Revascularización endovascular compleja multinivel y multivaso a través de un bypass fémoro-poplíteo ocluído en paciente con isquemia crónica con amenaza para las extremidades inferiores / Complex multilevel and multivessel endovascular revascularization through an occluded femoral-popliteal bypass in a patient with chronic limb threatening ischemia

Resumen La isquemia crónica con amenaza para las extremidades inferiores (ICAEI) representa el estadio final de la enfermedad arterial periférica, un problema de prevalencia creciente que conlleva el aumento de los costos de salud en todo el mundo. La ICAEI es una enfermedad con elevada morbilidad, generando mortalidad significativa, pérdida de miembros, dolor y disminución de la calidad de vida. La principal causa de amputaciones no-traumáticas de miembros inferiores está relacionada a la diabetes y a la ICAEI. Entre un 2% y 3% de los pacientes con enfermedad arterial periférica se presentan con un caso grave de ICAEI, condición que se correlaciona con enfermedad arterial multinivel y multiarterial, calcificación y oclusiones totales crónicas. Se describieron varias estrategias técnicas para cruzar con éxito largas oclusiones en segmentos arteriales. Se puede realizar la recanalización utilizando técnicas endoluminales, subintimales y retrógradas. Relatamos un caso de revascularización endovascular compleja multinivel y multiarterial a través de un bypass fémoro-poplíteo en una paciente con ICAEI.

Abstract Chronic limb-threatening ischemia (CLTI) represents the end stage of peripheral artery disease, a problem of growing prevalence and increased health care costs around the globe. CLTI is a highly morbid disease, incurring significant mortality, limb loss, pain, and diminished health-related quality of life. The major cause of non-traumatic lower extremity amputation are related to diabetes and CLTI. Between 2% to 3% of patients with peripheral artery disease present with a severe case of CLTI, a condition that is correlated with multilevel and multivessel arterial disease, calcification, and chronic total occlusions. Multiple technical strategies to successfully cross long occlusions in arterial segments have been described. Recanalization can be performed using endoluminal, subintimal, and retrograde techniques. We report a case of complex multilevel and multivessel endovascular revascularization through an occluded femoro-popliteal bypass in a patient with CLTI.

Infección de prótesis aórtica abdominal convencional: resultados del tratamiento mediante resección y revascularización extraanatómica / Aortic graft infection: outcomes of graft excision and extra anatomic revascularization

Introducción: la infección de prótesis después de cirugía abierta de aorta abdominal es infrecuente (0,7-3 %) y potencialmente mortal. El manejo clásico ha sido mediante revascularización extraanatómica y retiro del material protésico, y actualmente existen alternativas de reparación in situ. La mortalidad perioperatoria global es entre 4 y 40 % dependiendo de la serie y del tipo de reparación. Objetivos: reportar nuestra experiencia con revascularización extraanatómica y resección de la prótesis infectada. Metodología: estudio retrospectivo entre 1977 y 2020. Se incluyeron solo pacientes con infección de prótesis tratados mediante resección y reconstrucción extraanatómica. Se consideraron variables demográficas, comorbilidades, presentación clínica y agente microbiano. Como resultado primario utilizamos mortalidad posoperatoria y para resultados secundarios: reoperaciones, complicaciones precoces y tardías, amputación mayor, permeabilidad y sobrevida alejada. Se realizaron estadísticas descriptivas y asociaciones dicotómicas con chi-cuadrado. Resultados: dieciséis pacientes, todos masculinos. Edad promedio 69,2 años (55-82). Tiempo promedio de cirugía a infección de 27,8 meses (1-84). Fue más frecuente la infección en pacientes intervenidos por aneurisma roto que por otras causas (p < 0,05). Once pacientes (68,8 %) presentaban fiebre, 6 (37,5 %) debutaron con dolor abdominal o lumbar, 5 (31,3 %) con signos inflamatorios cutáneos (región inguinal o lumbar). Doce pacientes (75 %) presentaron comunicación aortoduodenal: 6 fístulas y 6 erosiones. Tres pacientes (18,8 %) debutaron con isquemia de miembros inferiores. Siete pacientes (43,8 %) presentaron complicaciones posoperatorias mayores y 2 pacientes fallecieron en el posoperatorio (12,5 %). La sobrevida actuarial al año y a 5 años fue de 86,7 % y 64,3 % respectivamente. Las permeabilidades primaria y secundaria de la reconstrucción extraanatómica a 5 años fue 77,8 % y 100 %, respectivamente...(AU)

