The Upper-Arm Basilic-Cephalic Loop: A Valueable Alternative for Below-Knee Arterial Reconstruction.

INTRODUCTION: Despite advances of endovascular interventions, bypass surgery remains the gold standard for treatment of long and complex arterial occlusions in the lower limb. Autologous vein is regarded superior to other options. As the graft of first choice, the great saphenous vein (GSV) is often not available due to previous bypass, stripping or poor quality. Other options like arm veins (AV) are important alternatives. As forearm portions of AVs are often unusable, a graft created from the upper arm basilic and cephalic veins provides a valuable alternative. PATIENTS AND METHODS: We analyzed consecutive patients treated at an academic tertiary referral center between 01/1998 and 07/2018 using arm veins as the main peripheral bypass graft. Study endpoints were primary patency, secondary patency, limb salvage and survival. RESULTS: In the observed time period 2702 bypass procedures were performed at our institution for below-knee arterial reconstructions. Vein grafts used included the ipsilateral GSV (iGSV; n = 1937/71.7%), contralateral GSV (cGSV; 192/7.1%), small saphenous vein (SSV; 133/4.9%), prosthetic conduits (61/2.3%) and different configurations of AV (379/14%). In the majority of patients receiving AV grafts a complete continuous cephalic or basilic vein (CAV) was used (n = 292/77%). If it was not possible to use major parts of these 2 veins, either spliced arm vein grafts (SAV) (42/11%) or an upper arm basilic-cephalic loop graft (45/12%) were used. Median follow-up was 27 (interquartile range: 8-50) months. After 3 years secondary patency (CAV: 85%; SAV: 62%; loop: 66%; p = 0.125) and limb salvage rates (CAV: 79%, SAV: 68%; loop: 79%; p = 0.346) were similar between the 3 bypass options. CONCLUSION: The encouraging results of alternative AV configurations highlight their value in case the basilic or cephalic veins are not useable in continuity. Especially for infragenual redo-bypass procedures, these techniques should be considered to offer patients durable revascularization options.

Arm Vein versus Small Saphenous Vein for Lower Extremity Bypass in the Absence of Both Great Saphenous Veins.

BACKGROUND: Bypass surgery remains the gold standard for long and complex arterial occlusions in the lower limb. The vein is regarded superior to prosthetic conduits in peripheral arterial bypass surgery. However, this option is often limited because of previous bypass, stripping, or poor quality of the ipsilateral and/or contralateral great saphenous vein (GSV). Under these circumstances, the arm vein (AV) and small saphenous vein (SSV) are the only alternative autologous vein grafts. METHODS: We analyzed all consecutive patients treated at an academic tertiary referral center between January 1998 and July 2018 using either the AV or SSV as the main peripheral bypass graft. Study end points were primary patency, secondary patency, limb salvage, and survival. RESULTS: In total, 416 bypass procedures using exclusively AV (n = 327) or SSV (n = 89) were performed. There was a predominance of male gender. The majority of risk factors were evenly distributed between groups. The mean follow-up period was 2.3 years (0.9 to 13.3 years). Five-year primary and secondary patency rates were 39% (95% CI: 31-47%) and 67% (59-75%) for AV and 53% (41-66%) and 76% (67-86%) for SSV, respectively (P = 0.2 and 0.25). The five-year limb salvage and survival rates were 71% (68-81%) and 84% (77-90%) for AV and 78% (67-88%) and 90% (82-98%) for SSV, respectively (P = 0.52 and 0.11). CONCLUSIONS: Both AV and SSV are equally effective alternatives for peripheral bypass if no GSV is available. Although there was a trend toward better results with the SSV, there was no significant difference between the 2 options.

Alternative Venous Conduits for Below Knee Bypass in the Absence of Ipsilateral Great Saphenous Vein.

