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Transpubic ilio—deep femoral—anterior tibial sequential bypass with nonreversed translocated saphenous vein for limb salvage
CASE R E P O R T
Transpubic ilio-decp femoral-anterior tibial sequential bypass with nonreversed translocated saphenous vein for limb salvage V. S. Sottiurai, M D , P h D , and J. D. Bernstein, M D , New Orleans, La. We report a case of successive occlusions of aortofemoral, femorofemoral, axillofemoral, and numerous thrombectomies successfitlly managed by the use of nonreversed translocated saphenous vein for transpubic ilio-deep femoral-anterior tibial sequential bypass. (J VAsc SURG 1988;8:86-8.)
Transpubic femoropopliteal bypass ~is a novel approach in limb salvage, particularly in patients who have no named arteries in one groin after occlusion o f several inflow bypass procedures and thrombectomies. This article describes a more suitable sizematching o f the nonreversed translocated saphenous vein (NTSV) in a transpubic ilio-deep femoralanterior tibial sequential bypass and subcutaneous placement o f the vein graft to expedite the procedure, and to avoid unnecessary dissection and disruption o f collateral vessels in the region. CASE REPORT
This patient was a 47-year-old black man with severely ischemic legs and two gangrenous ulcers on the left leg. Previously he had received multiple vascular procedures at another hospital for correction of arterial occlusive disorders: in 1978--aortofemoral bypass; in 1985--femorofemoral bypass; in 1986--1eft axillofemoral bypass and two thrombectomies. Aortography and runoff revealed complete occlusion of the left limb of the aortofemoral bypass, the left iliofemoral, superficial femoral and popliteal arteries with the anterior tibial artery being the solitary runoff plus a suprainguinal pseudoaneurysm in the right limb of the aortofemoral graft (Fig. 1). The patient had no history of coagulopathy but did have a history of hypertension, smoking, and intravenous drug abuse. Surgical procedure. The greater saphenous vein from the saphenofemoral junction to the ankle was exposed with a long continuous incision in the opposite (right) lower limb. Large side branches were doubly dipped to preserve From the Department of Surgery, Section of Vascular Surgery, Louisiana State UniversitySchool of Medicine. Reprint requests: V. S. Sottiurai, MD, PhD, Department of Surgery, Section of Vascular Surgery, Louisiana State University School of Medicine, 1542 Tulane Ave., New Orleans, LA 70112. 86
the side port for val~xtlotomy while small side branches were ligated with 4-0 silk sutures. Via a curvilinear incision that bisected the inguinal ligament, the retroperitoneal space was entered. The right limb of the aortofemoral bypass graft proximal to the femoral anastomosis and the origin of the previous femorofemoral graft was isolated. Proximal and distal control of the pseudoaneurysm was obtained. The pseudoaneurysm probably originated from the breakdown of a suture line previously used to dose an incision in the iliac arterial prosthesis for thrombectomy. The deep femoral artery of the left lower extremity was exposed through a vertical skin incision placed lateral to the sartorius muscle at the middle third of the thigh. With a vertical skin incision placed between the tibia and fibula at the mid portion of the leg, the anterior tibial artery was exposed by separating and retracting the tibialis anterior and extensor halluces muscles. A segment of the anterior tibial artery 2 inches in length was dissected free from the venae comitantes and encircled with vessel loops. Through the left thigh incision, a subcutaneous tunnel to the right groin incision was made with a curved tunneler. Another subcutaneous umnel superficial to the crural fascia was made from the left leg incision to the left thigh incision, by passing a ttmneler through a groove between the fibular head and the tibial condyle. The greater saphenous vein harvested from the opposite (right) leg was immediately flushed with papaverine solution (60 mg/100 ml Plasmalyte). While the vein was being prepared, the assistants closed the long skin incision created from harvesting the vein. After systemic heparinization (5000 units), a 6 cm segment of the preclotted 8 mm knitted Dacron graft was interposed into the right limb of the aortofemoral graft to replace the pseudoaneurysm. End-to-side anastomosis of the proximal saphenous vein to the interposition graft was completed with running 5-0 polypropylene sutures. Under arterial blood distention, the valves of the saphenous vein were incised with a modified Mills' valvulotome introduced
Volume 8 Number 1 }uly 1988
Ilio-deep j~moral-anterior tibial bypass 87
@ Fig. 2. Artist's rendition of ilio-deep femoral-anterior tibial sequential bypass with nonreversed translocated saphenous vein harvested from the contralateral lower extremity. The suprainguinal pseudoaneurysm in the right limb of the aortofemoral graft was corrected with a Dacron interposition graft (G). Circles highlight the proximal endto-side anastomosis of the NTSV with the Dacron interposition graft, side of the NTNSV with side of the deep femoral artery, and end-to-side of the NTSV with the anterior tibial artery. Arrow indicates occluded left limb of the aortofemoral graft.
