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Hybrid Approach to Limb Salvage in the Setting of an Infected Femoral–Femoral Bypass Graft
Case Report Hybrid Approach to Limb Salvage in the Setting of an Infected FemoraleFemoral Bypass Graft Douglas W. Jones, Andrew J. Meltzer, and Darren B. Schneider, New York, New York
Prosthetic vascular graft infection in patients with advanced peripheral arterial disease can lead to multiple additional procedures, including extra-anatomic bypass or even amputation. We report the case of an 88-year-old woman with critical limb ischemia and an infected prosthetic femoralefemoral bypass graft. Using a planned hybrid 2-stage approach, we performed endovascular recanalization of the native left iliac arterial system using remote access via the superficial femoral artery to avoid infected groin wounds. Recanalization of the patient’s Trans-Atlantic Inter-Society Consensus II D chronic iliac occlusion allowed for removal of the infected graft and placement of a profunda femoris artery to proximal posterior tibial artery bypass, thereby restoring inflow and avoiding the infected left groin. Newer endovascular techniques coupled with open surgical options may lead to limb salvage in patients with previously unreconstructable peripheral arterial disease.
CASE REPORT An 88-year-old woman was admitted with a prosthetic femoralefemoral bypass graft infection, recently placed for critical left lower extremity ischemia (Rutherford Class 5). Her medical history was significant for atrial fibrillation, coronary artery disease, diabetes mellitus, obesity, and a benign pelvic sarcoma. She had also previously undergone coronary artery bypass grafting. Examination was notable for a 1.5-cm ulcer over the posterior left heel with exposed Achilles tendon and purulent drainage from bilateral groin incisions. One month before, she underwent angiography, demonstrating multilevel occlusive disease from the left common iliac to posterior tibial artery. She subsequently underwent right common femoral endarterectomy and
Department of Vascular and Endovascular Surgery, New York Presbyterian Hospital, Weill-Cornell Medical Center, New York, NY. Correspondence to: Douglas W. Jones, MD, Department of Surgery, New York Presbyterian Hospital, Weill-Cornell Medical Center, 525 East 68th Street, New York, NY 10065, USA; E-mail: [email protected] Ann Vasc Surg 2014; -: 1–5 http://dx.doi.org/10.1016/j.avsg.2014.01.014 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: September 11, 2013; manuscript accepted: January 8, 2014; published online: ---.
right-to-left femoralefemoral bypass with 8 mm externally supported polytetrafluoroethylene graft at our institution. Postoperatively, she was discharged to a rehabilitation facility where she developed persistent drainage from bilateral nonhealing groin incisions. Cultures of the fluid grew Escherichia coli, Proteus mirabilis, Enterococcus faecalis, and Bacteroides fragilis. She was readmitted and started on broad spectrum IV antibiotics. A computed tomography scan was obtained which showed fat stranding around the femoralefemoral bypass as well as a 2.8-cm fluid collection in the left groin adjacent to the bypass graft (Fig. 1). She had no evidence of healing of her ankle ulceration. A monophasic Doppler signal was detected over her left posterior tibial artery. To treat her prosthetic graft infection and revascularize her left lower extremity, a hybrid 2-stage treatment plan was developed, involving: (1) repeat attempt of percutaneous recanalization of her native left iliac arteries and then (2) removal of the infected femoralefemoral bypass graft and left lower extremity distal bypass to the posterior tibial artery. The goals of this treatment plan were to provide durable blood flow to the foot to allow wound healing, while minimizing the risk of persistent infection. To avoid the infected left groin wound, the left superficial femoral artery (SFA) was accessed percutaneously just proximal to where it became occluded in the mid thigh with a micropuncture system under ultrasound guidance.
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2 Case Report
Annals of Vascular Surgery
Fig. 1. CT scan obtained following femoralefemoral bypass. (A) CT reconstruction shows the femorale femoral bypass. (B) Axial view through the area of the right femoral anastomosis shows groin defect and pockets
of air, indicated by arrow. (C) In the left groin, a fluid collection surrounding the graft is seen, indicated by arrow. CT, computed tomography.
