Does the length of bypassed bowel during distal gastric bypass affect weight loss?

INTRODUCTION: Weight recurrence (WR) affects > 20% of patients following Roux-en-Y gastric bypass (RYGB). Shortening of the common channel (CC) after RYGB (distal bypass) has been proposed for additional weight loss in patients with WR, but results vary, and concerns for vitamin deficiencies/malnutrition exist. Our aim was to determine whether the percentage of bowel bypassed after distal bypass is associated with the amount of postoperative weight loss. METHODS: Patients undergoing distal bypass between 2018 and 2022 were reviewed. Small bowel limb lengths before and after distal bypass were measured, and the percentage of bypassed bowel was calculated (= bypassed biliopancreatic limb/total small bowel length). Patients were dichotomized into two groups based on the percentage bypassed bowel (≤ 50% vs. > 50%). Weight loss (measured as excess BMI loss; EBIL%), comorbidities resolution, complications, and nutritional deficiencies were reviewed. RESULTS: Thirty female patients underwent distal bypass during the study period. After distal bypass, the Roux was lengthened to 150 cm (75-175 cm) from 75 cm (20-200 cm), and the CC shortened to 150 cm (100-310 cm) from 510 cm (250-1000 cm). These changes resulted in an increase in the size of the bypassed biliopancreatic limb from 40 cm (15-90 cm) to 330 cm (180-765 cm) and a total alimentary limb (TALL; Roux + CC) shortening from 590 cm (400-1075 cm) to 300 cm (250-400 cm). The group with > 50% bowel bypassed had higher EBIL%. Overall EBIL% was 36.9 ± 14.7%, 53.3 ± 25.6%, and 62.1 ± 36.9% at 0.5, 1, and 2 years, respectively. There were minimal vitamin deficiencies. Diabetes resolved in 100% (n = 3/3), HTN in 67% (n = 10/15), and GERD in 73% (n = 11/15). Complication rate was 23%. No reintervention for malnutrition or vitamin deficiencies was required. CONCLUSIONS: Distal bypass effectively leads to considerable weight loss and comorbidity improvement in patients with WR after RYGB, but the amount of weight loss depends on the percentage of bypassed bowel. An exact threshold of bypassed bowel that optimizes weight loss outcomes and simultaneously minimizes the nutritional complications needs to be determined. Meanwhile, close monitoring for vitamin deficiencies is recommended.

Outcomes of a bypass-first strategy in chronic limb-threatening ischemia based on the Global Vascular Guidelines.

OBJECTIVE: The Global Vascular Guidelines (GVGs) recommend initial revascularization (bypass or endovascular therapy) for chronic limb-threatening ischemia (CLTI) based on anatomical complexity and limb severity. This decision is made based on a prediction of the outcomes after endovascular intervention. This study was performed to evaluate outcomes after distal bypass in cases recommended for GVG bypass. METHODS: A total of 239 distal bypasses for CLTI were evaluated in 195 patients with a GVG bypass recommendation treated between 2009 and 2020 at a single center in Japan. Comparisons were made between crural and pedal bypass cases. RESULTS: The 195 patients (median age, 77 years; 67% male) underwent 133 crural bypasses (106 patients; 54%) and 106 pedal bypasses (89 patients; 46%). Hemodialysis was more common in pedal cases than in crural cases (P = .03). Hospital deaths occurred in two cases (1%) within 30 days. The whole cohort has a follow-up rate of 96% over a mean of 28 ± 26 months, with 3-year limb salvage rates of 87% and 3-year primary, assisted primary, and secondary patency rates of 40%, 65%, and 67%, all without significant differences between crural and pedal cases. The 1-year wound healing rate was 88% and tended to be higher in crural cases than in pedal cases (P = .068). The 3-year survival rate was 52% in the cohort and did not differ significantly between crural and pedal cases. CONCLUSIONS: Patients with CLTI with a GVG bypass recommendation had acceptable limb salvage, graft patency, wound healing, and survival after distal bypass, regardless of the bypass method. These findings indicate that a GVG bypass recommendation as an initial revascularization method is valid in the real world.

Distal gastric bypass revision for weight recurrence or nonresponse to primary procedure: initial experience and outcomes in an academic practice.