OBJECTIVE: Vein is regarded superior to artificial graft in peripheral arterial bypass surgery. However, this option is often limited owing to previous use or removal of the ipsilateral greater saphenous vein (iGSV). In this case, the contralateral great saphenous vein (cGSV), the small saphenous vein (SSV), or arm veins (AV) are possible alternatives. Experience with all three grafts for below knee vein bypass is reported. METHODS: Consecutive patients treated at an academic tertiary referral centre between January 1998 and July 2018 using the cGSV, SSV, or AV as the main peripheral bypass graft were analysed. Study end points were primary patency, secondary patency, limb salvage, and survival. RESULTS: Over the observed time period, 2642 bypass operations for treatment of peripheral artery disease with below knee target arteries were performed at the authors' institution: 1937 procedures using the iGSV; 644 bypass procedures using the cGSV (n = 186; 28.9%), SSV (n = 101; 15.7%), or AV (n = 357; 55.4%); and 61 procedures using a prosthetic graft. The median follow up period was 2.3 years (range 9 days-18.5 years). Thirty day mortality was 1.9% for the whole group and similar between the three groups. After five years, primary and secondary patency rates were comparable between the three groups. Secondary patency was 75% (95% confidence interval [CI] 66-83) in the cGSV and SSV groups, and 65% (95% CI 57-73) in the AV group (p = .47). Limb salvage and survival after five years were, respectively, 73% (95% CI 65-81) and 89% (95% CI 82-95) in the cGSV group, 79% (95% CI 69-89) and 87% (95% CI 79-95) in the SSV group, and 74% (95% CI 68-80) and 83% (77-89) in the AV group (p = .46). CONCLUSION: All three types of alternative autologous vein graft are equal regarding outcome parameters. Vascular surgeons should consider all autologous options if their preferred choice is not available.

Nitinol Stent Versus Bypass in Long Femoropopliteal Lesions: 2-Year Results of a Randomized Controlled Trial.

OBJECTIVES: This study sought to compare patency rates and clinical outcomes of nitinol stents and primary vein bypass in long femoropopliteal lesions. BACKGROUND: An endovascular-first strategy for long femoropopliteal lesions is widely recommended without sufficient data comparing it with bypass surgery. Nitinol stents are widely used as the standard endovascular therapy. METHODS: A single-center randomized controlled trial was performed with the primary endpoints of technical success, primary and secondary patency. Secondary endpoints were limb salvage, survival, complications, and clinical improvement. RESULTS: A total of 110 limbs (55 per group) in 103 patients were treated. Baseline and lesion characteristics were similar, with a mean lesion length of 276 mm. Critical limb threatening ischemia was the indication for treatment in 49% of limbs in both groups. Technical success was achieved in 87% in the stent group. During a 2-year follow-up, patency rates, limb salvage, survival and complications showed no significant differences between both groups. At 24 months, primary and secondary patency rates for the stent group were 60% and 72% versus 56% and 73% in the bypass group, respectively. Clinical improvement was significantly better in the bypass group. CONCLUSIONS: There were no significant differences regarding patency rates, limb salvage, survival, or complications after 2 years. Technical success and clinical improvement in the bypass group were significantly better, but the promising results of the stent group suggest that an endovascular-first strategy for femoropopliteal lesions up to 30 cm may be reasonable. Mid- as well as long-term results need to be awaited.

Trans-Iliac Bypass Grafting for Vascular Groin Complications.

OBJECTIVES: Groin complications following vascular reconstruction, extensive trauma, or severe radiation induced scarring may complicate future revascularisation procedures of the lower limb. Although several techniques have been described, only few cases of trans-iliac bypass grafting have been published. The aim of this study was to perform a review of the literature on trans-ilac bypass grafting and add the authors' experience. METHODS: A single centre retrospective data analysis and a literature review of all trans-iliac bypass procedures was performed. Data on indication, patency, limb salvage, and survival were collected. Study endpoints were patency, limb salvage, and patient survival. RESULTS: Eight trans-iliac wing bypass grafting procedures were performed in our institution between 2003 and 2018, which represents the largest single centre series. Twenty-three procedures were reported in the literature between 1989 and 2018. Prior to the bypass procedure in the eight patients, six had local infection and two irradiation of the groin. The indication for operation was ischaemia in six cases, bleeding in one case, and infection in another case. The external iliac artery was most often used for the proximal (6 cases) and the superficial femoral artery for distal anastomosis (6 cases). Great saphenous vein was the most commonly used graft material (6 cases). The median follow up was five years with three bypass occlusions after 1, 2, and 8 months, followed by two successful thrombectomy procedures. There were no major amputations and only one death after five months, which was not procedure related. CONCLUSIONS: Trans-iliac bypass grafting is a viable alternative extra-anatomic bypass technique in patients with vascular groin complications. Patency as well as limb salvage and survival are good and may be comparable to those reported for autologous in situ repair and obturator canal bypass grafting.

