Category: PAD

peripheral arterial disease

Categories
amputation bypass Commentary PAD trauma

When Better is Better Than Good

original bypass

The dictum that better is the enemy of good is one of the old chestnuts carried around surgery training forever. It is an admonition against an unhealthy perfectionism that arises from either vanity or self doubt, and in the worse cases, both. The typical scenario is a surgeon trying to make a textbook picture perfect result and finding the patient’s tissues lacking, will take down their work to make it better, and repeat this process while the patient and everyone else in the room lingers.

Trying to avoid this, many surgeons will try to avoid any difficulties -the bad patch of scar tissue, irradiated body parts, areas of prior infection. But the mental contortions involved in avoiding “perfect” can result in actual physical contortions that in the end don’t pay off in good enough. I have not been immune to this, and I don’t think any physician or surgeon can honestly say they haven’t experienced some variation on this.

This patient is a younger middle aged man who in his youth experienced a posterior dislocation of his left knee, resulting in an arterial transection. This was repaired with an in-situ graft. Subsequently, he had complications of osteomyelitis and had his knee fused after resection of his joint. He did well with this bypass for several decades, but it finally failed several years ago, and a new one was created (image above).

Rather than directing the graft in line as in the previous one, this was was taken from a medial exposure of the femoral artery and tunneled superficially around the fused knee to coil lateral, ending in the anterior tibial artery.

This graft in turn thrombosed and was lysed by the outside surgeons and underwent serial interventions of proximal and distal stenoses at the anastomoses. The patient, when I met him, was contemplating an above knee amputation as a path to returning to work as a nurse in a rural hospital.

While there should be no reason long bypasses should do any less better than short bypasses, I do have to say these things about this patient’s bypass:

  1. No vein is perfect and the longer your bypass, the more chances you will have that a segment of bad vein will end up in your bypass
  2. Turning flow sharply can cause harsh turbulence. Turbulence can cause transition of potential energy into kinetic energy which acts to damage intimal, resulting in intimal hyperplasia.
  3. Thrombosis is a sure sign that your graft is disadvantaged, and the longer the period of thrombosis, the longer the intima “cooks” in the inflammatory response that accompanies thrombosis, making the vein graft even more vulnerable to subsequent intimal hyperplasia, thrombosis, or stricture.
  4. A high flow, small diameter vein graft entering a larger, disease free bed results in more turbulence but also Bernoulli effects that cause the graft to close intermittently, vibrating like one of those party favors that make a Bronx Cheer (a Heimlich valve). This is the cause I think of the distal long segment narrowing on this graft.

This patient was decided on amputation when our service was consulted, and after reviewing his CTA, I offered balloon angioplasty as his symptoms were primarily of paresthesia and neuropathic pain. I used cutting balloons and got angiographically satisfactory results.

intervention

The patient, although he admitted to feeling much better, was sad. He relayed that he had felt this way several times before, only to have his life interrupted by pain and weakness signaling a restenosis.

 

A direct graft would require about 10 centimeters of vein
 
It was only a month later when I heard the patient had returned with the same symptoms. He wasn’t angry nor full of any “I told you so” that frankly I was muttering to myself. Reviewing his CTA, he had restenosed to a pinhole. The vein, to use a scientific term, was “no good.”

The other interesting finding was that he had an abundance of very good vein. Following surgical dictum, his original and subsequent surgeons had used his vein from his contralateral saphenous vein. His right leg, fused at the knee, lacked a good calf muscle pump action. While there were no varicose veins, the greater and lesser saphenous veins were large and generous conduits, at least by 3DVR imagery, confirmed on duplex (image below, white arrows).

veins
3DVR showing presence of potential conduit

The extant arteries were smooth and plaque-free. I decided to harvest his lesser saphenous vein and through the same incision expose his distal superficial femoral artery and tibioperoneal trunk. While I anticipated some scarring, I was confident that the sections of artery I wanted to expose were easy to access because of some distance from the fused knee.

IMG_6478
On left short saphenous vein was harvested then same exposure used to expose TP Trunk

The picture shows the exposure and reversed vein graft in-situ, using the segment of lesser saphenous vein. As in prior experience in redo surgery, you can never know if a dissection will be easy or hard simply based on fear or concern for breaking something. It’s not until you start bushwacking –carving through scar and dealing with extraneous bleeding will you learn whether it was easy or hard. You can only be certain it was necessary. The only hitch was the femoral artery while well exposed, was buried in scar, and I chose not to get circumferential control as I was fairly deep, and had avid backbleeding from a posteriorly oriented collateral that required a mass clamp of the deep tissues.