Introduction: aortic graft infection (AGI) after aortic open repair is an unusual (0.7-3 %) and potentially lethal complication. Standard treatment has been excision of infected graft and extra anatomic bypass, although currently there are in situ repair techniques. Global perioperative mortality is 4-40 % according to the series and the repair technique. Objectives: to report our experience with extra anatomic revascularization and excision of infected graft in AGI. Methodology: retrospective study between 1977 and 2020. Were included patients with AGI treated with extra anatomic revascularization and excision of infected graft only. Demographics, morbidities, clinical presentation and microbiological agents were considered. Primary outcome was postoperative mortality. Secondary outcomes were reinterventions, postoperative complications, major amputations, bypass patency and long-term survival. Descriptive statistics were performed and dycotomical asociations were established with chi-squared test. Results: sixteen patients, all male. Average age 69.2 years (55-82). Average time to infection from surgery was 27.8 months (1-84). AGI was more frequent in patients with ruptured aortic aneurysm (p < 0.05). Eleven patients (68.8 %) had fever, 6 (37.5 %) consulted with abdominal or lumbar pain, 5 (31.3 %) had inflammatory changes of local skin. Twelve patients (75 %) had aortoduodenal communications. Three patients (18.8 %) had lower limb ischemia. Seven patients (43.8 %) presented postoperative complications and 2 patients expired (12.5 %). Actuarial one-year and five-year survival were 86.7 % and 64.3 %, respectively. Five-year primary and secondary patency of the axillofemoral bypass were 77.8 % and 100 %, respectively. Conclusions: AGI is a serious condition, which treatment carries significant morbidity and mortality. Axillofemoral bypass grafting and infected graft excision currently is a safe alternative of treatment.

Bypass axilofemoral para pacientes con infección de prótesis aórtica. Experiencia en nuestro centro con el uso de la prótesis biosintética Omniflow II(R) y revisión de la bibliografía / Extraanatomic axillofemoral bypass in patients with aortic graft infection. Experience in our center with the use of Omniflow II(R) biosynthetic prosthesis and review of the bibliography

La infección abdominal de una prótesis aórtica en pacientes portadores de bypass aórticos, aortoilíacos o aortofemorales unilaterales o bilaterales es una de las complicaciones más temibles que a nivel vascular podemos encontrar dada su alta morbilidad y, sobre todo, su alta mortalidad. Su manejo siempre va a ser difícil y acompañado por lo general de mal pronóstico, pues su tratamiento quirúrgico requiere una indicación, un estudio y una programación individualizados en cada paciente. Sea cual sea la actitud terapéutica inicial, conservadora o agresiva, la resolución final de la infección va a llevar aparejada la exéresis de la prótesis infectada y la revascularización de las extremidades inferiores mediante técnicas y materiales diversos. En cuanto a las técnicas a emplear podemos optar por el empleo de una vía ortoanatómica o extraanatómica y actuar en un tiempo o en dos. Entre los materiales a emplear tenemos los injertos autólogos con vena, como los de elección en caso de disponer de ellos, o de otros materiales alternativos en caso contrario, de los que encontramos publicado en la literatura el uso de una prótesis biosintética. Describimos nuestra experiencia en el manejo de estos pacientes mediante el empleo de la prótesis Omniflow II(R) por vía extraanatómica

Abdominal infection of an aortic prosthesis in patients with aortic, aortoiliac or aortofemoral bypass is one of the most feared vascular complications that we can find, because its high morbidity and, above all, its high mortality. Its handling is always going to be difficult and usually accompanied by poor prognosis because surgical treatment requires an indication, study and programming individualized for each patient. Whatever the initial therapeutic approach, conservative or aggressive, the final resolution of the infection will be accompanied by the excision of the infected prosthesis and revascularization of the lower limbs using different techniques and materials. As for the techniques employed, we can choose to use an ortho-anatomic or extra-anatomic reconstruction and to act in one or two times. Among the materials used we have the autologous venous grafts, as those of choice in case of having them, or alternative materials otherwise, of which are reported in the literature the use of a biosynthetic prosthesis. We describe our experience in the management of these patients by using the Omniflow II(R) prosthesis extraanatomically

Management of acute type A aortic dissection with acute lower extremities malperfusion.

BACKGROUND: Acute type A aortic dissection complicated by malperfusion is a life - threatening emergency. The optimal management strategy for malperfusion remains controversial. CASE PRESENTATION: A 46-year-old man presented to another institution with acute type A aortic dissection with abdominal aorta occlusion. Motor and sensory grade of both lower extremities were zero. Immediate antegrade distal perfusion of both lower extremities was achieved, and total arch replacement with left axillo-bifemoral bypass was performed. At the time of discharge, motor and sensory grades of both lower extremities were 2 and 3, respectively. CONCLUSION: This case demonstrates many of the techniques in the management of acute type A aortic dissection with abdominal aorta occlusion. In this case, direct antegrade perfusion of both lower extremities and axillo-bifemoral bypass may be helpful for patients presenting with severe malperfusion of both lower extremities with acute type A aortic dissection.

