Contemporary Use of the Femoropopliteal Vein in Vascular Reconstructions.

INTRODUCTION: Current practice patterns favor endovascular treatment, resulting in fewer open procedures. When needed, greater saphenous vein and/or prosthetic conduits are considered the first choice for open vascular bypass. However, there is a cohort of patients in which these conduits are either not available or not suitable to address the surgical requirements. One alternative is to use femoropopliteal vein (FPV), an often-overlooked conduit. We report on the contemporary use of FPV in a tertiary vascular institution. METHODS: All patients who underwent FPV harvest, as defined by CPT code 35572, between 2005 and 2019 were identified. Patient demographics (sex, age, baseline laboratory values, medical co-morbidities), indication for use of FPV, complications specific to vein harvest, operative details, post-operative course, and outcomes were recorded. RESULTS: Ninety patients had harvest of FPV for creation of 123 conduits. In this study, a conduit was defined as a segment of vein used to perfuse a distinctly separate vascular bed. We identified four cohorts in which FPV was used: aorto-iliac reconstruction in 38 patients for infected graft (19), occlusive disease (8), aortitis (5), mycotic aneurysm (5), and malignancy (1); peripheral artery revascularization in 26 patients for ilio-femoral reconstruction (15), femoropopliteal reconstruction (4), upper extremity/cerebrovascular reconstruction (6), and coronary bypass (1); mesenteric revascularization in 20 patients for acute or acute on chronic ischemia (12), chronic ischemia (7) or aneurysm (1); and dialysis access in 6 patients. There was a high incidence of pre-existing comorbid conditions in all groups, but most notably those patients who underwent aorto-iliac reconstruction. Harvest-related or conduit-related complications included compartment syndrome, graft-associated hemorrhage, surgical site infection, and lymphatic complications. Primary graft patency at 3 years was 83% ± 4% (aorto-iliac), 83% ± 6% (peripheral), 100% (mesenteric), and 23% ± 19% (dialysis access, P < 0.001). CONCLUSIONS: While use of FPV has potential significant harvest-related, conduit-related, or systemic complications, FPV is useful for a variety of needs, almost universally available, and durable. In the current era where endovascular approach is the focus, FPV should not be forgotten as a potential conduit that can be used for a variety of vascular reconstruction indications.

Axillary Artery to Right Atrial Graft for Dialysis Access Using an Autologous Femoropopliteal Vein.

Patients with prolonged history of central venous catheters can develop central venous occlusion. We report the creation of an axillary artery to right atrial graft using the femoropopliteal vein (FPV) for dialysis access in a patient with end-stage renal disease on hemodialysis with history of central venous occlusion. The patient had previously developed steal syndrome following a right brachial artery to right atrial polytetrafluoroethylene graft requiring revision to a left axillary artery inflow which subsequently thrombosed. This is the first report of using an autologous FPV conduit to the right atrium for dialysis.

Massive necrotizing fasciitis following bellow-knee arterial surgery - A therapeutic challenge.

INTRODUCTION: Necrotizing fasciitis is a rare, progressive bacterial infection of superficial fascia followed by secondary subcutaneous tissue necrosis. We pressented a patient with massive fulminant lifethreatening necrotising fasciitis after bellow-knee femoro-popliteal vein bypass grafting successfully treated by antibiotics, surgical debridement and final skin reconstruction using the Tierch method. CASE REPORT: A 61-year-old patient was admitted to the Vascular Surgery Clinic for below-knee femoro-popliteal bypass grafting. He complained of intermittent claudication in the left leg after 50 m, ankle brachial indexes were 0.45 on the left and 1.0 on the right side. Femoropopliteal below-knee bypass grafting was done using the autologous great saphenous vein. In the very next day, initial signs of skin infection appeared including local inflammation, erythema, swelling and cellulitis restricted to saphenectomy site. These changes had rapidly spread in the following days on the deep tissue of the whole upper and lower leg, including the groin and with clinical signs of life-threatening systemic infection. Immediate surgical debridement was done followed by extensive wound packing and wide spectrum antibiotics administration for the next 33 days when final skin reconstruction by the Tierch method was performed. Interesting point is that this entire time wound swab was sterile. CONCLUSION: In the presented case immediate surgical debridement, wide spectrum antibiotics administration and consistent wound packing gave satisfactory results in this life-threatening systemic infection. Wound swab is not always a reliable indicator of the infection while clinical findings and surgeons' experience are of great significance in rapid reaction to this rare surgical complication.

