Creation of an Arterialized Cephalic Vein as Autologous Bypass for Below-Knee Reconstruction in Critical Limb Ischemia

Accepted Manuscript Creation of an arterialized cephalic vein as autologous bypass for below-kneereconstruction in critical limb ischemia Thermann F PII:

S0890-5096(18)30193-6

DOI:

10.1016/j.avsg.2017.12.019

Reference:

AVSG 3748

To appear in:

Annals of Vascular Surgery

Received Date: 26 November 2017 Revised Date:

11 December 2017

Accepted Date: 26 December 2017

Please cite this article as: F T, Creation of an arterialized cephalic vein as autologous bypass for below-knee-reconstruction in critical limb ischemia, Annals of Vascular Surgery (2018), doi: 10.1016/ j.avsg.2017.12.019. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Creation of an arterialized cephalic vein as autologous bypass for below-knee-reconstruction

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in critical limb ischemia

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Thermann F

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Carl-von-Basedow-Hospital Merseburg

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Teaching Hospital of the University Halle-Wittenberg

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Weiße Mauer 52

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06217 Merseburg

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Germany

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correspondent author:

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Thermann Florian, MD

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Head of department of Vascular surgery, Carl-von-Basedow-Hospital Merseburg

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Weiße Mauer 52

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06217 Merseburg

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Germany

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phone: +49-3461-273101

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fax:

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+49-3461-273102

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conflict of interests: none

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The patients consented to publishing this report.

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ACCEPTED MANUSCRIPT Abstract

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Two cases of below- knee-bypasses using an arterialized cephalic vein are presented. Both

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patients had critical ischemia but no greater or lesser saphenous veins were useable.

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According to ultrasound, the cephalic veins were thin but regularly positioned. Four weeks

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after wrist fistula was created, ultrasound showed adequate maturation and the bypass

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operations were performed. Both patients had uneventful courses and were discharged

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after a few days with patent bypasses since then (35 and 18 months). As this report shows,

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creation of a fistula can be a useful option to gain autologous bypass material in case of

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critical limb ischemia.

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ACCEPTED MANUSCRIPT Introduction

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Among vascular surgeons there is general consensus on the fact that in cases of below-knee

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bypass reconstructions autologous material is preferred to grafts for reasons of better

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patency and lower infection rates [1]. However, autologous material is rarely available;

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either because the greater saphenous vein (GSV) has already been used for other

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reconstructive operations or it was removed due to varicosis or its diameter is not sufficient

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for the use of a bypass; similarly, the lesser saphenous vein (LSV) may be either not long

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enough or of insufficient caliber. The deep femoral vein can be used also, but firstly the

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preparing is much more invasive and secondly its length is not sufficient for a below-knee-

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reconstruction. As another alternative the use of the cephalic vein has been described [2-4];

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however, often it is a vein of small caliber (lower arm) and with a more vulnerable wall

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compared to the veins of the leg. Furthermore its length is sometimes not sufficient for a

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below-knee-reconstruction [4].

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The use of a matured fistula vein as alternative bypass option has been described before [5;

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6] but has not actually played a role in autologous bypass creation since. In our own vascular

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center we have performed two bypass operations using a fistula vein of the arm. The aim of

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this report is to give an idea in which situations fistula bypasses might be a useful option in

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critical ischemia in order to widen the options for creating an autologous bypass.

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Surgical procedure

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For the bypass operations we used two teams. Accordingly, in both patients we could

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harvest the fistula vein and open the situs at the leg at the same time. After tunneling and

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pulling through the vein in a reversed manner, anastomoses were created simultaneously.

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Afterwards angiography was performed. Both patients were put on coumarins as we do in

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every patient undergoing below-knee-bypass.

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Patient one

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An 80 years old patient who was in good health had pain at rest. Further diseases:

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Hypertension, chronic kidney disease stage III. Angiography revealed obliteration of the

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tibiofibular trunc. The right GSV had been used for cardiac surgery; the GSV of the left leg

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was, as well as both LSV, of insufficient caliber (<0.2cm; preoperative ultrasound).

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Interestingly, the patient had a wrist fistula of the left arm created 10 years previously due

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to anticipated need for hemodialysis, which subsequently had not been necessary. The

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fistula vein was well matured along the lower and upper arm (0.40 – 0.45 cm) which gave us

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the idea of using it as a bypass vein (figure 1-3).

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Postoperatively, there was a regular course of events. The renal parameters were stable

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without any deterioration. The patient was discharged on post-operation-day (POD) twelve.

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The bypass has remained patent since then (35 months post-op).

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Patient two

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A 60 year old male had pain at rest for several weeks. Besides hypertension he suffered from

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no further diseases. Imaging revealed obliteration including the popliteal artery. Below-knee

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reconstruction was necessary. None of the epifascial veins (GSV, LSV) were useable. The

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cephalic vein of the left arm had a caliber of 0.20-0.25 cm with a regular anatomy from wrist

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to shoulder so we considered it matureable by arterialization. The pain could be controlled

ACCEPTED MANUSCRIPT by painkillers. Creation of the fistula was performed as a regular wrist fistula four weeks

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prior to the bypass-operation. By the time of the operation the caliber of the fistula vein had

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grown to 0.45 cm (figure 4). The course of events following surgery was uncomplicated and

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the patient could be discharged at POD ten. The bypass remains patent (18 months post-op).