Will this work better? Don’t know but it has a good chance, and I think a better chance. It is a large vein oriented in a straight path over a short distance going from good artery to good artery. This is better theoretically than a long meandering bypass with smaller vein. 

Categories
EndoRE PAD remote endarterectromy

My First Intentional Stent Removal Case -Arterial Restoration

removed stents

In 2007, at which I had performed about 20 standard EndoRE (Remote Endarterectomy, LeMaitre Vascular) cases over about two years, this patient in his later 40’s presented to me with ischemic rest pain of his right foot. He was a current heavy smoker who initially had severe claudication and a TASC D occlusion of his right superficial femoral artery. Prior to being referred to me, he had undergone a mitral valve replacement from which he recovered uneventfully. He then had treatment of claudication starting with iliac stenting and a vein bypass. He had undergone a femoral artery to below knee popliteal artery bypass with reversed greater saphenous vein which became occluded after being complicated by MRSA wound infections. When this graft developed problems at the distal anastomosis, he underwent revision with a jump graft from the arm. This graft went down after he developed MRSA infection of the cephalic vein harvest site. He then underwent SFA stenting with 5 femoral stents (at that time, long stents were not available), but these occluded and his access site was the nidus of MRSA based sepsis. He had had multiple hospitalizations for MRSA infection from phlebotomy sites when he presented. He had reintervention for in-stent restenosis, first with balloons, then an extra stent, then cryoballoon therapy, each episode complicated by MRSA infection. He presented with severe claudication and nocturnal rest pain. On exam, he had dependent rubor, elevation pallor and absence of pulses, despite having fairly benign anatomy on CTA.

 

CTA AP

There was two vessel runoff below a reconstituted popliteal artery, with stent occlusion and visible stump of the vein bypass.

CTA medial oblique

My options included bypass with PTFE, cadaveric vein, endovascular recanalization of the occluded stents, or EndoRE. While considering the MRSA which had been extensively worked up prior to presentation by ID including TEE and multiple cultures, it was decided that he was firmly colonized with MRSA despite efforts at eradication, and PTFE was not an option. Cadaveric vein I have used in infections with acceptable short term results -never great long term except for one individual who I inherited from a surgeon in Kansas who maintained a decade of patency of a cadaveric vein to tibial artery bypass with coumadin alone. This patient was not likely to be so lucky. Endovascular recanalization with atherectomy versus laser was considered, but I had at that point become disillusioned with those modalities in such extensive disease.

EndoRE made the most sense because it was my observation in a prior patient in whom I had unintentionally removed a 4cm stent with plaque that stents are placed inside plaques and when you remove plaque, theoretically, the stents have a layer of plaque between them at the adventitia. Also, he had none of the extensive calcium that made regular EndoRE challenging. Also, it would be repaired with native tissues through a single groin incision, and covered with a sartorius flap. And that is what I did.

The common femoral artery was exposed and the SFA controlled. The plaque dissection was started and the ring fitted around plaque and stent. There was a little more friction than expected, but I did inject via a catheter cold LR with the idea that it would shrink the nitinol a bit. Also, the wire that guided the catheter did double duty as a dissector as I was subintimal with it. The rings traveled well to the end point which I achieved with little difficulty.

Vollmer Ring Dissector around plaque & stents
Vollmer Ring Dissector around plaque & stents

ex vivo stents

The end point was dissected and required a short self expanding stent. The patient recovered well and was discharged, but as in prior admissions, developed a cellulitis on the groin wound that resolved with Vancomycin, presumably with MRSA. A CTA done at that admission showed excellent patency and he had palpable pulses.

CTA post oblique with center line

Three years later, he underwent intervention by one of my partners in cardiology at that time for a restenosis in the mid SFA and had ballooning and a stent -the second set of stents in this patient, and by the time I left Iowa, he was still patent and walking.

This operation fails with randomly distributed TASC A lesions that develop in sites of remnant smooth muscle. I think today, I would treat with a drug eluting balloon. Thrombosis is the other failure mode, but unlike PTFE grafts, there is no thromboembolism of the outflow, rather, the SFA thromboses with reconstitution of the original state, and is amenable to thrombolysis. Smokers such as this patient and those with limited outflow are anticoagulated with warfarin.

The Europeans call this now arterial restoration. The vessel is returned to its baseline state with a full complement of collaterals which are revived. Also, compliance is restored and I believe this plays a significant role in maintenance of patency. Also, as the native tissues heal, they return to a normal ultrastructure -I have taken pathology specimen with aortic punches to perform bypasses to the other leg from external iliacs treated so, and they were microscopically and visibly normal.