The efficacy of autologous femoropopliteal vein reconstruction for primary aortic and aortic graft infection.

BACKGROUND: The objective of our study was to analyze the efficacy of autologous superficial femoropopliteal vein reconstruction for primary aortic or aortic graft infection. METHODS: We performed a retrospective analysis of 14 patients treated for an infected aortic prosthesis or primary infected aorta between 2012 and 2014. Three patients had a primary mycotic aneurysm caused by a Salmonella or Coxiella burnetti infection. Seven patients were treated previously for aortic aneurysms with a conventional Dacron vascular prosthesis and 4 with an endovascular prosthesis. All infected prostheses were explanted via median laparotomy with subsequent debridement of the aortic aneurysm wall. Aortic reconstruction was performed with 1 or 2 superficial femoropopliteal veins, interpositioning the greater omentum when possible. The primary outcome measure was 30-day mortality. Secondary outcome measures were reoperation, operating time, amputation rate, length of intensive care unit (ICU) and hospital stay, reinfection rate, and limb edema requiring compression therapy. RESULTS: The 30-day mortality was 28%. Two patients died of an abdominal sepsis, one patient of a cerebrovascular accident and another of a hypovolemic shock. One patient died at home 2 years after surgery of unknown cause. Four patients required a reoperation. The median intraoperative blood loss was 1,500 mL (500-8000). Median operating time was 364 min (264-524). Median length of ICU stay was 3.5 days (1-47), and median hospital stay was 20 days (10-47). There were no limb amputations. Mild edema of the donor leg was documented in 2 patients. Compression stockings were not worn by any patients. Postoperative antibiotic treatment was administered for at least 6 weeks. No recurrent infections were diagnosed. CONCLUSIONS: Autologous venous reconstruction of the aorta offers advantages over other therapeutic approaches and deserves a prominent place in the treatment of the primary infected aorta or an infected aortic prosthetic graft.

Aneurysmal degeneration of deep lower extremity vein conduits used for vascular reconstruction.

BACKGROUND: Successful outcomes have been reported with the use of femoropopliteal vein (FPV) grafts as arterial conduits. We identified 2 patients with a rare complication, true, nonanastomotic aneurysmal degeneration. METHODS: Patients from 1997 through 2009 that utilized FPV grafts for revascularization were analyzed. We contacted survivors by phone and conducted a literature search of FPV aneurysms. RESULTS: Of the total of 14 patients in our practice whose FPV was used as a conduit during the study period, 2 developed nonanastomotic FPV graft aneurysms. The mean follow-up time was 33.44 months. Literature review uncovered only 1 previously published case of FPV aneurysmal degeneration. CONCLUSIONS: Our experience suggests that nonanastomotic aneurysms of FPV grafts may occur more often than those suspected previously. Our study represents the first reports of aneurysmal degeneration affecting FPV grafts when used for vascular reconstructions.

Neoaortoiliac System (NAIS) procedure for the treatment of the infected aortic graft.