BACKGROUND: Considerable weight recurrence (WR) after Roux-en-Y gastric bypass (RYGB) may occur in nearly 20% of patients. While several nonoperative, endoscopic, and surgical interventions exist for this population, the optimal approach is unknown. This study reports our initial experience with distal bypass revision (DGB) and provides a comparison with patients after primary RYGB. METHODS: Single-institution, retrospective review was conducted for patients who underwent DGB from 2018 to 2020. A Roux and common channel of 150 cm each were constructed (total alimentary limb 300 cm). A group of primary RYGB patients with similar demographics were selected as controls. Demographics, comorbidity resolution, surgical technique, complications, excess weight loss (EWL), total weight loss (TWL), BMI, and weight change data were compared. Patient postoperative weight loss (WL) was also compared after their primary and DGB operations. RESULTS: Sixteen DGB patients, all female, were compared with 29 controls. DGB was performed on average 12.3 years after primary RYGB. In the DGB group, mean BMI was 53.7 before primary RYGB, 31.9 at nadir, and 44.1 prior to DGB. Post-DGB, mean BMI was 40.5, 37.4, 34.8, and 34.4, at 3-, 6-, 12-, and 24-months, respectively. Five patients (31.3%) experienced complications and were readmitted within 30 days, with two of them (12.5%) requiring reintervention and one (6.3%) undergoing reoperation. Mean EWL and TWL up to 2 years after DGB were lower than that after the patient's original RYGB (52.3 ± 18.6 vs. 67.2 ± 33.2; p = 0.126 and 19.6 ± 13.3 vs. 29.6 ± 11.8; p = 0.027, respectively). CONCLUSIONS: DGB resulted in excellent WL up to 2 years after surgery but was associated with considerable postoperative complication rates. The magnitude of TWL was lower compared with the primary operation. Only a few patients experienced nutritional complications. Results of this study can help counsel patients pursuing DGB for WR or nonresponse to primary RYGB. The comparative effectiveness of this approach to other available options remains to be determined.

An Evaluation of Pre-Operative Nutritional Assessment Methods in Patients with Chronic Limb Threatening Ischaemia Having Distal Bypass.

OBJECTIVE: The purpose of this study was to evaluate the influence of pre-operative nutritional status on long term outcomes of patients with chronic limb threatening ischaemia (CLTI) after distal bypass. METHODS: Patients who underwent distal bypass for CLTI from 2011 to 2020 at a single centre were reviewed retrospectively in Japan. Comparisons were made between patients with malnutrition and normal nutrition, as diagnosed by four nutritional assessments: Controlling Nutritional Status (CONUT), Geriatric Nutritional Risk Index (GNRI), Glasgow Prognostic Score (GPS), and Prognostic Nutritional Index (PNI). The primary endpoint was survival, and the secondary endpoints were graft patency, limb salvage, and wound healing. RESULTS: A total of 314 distal bypasses were performed in 249 patients (169 males; median age, 76 years; diabetes mellitus, 70%; and end stage renal disease with haemodialysis, 40%). Malnutrition was observed in 103 patients (41%) evaluated by CONUT, 129 (52%) by GNRI, 76 (31%) by GPS, and 114 (46%) by PNI. The survival rates in the study cohort were 81% at one year, 55% at three years, and 47% at five years. Malnutrition in all assessments was statistically significantly associated with reduced survival rate (CONUT, p < .001; GNRI, p = .002; GPS, p < .001; PNI, p < .001). In multivariable analysis, CONUT was the best predictor of mortality (p = .014). Malnutrition did not affect graft patency and limb salvage, but malnutrition based on CONUT, GNRI, and GPS was statistically significantly associated with reduced wound healing (CONUT, p = .002; GNRI, p = .006; GPS, p = .011). In multivariable analysis, CONUT tended to be the best predictor of wound healing (p = .061). CONCLUSION: Malnutrition in patients with CLTI with distal bypass was associated with overall mortality and incomplete wound healing. CONUT assessment was most effective for prediction of survival and wound healing. Distal bypass for CLTI patients with malnutrition may be suboptimal, and endovascular treatment may be recommended as an initial revascularisation method.

Predictors of infrapopliteal vein bypass graft revision in patients with chronic limb-threatening ischemia.