Categories
PAD remote endarterectromy techniques

Arterial Restoration: more than just a pretty name

Progression
CTA on left shows occlusive plaque in SFA but contiguous plaque from external iliac origin into the popliteal artery. This was removed with EndoRE resulting in restoration of original artery patency -arteriogram on right. A single short stent was placed in the EIA origin and the above knee popliteal artery received a short stent as well.

This patient is a 90 plus year old man who developed ever worsening claudication to the point he was disabled and more worryingly, had developed pain over his left heel. His ABI’s were severely diminished.

preop ABI2

CTA showed that he had an occluded SFA with above knee reconstitute, but also had only single vessel runoff to the foot via a heavily diseased posterior tibial artery that had serial mild to moderate stenoses.

00016287326_20150730_1

00016287326_20150730_6

00016287326_20150730_7

An attempt at endovascular recanalization was performed at an outside institution, but the SFA lesion could not be crossed. Bypass was not a good option -the ipsilateral saphenous vein had been harvested for CABG, and a long operation was going to have a significant impact on this patient who also had mild dementia and drank 2-3 glasses of wine a day. It is not uncommon to have a successful operation, but have the patient lose 2-3 months in recovering from the physical effects of a long operation as well as from perioperative delirium.

I felt that removing the occlusive plaque from his arteries offered a minimally invasive solution. The plaque was easily accessible via an oblique, skin line incision in the groin, and clearance could be performed from the external iliac artery origin to the planned endpoint slightly beyond Hunter’s canal. While the outflow was not perfect, in my experience, aside from a single native vein bypass, long segment restoration of vessel elasticity results in very acceptable patency rates.

endoRE graphic

Remote endarterectomy is a bit of a lost art from the early days of vascular surgery. A ring dissector (Vollmer Ring Dissector, LeMaitre Vascular) is used to liberate the plaque from the remnant adventia. A cutting device (Moll Ring Cutter, LeMaitre Vascular) shown third from left below is used to divide the plaque.

LeMaitre

The common femoral artery plaque is usually contiguous with plaque in the external iliac artery and surgeons who perform a lot of CFA endarterectomy have various maneuvers to remove as much plaque as possible, up to stenting the end point of the plaque down to the endarterectomy patch. I have never been satisfied with this because the EIA behaves differenty than the CIA (am looking into this!) in my experience and placing stents even minimally across the inguinal ligament is not desirable. Sending the dissector up to the EIA origin frees the plaque to be removed completely with the CFA plaque. The clip below shows the Vollmer Ring dissecting plaque up to the EIA origin. I do this over a wire in the pelvis because in the rare instance of leak or rupture, rapid control is possible without having to open the abdomen.

Once freed, the cutter is used to transect the plaque and the end point is tacked down with a stent at the distal common iliac/EIA origin which is a better place for a stent than the inguinal ligament.

The PFA in this patient did not require endarterectomy and reconstruction, but if it did, I would have made the arteriotomy go onto the profunda from the CFA. The SFA plaque is then mobilized with the Vollmer ring. I don’t do this over a wire, but have a definite end point in mind based on what I see on CTA.

The CTA (images earlier) shows that the above knee popliteal artery has no significant calcified plaque. This doesn’t mean there isn’t fibrotic plaque. Cutting the plaque as in the clip below results in a coned in antegrade dissection which has to be crossed in the true lumen.

This is technically the most difficult part of the EndoRE procedure and it requires good imaging and wire skills. The trick here is that an ultrasound guided puncture of the popliteal or tibial vessel can give you distal true lumen access if needed. It was not necessary in this patient. The better maneuver is if the end point is surgically accessible is to cut down and tack down the plaque and patch the arteriotomy.

Angios -14

Angios -39

The patient regained multiphasic PT and DP signals at the end of the case, after the common femoral artery was patched and flow restored. The small groin incision was closed with a running absorbable monofilament after multilayer deep closure. The patient had a blood loss of 50mL. An ilioinguinal field block and local anesthesia provided excellent pain control. Postoperative ABI was improved to 0.82 from 0.34 and all pain was relieved. The patient felt good enough to go home on postoperative day 1.

postop PVR2

This illustrates what I feel to be a best application of both open and endovascular techniques. The above knee popliteal stent is short and in a position that is not going to result in fracture. The external iliac stent is in a protected position in the pelvis and quite large -10mm, which I expect will stay open for the life of the patient. The profunda femoral artery, the rescue artery, is widely patent, and numerous collaterals off the SFA have been restored to patency which I feel aid in maintaining the patency of this repair, along with the restored elasticity of the artery which mimics the biomechanics of autologous vein.