Using a stiff-angled glidewire (Terumo, Boston, MA), the left external iliac artery (EIA) and common iliac artery (CIA) occlusions were crossed retrograde in a subintimal dissection plane, but reentry into the aorta could not be achieved using standard wire and catheter manipulations. An attempt at aortic reentry was made with the Outback Reentry device (Cordis, Bridgewater, NJ), but the device could not be passed secondary to heavy calcification. From a left brachial artery approach, antegrade access was gained to the occluded left CIA and a stiff-angled glidewire was able to be passed into a subintimal dissection plane in the CIA. The antegrade wire was manipulated into a sheath that had been placed from the left SFA, creating brachialefemoral through wire access. After predilatation, an 8 mm 38 mm iCast (Atrium, Hudson, NH) balloon-expandable covered stent was placed at the origin of the left CIA, then two 7 mm 5 cm Viabahn (W.L. Gore, Flagstaff, AZ) covered stents were placed distally (Fig. 2). An additional 8 mm 60 mm Everflex bare metal stent (ev3, Plymouth, MN) was placed distally, extending the stented area to the left proximal common femoral artery and avoiding placement of a covered stent close to an area of active infection. Completion angiogram showed successful revascularization of the left iliac arteries with excellent flow through the left CIA and EIA stents (Fig. 3). Because the SFA was chronically occluded distal to our access site, a single 0.03500 Tornado coil (Cook Medical, Bloomington, IN) was deployed for hemostasis as the sheath was removed.
Two days later, the infected femoralefemoral graft excised and the common femoral arteries were repaired by patch angioplasty using saphenous vein. A left profunda femoris artery to proximal posterior tibial artery bypass was performed with reversed greater saphenous vein. A right rectus femoris flap and left sartorius flap were mobilized for coverage of bilateral groins. She received a 2-week course of intravenous antibiotics. At 2 months follow-up, she was seen in the office and surveillance duplex ultrasonography showed elevated velocities in her bypass graft. An angiogram was performed which showed a patent graft with a 2-cm mid-graft stenosis. This was treated with balloon angioplasty with good result (Fig. 4). The patient has had no recurrence of claudication or rest pain. The left ankle wound has healed with wound care and a split-thickness skin graft.
DISCUSSION Combined endovascular and open surgical techniques (hybrid procedures) have come to play an increasingly important role in the treatment of multilevel lower extremity atherosclerotic disease.1,2 Techniques for multiple forms of combined peripheral procedures are well described.3e7 Typically, endovascular techniques have been employed to treat proximal stenoses in an effort to improve
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2014
Case Report 3
Fig. 2. (A) Multiple stents placed into native left CIA to reestablish flow. (B) Angiography following stent placement shows restoration of flow.
Fig. 3. (A) Completion angiogram showing restoration of flow from the aorta to the left CFA and (B) an isolated view showing a patent left profunda femoris artery.
inflow to a bypass graft, thereby eliminating the additional morbidity associated with open procedures on the more proximal (typically aortoiliac) segment. Despite early skepticism regarding this approach, combined techniques have yielded favorable outcomes.8,9 This case highlights the utility of a staged, hybrid approach in the management of a patient with critical limb ischemia and prosthetic femoralefemoral graft infection. The unique aspects of this case included the use of remote access via the SFA to avoid the infected groin wounds and percutaneous recanalization of a Trans-Atlantic Inter-Society Consensus (TASC) II D chronic iliac occlusion to allow removal of an infected prosthetic graft.
When the common femoral artery cannot be accessed percutaneously because of infection, arterial disease, or scarring, the brachial artery is a common second choice but may not be ideal in lower extremity interventions because of distance.10 Percutaneous access using the SFA was described in the early endovascular experience when a cohort of 5 patients with failed or failing aortoiliofemoral reconstructions were treated with endovascular techniques.11 In 4 instances, the SFA was accessed and, in a retrograde fashion, either the native iliac system was recanalized or the failing graft was recanalized. Since then, some have used the SFA for antegrade intervention12e14 especially in the presence of a ‘‘hostile groin.’’15 However, retrograde
4 Case Report
Annals of Vascular Surgery
Fig. 4. Increased velocities on postoperative surveillance duplex ultrasonography prompted this angiogram which shows good proximal (A) and distal (B) flow through the
profunda femoriseposterior tibial artery bypass. Previously placed SFA coil is indicated by arrow.