Novel Use of the PECS II Block in Major Vascular Surgery: A Case Report.

Patients presenting for major vascular surgery are often elderly, medically complex, and at increased risk for general anesthesia-related complications. A search of the published literature produced no citation regarding PECS II block in the setting of extra-anatomic bypass procedures. We present a case report describing the use of the deep injection of the PECS II block in this context. Although further investigation is needed to determine the role of truncal blocks in major vascular surgery, our case illustrates that peripheral nerve blocks, combined with continuous spinal anesthesia, may be used as an alternative to general anesthesia for axillofemoral-femoral bypass.

The use of local anesthesia to perform lower limb revascularization in the fragile patient with critical limb ischemia.

Patients with critical limb ischemia are usually compromised, frequently making administration of general or regional anesthesia problematic. We treated 3 fragile patients presenting contraindications to undertake traditional anesthetic techniques for lower limb revascularization, in whom local anesthesia with conscious sedation was used to complete the operation. An axillo-bifemoral, a unilateral axillo-femoral and a femoro-femoral bypass were performed. Procedure was uneventful in all three cases despite the coexistence of specific surgical challenges (distal anastomosis at the profunda in two cases, redo surgery and scarred groin in the third). Surgical revascularization under local anesthesia may be considered in selected high risk patients.

Bilateral inguinal hernia after axillary-femoral artery bypass effectively treated with laparoscopic repair: A case report.

We report herein our experience with bilateral inguinal hernia surgery for a patient who had previously undergone a Y-shaped vascular graft for an abdominal aortic aneurysm and then right axillary-bilateral femoral artery bypass surgery. Preoperative physical examination and imaging revealed a subcutaneous vascular graft passing from the right axilla through the right flank region and branching at the lower abdomen to reach the femoral areas on both sides. As repair surgery by inguinal incision was considered difficult, we performed laparoscopic surgery. Bilateral direct hernia was observed on intraperitoneal observation. Essentially no intraperitoneal organ adhesion to the abdominal wall was present, and the previous surgery was also confirmed not to have reached the inguinal preperitoneal space. Transabdominal preperitoneal repair was therefore performed, yielding favorable results.

Double localization of a non-anastomotic pseudoaneurysm after an axillofemoral bypass: a case report and review of the literature.

BACKGROUND: A traumatic non-anastomotic pseudoaneurysm is a rare complication of an axillofemoral bypass graft. Fewer than 20 cases have been reported in the literature. Our case is unusual in that we report a double localization of this complication. CASE PRESENTATION: We report the case of a 60-year-old Arabic male patient who was diagnosed with two hematomas in the trajectory of his axillofemoral bypass secondary to a traumatism. The diagnosis of a non-anastomotic pseudoaneurysm was retained considering the results of a computed tomography angiography scan, which showed the double localization of the pseudoaneurysm. Surgical management consisted of flattening the pseudoaneurysm along with the interposition of a prosthetic segment. There were no postoperative complications and our patient was well 3 years after discharge. CONCLUSIONS: Non-anastomotic pseudoaneurysm is a rarely described complication of a axillofemoral bypass graft. To the best of our knowledge, a double localization has not been described in the literature before. Minimally invasive techniques as a treatment option are being widely used as an alternative to open repair.

Transverse rupture of ring-supported Dacron graft 10 years after axillobifemoral artery bypass: induced by graft deterioration and Fogarty thrombectomy.

A 70-year-old woman underwent an axillobifemoral artery bypass using a bifurcated ring-supported Dacron graft in 2004 and then noticed a pulsatile mass in the left flank 10 years later. A Fogarty thrombectomy was performed for acute graft occlusion. Eight months later, computed tomography revealed pseudoaneurysm formation in the graft body and surgical graft interposition was performed. The operative findings showed a transverse rupture of the graft just above the bifurcation. Histological findings revealed graft deterioration with filaments broken off from the graft. Although the cause of pseudoaneurysm formation was not apparent, the combination of graft deterioration and additional damage from the Fogarty thrombectomy was highly suspicious.

Axillary-Femoral Bypass May Provide Inadequate Distal Perfusion Compared with In-Line Large Diameter Aortic Reconstruction.

Axillary-femoral bypass is sometimes performed for complex aortoiliac occlusive disease in patients unfit for aortic surgery or in those with aortic infection. Typically, older patients with medical comorbidities that commonly accompany atherosclerotic or aneurysmal disease are involved and can tolerate the theoretic risk of limited flow volume associated with long, small diameter, axillary-femoral grafts. However, a subset of younger, healthier, more vigorous patients outside the typical atherosclerotic or aneurysmal demographic occasionally come to axillary-femoral bypass and may experience symptoms of distal hypoperfusion if flow volumes cannot meet demand. We present a series of patients with primary aortic infection treated with aortic ligation and axillary-femoral bypass, who then progressed to symptoms of visceral, spinal, or extremity ischemia from inadequate distal perfusion.