In most patients with compromised outflow, I start warfarin along with ASA at 81mg. Because of his age, I opted for Plavix+ASA. These fail with the development of random TASC A restenoses along the SFA which are amenable to balloon angioplasty. The role of drug eluting balloons in this situation is unknown but theoretically promising. Occlusion through thrombosis does not result in embolization and limb loss as in failure of prosthetic bypass grafts (another option in this patient), but rather leaves a situation where endovascular thrombectomy or lysis is technically feasible.

The great thing is that this is by far superior to stenting of a TASC D femoral arterial lesion.

Categories
AIOD aortoiliac occlusive disease (AIOD) CTA EndoRE PAD remote endarterectromy techniques

EndoRE-ABF -an alternative to the EndoABF which is in turn an alternative to the ABF.

  
The patient is 70 year old woman with prior history of smoking who developed severe claudication and near rest pain. She was unable to walk more than 50 feet before having to stop due to severe leg pain. On exam, neither femoral artery pulses were palpable. PVR’s (pulse volume recordings) and ABI’s (ankle brachial index) are shown below.

PVR pre2

PVR’s demonstrate the presence of severe inflow (aortoiliac occlusive disease or AIOD). CTA was acquired and the findings were consistent with the PVR’s.

preop centerline CTA composite

There was diffuse bilateral iliac atherosclerotic plaque with occlusion of the right common femoral artery and left common and external iliac artery. The 3DVR (three dimensional virtual reality) reconstruction image below shows this as well as the abdominal and pelvic wall collaterals feeding the legs around the occluded iliofemoral system.

Pre CTA

Plans were made to perform a hybrid common femoral and profunda femoral endarterectomy, remote external iliac artery endarterectomy (EndoRE), and common iliac artery stenting. The specific challenges to this case was getting into and staying in the true lumen. Typically, this is easiest to achieve from a left arm access with wires being pushed antegrade, but in a smaller person, particularly woman, this increases the chances for access site complications. My plan was to expose both common femoral arteries and get control of the external iliac arteries at the inguinal ligament and the profunda femoral arteries at the point the proximal plaque dissipated -typically at the second branch point, and then get micropuncture access of the right iliac system by accessing from the common femoral plaque. This would give me true lumen access, and with a sheath and curved catheter (VCF in this case, but a similarly shaped OMNI Flush catheter would do as well), wire access up and across the occluded left iliac system could be achieved and the wire retrieved from the left common femoral artery. This up and over access with the wire allows for control of the aortic bifurcation and both iliac systems.

I perform EndoRE over this wire -this allows for quick access if the artery is ruptured. To minimize blood loss, I gain control of the common femoral artery in the following fashion -a 4cm segment of common femoral artery is left intact and looped above the inferior epigastrics -this loop is brought out in the lateral lower quadrant of the abdomen so that the loop doesn’t travel distally over the arteriotomy. The second loop adjacent to the arteriotomy is sent through periadventitial tissues behind the artery to keep the loop migrating over the arteriotomy. The arteriotomy is created from the distal CFA (common femoral artery) onto the profunda femoral artery (PFA) where the endarterectomy is started. A separate arteriotomy on the superficial femoral artery (SFA) allows me to divide the plaque and mobilize the proximal segment up to the SFA origin, freeing the CFA plaque in this manner. It also gives me the option to perform EndoRE of the SFA if warranted. The dissected plaque and system of loops which I call the blood lock is shown below:

  
The yellow loops are major control points (the blood lock loop is drawn in the picture above) and the red loops are around smaller branch arteries. At this point, micropuncture access through the plaque core was achieved into the true lumen of the yet patent EIA (external iliac artery, picture below).

 
The right EIA plaque was mobilized with a Vollmer ring dissector, and cut with a Moll ring cutter (LeMaitre).

 

This allowed for cutting and removal of the plaque. 

  
Up and over access and control of the wire from the contralateral (left) arteriotomy allowed for EndoRE on the other side. The occluded left common iliac plaque was ballooned and wire access into the aorta from the left was achieved. 

  

Kissing balloon angioplasty was performed with revascularization of the aortoiliac bifurcation and common iliac arteries. 

  

The stents were extended across the dissected end points of the external iliac artery origins. The arteriotomies were closed with bovine pericardial patches. Because the PFA were of small caliber, to avoid narrowing the distal end of the patch, the patches were sewn over Argyll shunts which also allowed perfusion of the legs during the suturing of the patches. The loops made this a straighforward maneuver. 