We aim to provide a thorough and current summary highlighting the use of autologous vein grafts during reconstruction of infected aortic grafts. Aortic graft infections, while rare, remain one of the most difficult problems that a vascular surgeon can encounter. Optimal management of patients with aortic graft infections requires a full understanding of all potential therapeutic interventions available. Reconstruction with autologous vein grafts is a technique that has evolved and has been refined during the past 2 decades, representing a major advance in the treatment of aortic graft infections. Thirty-day operative mortality is ≤ 10%, with 5-year mortality rates of 30% to 50%. Thirty-day major amputation rates range from 2% to 7.4%, with 5-year limb-salvage rates ranging between 89% and 96%. Early occlusion of the grafts are rare, with <4% undergoing thrombosis within the first 30 days; 5-year primary patency ranges from 75% to 91%, with secondary patency approaching 91% at 5 years. Recurrent infection is very rare, occurring in <2% of patients. Venous morbidity is similarly low, with fasciotomy rates of 12%, and only 15% of patients experiencing chronic venous insufficiency at 5 years. Aneurysmal degeneration is also exceptionally rare. Use of autologous vein grafts for in situ reconstruction of infected aortic grafts represents the standard of care in the treatment of aortic graft infections. With appropriate patient selection, centers with sufficient resources should be able to comparable outcomes.

A 10-year experience of using femoro-popliteal vein for re-vascularisation in graft and arterial infections.

BACKGROUND: Infected prosthetic grafts and mycotic aneurysms carry a high mortality and morbidity rate, with a substantial risk of persistent graft infection, but there is evidence that this can be minimised by using femoro-popliteal vein for arterial reconstruction after debridement and graft excision. We present our 10-year experience of this technique. METHODS: Forty-six patients underwent 48 arterial reconstructions with femoro-popliteal vein (24 aortic). Six had mycotic aneurysms (three aortic) and 40 had graft infections (16 aortic). RESULTS: There were two early postoperative deaths (4.3%) and two patients with pre-existing ischaemia underwent major amputation despite a patent graft. Median follow-up was 4.1 ears (range: 2 months to 10 years). Patient survival was 70% and limb salvage 96% at 5 years. Primary graft patency was 75% and 62% and secondary patency 93% and 91% at 2 and 5 years, respectively. Two patients required further surgery for recurrent infection. Anastomotic or graft stenosis occurred in 11 patients (24%). There were three major wound infections. Donor-limb swelling was transient. CONCLUSION: For arterial and prosthetic graft infections, femoro-popliteal vein is an excellent conduit for vascular reconstruction after drainage and debridement of infected tissue and graft material under antibiotic cover, providing good long-term survival and limb salvage.

Staging the neoaortoiliac system: feasibility and short-term outcomes.

BACKGROUND: The neoaortoiliac system (NAIS) has gained popularity as a durable procedure for treating aortic graft infections. However, one of the disadvantages has been a long operation that can take up to 10 hours. The goal of this study was to assess the feasibility of staging the NAIS procedure with deep vein harvest a day before the aortofemoral bypass and evaluate if staging had any effect on graft patency or morbidity and mortality, or both. METHODS: We reviewed data for all the NAIS procedures performed for aortic graft infections at a tertiary care university hospital. The femoral popliteal veins of patients undergoing the staged NAIS were harvested a day in advance and left in situ. The next day patients underwent the prosthetic graft excision with reconstruction using the femoral popliteal veins. Patients with aortic occlusion on presentation were not candidates for vein harvest in advance and underwent a unilateral bypass with a subsequent femorofemoral bypass as a second stage. RESULTS: In the last 8 years, 26 patients (17 men, 9 women; mean age, 62.6 +/- 8.3 years) underwent the NAIS procedure for aortic graft infections. Mean follow-up was 15.7 months. Primary assisted graft patency was 100%. There were 11 patients in the staged group and 10 patients in the nonstaged group. All the staged patients underwent vein mobilization a day before excision of aortic prosthesis. Despite undergoing a separate procedure for vein harvesting at a different time, there was no difference in total operative time (12.0 +/- 1.8 vs 11.9 +/- 2.2 hours), operative blood loss (2.6 +/- 1.2 vs 3.4 +/- 2.4 L), and requirements for transfusion for blood products (6.7 +/- 3.7 vs 6.0 +/- 5.4 U) or crystalloid (11.3 +/- 3.1 vs 10.9 +/- 2.4 L) between the staged group and nonstaged groups. One amputation occurred in each group. The perioperative mortality was 18% for the staged group and 20% for nonstaged group. The 12-month survival was 72% for staged and 70% for nonstaged NAIS. No graft-related complications were observed from the preoperative vein harvest. CONCLUSION: The NAIS can be staged without compromising the efficacy of the procedure as evident by excellent long-term patency and control of the infection. By reducing the duration of the primary procedure, staging may be beneficial to both the patient and the surgeon.