access of the SFA is not commonly employed. Disadvantages to this approach include artery size limitations and the lack of reliable techniques for arterial closure, sometimes necessitating open arterial exposure. In fact, inadvertent puncture of the SFA is implicated as a major contributor to the development of pseudoaneurysm or arteriovenous fistula following attempted CFA access.16 In this case, the SFA was chosen for access because of the patients’ active groin infection. Access was gained using a micropuncture needle under ultrasound guidance and, in a retrograde fashion, the ipsilateral iliofemoral occlusion was crossed subintimally. Using this technique, combined with brachial access, inflow was restored to the profunda femoris artery, the origin of the planned bypass graft. The coil that was placed in the SFA upon completion assured hemostasis in the occluded SFA. One of the most feared complications in bypass surgery is prosthetic vascular graft infection, occurring in 1e3% of patients.17,18 Graft excision is nearly always required as partial removal leads to a high rate of persistent sepsis.19 This can present unique challenges in a patient with ongoing limb ischemia who is already proven to have severe native vessel disease. As endovascular techniques have advanced and more severe iliac lesions are being managed endovascularly (TASC C and D),20
treatment of native vessel disease has become a viable alternative to extra-anatomic bypass. In one report, 2 patients with prosthetic vascular graft infections underwent successful endovascular native vessel recanalization and graft excision to maintain limb perfusion and have had good clinical results.21 In our case, the patient required lower extremity bypass for limb salvage, but had no appropriate inflow. The presence of an infected groin added complexity because it precluded the use of the left groin, especially as the origin of a new bypass graft. In using remote access to treat the native iliofemoral disease and by choosing the profunda femoris as the new graft origin, the infected field was avoided entirely. This case highlights the use of a hybrid approach in a patient with critical limb ischemia and prosthetic graft infection. With a combination of creative endovascular and open surgical techniques, revascularization from the aorta to posterior tibial artery was performed, permitting wound healing and facilitating the excision of the infected femoralefemoral bypass graft. Of particular interest is our use of retrograde access of the SFA to recanalize an occluded iliac system. This technique is not commonly described and was essential in performing this procedure. In addition, this case highlights the importance of careful preoperative planning for staged
Vol.
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No.
-, -
2014
procedures, which, in this case, permitted a novel approach to a complex constellation of problems, leading to a favorable outcome. REFERENCES 1. Ebaugh JL, Gagnon D, Owens CD, et al. Comparison of costs of staged versus simultaneous lower extremity arterial hybrid procedures. Am J Surg 2008;196:634e40. 2. Dosluoglu HH, Lall P, Cherr GS, et al. Role of simple and complex hybrid revascularization procedures for symptomatic lower extremity occlusive disease. J Vasc Surg 2010;51:1425e35.e1. 3. Schneider PA. Iliac angioplasty and stenting in association with infrainguinal bypasses: timing and techniques. Semin Vasc Surg 2003;16:291e9. 4. Schneider PA, Caps MT, Ogawa DY, et al. Intraoperative superficial femoral artery balloon angioplasty and popliteal to distal bypass graft: an option for combined open and endovascular treatment of diabetic gangrene. J Vasc Surg 2001;33:955e62. 5. Reed AB. Hybrid procedures and distal origin grafts. Semin Vasc Surg 2009;22:240e4. 6. Slovut DP, Sullivan TM. Combined endovascular and open revascularization. Ann Vasc Surg 2009;23:414e24. 7. Slovut DP, Sullivan TM. Critical limb ischemia: medical and surgical management. Vasc Med 2008;13:281e91. 8. Chang RW, Goodney PP, Baek JH, et al. Long-term results of combined common femoral endarterectomy and iliac stenting/ stent grafting for occlusive disease. J Vasc Surg 2008;48:362e7. 9. Dougherty MJ, Young LP, Calligaro KD. One hundred twentyfive concomitant endovascular and open procedures for lower extremity arterial disease. J Vasc Surg 2003;37:316e22. 10. Schneider PA. Superficial Femoral Artery Access for Endovascular Procedures: When the Common Femoral Cannot Be Used Due to Scarring, Disease, or Infection. in VEITH symposium (New York, NY, 2009).