The completed CFA to PFA patch on the left is shown below:

  

Closure involved reapproximating the Scarpa’s type investing fascia of the femoral triangle and a running dermal layer of absorbable monofilament, dressed with a surgical glue. No drains were used, but if needed, they would be exited through the counter incisions created for the EIA loops. 

The patient recovered well. I always use cell salvage -sometimes, profundaplasties can be bloody, particularly if they are in reoperative fields. The ABI’s and PVR’s at the ankles improved significantly.

  The postoperative CTA shows good results as well. Below is the composite right and left centerline from aorta to the PFA’s. 

  
The 3DVR reconstruction images are shown below, with the comparison to preop shown in the first image of this blog entry:

  
The pre and postoperative images of the centerlines (composited) are shown below:

  
EndoABF is an established hybrid procedure involving an open endarterectomy of the common femoral and PFA/SFA with iliac balloon angioplasty and stenting, often taking the stents distally into the CFA and the patch to deal with complex distal EIA plaque. This procedure, which would be an EndoRE ABF, offers some advantages in eliminating the need for EIA stents which are often placed across the inguinal ligament and into the patch during EndoABF. In my experience, the EIA EndoRE performed as an extension of a CFA endarterectomy is safe, and made even safer by performing the EndoRE over a wire. Published results from Europe shows for TASC C and D disease, EIA EndoRE has excellent patency, and I would expect the same here. EndoRE and Endo ABF both offer advantages over traditional ABF, particularly in patients with medical comorbidities. 

  

Categories
EndoRE PAD remote endarterectromy

Should the SFA be revascularized during an inflow procedure?

Sketches - 12

The patient is a 70 year old man who arrived with complaints of worsening claudication, worse on the left leg. He smokes over a pack a day. On exam, he only had femoral pulses, nothing was palpable below. PVR showed multilevel disease with an ABI of 0.42 on the left leg.

PVR preop

CTA was done showing that both his SFA and PFA were occluded, along with occlusion of his AT in the mid leg, and tibioperoneal trunk.

cta TIBIAL_1

There is a reconstitution point on the PFA, and there is also SFA constitution. Looking at this, it was apparent to me that it would be possible to endarterectomize the whole of the iliofemoral and femoropopliteal system from a single groin incision, but the question being, would a profundaplasty be sufficient.

Arrow points to calcium free terminus for SFA EndoRE
Arrow points to calcium free terminus for SFA EndoRE

The textbook answer is profundaplasty, but given my experience with endarterectomy, it has become apparent that removing all the plaque, including CFA and iliofemoral plaque reduces the chance that clamp injury and stenosis occur, and that placed in the common iliac system have better patency than those placed in the external iliac, particularly crossing the inguinal ligament into a patch.

The other observation is that with this exposure, SFA remote endarterectomy is very simple to do, but becomes more difficult in a redo situation. The only problem with going ahead with it is that the runoff is poor -all three tibial vessels occlude, but a very robust posterior tibial artery reconstitutes proximally from well developed collaterals.

The CFA, PFA, and SFA were exposed as shown in my sketch at the beginning of the post. Wire access up and over from the right side allowed for secure control of the aortoiliac segment. The endarterectomy was started from the PFA reconstitution point and the CFA plaque was mobilized. The SFA plaque was transected in a proximal arteriotomy and the plaque was mobilized with a ring to its origin. The CFA plaque then was mobilized with the ring dissector over a wire (for security in case of rupture), up to the EIA origin and cut.

Image-5

The distal SFA plaque was endarterectomized to the planned end point above the knee joint.

Image-4

The specimen is shown below.

specimen

The arteriotomies were repaired with patches. The common iliac artery was stented to improve the flow. The SFA end point was managed with a stent, placed proximal to the first large geniculate collateral.

prepost sfa endpoint

Completion angiograms show widely patent EIA, CFA, PFA, and SFA

Completion

The patient recovered and was discharged on POD#3. His postop ABI’s are shown below.

ABI post2

They are improved compared to preop, with ABI’s of 0.65. Notably, he did have a weakly palpable posterior tibial artery pulse, and multiphasic signals in all three tibial vessels. While I don’t know if the SFA revascularization will stay open, I am confident the PFA will, and this will keep him from his symptoms recurring and is a durable procedure.

