy was attempted, but it was thought that the profunda runoff alone would not sustain a bypass graft. A 5 mm polytetrafluoroethylene ( P T F E ) j u m p graft was anastomosed from the distal limb of the graft to the L C F A . The left profunda femoris artery was occluded through its entire length. A short 5 mm PTFE jump graft was anastomosed t?om the adjacent functioning aortopopliteal bypass graft to the LCFA. Bilateral diminished femoral pulses were noted in 1989. but the patient refused artefiography. The entire graft thrombosed in early 1990, and he presented with severe bilateral pedal ischemia. No artefiogram was obtained. At surgery an inflow problem was documented, A new 16x8 mm Dacron graft was implanted end-to-side to the supraceliac aorta. Each limb of the new bifurcated graft was anastomosed to the LCFA, replacing the 5 mm PTFE jump grafts which were taken down. One year later, artefiography demonstrated a patent graft (Fig. 1), with no identifiable superficial or profunda femoris artery visualized on either side. The patient
B y p a s s to t h e c o m m o n , p r o f u n d a , o r superficial f e m o r a l a r t e r y h a s e m e r g e d as the p r e f e r r e d t r e a t ment for severe aortoiliac occlusive diseases, T w o p a t i e n t s with s e v e r e a o r t o i l i a c d i s e a s e p r e s e n t e d w i t h t o t a l o c c l u s i o n o f all m a j o r f e m o r a l a r t e r i e s , i n c l u d i n g the d i s t a l p r o f u n d a f e m o r i s art e r y . B y p a s s to t h e l a t e r a l c i r c u m f l e x f e m o r a l a r t e r y ( L C F A ) , a b r a n c h o f the p r o f u n d a f e m o r i s a r t e r y , w a s s u c c e s s f u l in e a c h p a t i e n t .
CASE REPORTS
Patient No. 1 In 1982 a 50-year-old man had a bifurcated aortic graft implanted. The right limb was anastomosed to a diseased
From the Department of Surgel3', Cedars-Sinai Medica/ Center, Los Angeles, California. Presented at the Tenth Annual Meeting of the Southern California Vascular Surgical Society, September 27-29, 1991, Marina Del Re3', California, Reprint requests: Wayne S. Gra~bnan, MD, 8631 West Third Street, Suite 545E, Los Angeles, Califi)rnia 90048. 344
VOLUME6 No 4 - 1992
B Y P A S S TO LA TERAL C I R C U M F L E X F E M O R A L
a
345
b
Fig. 1. (a) Bypass to right lateral circumflex femoral artery in Patient No. 1. (b) Bypass to left lateral circumflex femoral artery in Patient No. 1.
has not needed additional bypass surgew. The ankle-brachial index is 0.6.
Patient No. 2
A 52-year-old man was referred with an ischemic right above-knee amputation stump, He had previously undergone multiple attempts to revascularize the right lower extremity for occlusive disease of the iliac and femoral arteries. These procedures were followed by a belowknee amputation and, when that failed, an above-knee amputation. The patient refused revision of the above-knee amputation, An arteriogram demonstrated occlusion of the right common, external, and internal iliac arteries, as well as the common, superficial, and profunda femoris arteries. The descending branch of the LCFA, which fed from the ascending branch of the LCFA, was visualized. however (Fig. 2). At surgery the LCFA was fragile and readily went into spasm, but it accepted a 2.5 mm dilator. Reversed saphenous vein from the contralateral thigh was grafted from the left common femoral artery to the right LCFA. At the conclusion of the procedure there was good Doppler flow in the graft. The stump ischemia and pain abated promptly in the postoperative period. The patient now ambulates with a prosthesis.