Case Report 5
11. Sanchez LA, Marin ML, Veith FJ, et al. Placement of endovascular stented grafts via remote access sites: a new approach to the treatment of failed aortoiliofemoral reconstructions. Ann Vasc Surg 1995;9:1e8. 12. Berman HL, Katz SG, Tihansky DP. Guided direct antegrade puncture of the superficial femoral artery. AJR Am J Roentgenol 1986;147:632e4. 13. Gutzeit A, Schoch E, Sautter T, et al. Antegrade access to the superficial femoral artery with ultrasound guidance: feasibility and safety. J Vasc Interv Radiol 2010;21:1495e500. 14. Gutzeit A, Graf N, Schoch E, et al. Ultrasound-guided antegrade femoral access: comparison between the common femoral artery and the superficial femoral artery. Eur Radiol 2011;21:1323e8. 15. Marcus AJ, Lotzof K, Howard A. Access to the superficial femoral artery in the presence of a ‘‘hostile groin’’: a prospective study. Cardiovasc Intervent Radiol 2007;30:351e4. 16. Kim D, Orron DE, Skillman JJ, et al. Role of superficial femoral artery puncture in the development of pseudoaneurysm and arteriovenous fistula complicating percutaneous transfemoral cardiac catheterization. Cathet Cardiovasc Diagn 1992;25:91e7. 17. Liekweg WG Jr, Greenfield LJ. Vascular prosthetic infections: collected experience and results of treatment. Surgery 1977;81:335e42. 18. Edwards WH Jr, Martin RS 3rd, Jenkins JM, et al. Primary graft infections. J Vasc Surg 1987;6:235e9. 19. Mertens RA, O’Hara PJ, Hertzer NR, et al. Surgical management of infrainguinal arterial prosthetic graft infections: review of a thirty-five-year experience. J Vasc Surg 1995;21:782e90; discussion, 790e1. 20. Leville CD, Kashyap VS, Clair DG, et al. Endovascular management of iliac artery occlusions: extending treatment to TransAtlantic Inter-Society Consensus class C and D patients. J Vasc Surg 2006;43:32e9. 21. Erzurum VZ, Clair D. Endovascular native vessel recanalization to maintain limb perfusion after infected prosthetic vascular graft excision. J Vasc Surg 2005;41:332e6.
Prosthetic vascular graft infection in patients with advanced peripheral arterial disease can lead to multiple additional procedures, including extra-anatomic bypass or even amputation. We report the case of an 88-year-old woman with critical limb ischemia and an infected prosthetic femoralefemoral bypass graft. Using a planned hybrid 2-stage approach, we performed endovascular recanalization of the native left iliac arterial system using remote access via the superficial femoral artery to avoid infected groin wounds. Recanalization of the patient’s Trans-Atlantic Inter-Society Consensus II D chronic iliac occlusion allowed for removal of the infected graft and placement of a profunda femoris artery to proximal posterior tibial artery bypass, thereby restoring inflow and avoiding the infected left groin. Newer endovascular techniques coupled with open surgical options may lead to limb salvage in patients with previously unreconstructable peripheral arterial disease.
CASE REPORT An 88-year-old woman was admitted with a prosthetic femoralefemoral bypass graft infection, recently placed for critical left lower extremity ischemia (Rutherford Class 5). Her medical history was significant for atrial fibrillation, coronary artery disease, diabetes mellitus, obesity, and a benign pelvic sarcoma. She had also previously undergone coronary artery bypass grafting. Examination was notable for a 1.5-cm ulcer over the posterior left heel with exposed Achilles tendon and purulent drainage from bilateral groin incisions. One month before, she underwent angiography, demonstrating multilevel occlusive disease from the left common iliac to posterior tibial artery. She subsequently underwent right common femoral endarterectomy and
Department of Vascular and Endovascular Surgery, New York Presbyterian Hospital, Weill-Cornell Medical Center, New York, NY. Correspondence to: Douglas W. Jones, MD, Department of Surgery, New York Presbyterian Hospital, Weill-Cornell Medical Center, 525 East 68th Street, New York, NY 10065, USA; E-mail: [email protected] Ann Vasc Surg 2014; -: 1–5 http://dx.doi.org/10.1016/j.avsg.2014.01.014 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: September 11, 2013; manuscript accepted: January 8, 2014; published online: ---.
