Efficacy and safety of iliofemoral bypass using arm veins as an alternative conduit for chronic limb-threatening ischemia.

OBJECTIVE: The use of basilic vein in iliofemoral revascularizations was previously described in the literature as an autologous option for the treatment of vascular prosthesis infection and as a primary conduit in patients at high risk of infectious surgical complications. However, the publications available include several different indications and are limited to case reports. Therefore, the aim of this study was to evaluate the outcomes of the use of arm veins as a safe and effective autologous alternative for iliofemoral reconstruction in patients with chronic limb-threatening ischemia (CLTI) and at high risk of prosthesis infection. METHODS: We performed a multicenter, retrospective cohort study with 53 consecutive iliofemoral bypasses using arm veins as an alternative conduit. The procedures were performed between November 2013 and November 2021, exclusively for patients with CLTI classified as TASC aortoiliac C or D with increased risk of postoperative surgical infection. Demographic, clinical variables, and outcomes were collected from a prospective database. Main endpoints were amputation-free survival (AFS) and major adverse cardiovascular events. Secondary endpoints included primary and secondary patencies and overall survival. Cox regression analysis was used to identify the predictors of AFS. Postoperative surgical complications and 30-day mortality were also assessed. RESULTS: The mean age was 64.2 ± 8.4 years, with a predominance of male gender. The median follow-up period was 615 days. All patients had CLTI, with a predominance of tissue loss (n = 51; 96.2%) and a median ankle-brachial index of 0.28. The basilic vein was utilized in most procedures (69.8%). Thirty-day major adverse cardiovascular events occurred in five cases (9.4%), and the 30-day mortality rate was 3.8%. The AFS, primary patency, secondary patency, and overall survival in 720 days were 71%, 72%, 89%, and 75%, respectively. Cox regression analysis revealed no association between the variables analyzed for AFS. There was no graft late infection nor pseudoaneurysmal degeneration. CONCLUSIONS: Iliofemoral bypass using arm veins as an autologous conduit proved to be an effective and safe procedure with low incidence of postoperative cardiovascular complications and high rates of AFS in patients with CLTI. Also, this suggests that arm veins can be an interesting and suitable autologous alternative conduit for iliofemoral reconstructions, especially in cases in which a prosthesis should be avoided or when it is not available.

Eversion Endarterectomy of the External Iliac Artery in Treating Chronic Limb-Threatening Ischemia in TASC II C and D Iliofemoral Occlusive Disease.

BACKGROUND: Endovascular treatment of iliofemoral occlusive disease is a challenging approach, especially for TransAtlantic Inter-Society C and D lesions. Therefore, the revascularization procedure in such situations is preferably performed by bypass graft surgery with synthetic materials. The purpose of this study is to report the feasibility and mid-term results of eversion endarterectomy of the external iliac artery (EEEIA), as an alternative autologous option. METHODS: Retrospective study with 18 EEEIA performed between September 2015 and February 2020, exclusively for chronic limb-threatening ischemia treatment in patients with increased risk of postoperative surgical infection and inadvisable for endovascular treatment. Demographic, clinical variables and outcomes were collected from a prospective database. The main end points are: amputation-free survival (AFS) and 30-day mortality. Secondary end points include: primary patency (PP), cumulative patency (CP), overall survival (OS), and postoperative surgical complication. Kaplan-Meier analysis was used to estimate cumulative time of outcomes. RESULTS: The mean age was 64.8 ± 8.3 years, with predominance of men. The median follow-up period was 1012 days, 95% confidence interval [119, 1365] days. Most had Rutherford 5 (n = 13, 72.2%) and mean ankle brachial index was 0.38 ± 0.22. The PP, CP, AFS, and OS in 730 days were 81%, 92%, 80%, and 88%, respectively. There was no 30-day mortality or postoperative surgical infection. CONCLUSIONS: Iliofemoral reconstruction through EEEIA is an effective surgical procedure with good patency rates, AFS and OS. In addition, it can be considered an useful and safe option, especially in cases in which a prosthesis should be avoided.