DISCUSSION Patients often present with multilevel occlusive disease of the iliac and femoral arteries. In this setting, a bypass establishing flow to the proximal profunda femoris artery is the preferred treatment, and is almost always possible. When the proximal profunda femoris artery is also occluded, b y p a s s to the distal profunda femoris artery should then be considered [1,2]. Direct axillo- or aortopopliteal b y p a s s grafts are reserved for rare instances of groin infection or thrombotic obliteration of all femoral arteries [3], The p a t e n c y rate for such long grafts, h o w e v e r , is poor. Bypass to the hypogastric artery m a y be successful in selected cases [4]. Each patient described in this report had previously undergone multiple b y p a s s e s to revascularize the profunda femoris artery. Eventually, the entire profunda b e c a m e unsuitable for bypass. The L C F A remained patent, however, and served as an acceptable low-resistance target vessel. The L C F A arises from the lateral aspect of the profunda femoris artery [5]. In 20% of cases it arises separately from the c o m m o n femoral artery. The artery divides into three branches. The ascending
346
BYPASS TO LA TERAL CIRCUMFLEX FEMORAL
ANNALSOF VASCULAR SURGERY
b r a n c h f o r m s collaterals with the gluteal vessels. T h e small t r a n s v e r s e b r a n c h encircles the f e m u r to meet the c o r r e s p o n d i n g b r a n c h o f the medial circumflex femoral artery. The d e s c e n d i n g b r a n c h o f the L C F A d e s c e n d s along the vastus m u s c l e in a plane anterior to the profunda, It usually e x t e n d s the full length o f the thigh, supplying the local m u s c u l a t u r e . Distally, it a n a s t o m o s e s with the lateral superior genicular artery. T h e medial circumflex f e m o r a l artery does not have a d e s c e n d i n g b r a n c h . B y p a s s i n g it alone, without adding a sequential graft to a m o r e distal vessel, would p r o b a b l y not perfuse the foot satisfactorily, The L C F A is fragile and readily goes into spasm. S t a n d a r d fine v a s c u l a r surgical technique, including loupe magnification, was used to m a x i m i z e patency. Sequential grafts to m o r e distal vessels have not been n e c e s s a r y in Patient N o . 1, although he bec o m e s c l a u d i c a t o r y at t w o blocks. In s u m m a r y , the L C F A can serve as a suitable target vessel in patients with e x t e n s i v e p r o f u n d a femoris disease.
REFERENCES
Fig. 2. Arteriogram in Patient No. 2 showing ascending branch of lateral circumflex femoral artery supplying collateral circulation to descending branch of lateral circumflex femoral artery. B B B
I. OURIEL K, DEWEESE JA, RICOTTA J J. et al. Revascularization of the distal profunda femoris artery in the reconstructive treatment of aortoiliac occlusive disease. J Vase Surg 1987:6:217-220. 2. NUNEZ AA, VEITH FJ, COLLIER P, et al. Direct approaches 1o the distal portions of the deep femoral artery for limb salvage bypasses, J Vase Sur~, 1988:8:576-581. 3. ASCER E. VEITH FJ, GUPTA S. Axillopopliteal bypass grafting; indications, late results, and determinants of longterm patency. J Vase Stirs4 1989:10:285-291. 4. C1KRIT DF, O'DONNELL DM, DALSING MC, et al. Clinical implications of combined hypogastric and profunda femoral artery occlusion. Am J Sttrg, 1991;162:137-141. 5. CLEMENTE CD (ed). Gray's Textbook o f Anatomy. 30th American Edition. Philadelphia: Lea & Febiger, 1985: pp 767.