Fig. 1. Aortogram and runoff revealed complete occlusion of the left iliofemoral, superficial femoral-popliteal arteries, and reconstitution of the anterior tibia] solitary runoff (arrow at bottom). Left limb of the aortofemoral graft was occluded at the bifurcation. Pseudoaneurysm in the right groin (arrow). Occluded femorofemoral graft (asterisk). via the side branches and through the distal end of the vein graft. All side branches of the saphenous vein were carefially identified and tied with 4-0 silk sutures. The NTSV distended with arterial blood was then placed in the previously created subcutaneous tunnel. Particular care was taken not to twist or kink the graft while tunneling. Side-to-side
anastomosis of the vein graft to the deep femoral artery was completed with rtmning 6-0 polypropylene sutures. The end-to-side anastomosis to the anterior tibial artery was performed with rt~fing 7-0 polypropylene sutures (each of the latter two anastomoses were approximately 2.5 cm long) (Fig. 2). Numerous flushing of the vein graft was carried out to evacuate potential clots in the graft before completion of the distal anastomosis. Completion intraoperative arteriography was obtained and skin incisions were closed with interrupted 3-0 polyglactin (Vicryl) sutures followed by subcuticular 4-0 polyglycolic acid (Daxon) sutures. Before the patient's discharge from the hospital, an arteriogram was performed to visualize the entire length of the bypass (Fig. 3). The anlde-brachial indexes improved from 0.20 to 0.78 after the operation. The patient was discharged with a regimen of aspirin and dipyridamole; he has been seen every 4 months since April 1987.
Journ~ of VASCULAR SURGERY
88 Sottiurai and Bernstein
DISCUSSION Sequential transpubic ilio-deep femoral-anterior tibial artery bypass is a fast and easily performed procedure involving minimal dissection and tissue traumatization. To our knowledge this procedure has not been described. The subcutaneous ~ n n e l obviates ~ n e consuming dissection through the groin scarred from previous multiple operations. It is apparent that such a bypass procedure is clearly beyond the scope of the in situ technique. 2 Because of the subcutaneous placement of the bypass graft, it is theoretically more susceptible to extrinsic compression and injury. The patient should be specifically instructed to protect and care for the graft. Despite this potential hazard, all patients who have had the sequential femorodistal (anterior tibial or peroneal) bypass with lateral tunneling have done well for 5 years or more. 3 REFERENCES
1. Vetto RM. The treatment of unilateral iliac artery obstruction with transabdominal subcutaneous femoropoplitealgraft. Surgery 1962;52:342-8. 2. Leather RP, Shah DM, Karmody AM. Infrapopliteal arterial bypass for limb salvage: increased patency and utilizanon of saphenous vein used in situ. Surgery 1981;90:1000-8. 3. Batson RC, Sottiurai VS. Nonreversedand in sire vein grafts: clinical and experimental observations. Ann Surg 1985; 201:771-9.
Fig. 3. Completion arteriography of the transpubic iliodeep femoral-anterior tibial bypass. Stump of occluded femorofemoral bypass (asterisk). Black arrowheads point to site of anastomoses of NTSV to interposition Dacron graft proximally, side-to-side to the deep femoral ratery, and end-to-side to the anterior tibial artery. Thin arrow identifies the dorsalis pedis artery. White arrowheads outline the course of the distal portion of the vein graft.