PURPOSE: Surgical revascularization is the standard treatment for chronic limb-threatening ischemia (CLTI). However, some patients may require reintervention. The Global Anatomic Staging System (GLASS), which evaluates the complexity of infrainguinal lesions, was proposed. This study aimed to identify predictors for graft revision and evaluate whether GLASS impacts vein graft revision. METHODS: Between 2011 and 2018, CLTI patients who underwent de novo infrapopliteal bypass using autogenous veins were retrospectively analyzed. To assess anatomic complexity with GLASS, femoropopliteal, infrapopliteal, and inframalleolar/pedal (IM) disease grades were determined. The outcomes of patients with or without graft revision were compared. Cox regression analysis was performed. RESULTS: Thirty-six of the 80 patients underwent reintervention for graft revision. Compared to the non-graft revision group, the graft revision group exhibited significantly higher rates of GLASS stage III (66% vs 81%, p = 0.046) and grade P2 IM disease (25% vs 58%, p = 0.009). Multivariate analysis revealed that IM grade P2 (hazard ratio [HR], 3.35; 95% confidence interval [CI], 1.66-6.75; p = 0.001) and spliced vein grafts (HR, 3.18; 95% CI, 1.43-7.06; p = 0.005) were significantly associated with graft revision. CONCLUSIONS: This study demonstrated that IM grade P2 and spliced vein grafts were predictors of graft revision. The GLASS stratification of IM disease grade may be useful in optimizing treatment for CLTI.

Does the Global Limb Anatomic Staging System Inframalleolar Modifier Influence Long Term Outcomes of Chronic Limb Threatening Ischaemia after Distal Bypass?

OBJECTIVE: The purpose of this study was to evaluate the influence of inframalleolar disease (Global Limb Anatomic Staging System Inframalleolar [GLASS IM] modifier) on long term outcomes of patients with chronic limb threatening ischaemia (CLTI) after distal bypass. METHODS: Patients who underwent distal bypass for CLTI from January 2012 to December 2019 at a single centre were reviewed retrospectively. Comparisons including baseline characteristics, procedural details, and long term outcomes were made between patients with an intact pedal arch (GLASS IM modifier P0), an absent or severely diseased pedal arch (P1), and no target artery crossing the ankle into the foot (P2), diagnosed by pre- and intra-operative high quality angiography. The primary endpoint was limb salvage. The secondary endpoints were graft patency and wound healing. RESULTS: A total of 254 distal bypasses were performed in 206 patients (139 males; median age, 76 years). The GLASS IM modifier was P0 in 80 (32%) limbs, P1 in 127 (50%), and P2 in 47 (18%). During the follow up period, 22 limbs (9%) required major amputation. The limb salvage rates at three years in P0, P1, and P2 cases were 94%, 89%, and 93%, respectively, with no significant differences among the modifiers. The primary patencies at three years in P0, P1, and P2 cases were 49%, 38% and 24%, respectively. The primary patency in P2 cases was significantly lower than that in P0 cases (p < .050). The respective wound healing rates at 12 months were 97%, 93%, and 79%, and again the wound healing rate in P2 cases was significantly lower than those in other cases (p < .050). CONCLUSION: Long term outcomes including patency, limb salvage, and wound healing after distal bypass for CLTI patients with an infrapopliteal lesion were acceptable in cases in each GLASS IM modifier.

Effectiveness of combined superficial femoral artery endovascular therapy with popliteal-to-distal bypass: A paradigm shift in surgical open bypass for chronic limb-threatening ischemia.

OBJECTIVES: The purpose of this study was to evaluate the results of combining superficial femoral artery endovascular therapy with distal bypass originating from the popliteal artery as a method of lower extremity revascularization in patients with chronic limb-threatening ischemia. METHODS: The records of patients undergoing combined superficial femoral artery endovascular therapy with popliteal-to-distal bypass for chronic limb-threatening ischemia from January 2014 to April 2020 at a single institution were retrospectively reviewed. The patients' background, operative details, and long-term outcomes were analyzed. RESULTS: Fifty-two popliteal-to-distal bypasses with superficial femoral artery endovascular therapy were performed in 49 patients (33 men; mean age, 76 ± 9 years; diabetes mellitus, 80%; end-stage renal disease with hemodialysis, 47%). The Trans-Atlantic Inter-Society Consensus II classification of superficial femoral artery-popliteal lesion was "A" in 8 (15%) patients, "B" in 14 (27%) patients, "C" in 24 (46%) patients, and "D" in 6 (12%) patients. The intervention for superficial femoral artery lesions was plain old balloon angioplasty in 4 patients, self-expandable nitinol stent in 15 patients, drug-coated balloon in 18 patients, drug-eluting stent in 4 patients, stent graft in 10 patients, and interwoven nitinol stent in 1 patient. Distal bypass originated from the above-knee popliteal artery in 9 (17%) limbs and the below-knee popliteal artery in 43 (83%) limbs. The most common outflow artery was the posterior tibial artery (44%). The mean follow-up period was 17 ± 17 months. The primary and secondary patency of the graft was 44% and 72%, respectively, at 1 year and 39% and 72%, respectively, at 3 years. Primary patency and freedom from clinical-driven target lesion revascularization of superficial femoral artery endovascular therapy lesions were 85% and 90%, respectively, at 1 year and 63% and 75%, respectively, at 3 years. Limb salvage was 97% at 1 year and 92% at 3 years. Wound healing was 67% at 6 months and 83% at 12 months. CONCLUSIONS: Combined superficial femoral artery endovascular therapy with popliteal-to-distal bypass may be a promising approach for patients with chronic limb-threatening ischemia because of durable patency, acceptable wound healing, and good limb salvage.