[Lower extremity deep vein as arterial replacement in the treatment of prosthetic graft infection]. / Hluboká zíla dolní koncetiny jako tepenná náhrada pri resení infekce cévní protézy.

In June 2007, an autologous lower extremity deep vein was used for arterial reconstruction for the first time in the Czech Republic. For this procedure, the superficial femoral vein was harvested in its full length, including part of the popliteal vein. Due to previous explantation of an infected prosthesis, the patient had critical ischemia and progressive gangrene of the lower extremity. His condition required an iliac-femoral artery reconstruction. Because of the high risk of recurrent infection, none of the conventional approaches involving a vascular prosthesis could be used. The implantation of a lower extremity deep vein appears to be very efficient in the treatment of prosthetic graft infection, which is one of the most serious and feared complications in vascular surgery.

Neoaortoiliac reconstructions using femoropopliteal veins: MDCT angiography findings.

OBJECTIVE: In this article, we discuss the neoaortoiliac system procedure, a surgical procedure that uses femoropopliteal vein segments for arterial reconstructions in patients with aortofemoral prosthetic graft infections. CONCLUSION: CT angiography (CTA) is a powerful imaging tool that can be used in the follow-up of patients after this complex surgery. CTA accurately detects early and late complications that may develop after the neoaortoiliac system procedure.

Aortic reconstruction with femoral-popliteal vein: graft stenosis incidence, risk and reintervention.

BACKGROUND: Management using femoral-popliteal vein (FPV) of aortic graft infections, failing aortofemoral bypass, and aortoiliac occlusive disease in young patients with a small aorta is now an accepted therapeutic method and is performed frequently at our institution. A high reintervention rate for FPV graft stenosis has recently been reported. The purpose of this study was to determine the incidence of FPV graft failure due to stenosis after neoaortoiliac system (NAIS) reconstruction, and to identify risk factors for this complication. METHODS: A review was performed of 240 patients who underwent NAIS reconstruction at our institution between January 1991 and December 2005. All patients were entered into a prospective database and were evaluated for the incidence of vein graft stenosis requiring reintervention, risk factors for stenosis, and the rate and type of reintervention required to assist patency. Patients with occlusion are evaluated and reported, but excluded from detailed analysis. Risk factors assessed included gender, operative features, FPV size (diameter), smoking history, and medical comorbidities. RESULTS: Of the 240 NAIS procedures performed during this time period, 11 (4.6%) patients have required 12 graft revisions (one patient required a second intervention) for stenosis using open and endovascular techniques. Over the same time period, graft occlusion occurred in nine patients (3.8%). This provided a primary patency at 2 and 5 years of 87% and 82%, and an assisted primary patency rate of 96% and 94%. Mean time to revision was 23.5 months (range 5.5 to 83.5 months). Median FPV graft size in the nonrevised patients was 7.8 mm (range 4.0 to 11.4 mm), and 6.4 mm (range 4.7 to 8.7 mm) in the revised group (P = .006). Survival analysis revealed small vein graft size (<7.2 mm), coronary artery disease (CAD), and extensive smoking history as independent predictors of time to stenosis (P = .002, .02, .01, respectively), with multivariable analysis confirming these results (P = .002, .06, .012). Patients with CAD combined with small graft size were found to be at especially high risk for stenosis, with 8/36 (22.2%) requiring revision vs 3/184 (1.6%) of patients without both factors (P < .0001). CONCLUSIONS: FPV graft stenosis requiring revision after NAIS reconstruction is uncommon. Risk factors for stenosis include small graft size, history of CAD, and smoking. All patients merit aggressive counseling for smoking cessation, and patients exhibiting multiple risk factors should undergo close postoperative surveillance for graft stenosis.