Two patients with severe aortoiliac disease presented with total occlusion of all major femoral arteries, including the distal profunda femoris artery. Bypass to the lateral circumflex femoral artery, the most proximal branch of the profunda femoris artery, was successful in each patient. One patient had a bifurcated Dacron graft implanted from the aorta to the lateral circumflex femoral artery on each side. No sequential bypass to more distal vessels has since been necessary. The second patient underwent bypass to the lateral circumflex femoral artery from the contralateral femoral artery using saphenous vein. The procedure obviated the need to revise an above-knee amputation. The lateral circumflex femoral artery can provide suitable outflow in patients with thrombosis of the entire profunda femoris artery. (Ann Vasc Surg 1992; 6:344-346). KEY WORDS:
Femoral artery; bypass; aortoiliac disease.
profunda femoris artery. The left limb was anastomosed directly to the suprageniculate popliteal artery after a thorough exploration of the left groin revealed no vessel suitable for bypass. He was referred in 1985 with thrombosis of the right limb of the graft. At surgery the right proximal and distal profunda femoris arteries were calcified and occluded with organizing thrombus. A thrombectomy was attempted, but it was thought that the profunda runoff alone would not sustain a bypass graft. A 5 mm polytetrafluoroethylene ( P T F E ) j u m p graft was anastomosed from the distal limb of the graft to the L C F A . The left profunda femoris artery was occluded through its entire length. A short 5 mm PTFE jump graft was anastomosed t?om the adjacent functioning aortopopliteal bypass graft to the LCFA. Bilateral diminished femoral pulses were noted in 1989. but the patient refused artefiography. The entire graft thrombosed in early 1990, and he presented with severe bilateral pedal ischemia. No artefiogram was obtained. At surgery an inflow problem was documented, A new 16x8 mm Dacron graft was implanted end-to-side to the supraceliac aorta. Each limb of the new bifurcated graft was anastomosed to the LCFA, replacing the 5 mm PTFE jump grafts which were taken down. One year later, artefiography demonstrated a patent graft (Fig. 1), with no identifiable superficial or profunda femoris artery visualized on either side. The patient
B y p a s s to t h e c o m m o n , p r o f u n d a , o r superficial f e m o r a l a r t e r y h a s e m e r g e d as the p r e f e r r e d t r e a t ment for severe aortoiliac occlusive diseases, T w o p a t i e n t s with s e v e r e a o r t o i l i a c d i s e a s e p r e s e n t e d w i t h t o t a l o c c l u s i o n o f all m a j o r f e m o r a l a r t e r i e s , i n c l u d i n g the d i s t a l p r o f u n d a f e m o r i s art e r y . B y p a s s to t h e l a t e r a l c i r c u m f l e x f e m o r a l a r t e r y ( L C F A ) , a b r a n c h o f the p r o f u n d a f e m o r i s a r t e r y , w a s s u c c e s s f u l in e a c h p a t i e n t .
CASE REPORTS
Patient No. 1 In 1982 a 50-year-old man had a bifurcated aortic graft implanted. The right limb was anastomosed to a diseased
From the Department of Surgel3', Cedars-Sinai Medica/ Center, Los Angeles, California. Presented at the Tenth Annual Meeting of the Southern California Vascular Surgical Society, September 27-29, 1991, Marina Del Re3', California, Reprint requests: Wayne S. Gra~bnan, MD, 8631 West Third Street, Suite 545E, Los Angeles, Califi)rnia 90048. 344
VOLUME6 No 4 - 1992
B Y P A S S TO LA TERAL C I R C U M F L E X F E M O R A L
a
345
b
Fig. 1. (a) Bypass to right lateral circumflex femoral artery in Patient No. 1. (b) Bypass to left lateral circumflex femoral artery in Patient No. 1.
has not needed additional bypass surgew. The ankle-brachial index is 0.6.
Patient No. 2
A 52-year-old man was referred with an ischemic right above-knee amputation stump, He had previously undergone multiple attempts to revascularize the right lower extremity for occlusive disease of the iliac and femoral arteries. These procedures were followed by a belowknee amputation and, when that failed, an above-knee amputation. The patient refused revision of the above-knee amputation, An arteriogram demonstrated occlusion of the right common, external, and internal iliac arteries, as well as the common, superficial, and profunda femoris arteries. The descending branch of the LCFA, which fed from the ascending branch of the LCFA, was visualized. however (Fig. 2). At surgery the LCFA was fragile and readily went into spasm, but it accepted a 2.5 mm dilator. Reversed saphenous vein from the contralateral thigh was grafted from the left common femoral artery to the right LCFA. At the conclusion of the procedure there was good Doppler flow in the graft. The stump ischemia and pain abated promptly in the postoperative period. The patient now ambulates with a prosthesis.