Surgical revascularization and reconstruction procedures in diabetic foot ulceration.

This article summarizes surgical procedures for preservation of the foot in diabetic patients with peripheral artery disease. Distal bypass surgery performed to perigeniculate arteries and to an isolated 'blind' popliteal segment with visible collaterals can be performed with limb salvage rates close to what can be achieved with standard bypass to crural arteries. This is also the case when performing bypass to the dorsalis pedis artery. Bypass to the medial or lateral plantar artery or to the lateral tarsal artery is associated with a relatively high rate of early occlusion, but in the patients who have persistently open grafts, limb salvage is common. The use of an arteriovenous fistula as an adjunct to distal bypass surgery does not improve prognosis. Venous arterialization, either creating retrograde perfusion of the superficial or of the deep veins of the foot has been successful in several cases although it is difficult to predict which patients will benefit. Reconstructive surgery is often performed in a multidisciplinary team including plastic surgeons. In patients with need of more extensive cover of defects, the transplant of muscular or fasciocutaneous free flaps has provided good results in the few centres that have applied this technique. This procedure can be combined with a revascularization in the same session or at a later stage. A majority of the described techniques can be implemented in most vascular centres and they should be considered in complicated cases when standard methods of revascularization and reconstruction do not suffice.

Ten Year Experience of Using Cryopreserved Arterial Allografts for Distal Bypass in Critical Limb Ischaemia.

OBJECTIVE/BACKGROUND: In critical limb ischaemia (CLI), current guidelines recommend revascularisation whenever possible, preferentially through endovascular means. However, in the case of long occlusions or failed endovascular attempts, distal bypasses still have a place. Single segment great saphenous vein (GSV), which provides the best conduit, is often not available and currently there is no consensus about the best alternative graft. METHODS: From January 2006 to December 2015, 42 cryopreserved arterial allografts were used for a distal bypass. Autologous GSVs or alternative autologous conduits were unavailable for all patients. The patients were observed for survival, limb salvage, and allograft patency. The results were analysed with Kaplan-Meier graphs. RESULTS: Estimates of secondary patency at one, two and five years were 81%, 73%, and 57%, respectively. Estimates of primary patency rates at one, two and five years were 60%, 56%, and 26%, respectively. Estimates of limb salvage rates at one, two and five years were 89%, 89%, and 82%, respectively. Estimates of survival rates at one, two and five years were 92%, 76% and 34%, respectively. At 30 days, major amputations and major adverse cardiac events were one and zero, respectively. Six major amputations occurred during the long-term follow up. CONCLUSION: Despite a low primary patency rate at two years, the secondary patency of arterial allografts is acceptable for distal bypasses. This suggests that cryopreserved arterial allografts are a suitable alternative for limb saving distal bypasses in the absence of venous conduits, improving limb salvage rates and, possibly, quality of life.

Distal bypass to a critically ischemic foot increases the skin perfusion pressure at the opposite site of the distal anastomosis.

INTRODUCTION: The purpose of the study was to reveal the effect of blood flow supply to the foot by analyzing the skin perfusion pressure values and the pedal arch connection after bypass surgery. PATIENTS AND METHODS: We selected 48 operated limbs whose skin perfusion pressure was measured pre- and post-operatively on the opposite site of distal anastomosis. We also assigned the ischemic limbs to three groups according to the patency of the pedal arch: good, intermediate, and poor. RESULTS: The mean value of skin perfusion pressure increased significantly from 27.0 ± 14.9 to 52.8 ± 16.0 (p < 0.001) post-operatively. Skin perfusion pressure improved in most of the limbs post-operatively and decreased or unchanged in only four limbs, all of which showed improved tissue loss. Three amputated limbs were due to infection, and all showed an increase in skin perfusion pressure. CONCLUSION: It was difficult to correlate limb prognosis to skin perfusion pressure and the pedal arch connection.