Vascular reconstruction using deep vein for limb length discrepancy in a child.

Iatrogenic vascular injuries can result in claudication and limb length discrepancy in growing children. Traditional reconstruction has been performed with great saphenous vein as a conduit. We report the case of a 7-year-old boy with a symptomatic limb length discrepancy and vascular reconstruction using femoropopliteal vein. The use of deep vein as an autogenous conduit may facilitate reconstruction of iliofemoral arteries in preadolescent children, providing an excellent size match and an efficacious means of restoring normal blood flow.

Aneurisma de la vena poplítea: tratamiento quirúrgico / The surgical treatment of popliteal vein aneurysms

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Pancreatic abscess involving the aortic graft following repair of a ruptured aortic aneurysm: successful replacement with femoro-popliteal vein.

Acute pancreatitis is a rare complication after aortic surgery and carries a high mortality. We report the successful management of an infected aortic graft secondary to complicated severe pancreatitis in a 77-year-old man by open drainage of the abscess and replacement of the prosthetic graft with superficial femoro-popliteal vein (SFPV). The patient remains free from infection with a patent graft 8 months later.

Femorofemoral bypass with femoral popliteal vein.

BACKGROUND: The femoropopliteal vein (FPV) has been used successfully for vascular reconstructions at multiple sites. To date, there have been no studies documenting patency of the FPV graft in the femorofemoral position. Our goal was to assess long-term patency of the FPV graft used for femorofemoral bypass (FFBP). METHODS: Patients undergoing FFBP over a 10-year period were studied. Those in whom the FPV was used as a conduit were analyzed for runoff resistance score to assess how patients with poor runoff fared. Poor runoff was defined as a runoff resistance score of > or =7 (1 = normal runoff, 10 = total occlusion of all runoff vessels). RESULTS: Fifty-four patients underwent FPV FFBP as a sole procedure (n = 16, 30%) or as a portion of an aortofemoral reconstruction with a FFBP component (n = 38, 70%). Mean (+/- SD) follow-up was 47 +/- 33 months. The 1-, 3-, and 5-year primary patencies were 97%, 93%, and 76%. The 5-year assisted primary and secondary patency rates were 85% and 90%. Among 27 patients with poor runoff (runoff resistance score of > or =7), the cumulative 40 month patency rate was 90%. Among patients in whom FPV FFBP was performed as a primary procedure (no aortofemoral component), there were no graft failures. CONCLUSIONS: FFBP performed with FPV has excellent 1-, 3, and 5-year patency rates. FPV has sustained patency for FFBP in patients with poor runoff.

Arterial reconstruction of infected femoral artery pseudoaneurysms using superficial femoral-popliteal vein.

BACKGROUND: Infected femoral artery pseudoaneurysms (IFAPs) secondary to percutaneous arterial access, injection of illegal substances, and from infected synthetic grafts, appear to be increasing in incidence. Ligation of IFAPs without revascularization offers control of infection but may risk limb ischemia. Revascularization with extraanatomic synthetic grafts may risk reinfection and abrupt thrombosis. Excision of IFAPs with revascularization using superficial femoral popliteal vein (SFPV) provides both control of infection and excellent limb perfusion. STUDY DESIGN: A retrospective review was conducted of patients diagnosed with IFAP who underwent resection and revascularization with SFPV at a single medical center. Outcomes measured included reinfection and amputation rate. These were compared with other series using various methods to treat IFAPs. RESULTS: Eleven patients with IFAP were encountered from 1992 to 2004. Mean age was 64 years (+/-10 SD). Five patients developed IFAP secondary to percutaneous arterial access procedures. Four patients developed infected femoral artery pseudoaneurysms secondary to synthetic graft infection. Two patients developed IFAP secondary to injection of illegal substances in the femoral region. All patients had positive wound cultures initially. Staphylococcus was the most common organism found in wound cultures. All patients underwent resection of IFAP with lower extremity revascularization using SFPV. There was no incidence of limb ischemia and no perioperative deaths in this series. CONCLUSIONS: Excision of IFAP with revascularization can be successfully achieved using SFPV. This method may prove to be superior to other methods with apparent higher patency rates and resistance to reinfection.