DISCUSSION Patients often present with multilevel occlusive disease of the iliac and femoral arteries. In this setting, a bypass establishing flow to the proximal profunda femoris artery is the preferred treatment, and is almost always possible. When the proximal profunda femoris artery is also occluded, b y p a s s to the distal profunda femoris artery should then be considered [1,2]. Direct axillo- or aortopopliteal b y p a s s grafts are reserved for rare instances of groin infection or thrombotic obliteration of all femoral arteries [3], The p a t e n c y rate for such long grafts, h o w e v e r , is poor. Bypass to the hypogastric artery m a y be successful in selected cases [4]. Each patient described in this report had previously undergone multiple b y p a s s e s to revascularize the profunda femoris artery. Eventually, the entire profunda b e c a m e unsuitable for bypass. The L C F A remained patent, however, and served as an acceptable low-resistance target vessel. The L C F A arises from the lateral aspect of the profunda femoris artery [5]. In 20% of cases it arises separately from the c o m m o n femoral artery. The artery divides into three branches. The ascending
346
BYPASS TO LA TERAL CIRCUMFLEX FEMORAL
ANNALSOF VASCULAR SURGERY
b r a n c h f o r m s collaterals with the gluteal vessels. T h e small t r a n s v e r s e b r a n c h encircles the f e m u r to meet the c o r r e s p o n d i n g b r a n c h o f the medial circumflex femoral artery. The d e s c e n d i n g b r a n c h o f the L C F A d e s c e n d s along the vastus m u s c l e in a plane anterior to the profunda, It usually e x t e n d s the full length o f the thigh, supplying the local m u s c u l a t u r e . Distally, it a n a s t o m o s e s with the lateral superior genicular artery. T h e medial circumflex f e m o r a l artery does not have a d e s c e n d i n g b r a n c h . B y p a s s i n g it alone, without adding a sequential graft to a m o r e distal vessel, would p r o b a b l y not perfuse the foot satisfactorily, The L C F A is fragile and readily goes into spasm. S t a n d a r d fine v a s c u l a r surgical technique, including loupe magnification, was used to m a x i m i z e patency. Sequential grafts to m o r e distal vessels have not been n e c e s s a r y in Patient N o . 1, although he bec o m e s c l a u d i c a t o r y at t w o blocks. In s u m m a r y , the L C F A can serve as a suitable target vessel in patients with e x t e n s i v e p r o f u n d a femoris disease.
REFERENCES
Fig. 2. Arteriogram in Patient No. 2 showing ascending branch of lateral circumflex femoral artery supplying collateral circulation to descending branch of lateral circumflex femoral artery. B B B
I. OURIEL K, DEWEESE JA, RICOTTA J J. et al. Revascularization of the distal profunda femoris artery in the reconstructive treatment of aortoiliac occlusive disease. J Vase Surg 1987:6:217-220. 2. NUNEZ AA, VEITH FJ, COLLIER P, et al. Direct approaches 1o the distal portions of the deep femoral artery for limb salvage bypasses, J Vase Sur~, 1988:8:576-581. 3. ASCER E. VEITH FJ, GUPTA S. Axillopopliteal bypass grafting; indications, late results, and determinants of longterm patency. J Vase Stirs4 1989:10:285-291. 4. C1KRIT DF, O'DONNELL DM, DALSING MC, et al. Clinical implications of combined hypogastric and profunda femoral artery occlusion. Am J Sttrg, 1991;162:137-141. 5. CLEMENTE CD (ed). Gray's Textbook o f Anatomy. 30th American Edition. Philadelphia: Lea & Febiger, 1985: pp 767.