Arteriovenous fistula as adjuvant treatment in arterial revascularization of an at-risk limb.

Acute arterial occlusion remains a major challenge for the vascular surgeon. The therapeutic approach depends mostly upon the severity of the tissue injury and the duration of symptoms. Several techniques are available in the current therapeutic arsenal, however, regardless of the technique chosen, postoperative factors frequently observed, such as poor outflow status, or even low graft flow, can contribute negatively to the outcome of revascularization. We describe a case of acute limb ischemia, in the postoperative period of a femoral-tibial bypass, which was occluded due to outflow limitation and high peripheral vascular resistance. The patient underwent a second tibial revascularization combined with construction of an arteriovenous fistula, followed by forefoot amputation and partial skin graft. An energetic approach to the at-risk limb makes it possible to reduce unfavorable outcomes, such as amputation and death, and accelerates recovery of tissues affected by acute ischemia.

Alternative iliofemoral revascularization in extensive aortoiliac occlusive disease.

Over recent decades, there has been a considerable increase in use of endovascular methods to treat aortoiliac occlusive disease. It has been demonstrated that this approach offers many benefits, primarily for non-complex arterial lesions of the iliac axis, but difficulties persist with achieving adequate results over the medium and long term when treating extensive occlusive disease. Arterial bypasses to alternative vicarious arteries of the femoral-genicular complex for limb salvage are well known in the literature describing cases that are not favorable for conventional or endovascular surgery. We describe the case of a patient with extensive aortoiliac occlusive disease treated with an arterial bypass in the iliofemoral territory, using an alternative autologous substitute and the descending lateral femoral artery as recipient artery. Alternative bypasses and substitutes that are normally reserved for exceptional cases can and should be part of the vascular therapeutic arsenal and have a contribution to make in cases in which endovascular surgery does not yet enable us to achieve good results.

Fístula arteriovenosa como tratamento adjunto na revascularização arterial do membro em risco / Arteriovenous fistula as adjuvant treatment in arterial revascularization of an at-risk limb

Resumo A oclusão arterial aguda do membro inferior continua sendo um grande desafio para o cirurgião vascular. A abordagem cirúrgica depende principalmente da gravidade da lesão tecidual e da duração dos sintomas. Diversas técnicas estão disponíveis no arsenal terapêutico atual; porém, independentemente da técnica escolhida, fatores pós-operatórios, como o escoamento arterial limitado e o baixo fluxo nos substitutos arteriais, podem contribuir negativamente no resultado da revascularização. Descrevemos um caso de oclusão arterial aguda de membro inferior, no pós-operatório de uma derivação femorotibial, que se encontrava ocluída devido a limitação de escoamento e a alta resistência vascular periférica. Foi submetido a nova revascularização femorotibial, associada à confecção de uma fístula arteriovenosa, seguido de amputação de antepé e enxerto parcial de pele. O investimento enérgico no membro em risco possibilita reduzir os desfechos desfavoráveis, como amputação e óbito, e acelera a recuperação dos tecidos acometidos pela isquemia aguda.

Abstract Acute arterial occlusion remains a major challenge for the vascular surgeon. The therapeutic approach depends mostly upon the severity of the tissue injury and the duration of symptoms. Several techniques are available in the current therapeutic arsenal, however, regardless of the technique chosen, postoperative factors frequently observed, such as poor outflow status, or even low graft flow, can contribute negatively to the outcome of revascularization. We describe a case of acute limb ischemia, in the postoperative period of a femoral-tibial bypass, which was occluded due to outflow limitation and high peripheral vascular resistance. The patient underwent a second tibial revascularization combined with construction of an arteriovenous fistula, followed by forefoot amputation and partial skin graft. An energetic approach to the at-risk limb makes it possible to reduce unfavorable outcomes, such as amputation and death, and accelerates recovery of tissues affected by acute ischemia.