right-to-left femoralefemoral bypass with 8 mm externally supported polytetrafluoroethylene graft at our institution. Postoperatively, she was discharged to a rehabilitation facility where she developed persistent drainage from bilateral nonhealing groin incisions. Cultures of the fluid grew Escherichia coli, Proteus mirabilis, Enterococcus faecalis, and Bacteroides fragilis. She was readmitted and started on broad spectrum IV antibiotics. A computed tomography scan was obtained which showed fat stranding around the femoralefemoral bypass as well as a 2.8-cm fluid collection in the left groin adjacent to the bypass graft (Fig. 1). She had no evidence of healing of her ankle ulceration. A monophasic Doppler signal was detected over her left posterior tibial artery. To treat her prosthetic graft infection and revascularize her left lower extremity, a hybrid 2-stage treatment plan was developed, involving: (1) repeat attempt of percutaneous recanalization of her native left iliac arteries and then (2) removal of the infected femoralefemoral bypass graft and left lower extremity distal bypass to the posterior tibial artery. The goals of this treatment plan were to provide durable blood flow to the foot to allow wound healing, while minimizing the risk of persistent infection. To avoid the infected left groin wound, the left superficial femoral artery (SFA) was accessed percutaneously just proximal to where it became occluded in the mid thigh with a micropuncture system under ultrasound guidance.
1
2 Case Report
Annals of Vascular Surgery
Fig. 1. CT scan obtained following femoralefemoral bypass. (A) CT reconstruction shows the femorale femoral bypass. (B) Axial view through the area of the right femoral anastomosis shows groin defect and pockets
of air, indicated by arrow. (C) In the left groin, a fluid collection surrounding the graft is seen, indicated by arrow. CT, computed tomography.
Using a stiff-angled glidewire (Terumo, Boston, MA), the left external iliac artery (EIA) and common iliac artery (CIA) occlusions were crossed retrograde in a subintimal dissection plane, but reentry into the aorta could not be achieved using standard wire and catheter manipulations. An attempt at aortic reentry was made with the Outback Reentry device (Cordis, Bridgewater, NJ), but the device could not be passed secondary to heavy calcification. From a left brachial artery approach, antegrade access was gained to the occluded left CIA and a stiff-angled glidewire was able to be passed into a subintimal dissection plane in the CIA. The antegrade wire was manipulated into a sheath that had been placed from the left SFA, creating brachialefemoral through wire access. After predilatation, an 8 mm 38 mm iCast (Atrium, Hudson, NH) balloon-expandable covered stent was placed at the origin of the left CIA, then two 7 mm 5 cm Viabahn (W.L. Gore, Flagstaff, AZ) covered stents were placed distally (Fig. 2). An additional 8 mm 60 mm Everflex bare metal stent (ev3, Plymouth, MN) was placed distally, extending the stented area to the left proximal common femoral artery and avoiding placement of a covered stent close to an area of active infection. Completion angiogram showed successful revascularization of the left iliac arteries with excellent flow through the left CIA and EIA stents (Fig. 3). Because the SFA was chronically occluded distal to our access site, a single 0.03500 Tornado coil (Cook Medical, Bloomington, IN) was deployed for hemostasis as the sheath was removed.
Two days later, the infected femoralefemoral graft excised and the common femoral arteries were repaired by patch angioplasty using saphenous vein. A left profunda femoris artery to proximal posterior tibial artery bypass was performed with reversed greater saphenous vein. A right rectus femoris flap and left sartorius flap were mobilized for coverage of bilateral groins. She received a 2-week course of intravenous antibiotics. At 2 months follow-up, she was seen in the office and surveillance duplex ultrasonography showed elevated velocities in her bypass graft. An angiogram was performed which showed a patent graft with a 2-cm mid-graft stenosis. This was treated with balloon angioplasty with good result (Fig. 4). The patient has had no recurrence of claudication or rest pain. The left ankle wound has healed with wound care and a split-thickness skin graft.
DISCUSSION Combined endovascular and open surgical techniques (hybrid procedures) have come to play an increasingly important role in the treatment of multilevel lower extremity atherosclerotic disease.1,2 Techniques for multiple forms of combined peripheral procedures are well described.3e7 Typically, endovascular techniques have been employed to treat proximal stenoses in an effort to improve
Vol.