Ideally, if he had needed a distal revascularization, a vein bypass would be the answer, but in the setting of inadequate conduit, it is very simple to endarterectomize from the below knee popliteal artery the remaining plaque and either patch to the patent tibioperoneal trunk or perform a short POP to posterior tibial artery bypass. He did not require this.

I don’t know the answer to the titular question, but in the setting of an inflow procedure, the best chance at opening the SFA is during the inflow procedure because of the exposure, and it is very simple to do when the lesion is minimally calcified.

Categories
EndoRE PAD remote endarterectromy techniques

Removing Occluded Stents For Critical Limb Ischemia

Image-22

The patient severe claudication and nocturnal rest pain and had undergone an inflow procedure at another hospital consisting of a common femoral endarterectomy and a single stent to the external iliac artery near its origin from the iliac bifurcation. He also had undergone a concurrent SFA atherectomy which closed and was treated with SFA stents extending from the SFA origin to the above knee popliteal artery. Unfortunately, his rest pain worsened.

ABI2

On exam, he had a femoral pulse only and no distal pulses, only monophonic and weak pedal signals. The right groin wound had been treated for postoperative wound infection and there was still some swelling and a stitch abscess, but no deep infection. CTA showed that his profunda femoral artery had a focal dissection or stenosis at the origin along with overhang of his SFA stents across the origin of the PFA. The SFA stents were occluded along their whole length. There was remnant disease of the external iliac artery as well.

00020868139_20150409_8

00020868139_20150409_1

There was reconstitution of a diseased but patent above knee popliteal artery with three vessel runoff. He had had harvest of his greater saphenous vein. Treatment options included multisegment arm vein with redo profundaplasty, but given the inflammation around his recently operated, recently infected groin, I was concerned for wound infection. He was also quite disabled by his worsened pain. The other option was to access the left common femoral artery and placed a sheath up and over and wire across the diseased profunda and intervene on it, but with the stent in place, I would have to place likely another stent across the origin. I could then attempt a bypass with arm vein or prosthetic graft using this compromised artery as inflow for a bypass to the below knee popliteal artery or a tibial vessel but I doubted this would be durable, nor resistant to infection if prosthetic was used.

Remote endarterectomy (EndoRE) gave me a third option. It is a hybrid technique, but based on an old and established technique of open remote endarterectomy dating from the 60’s. Rings (Vollmer Rings, LeMaitre Vascular) are used to dissect occlusive plaque under fluoroscopy, and a cutting ring (Moll Ring Cutter, LeMaitre Vascular) is used to cut the plaque at the chosen location. Because the distal end point of dissection is not surgically exposed, but rather fluoroscopically guided, it is termed Remote Endarterectomy. Wire skills are required to access and repair any dissections that may occur.

I have presented in the past a series of cases where I removed occluded stents. Because the dissection is carried out outside the plaque, it is also outside the stent. Retrograde EndoRE of SFA plaque can be carried out up to the SFA origin, and avoid a groin incision which in this case was important. Therefore, a proximal thigh exposure of the SFA and EndoRE was planned with endovascular access by left CFA as described.

Photo Apr 15, 10 08 52 AM

The SFA was a hard, calcified pipe and control was achieved with vessel loops which allow passage of the ring and occlusion of the artery once the plaque and stents were removed. The artery was opened via longitudinal arrteriotomy and the plaque mobilized and divided. The proximal SFA plaque was then dissected (above and below).

proximal dissection

There was immediate establishment of a robust pulse in the proximal SFA after removal of the plaque.

Photo Apr 15, 10 14 06 AM

Distally, the plaque would not mobilize at a point in the artery where there was laxity in the artery and especially adherent plaque and therefore, the distal SFA was cut down on to reaccess the stent from below.

Cutdown to reaccess plaque, basically a reversion to the original pre-endovascular technique.
Cutdown to reaccess plaque, basically a reversion to the original pre-endovascular technique.
Mobilizing stent from above and below
Mobilizing stent from above and below
The distal plaque was cut with a Moll Ring Cutter. The removed specimen in total is below.Photo Apr 15, 12 03 16 PM

The arteriotomies were repaired with patch angioplasties using bovine pericardium. This allowed for completing the procedure with endovascular techniques which included the distal end point dissection, profunda stenosis, and external iliac stenosis.

Distal end point managed with self expanding stent.
Distal end point managed with self expanding stent.
PFA

EIA

At completion, there was a palpable dorsalis pedis artery pulse. The composite angio with preop CTA centerline reconstruction are shown below.

completion

He had relief of his symptoms. Prior to discharge, ABI and PVR’s show normalization of flow to his foot.