Validation of the Guy's scoring system in patient selection for femoro-distal bypass grafting to a single calf or pedal artery.

OBJECTIVES: First external validation of a preoperative scoring system (Guy's) in patient selection for femoro-distal bypass grafting to single calf or pedal artery in critical limb ischemia (Fontaine III & IV/Rutherford grade IV, V & VI). MATERIAL AND METHODS: A prospective study of 76 (n = 76) consecutive femoro-crural/pedal bypass grafts on 72 individuals (n = 72) from 2008 to 2011 with 36 months mean follow-up was performed. All cases were scored against a previously designed and published scoring system (ranging from 0 to 10) based on: inflow, outflow, graft material, flow type, patent pedal vessels and diabetes mellitus. RESULTS: Preoperative score of 0-4 (n = 37) demonstrated the primary patency of 27% at 10.3 months. This value for intermediate group 5-7 (n = 34) was 70.6% at 18.9 months. The high-score group 8-10 (n = 4) showed the longest primary patency (80%) at 27.3 months. Kaplan-Meier survival analysis exhibited a consistent and significant difference in primary assisted, secondary patency and overall limb/foot salvage amongst all individual scoring groups (p < 0.001). CONCLUSION: This study validates and complements the Guy's scoring system and provides a platform for the identification of critical limb ischemia patients in whom the result of femoro-crural/distal bypass grafting is so poor that primary amputation may be both clinically and economically more justified.

New simple image overlay system using a tablet PC for pinpoint identification of the appropriate site for anastomosis in peripheral arterial reconstruction.

PURPOSE: To evaluate the accuracy and utility of a new image overlay system using a tablet PC for patients undergoing peripheral arterial reconstruction. METHODS: Eleven limbs treated with distal bypass surgery were studied. Three-dimensional images obtained by processing a preoperative contrast-enhanced computed tomography scan were superimposed onto the back-camera images of a tablet PC. We used this system to pinpoint a planned distal anastomotic site preoperatively and to make a precise incision directly above it during surgery. We used a branch artery near the distal anastomotic site as a reference point and the accuracy of the system was validated by comparing its results with the intraoperative findings. The precision of the system was also compared with that of a preoperative ultrasonographic examination. RESULTS: Both the image overlay system and ultrasonography (US) accurately identified the target branch artery in all except one limb. In that limb, which had a very small reference branch artery, preoperative US wrongly identified another branch, whereas the image overlay system located the target branch with an error of 10 mm. CONCLUSIONS: Our image overlay system was easy to use and allowed us to precisely identify a target artery preoperatively. Therefore, this system could be helpful for pinpointing the most accurate incision site during surgery.

Distal Bypass Improves Skin Perfusion Pressure at the Whole Foot Regardless of Angiosomes in Patients with Chronic Limb-Threatening Ischemia.

Objectives: Distal bypass surgery's effect on tissue blood pressure beyond a focal angiosome remains debated. This study assessed tissue blood pressure in both direct revascularized angiosome (DRA) and indirect revascularized angiosome (IRA) after bypass surgery, utilizing repeated skin perfusion pressure (SPP) measurements. Methods: Twenty-nine limbs in 27 chronic limb-threatening ischemia (CLTI) patients (22 males and five females, age: 70.2 ± 9.3 years) who received distal bypass surgery were enrolled. SPP measurements were conducted for the DRA and IRA at 10 time intervals, encompassing both preoperative and postoperative periods of every 3-5 days until 30 days. Results: In total, 486 SPP measurements were collected from 58 measurement sites, and the transition of the SPP at the DRA was 35.4-62.5-59.5-70.2-58.2-62.2-63.1-63.6-63.8-73.4 mmHg and IRA was 29.4-53.4-53.7-58.8-51.3-63.1-47.9-62.1-57.6-61.0 mmHg. No significant differences were observed between SPP at the DRA and IRA. Fifteen wounds on the DRA (63%) and five on the IRA (100%) healed. Conclusion: Distal bypass improves SPP in both direct and IRAs of CLTI patients. These data indicated distal bypass improves tissue blood flow at entire foot regardless of angiosomes.