Small Saphenous Vein and Arm Vein as Bypass Grafts for Upper Extremity Ischemia.

BACKGROUND: Bypass in the upper extremity is a rare procedure mainly performed for chronic ischemia, trauma, or hemodialysis access complications. Feasibility and success of use of the arm vein and small saphenous vein (SSV) for autologous vein bypass have been reported in peripheral artery bypass procedures. There are very few reports on the use of alternative veins in upper extremity bypass. We report our experience with arm vein and SSV as a graft source in upper extremity arterial disease. METHODS: Retrospective analysis of a consecutively collected case series in an academic tertiary referral center from January 2010 to February 2018. Study end points were primary patency, secondary patency, limb salvage, and survival. RESULTS: In total, 47 patients were treated with upper extremity bypass either using the SSV (n = 17) or arm veins (n = 30). Indications were either acute (n = 12) or chronic ischemia (n = 35) caused by acute (n = 8) and chronic (n = 9) trauma, sequela of iatrogenic interventions (n = 4), peripheral artery disease (n = 14), thrombangiitis obliterans (n = 3), and dialysis-access-related complications (n = 9). An arm vein was used in 30 and the SSV in 17 patients. Primary patency after 12 months was 87% with the SSV and 75% with an arm vein (P = 0.8) and 63% and 75% after 36 months (P = 0.9). Secondary patency were 100% with an arm vein and 100% with the SSV after 36 months (P = 0.4). One patient had to undergo major amputation and 2 minor amputations. CONCLUSIONS: Arm vein revascularization using the primarily arm vein or SSV as a bypass conduit can be performed with reasonable mortality and morbidity rates and provide good results comparable with the greater saphenous vein.

The Small Saphenous Vein: An Underestimated Source for Autologous Distal Vein Bypass.

OBJECTIVES: The small saphenous vein (SSV) is a potential vein source for bypass if neither greater saphenous vein nor arm vein is available. This study reports experience using SSV as part of an all autologous vein bypass policy. METHODS: This study comprised single centre retrospective data analysis of all consecutive patients treated at an academic tertiary referral centre from January 1998 to February 2017 using the SSV as the main peripheral bypass graft. Study endpoints were primary patency, secondary patency, limb salvage, and survival. RESULTS: One hundred and twenty operations were performed in 118 patients using SSV. Indications were peripheral arterial occlusive disease (n = 91; Rutherford classification 3: n = 11; 4: n = 21; 5,6: n = 59), acute ischaemia (n = 14), popliteal artery aneurysm (n = 12), and bypass revisions (n = 3). Median follow up was 30.5 months (10 months-13.7 years). Primary patency after one, three and five years was 68% (CI: 59-77%), 58% (49-68%), and 54% (45-64%). Secondary patency was 83% (76-89%) after one year and 77% (69-85%) after three and five years. Limb salvage after one year was 88% (82-94%) and 78% (70-86%) after five years. Survival was 96% (92-99%) after one year and 91% (85-97%) at five years. Multivariable analysis identified redo surgery as an independent risk factor. Patients receiving a primary (n = 59) vs. a redo bypass (n = 61) were compared. Primary patency and secondary patency were both significantly better in the primary bypass group than in the redo group (p = .0036 and p = .0003, respectively). Limb salvage was also significantly better in primary bypass patients than in the redo group (p = .0007), whereas overall survival did not differ significantly (p = .48). CONCLUSION: The SSV is a valuable alternative vein graft in peripheral bypass surgery. It achieves excellent long-term results, particularly in patients with primary procedures but also acceptable results in patients with redo surgery.

Arm veins versus contralateral greater saphenous veins for lower extremity bypass reconstruction: preliminary data of a randomized study.