Transpubic ilio-decp femoral-anterior tibial sequential bypass with nonreversed translocated saphenous vein for limb salvage V. S. Sottiurai, M D , P h D , and J. D. Bernstein, M D , New Orleans, La. We report a case of successive occlusions of aortofemoral, femorofemoral, axillofemoral, and numerous thrombectomies successfitlly managed by the use of nonreversed translocated saphenous vein for transpubic ilio-deep femoral-anterior tibial sequential bypass. (J VAsc SURG 1988;8:86-8.)
Transpubic femoropopliteal bypass ~is a novel approach in limb salvage, particularly in patients who have no named arteries in one groin after occlusion o f several inflow bypass procedures and thrombectomies. This article describes a more suitable sizematching o f the nonreversed translocated saphenous vein (NTSV) in a transpubic ilio-deep femoralanterior tibial sequential bypass and subcutaneous placement o f the vein graft to expedite the procedure, and to avoid unnecessary dissection and disruption o f collateral vessels in the region. CASE REPORT
This patient was a 47-year-old black man with severely ischemic legs and two gangrenous ulcers on the left leg. Previously he had received multiple vascular procedures at another hospital for correction of arterial occlusive disorders: in 1978--aortofemoral bypass; in 1985--femorofemoral bypass; in 1986--1eft axillofemoral bypass and two thrombectomies. Aortography and runoff revealed complete occlusion of the left limb of the aortofemoral bypass, the left iliofemoral, superficial femoral and popliteal arteries with the anterior tibial artery being the solitary runoff plus a suprainguinal pseudoaneurysm in the right limb of the aortofemoral graft (Fig. 1). The patient had no history of coagulopathy but did have a history of hypertension, smoking, and intravenous drug abuse. Surgical procedure. The greater saphenous vein from the saphenofemoral junction to the ankle was exposed with a long continuous incision in the opposite (right) lower limb. Large side branches were doubly dipped to preserve From the Department of Surgery, Section of Vascular Surgery, Louisiana State UniversitySchool of Medicine. Reprint requests: V. S. Sottiurai, MD, PhD, Department of Surgery, Section of Vascular Surgery, Louisiana State University School of Medicine, 1542 Tulane Ave., New Orleans, LA 70112. 86
the side port for val~xtlotomy while small side branches were ligated with 4-0 silk sutures. Via a curvilinear incision that bisected the inguinal ligament, the retroperitoneal space was entered. The right limb of the aortofemoral bypass graft proximal to the femoral anastomosis and the origin of the previous femorofemoral graft was isolated. Proximal and distal control of the pseudoaneurysm was obtained. The pseudoaneurysm probably originated from the breakdown of a suture line previously used to dose an incision in the iliac arterial prosthesis for thrombectomy. The deep femoral artery of the left lower extremity was exposed through a vertical skin incision placed lateral to the sartorius muscle at the middle third of the thigh. With a vertical skin incision placed between the tibia and fibula at the mid portion of the leg, the anterior tibial artery was exposed by separating and retracting the tibialis anterior and extensor halluces muscles. A segment of the anterior tibial artery 2 inches in length was dissected free from the venae comitantes and encircled with vessel loops. Through the left thigh incision, a subcutaneous tunnel to the right groin incision was made with a curved tunneler. Another subcutaneous umnel superficial to the crural fascia was made from the left leg incision to the left thigh incision, by passing a ttmneler through a groove between the fibular head and the tibial condyle. The greater saphenous vein harvested from the opposite (right) leg was immediately flushed with papaverine solution (60 mg/100 ml Plasmalyte). While the vein was being prepared, the assistants closed the long skin incision created from harvesting the vein. After systemic heparinization (5000 units), a 6 cm segment of the preclotted 8 mm knitted Dacron graft was interposed into the right limb of the aortofemoral graft to replace the pseudoaneurysm. End-to-side anastomosis of the proximal saphenous vein to the interposition graft was completed with running 5-0 polypropylene sutures. Under arterial blood distention, the valves of the saphenous vein were incised with a modified Mills' valvulotome introduced
Volume 8 Number 1 }uly 1988
Ilio-deep j~moral-anterior tibial bypass 87
@ Fig. 2. Artist's rendition of ilio-deep femoral-anterior tibial sequential bypass with nonreversed translocated saphenous vein harvested from the contralateral lower extremity. The suprainguinal pseudoaneurysm in the right limb of the aortofemoral graft was corrected with a Dacron interposition graft (G). Circles highlight the proximal endto-side anastomosis of the NTSV with the Dacron interposition graft, side of the NTNSV with side of the deep femoral artery, and end-to-side of the NTSV with the anterior tibial artery. Arrow indicates occluded left limb of the aortofemoral graft.
