The Use of a Diseased Native Artery as Conduit in a Composite Lower Limb Bypass
Article Outline
Abstract
We describe the use of a diseased native superficial femoral artery as conduit in a 57-year-old diabetic female who presented with a mixed aetiology lower leg ulcer. She underwent a staged ilio-profunda and profunda to above knee popliteal bypass graft. Owing to the lack of a sufficient length of venous conduit, a segment of the diseased native superficial femoral artery was harvested and used as a conduit in a composite graft. A diseased native artery can be used as a conduit for bypass if a sufficient length of vein is not available at operation.
Keywords: Superficial femoral artery, Conduit, Bypass
Introduction
Lower limb bypass was first reported in 19491 and is now a well established procedure for limb salvage in peripheral vascular disease. Autogenous greater saphenous vein is the most reliable and durable conduit for infrainguinal bypass.2 The lesser saphenous, arm veins and prosthetic materials may be used as an alternative if the greater saphenous vein is not available. Healthy native arteries have been used as conduits particularly in coronary revascularization3 but the use of a diseased native artery as a conduit has not been described before. We describe the use of a diseased native artery as a conduit in a patient in whom there was insufficient vein and a prosthetic bypass was relatively contraindicated.
Case Report
A 57-year-old woman presented with a painful ulcer on her left lower leg. The ulcer developed following a minor injury 4 months previously and had failed to heal with simple dressings. She also described symptoms consistent with rest pain. Her relevant medical history included smoking, hypertension, insulin dependent diabetes mellitus and left leg varicose vein surgery 8 years ago.
On examination she had an ulcer of 3/4 circumference of the left lower leg (Fig. 1) with a necrotic sloughy base. Left leg arterial pulses were absent. An arterial duplex scan confirmed a left external iliac artery, common femoral artery and superficial femoral artery occlusion. The popliteal artery and the calf vessels were patent. A left common iliac (extra-peritoneal exposure) to profunda femoris bypass (8
mm diameter PTFE graft) was performed and the ulcer was also debrided. Her rest pain resolved and she was allowed home. However, she was readmitted a week later with swelling and recurrent rest pain in the left foot. The ilio-profunda bypass was found to be patent but ankle Doppler signals were damped. She was unable to tolerate a cuff to measure the ankle brachial pressure index. We elected to perform a bypass from the left profunda to the above knee popliteal artery. On pre-operative assessment with a duplex, only the left cephalic vein was found to be suitable for use as a bypass conduit. The above knee popliteal was explored and an on-table angiogram showed a moderate stenosis in the below knee popliteal but good calf vessels. In view of extensive ulceration of the lower leg with infection and induration it was not possible to perform a below knee bypass. The left cephalic vein was harvested but was found to be only suitable from elbow upwards and of insufficient length for the proposed bypass. We were reluctant to use a prosthetic graft in this patient due to a high risk of graft infection. We, therefore, harvested an 8–10cm length of occluded superficial femoral artery. The artery was opened longitudinally and an endarterectomy was performed. The artery was then reconstituted, with a primary closure, as a tube and anastomosed end to end to the good quality segment of reversed cephalic vein. The arterial end of the composite graft was anastomosed to the distal profunda femoris artery and the venous end to the above knee popliteal artery (Fig. 2a).
Figure 1
A photograph showing extensive ulceration of the left lower leg.
Figure 2
(a) An angiogram showing the upper part of the composite left profunda femoris to above knee popliteal bypass (the arrows indicate the length of arterial conduit). (b) An angiogram demonstrating the site of stenosis (arrow) in the arterial segment of the bypass.
Post-operatively the patient made an excellent recovery. The ulcer has healed with compression bandaging (after 26 months). The composite artery-venous bypass graft has required three angioplasties at 5, 10 and 19 months (Fig. 2b) post-operatively for stenosis in the arterial segment but remains patent at 3 years follow-up.
Discussion
Arterial bypass surgery was pioneered by Alexis Carrel4 who demonstrated that in animals a segment of artery could be replaced with another artery or vein. The autogenous greater saphenous vein remains the conduit of choice for infrainguinal bypass surgery and offers the best long-term results.2 The lesser saphenous, arm veins, human umbilical vein, Dacron and PTFE can be used as an alternative if the greater saphenous vein is not available.
The internal mammary, gastroepiploic and radial arteries have been utilised for coronary artery bypass grafting.3 Native arteries have also been as patches (superior thyroid artery to patch carotid),5 but to our knowledge the use of a diseased native artery as a conduit has never been described before. The primary closure of the endarterectomised artery may have been a factor influencing restenoses in our patient. An eversion endarterectomy or patch closure may have reduced the risk of this complication. In the current era of MRSA we endeavor to use autogenous vein whenever possible and avoid using a prosthetic bypass in lower limb revascularisation. If at the time of the operation the autogenous vein is insufficient, as in our patient, then harvesting a length of occluded native SFA and using this as a conduit may be an alternative option to performing a composite vein-prosthetic bypass.
Conflict of Interest
None.
References
- . Le traitement de l' arterite obliterante par le greffe veineuse. Arch Mal Coeur Vaiss. 1949;42:371–374
- The consequences of a failed femoropopliteal bypass grafting: comparison of saphenous vein and PTFE grafts. J Vasc Surg. 2000;32(3):498–505
- Arterial grafts for coronary artery bypass grafting: biological characteristics, functional classification, and clinical choice. Ann Thorac Surg. 1999;67:277–284
- . The surgery of blood vessels, etc. Johns Hopkins Hospital Bulletin. 1907;18(190):18–28
- . Patch angioplasty following carotid endarterectomy using the ipsilateral superior thyroid artery. Eur J Vasc Endovasc Surg. 1997;14(1):60–62
PII: S1533-3167(08)00012-5
doi:10.1016/j.ejvsextra.2008.08.005
© 2008 European Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
Refers to article:
- The Use of a Diseased Native Artery as Conduit in a Composite Lower Limb Bypass , 24 September 2008
