Experience with a modified composite sequential bypass technique for limb-threatening ischemia.

BACKGROUND: Composite sequential femoro-popliteal-distal bypass is a valuable option for treatment of critical limb ischemia when autogenous vein is limited and an isolated popliteal or distal arterial segment exists. We report a modified technique for composite sequential bypass and the results with its use over a 14-year period. METHODS: Twenty-five modified composite sequential bypass procedures were performed on 24 patients to treat gangrene, ischemic ulceration, and severe rest pain. Vein grafts were anastomosed from blind popliteal or blind distal arterial segments above-knee (7) or below-knee (18) to a distal outflow vessel including the below-knee popliteal (1), posterior tibial (5), anterior tibial (7), or peroneal (12) artery. Polytetrafluoroethylene bypass grafts were then placed from a suitable inflow artery to the proximal hood of the vein graft. RESULTS: Cumulative primary patency rates were 80% at 3 years, and 65% at 5 years. The limb-salvage rate was 85% at 4 years. Occlusion of the prosthetic segment with a patent distal vein segment was recognized in two patients who presented with less severe recurrent ischemia. Limb-salvage in these patients was achieved by a secondary prosthetic graft to the patent vein graft. CONCLUSION: Our modified configuration of the prosthetic-vein anastomosis for composite sequential bypass is an alternative to the conventional procedure and may help preserve vein graft patency should the polytetrafluoroethylene graft thrombose.

Experience with covered stents for the management of hemodialysis polytetrafluoroethylene graft seromas.

Prosthetic graft seromas is a rare complication that has been traditionally managed with open methods using partial graft replacement and open drainage. We report the first two cases of hemodialysis graft seromas successfully treated with a covered stent. Both patients underwent arteriovenous graft placement from the brachial artery to the axillary vein using a standard wall, tapered 4 to 7 mm polytetrafluoroethylene graft, but developed a seroma at the arterial end of the graft. Unsuccessful attempts were made to treat these seromas with percutaneous and open drainage. In both patients, an 8 mm x 50 mm Wallgraft (Boston Scientific, Natick, Mass) was retrogradely deployed "bareback" at the arterial end of the graft allowing for complete resolution of the graft seromas.

Femoral artery to prosthetic graft anastomotic dehiscence owing to infection: successful treatment with arterial reconstruction and limb salvage.

A 66-year-old man had foot gangrene and a fixed contracture of the knee following two failed femoropopliteal bypasses, one with vein and one with polytetrafluoroethylene (PTFE). An external iliac to anterior tibial artery bypass and skeletal traction via the os calcis resulted in limb salvage and successful normal ambulation. After 3 months, he ruptured the infected femoral anastomosis of the failed PTFE femoropopliteal bypass with external bleeding. The use of arteriography and a balloon catheter to obtain proximal control allowed arterial repair, removal of the graft, and preservation of flow within a patent common and deep femoral artery. This flow preservation maintained the viability and function of the limb when the anterior tibial bypass closed 4 years later, and the limb continues to be fully functional 3 years later. Aggressive secondary attempts at limb salvage are worthwhile even in unfavorable circumstances.