Fig. 1. Aortogram and runoff revealed complete occlusion of the left iliofemoral, superficial femoral-popliteal arteries, and reconstitution of the anterior tibia] solitary runoff (arrow at bottom). Left limb of the aortofemoral graft was occluded at the bifurcation. Pseudoaneurysm in the right groin (arrow). Occluded femorofemoral graft (asterisk). via the side branches and through the distal end of the vein graft. All side branches of the saphenous vein were carefially identified and tied with 4-0 silk sutures. The NTSV distended with arterial blood was then placed in the previously created subcutaneous tunnel. Particular care was taken not to twist or kink the graft while tunneling. Side-to-side
anastomosis of the vein graft to the deep femoral artery was completed with rtmning 6-0 polypropylene sutures. The end-to-side anastomosis to the anterior tibial artery was performed with rt~fing 7-0 polypropylene sutures (each of the latter two anastomoses were approximately 2.5 cm long) (Fig. 2). Numerous flushing of the vein graft was carried out to evacuate potential clots in the graft before completion of the distal anastomosis. Completion intraoperative arteriography was obtained and skin incisions were closed with interrupted 3-0 polyglactin (Vicryl) sutures followed by subcuticular 4-0 polyglycolic acid (Daxon) sutures. Before the patient's discharge from the hospital, an arteriogram was performed to visualize the entire length of the bypass (Fig. 3). The anlde-brachial indexes improved from 0.20 to 0.78 after the operation. The patient was discharged with a regimen of aspirin and dipyridamole; he has been seen every 4 months since April 1987.
Journ~ of VASCULAR SURGERY
88 Sottiurai and Bernstein
DISCUSSION Sequential transpubic ilio-deep femoral-anterior tibial artery bypass is a fast and easily performed procedure involving minimal dissection and tissue traumatization. To our knowledge this procedure has not been described. The subcutaneous ~ n n e l obviates ~ n e consuming dissection through the groin scarred from previous multiple operations. It is apparent that such a bypass procedure is clearly beyond the scope of the in situ technique. 2 Because of the subcutaneous placement of the bypass graft, it is theoretically more susceptible to extrinsic compression and injury. The patient should be specifically instructed to protect and care for the graft. Despite this potential hazard, all patients who have had the sequential femorodistal (anterior tibial or peroneal) bypass with lateral tunneling have done well for 5 years or more. 3 REFERENCES
1. Vetto RM. The treatment of unilateral iliac artery obstruction with transabdominal subcutaneous femoropoplitealgraft. Surgery 1962;52:342-8. 2. Leather RP, Shah DM, Karmody AM. Infrapopliteal arterial bypass for limb salvage: increased patency and utilizanon of saphenous vein used in situ. Surgery 1981;90:1000-8. 3. Batson RC, Sottiurai VS. Nonreversedand in sire vein grafts: clinical and experimental observations. Ann Surg 1985; 201:771-9.
Fig. 3. Completion arteriography of the transpubic iliodeep femoral-anterior tibial bypass. Stump of occluded femorofemoral bypass (asterisk). Black arrowheads point to site of anastomoses of NTSV to interposition Dacron graft proximally, side-to-side to the deep femoral ratery, and end-to-side to the anterior tibial artery. Thin arrow identifies the dorsalis pedis artery. White arrowheads outline the course of the distal portion of the vein graft.