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Post-op Duplex ultrasound shows the distal anastomosis (figure 5).

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ACCEPTED MANUSCRIPT Discussion

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We generally use the GSV or the LSV; if necessary we create spliced veins in order to gain the

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necessary length for a crural bypass. The deep femoral vein (DFV) we find too short and of a

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caliber which is too wide to use as bypass-option for below knee reconstructions.

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Furthermore the harvesting is more onerous than in superficial veins. We use the DFV in

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case of infection of grafts especially in the groin.

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Creating a fistula first in order to develop a useable bypass vein has scarcely been reported

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before [5; 6]. Before using the Cephalic vein (CV), of course it has to be considered that the

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patient needs an additional operation (even though it may be a small one) and that in case

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of necessary hemodialysis in the future there are less options for access. Furthermore the CV

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can either be too short for a bypass or of atypical configuration (draining into the basilic

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vein, no regular anatomy regarding length or location) [4]. Consequently, the vein should not

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be used in such cases. Another disadvantage is that in cases of critical ischemia, patients

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usually cannot wait for another 4-5 weeks until the vein is adequately matured for the

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bypass-operation. On the other hand, creating a fistula first can make a CV useable for

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bypass surgery which often is not the case in “unprepared” CV (small caliber, thin wall [4]).

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Furthermore, the direction of maturation (from distal to proximal) makes the vein perfectly

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shaped for a bypass (large caliber at the proximal anastomosis) so avoiding a caliber

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mismatch.

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As others do we perform a meticulous ultrasound investigation preoperatively in order to

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describe and judge the epifascial veins with the aim of avoiding graft material. In the two

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cases described, using the CV after the creation of an AV-fistula was a very good option that

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made it possible to perform below-knee-reconstructions without using prosthetic grafts. In

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both cases, the course of events was uncomplicated.

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ACCEPTED MANUSCRIPT As the length of the CV is limited, it may be necessary to adapt the operative technique

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accordingly; in patient two we performed a distal origin bypass to reduce the needed

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distance.

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Naturally, the decision for this special procedure cannot be made for every patient; on the

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contrary, we think that only in few patients (need for below knee-reconstruction; no

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epifascial veins; time frame for arterial reconstruction within 4-5 weeks) is this kind of

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bypass-creation suitable.

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The question remains why this technique has been forgotten over the last decades. Among

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the reasons are the creation of better graft prostheses (heparin bonded, preformed cuff,

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tapered grafts, etc.) with improved patency rates compared to former grafts, which may

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have left behind the urgent need for more complicated ways of creating autologuous

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bypasses, supported by the respective companies [7]. However, we think that every vascular

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surgeon should know and keep in mind as many techniques as possible, including the one

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described by this case report.

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References

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1. Londrey GL, Ramsey DE, Hodgson K J, Barkmeier LD, Sumner DS. Infrapopliteal bypass for

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severe ischemia: comparison of autogenous vein, composite, and prosthetic grafts. J Vasc

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Surg 1991;13:631–6

2. Arvela E, Söderström M, Albäck A, Aho PS, Venermo M, Lepäntalo M. Arm vein

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conduit vs. prosthetic graft in infrainguinal revascularization for critical leg ischemia. J

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Vasc Surg 2010 Sept; 52: 616-23

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3. Browning N, Zammit M, Rodriguez D, Sauvage L, Loudenback D, Raghavan A. Use of

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arm veins for lower extremity arterial bypass – results, anatomical features and

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4. Dae-Joon Park, Yang-Jin Park, Kyoung Won Yoon, Seon-Hee Heo, Dong-Ik Kim, Young-

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Wook Kim. Lower Extremity Arterial Bypass with Arm Vein Conduits and Literature

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note: the use of arterialized arm veins in infrainguinal bypass. Acta Chir Belg 1995;

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6. Stefanov G, Cheshmedzh M, Andreev A, Denchev B, et al. Arterialized cephalic vein as

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a femoropopliteal bypass graft: A case report. Int J Angiol. 2007 Winter;16(4):146-8.

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7. Avgerinos E, Sachdey U, Naddaf A, Doucet D, Mohapatra A, Leers S, et al.

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Autologuous alternative veins may not provide better outcomes than prosthetic

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conduits for below-knee-bypass when GSV is unavailable. J Vasc Surg 2015; 62: 385-

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ACCEPTED MANUSCRIPT Figure legends figure 1 Patient 1: fistula vein of the left arm marked preoperatively

Patient 1: anatomy of the distal situs

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Patient 2: prepared vein: before use as below knee bypass

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Patient 1: intraoperative angiography depicting the distal anastomosis

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Patient 2: Duplex ultrasound of the distal anastomosis (ATA = tibial anterior artery)

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