Multiple Sequence Revascularization of Infrapopliteal Arteries in the Management of Critically Ischemic Extremity

Czech version

Authors: M. Šlais; P. Mitáš ¹; M. Semrád ¹; J. Hrubý ¹; J. Lindner ¹; P. Štádler
Authors‘ workplace: Nemocnice Na Homolce, Oddělení cévní chirurgie, prim. MUDr. Petr Štádler, Ph. D. ; II. chirurgická klinika kardiovaskulární chirurgie VFN a 1. LF UK, přednosta doc. MUDr. Jaroslav Lindner, CSc. ¹
Published in: Rozhl. Chir., 2010, roč. 89, č. 1, s. 59-63.
Category: Monothematic special - Original

Overview

Aim of the study:
Most cases of distal bypasses closures are caused by reduced blood flow within the affected peripheral vasculature, resulting in corresponding reduction in the graft’s blood supply. The authors use multiple, sequence, Y grafting and bridge grafting procedures on crural and pedal arteries, in order to improve the above hemodynamic features. Furthermore, the techniques facilitate better circulation within larger extremity regions.

Methods:
From April 2007 to January 2009, the authors completed a total of 38 sequence bypass procedures. The procedures included 30 Y graft procedures with peripheral anastomoses with crural arteries, 4 Y graft procedures with peripheral anastomoses with pedal arteries and 4 bridge graft procedures.

Y grafting is a technique, in which a classical distal bypass is formed, to which another bypass is attached end-to-side in an acute angle. The composite bypasses form a reversed letter Y. Its distal branches anastomose with crural or pedal arteries.

Bridge grafting is a technique, where a short bypass between crural arteries is formed, using a venous graft with removed valves, allowing for a two-way flow. The distal anastomosis is attached end-to-side.

All the above vascular reconstructions were indicated for critical extremity ischemia, some patients had a history of endovascular re-interventions. In the patient group, autologuos veins were used in 20 reconstructions, while PTFE prostheses were used in 10 reconstructions. Clinical and sonographic examinations were performed on discharge, followed by check ups at 1, 3, 6 and 12 months.

Results:
The follow up period in patients with Y graft reconstructions was 6–20 months (mean duration of 12 months). Two patients underwent major amputation, required for bypass closures, 3 subjects exited with patent vascular reconstructions, their deaths were not related to the procedure. The authors recorded 4 bypass closures, with the main trunk patency. Primary/secondary 30-day patency rate was 90%/97%, the long-term patency rate was 93%.

Conclusion:
The vascular reconstructions results are similar to those presented in literature. In order to perform more accurate assessment of individual revascularization variants, long- term follow up studies, including randomized studies, are required.

Key words:
critical extremity ischemia – crural bypass – pedal bypass – Y-graft bypass

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