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No.
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2014
Case Report 3
Fig. 2. (A) Multiple stents placed into native left CIA to reestablish flow. (B) Angiography following stent placement shows restoration of flow.
Fig. 3. (A) Completion angiogram showing restoration of flow from the aorta to the left CFA and (B) an isolated view showing a patent left profunda femoris artery.
inflow to a bypass graft, thereby eliminating the additional morbidity associated with open procedures on the more proximal (typically aortoiliac) segment. Despite early skepticism regarding this approach, combined techniques have yielded favorable outcomes.8,9 This case highlights the utility of a staged, hybrid approach in the management of a patient with critical limb ischemia and prosthetic femoralefemoral graft infection. The unique aspects of this case included the use of remote access via the SFA to avoid the infected groin wounds and percutaneous recanalization of a Trans-Atlantic Inter-Society Consensus (TASC) II D chronic iliac occlusion to allow removal of an infected prosthetic graft.
When the common femoral artery cannot be accessed percutaneously because of infection, arterial disease, or scarring, the brachial artery is a common second choice but may not be ideal in lower extremity interventions because of distance.10 Percutaneous access using the SFA was described in the early endovascular experience when a cohort of 5 patients with failed or failing aortoiliofemoral reconstructions were treated with endovascular techniques.11 In 4 instances, the SFA was accessed and, in a retrograde fashion, either the native iliac system was recanalized or the failing graft was recanalized. Since then, some have used the SFA for antegrade intervention12e14 especially in the presence of a ‘‘hostile groin.’’15 However, retrograde
4 Case Report
Annals of Vascular Surgery
Fig. 4. Increased velocities on postoperative surveillance duplex ultrasonography prompted this angiogram which shows good proximal (A) and distal (B) flow through the
profunda femoriseposterior tibial artery bypass. Previously placed SFA coil is indicated by arrow.
access of the SFA is not commonly employed. Disadvantages to this approach include artery size limitations and the lack of reliable techniques for arterial closure, sometimes necessitating open arterial exposure. In fact, inadvertent puncture of the SFA is implicated as a major contributor to the development of pseudoaneurysm or arteriovenous fistula following attempted CFA access.16 In this case, the SFA was chosen for access because of the patients’ active groin infection. Access was gained using a micropuncture needle under ultrasound guidance and, in a retrograde fashion, the ipsilateral iliofemoral occlusion was crossed subintimally. Using this technique, combined with brachial access, inflow was restored to the profunda femoris artery, the origin of the planned bypass graft. The coil that was placed in the SFA upon completion assured hemostasis in the occluded SFA. One of the most feared complications in bypass surgery is prosthetic vascular graft infection, occurring in 1e3% of patients.17,18 Graft excision is nearly always required as partial removal leads to a high rate of persistent sepsis.19 This can present unique challenges in a patient with ongoing limb ischemia who is already proven to have severe native vessel disease. As endovascular techniques have advanced and more severe iliac lesions are being managed endovascularly (TASC C and D),20
treatment of native vessel disease has become a viable alternative to extra-anatomic bypass. In one report, 2 patients with prosthetic vascular graft infections underwent successful endovascular native vessel recanalization and graft excision to maintain limb perfusion and have had good clinical results.21 In our case, the patient required lower extremity bypass for limb salvage, but had no appropriate inflow. The presence of an infected groin added complexity because it precluded the use of the left groin, especially as the origin of a new bypass graft. In using remote access to treat the native iliofemoral disease and by choosing the profunda femoris as the new graft origin, the infected field was avoided entirely. This case highlights the use of a hybrid approach in a patient with critical limb ischemia and prosthetic graft infection. With a combination of creative endovascular and open surgical techniques, revascularization from the aorta to posterior tibial artery was performed, permitting wound healing and facilitating the excision of the infected femoralefemoral bypass graft. Of particular interest is our use of retrograde access of the SFA to recanalize an occluded iliac system. This technique is not commonly described and was essential in performing this procedure. In addition, this case highlights the importance of careful preoperative planning for staged
Vol.
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No.