Clinical Outcomes After Distal Bypass in Patients With Chronic Limb-Threatening Ischemia due to Connective Tissue Disease.

OBJECTIVES: Chronic limb-threatening ischemia (CLTI) is mostly caused by arteriosclerosis, but is sometimes due to connective tissue disease. However, there is a limited knowledge of clinical outcomes of patients with CLTI with connective tissue disease. The objective of the study was to assess outcomes after distal bypass in these patients using global vascular guidelines. MATERIAL AND METHODS: Data from distal bypasses performed for CLTI at a single center from 2014 to 2023 were evaluated retrospectively. Clinical outcomes after distal bypass were compared for patients with CLTI with arteriosclerosis (AS group) and those with connective tissue disease (CD group). The primary endpoints were limb salvage and wound healing. RESULTS: Of the 282 distal bypasses performed for 222 patients with CLTI, 22 were conducted for 21 patients with connective tissue disease (CD group). The connective tissue disease was progressive systemic scleroderma (n = 11 patients), pemphigoid diseases (n = 2), polyarteritis nodosa (n = 2), rheumatoid arthritis (n = 2), and others (n = 4). Compared with the AS group, the CD group included more females (P = .007) and had greater oral steroid use (P < .001) and a higher Global Limb Anatomical Staging System (GLASS) inframalleolar (IM) modifier P2 (P < .001). The mean follow-up period of the whole cohort was 27 ± 22 months with no significant difference between the groups (P = .25), and 22 limbs required major amputation during this period. The 2-year limb salvage rate was significantly lower in the CD group compared to the AS group (75% vs 94%, P = .020). Wound healing was achieved in 220 (78%) limbs, and the 12-month wound healing rate was significantly lower in the CD group (52% vs 86%, P = .006). CONCLUSION: The low 2-year limb salvage and 12-month wound healing rates in patients with CLTI with connective tissue disease indicate that distal bypass may be challenging in these patients.

Iatrogenic acute limb ischemia with complete traumatic rupture of the popliteal artery associated with total knee arthroplasty.

Acute limb ischemia (ALI) related to total knee arthroplasty (TKA) is rare. Most occlusions are caused by thrombus formation in the popliteal artery (PA). Currently such cases are revascularized using less invasive approaches such as endovascular therapy or Fogarty thrombectomy. We report a case of ALI in a 65-year-old woman with complete rupture of the PA due to a TKA procedure. She had resting pain and motor paralysis in her right lower extremity after TKA. Contrast-enhanced computed tomography showed occlusion of the right femoropopliteal artery. Subsequently, she was referred to our hospital with a diagnosis of ALI. Initially, a less invasive revascularization procedure was unsuccessfully attempted. Therefore, we performed an emergency distal bypass and succeeded in revascularization. Intraoperative examination revealed a complete rupture of the PA. Postoperatively, the patient exhibited no signs of myonephropathic metabolic syndrome. Although there was significant motor impairment, the affected limbs were successfully salvaged. ALI with complete rupture of the PA associated with TKA has not been reported previously. In cases of iatrogenic ALI after TKA, it would be essential to consider diagnostic and revascularization methods that account for the possibility of severe injury to the PA. Learning objective: Acute limb ischemia after total knee arthroplasty is a rare and life- and limb-threatening condition. The underlying pathological mechanism is often thrombus occlusion due to mechanical stimuli of the popliteal artery (PA). There are no established treatments for this condition, and less invasive approaches such as endovascular procedures and Fogarty thrombectomy are often used. However, in cases involving severe damage to the PA, bypass surgery may be necessary, and revascularization procedures should be considered accordingly.

Successful Pedal Bypass in a Patient With Pseudoxanthoma Elasticum.