A new technique to explant an infected aortic endograft.

The management of an infected aortic endograft can be challenging both operatively and clinically. Although aortic endograft infection is rare, the incidence is likely to increase in the coming years because of ever rising numbers of endovascular aneurysm repairs. Definitive management involves the removal of the endograft through laparotomy. Removal of the graft is technically challenging; no manufacturer's device is available to assist in disengagement of barbed hooks that hold the endograft in position. We present a new technique using the disposable proctoscope as a device to facilitate safe removal of the endograft with minimal damage to the aortic wall.

Dutch randomized trial comparing standard catheter-directed thrombolysis and ultrasound-accelerated thrombolysis for arterial thromboembolic infrainguinal disease (DUET).

PURPOSE: To report the results of the Dutch randomized trial comparing standard catheter-directed and ultrasound-accelerated thrombolysis (UST) for the treatment of arterial thromboembolic occlusions. METHODS: The DUET study ( controlled-trials.com ; identifier ISRCTN72676102) was designed to assess whether UST can reduce therapy time significantly compared with standard thrombolysis (ST). Sixty patients (44 men; mean age 64 years) with recently (7-49 days) thrombosed infrainguinal native arteries or bypass grafts causing acute limb ischemia (Rutherford category I or IIa) were randomized to ST (n = 32) or UST (n = 28). The primary outcome was the duration of thrombolysis needed for uninterrupted flow (> 95% thrombus lysis), with outflow through at least 1 below-the-knee artery. Continuous data are presented as means ± standard deviations. RESULTS: Thrombolysis was significantly faster in the UST group (17.7 ± 2.0 hours) than in the ST group (29.5 ± 3.2 hours, p = 0.009) and required significantly fewer units of urokinase (2.8 ± 1.6 × 10(6) IU in the ST group vs. 1.8 ± 1.0 × 10(6) IU in the UST group, p = 0.01) for uninterrupted flow. Technical success was achieved in 27 (84%) patients in the ST group vs. 21 (75%) patients in the UST group (p = 0.52). The combined 30-day death and severe adverse event rate was 19% in the ST group and 29% in the UST group (p = 0.54). The 30-day patency rate was 82% in the ST group as compared with 71% in the UST group (p = 0.35). CONCLUSION: Thrombolysis time was significantly reduced by UST as compared with ST in patients with recently thrombosed infrainguinal native arteries or bypass grafts.

Perigraft seroma as a rare angiosurgical complication.

Perigraft seroma is quite a rare complication that may occur after implantation of Dacron or expanded polytetrafluoroethylene (ePTFE) vascular grafts. We report a case of a 54-year-old patient with perigraft seroma around an axillofemoral bypass (ePTFE graft). Definitive treatment involved the explantation of this extraanatomic bypass with perigraft seroma and the implantation of an aortobiiliac bypass using vascular prosthesis made of a different material. Based on published studies, therapeutic options for this complication are discussed. No guidelines or recommendations are available. In conclusion, the approach to perigraft seroma treatment remains strictly individual. Vascular graft replacement using grafts made of different material seems to be the best option in the case of recurring perigraft seroma, where less invasive procedures were not successful.

A 56-year-old man with co-prevalence of Leriche syndrome and dilated cardiomyopathy: case report and review.

We report about a 56-year-old man with dyspnoea and leg pain diagnosed with Leriche syndrome and chronic heart failure caused by dilated cardiomyopathy (DCM) with acute cardiac decompensation. Optimising of chronic heart failure therapy with diuretic and antihypertensive drugs leaded to recompensation. A defibrillator was implanted, and afterwards surgical therapy of Leriche syndrome was planned.Leriche syndrome is an uncommon variant of atherosclerotic occlusive disease characterised by total occlusion in abdominal aorta and/or both iliac arteries. If aortic stenosis develops slowly, collateral vascular circulation can be found frequently. Typical symptoms are claudication, symptoms related to an arterial insufficiency of the lower extremities, erectile dysfunction and weight loss. Risk factors of Leriche syndrome are diabetes mellitus, hypertension, hyperlipaemia and smoking. Further it is often associated with chronic renal failure and coronary artery disease. Diagnosis is normally made by computed tomography (CT) or magnetic resonance imaging (MRI). Standard therapy is surgical revascularisation.DCM is a common cause of a congestive heart failure, which could be induced by coronary artery disease, hypertension, toxic, metabolic, inflammatory and infectious agents, and inherited gene defects.