-, -
2014
procedures, which, in this case, permitted a novel approach to a complex constellation of problems, leading to a favorable outcome. REFERENCES 1. Ebaugh JL, Gagnon D, Owens CD, et al. Comparison of costs of staged versus simultaneous lower extremity arterial hybrid procedures. Am J Surg 2008;196:634e40. 2. Dosluoglu HH, Lall P, Cherr GS, et al. Role of simple and complex hybrid revascularization procedures for symptomatic lower extremity occlusive disease. J Vasc Surg 2010;51:1425e35.e1. 3. Schneider PA. Iliac angioplasty and stenting in association with infrainguinal bypasses: timing and techniques. Semin Vasc Surg 2003;16:291e9. 4. Schneider PA, Caps MT, Ogawa DY, et al. Intraoperative superficial femoral artery balloon angioplasty and popliteal to distal bypass graft: an option for combined open and endovascular treatment of diabetic gangrene. J Vasc Surg 2001;33:955e62. 5. Reed AB. Hybrid procedures and distal origin grafts. Semin Vasc Surg 2009;22:240e4. 6. Slovut DP, Sullivan TM. Combined endovascular and open revascularization. Ann Vasc Surg 2009;23:414e24. 7. Slovut DP, Sullivan TM. Critical limb ischemia: medical and surgical management. Vasc Med 2008;13:281e91. 8. Chang RW, Goodney PP, Baek JH, et al. Long-term results of combined common femoral endarterectomy and iliac stenting/ stent grafting for occlusive disease. J Vasc Surg 2008;48:362e7. 9. Dougherty MJ, Young LP, Calligaro KD. One hundred twentyfive concomitant endovascular and open procedures for lower extremity arterial disease. J Vasc Surg 2003;37:316e22. 10. Schneider PA. Superficial Femoral Artery Access for Endovascular Procedures: When the Common Femoral Cannot Be Used Due to Scarring, Disease, or Infection. in VEITH symposium (New York, NY, 2009).
Case Report 5
11. Sanchez LA, Marin ML, Veith FJ, et al. Placement of endovascular stented grafts via remote access sites: a new approach to the treatment of failed aortoiliofemoral reconstructions. Ann Vasc Surg 1995;9:1e8. 12. Berman HL, Katz SG, Tihansky DP. Guided direct antegrade puncture of the superficial femoral artery. AJR Am J Roentgenol 1986;147:632e4. 13. Gutzeit A, Schoch E, Sautter T, et al. Antegrade access to the superficial femoral artery with ultrasound guidance: feasibility and safety. J Vasc Interv Radiol 2010;21:1495e500. 14. Gutzeit A, Graf N, Schoch E, et al. Ultrasound-guided antegrade femoral access: comparison between the common femoral artery and the superficial femoral artery. Eur Radiol 2011;21:1323e8. 15. Marcus AJ, Lotzof K, Howard A. Access to the superficial femoral artery in the presence of a ‘‘hostile groin’’: a prospective study. Cardiovasc Intervent Radiol 2007;30:351e4. 16. Kim D, Orron DE, Skillman JJ, et al. Role of superficial femoral artery puncture in the development of pseudoaneurysm and arteriovenous fistula complicating percutaneous transfemoral cardiac catheterization. Cathet Cardiovasc Diagn 1992;25:91e7. 17. Liekweg WG Jr, Greenfield LJ. Vascular prosthetic infections: collected experience and results of treatment. Surgery 1977;81:335e42. 18. Edwards WH Jr, Martin RS 3rd, Jenkins JM, et al. Primary graft infections. J Vasc Surg 1987;6:235e9. 19. Mertens RA, O’Hara PJ, Hertzer NR, et al. Surgical management of infrainguinal arterial prosthetic graft infections: review of a thirty-five-year experience. J Vasc Surg 1995;21:782e90; discussion, 790e1. 20. Leville CD, Kashyap VS, Clair DG, et al. Endovascular management of iliac artery occlusions: extending treatment to TransAtlantic Inter-Society Consensus class C and D patients. J Vasc Surg 2006;43:32e9. 21. Erzurum VZ, Clair D. Endovascular native vessel recanalization to maintain limb perfusion after infected prosthetic vascular graft excision. J Vasc Surg 2005;41:332e6.