Arm vein bypass from distal deep femoral to superior medial genicular artery for limb salvage

Abstract

Bypass to the perigeniculate collateral arteries is an option for limb salvage. Lack of usual distal runoff or suitable, long lower limb vein for reconstruction are conditions that justify this option. Increased flow through collaterals, mainly nurtured by the perigeniculate arteries, is the rationale for this operation. Raised perfusion pressure, even though no pulsatile flow may be attained at the foot, may be enough to ensure healing of limb-threatening ischemic lesions.Initial attention to this possibility was brought to light by Barral et al. 1 The need to harvest arm veins because of the absence of lower limb veins and the use of the distal portion of the deep femoral as a donor artery, to reduce the need of vein, and due to incisions at the inguinal area from previous attempted revascularizations, are corollaries to explain technical aspects of these unusual reconstructions. 2 The present case illustrates these features. A 59-year-old woman presented with fifth toe gangrene, ischemic pain, and an anklebrachial index of 0.4. The patient had an occluded nonreversed saphenous vein bypass from the left common femoral to dorsalis pedis artery done 4 years earlier and a right transfemoral amputation.An arteriogram (A) showed extensive occlusion of the superficial femoral, popliteal, and major leg arteries. The dorsalis pedis was still patent, but this area had undergone a previous operation. No suitable lower limb vein was available because the homolateral vein had been used for the initial revascularization, and the other limb had a thigh amputation. A medial descending genicular artery was observed communicating with a large group of collaterals and was the foundation for the procedure that was performed.A basilic vein was harvested from right arm, and a nonreversed bridge from a distal zone of the profunda femoral up to the medial superior genicular artery was created. Relief of the ischemia was achieved, and ultimate healing of the foot was obtained after fifth toe amputation. The ankle-brachial index increased to 0.7. Control computed tomography angiography at the 6-month follow-up shows patency of the graft (Cover) and details of the proximal (B) and distal anastomosis (C), with collateral filling of leg arteries. REFERENCES 1. Latour B, Nourissat G, Duprey A, Berger L, Favre JP, Barral X. Bypass to the perigeniculate collateral arteries: mid-term results. Eur J Vasc Endovasc Surg 2008;35:473-9. 2. Brochado Neto FC, Albers M, Romiti M. The distal zone of the deep femoral artery as the inflow site in femorodistal bypass grafting. Eur J Vasc

Revascularização ilíaco-femoral alternativa em doença oclusiva aortoilíaca extensa

“…This use has not yet been described in the literature, but similar procedures with alternative vicarious arteries, such as the descending genicular artery and the sural genicular arteries, are good bypass options in cases in which possible substitutes are limited, or in cases in which we cannot identify adequate trunk arteries to use as recipients. 7,14 One possible criticism of our conduct with relation to this procedure could be the possibility of performing a hybrid treatment using PTA for the lesion of the right common iliac with an arterial bypass to the anastomotica magna artery, thereby avoiding a crossover graft. However, the necessary endovascular material was not available when this patient was admitted.…”

“…Alternative bypasses and substitutes that are normally reserved for exceptional cases can and should be part of the vascular therapeutic arsenal and have a contribution to make in cases in which endovascular surgery does not yet enable us to achieve good results. 4,5,7,15,16…”

“…1,2 Currently, endarterectomy, iliofemoral arterial bypass, or even aortofemoral bypass, are the most widely performed procedures in these cases. 3 Bypass to alternative collateral arteries in the lower limbs has already been well-described in the literature by Barral et al, 4 Brochado-Neto et al, 5 and De Luccia et al, 6,7 using the descending genicular artery and the sural genicular arteries. The latter are extremely important in patients with extensive femoropopliteal occlusion and no trunk arteries to receive outflow.…”

“…In common with the great saphenous vein, which remains the first choice when available, upper limb veins have demonstrated good results as alternative substitutes. 7 Infection of surgical vascular access at the groin is still of great concern to vascular surgeons, because of the potential for severe outcomes, including limb loss and death. 8,9 The principal factors involved in complications are diabetes, obesity, and malnutrition.…”

Sural Artery Bypass in Buerger's Disease: Report of a Case

“…Previous studies have described bypass to the perigeniculate collateral arteries as an option for limb salvage in selected patients, such as in cases of extensive disease, previous failed endo-or open vascular attempts, lack of the usual crural arterial runoffs or autogenous substitutes being common scenarios. [1][2][3][4][5][6][7] However, the use of this bypass has been restricted to a few groups of vascular surgeons. This report presents one case of a successful sural artery bypass in a patient with Buerger's disease, who presented with rest pain in the leg due to occlusion of the previous distal bypass.…”