Image-2

Conclusion: In my experience, the longevity of these lesions is dependent on the same factors dictating other revascularizations -excellence of inflow, optimization of profunda outflow, and good tibial outflow. The conduit, being the recanalized original artery, is not as good as a single vein, but it remodels and becomes normal artery based on micro pathology. Failure occurs at the stent with the usual restenosis that can occur in some but not all people, and in isolated points in the artery where likely remnant tissues scar creating focal lesions. Frequent surveillance achieves acceptable primary and secondary patencies. Thromboses do occur. Unlike PTFE grafts, thromboses in EndoRE is usually limited to the recanalized artery without distal embolization. Stent removal is challenging but feasible. In this patient, a second cut down was required to achieve plaque and stent removal. The groin was not re-entered, avoiding dissection in a recently infected, surgical wound. If the popliteal was occluded, a popliteal endarterectomy via a below knee cutdown is possible achieving total femoropopliteal plaque clearance, and the below knee popliteal artery can then be used for a very short bypass to one of the tibial arteries if indicated and if autologous vein is limited in availability.

EndoRE offers a third option after bypass and intervention and should be in a vascular surgeon’s armamentarium.

Categories
bypass PAD techniques Wounds

Deep rescue from a hospice: saving a patient from hip disarticulation with advanced hybrid inflow procedure and vein bypasses

PREOP.001

The patient is an elderly man who had bilateral above knee amputations after failure of aortobifemoral bypass grafts at an outside institution. Unfortunately, he had no femoral pulses and his amputation on the right broke down (image above). His left stump had erosion of his femur to the skin with rest pain as well, but was at least covered by skin for now. He was declared too sick for hip disarticulations and was sent to a hospice where he failed to pass away. After a year there, he was sent to us for an evaluation.

He was suffering from rest pain and had complete breakdown of the skin over his amputation stump. More worrisome was the development of gangrenous scrotal and decubitus ulcers which were small but persistent and also foci of pain. CTA showed the following:

PREOP CTA.001

The aorta was occluded below his renal arteries. An AV fistula near his common femoral vein lit up his right iliac vein on the CT above. He had had a prior aortobifemoral bypass but this was occluded. Gratifyingly, it was anastomosed proximally end to side, giving us options. As with any revascularization, we had an inflow source -his aorta, and several potential outflow sources (CTA below, contrast filling iliac vein from AVF’s).

OUTFLOW.001

In particular, his distal profunda femoral artery showed promise. Vein mapping revealed a short segment of basilic vein in his arm to use as bypass, but we needed inflow from the aorta.

I have come to appreciate two things about aortoiliac recanalization. First is that passing the wire antegrade is far likelier to stay in the true lumen at least in the aortic inflow segment -retrograde wire passage inevitably dissects the occlusive aortic plaque and reentry into the true lumen of the diseased aorta is just as challenging as in the leg. The second is vein bypasses have excellent patency in challenging conditions -you just need excellent inflow and an arterial bed to perfuse.

My plan was to cross the aortoiliac occlusion with a wire from the left arm. Once the right iliac system was entered, it didn’t matter if I was in a subintimal plane. The wire could be seated in the common femoral artery to access with a surgical exposure. Once this was done, my intention was to perform remote endarterectomy of the external iliac artery and stent from the aorta to the common iliac artery. The endarterectomized external iliac artery would be the inflow source of a later staged ilio-cross femoral bypass to revascularize his left AKA stump. The common femoral artery at its origin would provide inflow to a short vein bypass to his profound femoral artery.

The wire passed readily into the right iliofemoral system and a groin exposure and common femoral arteriotomy allowed me to retrieve the wire which had been passed from the left arm. A remote endarterectomy was performed over the wire which I do to ensure access in case the artery ruptures (specimen below).

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This allowed me to place a sheath into the right iliac system in the now reopened external iliac artery. Balloon angioplasty of the aortoiliac segment created working space for placement of balloon expandable stents from the infrarenal aorta to the common iliac artery, restoring an excellent pulse in the right groin.

The profunda femoral artery was encased in scar tissue, but following the occluded PFA from the CFA, I was able to expose an open segment and cut it open in the scar tissue. There was back bleeding, and I controlled the artery by placing a small Argyll shunt into the artery and reperfusing it from the recanalized right iliac system.

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The Doppler flow in the shunt was excellent, suggesting great outflow potential. The bypass was performed over the shunt with reversed basilic vein. Completion arteriography showed excellent flow.

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The amputation stump was debrided of dead bone and muscle and the graft was covered with a sartorius muscle flap.