Outcome after autogenous brachial-axillary translocated superficial femoropopliteal vein hemodialysis access.

OBJECTIVE: The optimal configuration for patients with "complex" or "tertiary" hemodialysis access needs remains undefined. This study was designed to examine the utility of the autogenous brachial-axillary translocated superficial femoropopliteal vein access (SFV ACCESS) in this subset of patients. METHODS: Patients presenting for permanent hemodialysis access without a suitable upper extremity vein for autogenous access identified by duplex ultrasound mapping and those with repeated prosthetic access failures were considered candidates for SFV ACCESS. Ankle-brachial indices were obtained, and duplex scanning of the superficial femoropopliteal and saphenous veins was performed. Patients deemed candidates for SFV ACCESS also underwent preoperative upper extremity arteriography and venography. A retrospective review of the complete medical record was performed, and a follow-up telephone or personal interview was conducted. RESULTS: Thirty patients (mean age +/- SD, 54 +/- 15 years; male, 33%; white, 37%; with diabetes, 50%; obese, 21%) underwent SFV ACCESS among approximately 650 access-related open surgical procedures during the study period. The patients had been receiving dialysis for 4 +/- 5 years (range, 0-24 years), and had 3 +/- 3 (range, 0-17) prior permanent accesses, whereas 90% were actively dialyzed through tunneled catheters. In-hospital 30-day mortality was 3%, and the hospital length of stay was 7 +/- 7 days. Fifty-seven percent of the patients experienced some type of perioperative complication, and 38% required a remedial surgical procedure. Hand ischemia developed in 43% of the patients (severity grade: 1, 10%; 2, 7%; 3, 27%), and a distal revascularization, interval ligation was performed in all those with grade 3 ischemia. Thigh wound complications or hematomas developed in 23% of the patients, and arm wound complications or hematomas developed in 17%. The incidence of thigh wound complications was significantly greater (57% vs 9%; P =.03) in obese patients, but the other perioperative complications analyzed could not be predicted on the basis of age, gender, or comorbid conditions. The SFV ACCESS was cannulated 7 +/- 1 weeks postoperatively. The primary, primary assisted, and secondary patency rates were 96% +/- 4%, 100% +/- 0%, and 100% +/- 0%, respectively, at 6 months; 79% +/- 8%, 91% +/- 6%, and 100% +/- 0%, respectively, at 12 months; and 67% +/- 13%, 86% +/- 9%, and 100% +/- 0%, respectively, at 18 months (life table analysis; % +/- SE). CONCLUSIONS: The intermediate term functional patency rate after SFV ACCESS is excellent, although the magnitude of the procedure and the complication rate are significant. SFV ACCESS should only be considered in patients with limited access options.

In situ femoral to popliteal bypass graft using superficial femoral vein to popliteal vein.

During the evolution of vascular surgery as a specialty, many conduits have been used to revascularize the lower extremities. Superficial veins and prosthetic materials make up the majority of materials used to bypass diseased segments of native artery. The deep veins of the thigh have also been reported as alternatives for arterial bypass. However, the use of the in situ superficial femoral and popliteal vein bypass has not been reported to our knowledge in current literature. We report a 79-year-old white female with lower extremity rest pain who underwent an in situ femoral popliteal bypass graft for limb salvage.