OBJECTIVES: Pseudoxanthoma elasticum (PXE) is a rare metabolic disease, causing calcification in the arterial media layer and further peripheral artery disease (PAD). A high rate of failure has been reported after endovascular and open surgical management of PAD among patients with PXE. Critical limb ischemia (CLI) rarely develops in PXE, and there are only few reports of its treatment. METHODS: We present a case report of a 57 year-old female diagnosed with pseudoxanthoma elasticum (PXE). She presented with critical limb ischemia (CLI) and was successfully treated with pedal bypass using the great saphenous vein. RESULTS: Despite obtaining suboptimal outcomes through the initial approach of percutaneous transluminal angioplasty to treat critical limb ischemia, the subsequent bypass operation proved to be a success. At the first follow-up appointment at 1 month, the patient was asymptomatic and the ulceration had almost healed. The patient underwent an ultrasound examination at 3, 6, 12, and 24 months after discharge, and the surveillance was uncomplicated. CONCLUSIONS: With a clear indication for surgery, limb-threatening ischemia can be successfully treated with distal bypass, if necessary, in patients with PXE similarly to atherosclerotic PADs. Appropriate diagnostic and surveillance imaging and the utilization of a multidisciplinary team are key components for effective management of PAD in patients with PXE.

A Novel Graft Route by Passage under the Achilles Tendon in Paramalleolar Distal Bypass Using the Small Saphenous Vein.

A 77-year-old man with diabetes presented to our hospital because of left toe gangrene, requiring infrapopliteal revascularization. The patient was on hemodialysis for renal dysfunction. The great saphenous veins had been used for a previous coronary artery bypass. Hence, the small saphenous vein was applied in a popliteal-to-distal posterior tibial artery bypass. The vein graft was passed under the Achilles tendon to reduce graft length, preventing external compression around the ankle. We performed minor amputation and provided negative pressure wound therapy to promote ulcer healing. The wounds healed entirely after two months.

Novel combination therapy of pedal arch angioplasty and dual distal bypass as an alternative treatment option for vasculitis in patients with chronic limb-threatening ischemia.

A 68-year-old man with chronic limb-threatening ischemia caused by atypical vasculitis was successfully treated by the combination of pedal arch angioplasty and dual distal bypass. Angioplasty alone failed; therefore, we performed pedal arch angioplasty followed by distal bypass revascularized to the newly created dorsalis pedis artery and posterior tibial artery anastomosis sites. Restenosis occurred twice, and both cases were successfully treated by immediate angioplasty. Both branches of the graft remained patent for >2.5 years, and the wound healed completely. This unique combination of techniques can provide favorable results for selected patients with chronic limb-threatening ischemia.

Rheocarna® therapy after distal bypass surgery.

Objectives: Rheocarna® therapy has recently been reported to improve peripherally measured blood flow as an adjuvant treatment after revascularization in patients with chronic limb-threatening ischemia. We investigated whether skin perfusion pressure and continuous walking distance were improved by performing Rheocarna® therapy after distal bypass surgery. Methods: This study included 10 patients who underwent Rheocarna® therapy after distal bypass surgery between June 2022 and March 2023. Rheocarna® therapy was performed five times after distal bypass surgery, and the skin perfusion pressure and continuous walking distance after distal bypass surgery were compared with those after Rheocarna® therapy. Results: The average age was 74.7 years, and nine patients (90%) were male. All patients were undergoing dialysis, with an average of 14.5 years of dialysis history. There were six patients (60%) with diabetes mellitus and five (50%) with hyperlipidemia. The ankle-brachial index was 0.62 ± 0.36 before distal bypass surgery and 0.936 ± 0.16 after Rheocarna® therapy, indicating a significant increase (p = 0.0117). Skin perfusion pressure dorsalis pedis was 71.5 ± 27.0 mmHg after Rheocarna® therapy, showing a marked increase from the preoperative value (p = 0.0020). Skin perfusion pressure planta pedis was 65.0 ± 26.3 mmHg after Rheocarna® therapy, which was a significant increase from the preoperative value (p = 0.0293). The continuous walking distance was 78.5 ± 102.7 m after the Rheocarna® therapy, which was a significant increase from the preoperative value (p = 0.0039). Conclusion: The skin perfusion pressure and continuous walking distance were significantly improved by Rheocarna® therapy after distal bypass surgery.

Distal Bypass Versus Infrageniculate Endovascular Intervention for Chronic Limb-Threatening Ischemia.

Chronic limb-threatening ischemia (CLTI) carries a high risk of amputation and warrants urgent intervention. CLTI involving the infrageniculate vessels, in particular, carries a considerably higher risk of major limb amputation. Open surgical bypass is the historical gold standard for the treatment of tibial arterial disease; however, endovascular therapy provides an attractive alternative in this high-risk patient population. In this article, we review the existing literature regarding distal bypass and infrageniculate endovascular intervention in patients with CLTI.