BACKGROUND: The aim of this randomized study was to determine whether arm vein (AV) or contralateral greater saphenous vein (CGSV) is the better alternative vein source for lower extremity bypass reconstruction. METHODS: Consecutive patients with absent ipsilateral greater saphenous vein undergoing lower extremity revascularization were allocated to group A (AV bypass) or B (CGSV bypass). RESULTS: From 6, 2010, to 11, 2013, 64 patients (32 each group) were randomized. In all, 29 of 93 patients had to be excluded for various reasons. Median age was 76 years vs. 71 years (P = 0.01) for group A and B patients. There were no statistically significant differences regarding gender, cardiovascular risk factors, redo bypass procedures (P = 0.77), below-knee bypass procedures (P = 0.61), median bypass length (P = 0.6), and median length of incision on ipsilateral leg to perform anastomoses (P = 0.2) between group A and B patients, respectively. Incisions for vein harvest were longer in group A (P = 0.003). Overall surgical site infections (SSIs, P = 1.0) and SSI from vein harvest (P = 1.0) were equally distributed. No patient was lost to follow-up (17 vs. 18 months, P = 0.74). There was no statistically significant difference regarding primary (P = 0.77) and secondary (P = 0.25) patency rates at 1 year (group A: 52% vs. group B: 54% and group A: 72% vs. group B: 61%) and at 2 years (52% vs. 48% and 64% vs. 61%), respectively. There were 4 vs. 6 major amputations (P = 0.23) and 5 vs. 2 deaths (P = 0.1) in groups A and B during follow-up. CONCLUSIONS: Preliminary results suggest that both AV and CGSV may serve as a secondary vein bypass graft equally well.

Urethra reconstruction following resection of penile leiomyosarcoma.

Leiomyosarcoma is a rare tumor, particularly in genital area. We present a case of penile lyomyosarcoma. Surgical treatment involved subcutaneous penectomy, preserving a sensate skin envelope, bilateral groin dissection and perineal urethrostomy. Reconstruction of the urethra and soft tissue was carried out using a free radial forearm flap. We believe that subcutaneous penectomy should be considered as a treatment option in selected cases of penile tumor as this facilitates urethral reconstruction.

Flap technology for reconstructions of urogenital organs.

PURPOSE OF REVIEW: The purpose of this review is to summarize the different reconstructive options for urogenital indications. The development of various flap techniques to restore congenital and acquired urogenital defects is presented. RECENT FINDINGS: Various reconstructive techniques have been demonstrated recently. On the basis of the reconstructive requirements, two main techniques can be defined: the standard local or regional flap technique (pedicled flap) and the more sophisticated microvascular free flap technique. Free tissue transplantation (transfer) is a procedure that involves microvascular transplantation of a flap (a fasciocutaneous, muscle or composite flap) in one stage from a donor site in the body to a distant recipient site. The viability of the transplanted flap is maintained by microvascular anastomosis between the flap's vessels (at least one artery and one vein) and recipient vessels. Re-innervation and functioning muscle contraction is achieved by suturing the vessels and a motor nerve in the recipient area to a motor nerve of a free transplanted muscle. After regeneration of the nerve and re-innervation of the transplanted muscle, a functioning free transplanted muscle offers enough contractile capacity and strength to replace the function of the missing muscles at the recipient site. The technique of microvascular free tissue transfer necessitates extensive experience in microvascular technique and this approach could be efficiently applied in cooperation with other specialists. Recent studies show the development and clinical application of these new surgical techniques in urology (e.g. in the treatment of bladder acontractility using innervated free latissimus dorsi muscle and in the use of a free microvascular fillet lower leg flap for the reconstruction of a large pelvic-floor defect). SUMMARY: Various reconstructive requirements define the techniques for reconstruction. The main principle is to obtain optimal anatomical and functional reconstruction with minimal donor site morbidity. Depending on the etiology of the defect, different reconstructive options are available to optimize the reconstructive result. Optimal reconstruction might best be achieved by adopting an interdisciplinary approach in which the primary objective is to provide the best possible outcome for each patient. This review presents the main indications for and principles of flap selection according to the reconstructive requirements.