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Before and after images are shown. The remaining open wound granulated well, and ultimately accepted a split thickness skin graft. His scrotal and decubitus ulcers healed as well (below at 6 months post op).

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His left AK stump subsequently degraded while he recovered so three months after this operation, he underwent a right external iliac to left profunda femoral artery bypass with cadaveric vein.

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I don’t like using cadaveric vein, but we really had no options. The right external iliac artery was approached through a right lower quadrant (transplant) incision and a punch biopsy of the artery revealed only normal adventitia on pathology. The EIA was soft and sewed well -essentially a normal artery brought back from the dead. The left profunda femoral artery was large after endarterctomizing its origin and accepted the bypass flow well.

The mortality from hip disarticulation in the setting of gangrene and infection is very high, and I feel that standard approaches to this problem -prosthetic axillo femoral bypasses, thoracobi-femoral bypasses, in the setting of advanced infection and gangrene were unlikely to succeed. In over 1.5 years of followup, everything has remained patent, and the patient lives independently.

Categories
bypass PAD techniques Uncategorized

The best last conduit is your own artery

  

 

The patient is a 60 year old with severe peripheral vascular disease. Risk factors included smoking, hypertension, and type I diabetes. The patient had developed gangrenous eschar over toes 1, 2, and 3. He had had prior bilateral femoropopliteal bypasses with saphenous vein, which was occluded on his symptomatic side, and stent grafts had been placed on his distal femoral to popliteal artery, but these were occluded. He also had chronic edema with some early lipodermatosclerosis and pitting edema. He was emaciated and had a low prealbumin. 

CTA showed diffuse aortoiliac atherosclerosis with a severe stenosis in the proximal common femoral artery.

 

The femoropopliteal stent grafts were occluded but the popliteal artery reconstituted into a diseased set of tibial vessels -only the posterior tibial artery remained patent into the foot and remained as a target.

  

Preoperative angiography corroborated the CT findings.

  

  

 

The preoperative vein mapping suggested there was an acceptable anterior thigh tributary vein and marginal segments of vein below the knee. Arm vein was available as well. 

My plan was to explore the veins on his legs and expose his CFA and BKPOP along with the posterior tibial artery. If the veins were inadequate, I would proceed with open endarterectomy of the common femoral artery and remote endarterectomy of the external iliac artery and stenting of the diffusely diseased common iliac artery and remote endarterectomy of the femoropopliteal segment above the stent to use as inflow for a shorter bypass with the vein we had. 

Exploration showed that the anterior thigh vein was thin walled and became diminutive in the mid thigh. The infrageniculate veins were numerous and too small. I thought I might have enough for a short bypass from a recanalized mid SFA. 

The remote endarterectomy of the external iliac and stenting of the common iliac went without complications. I do this over a wire to ensure access in case of rupture. A postop CTA shows the results in the aortoiliac segment.

  

Remote endarterectomy of the SFA went smoothly but was held up by calcified plaque above the occluded stents. 

SFA plaque

I cut down on the SFA and found that the vein from the thigh would be short. I mobilized the plaque and re engaged the Vollmer ring and was able to dissect the stents. By starting another dissection from the below knee popliteal artery, the stent was mobilized and removed.

Viabahn stent grafts, occluded, removed

The figure below shows the procedure angiographically. I used a tonsil clamp to remove the mobilized stents.

Left, prior to remote endarterectomy, Mid -stent removal, Right -completion

The common femoral and mid SFA arteriotomies were repaired with patch angioplasties. The infrageniculate popliteal arteriotomy was used as inflow to a very short reversed vein bypass with the best segment of thigh vein to a soft posterior tibial artery.

Before and after of thigh segment

 

Before and after, the CTA on right is late in phase and has venous contrast.

Before and after, centerline.

The patient had a palpable posterior tibial artery pulse at the ankle. CTA predicted the plaque found in the tibioperoneal trunk which compelled me to do the short bypass. In my experience, remote endarterectomy, sometimes with short single segment bypass, successfully restores native vessel circulation without need for lengthy multisegment arm vein bypass. Remote endarterectomy of the external iliac artery avoids the difficult CFA plaque proximal end point that often requires stenting across the ligament down to the patch. Only a single common iliac stent is required. I generally anticoagulate these patients with warfarin, especially if they are likely to resume smoking or have poor runoff. I hope to show this is the equal of multisegment vein bypass, and superior to it by virtue of avoiding long harvest incisions which are the source of much morbidity and now readmissions which are penalized.

     

Categories
Journal Club PAD

February Journal Club Articles -Aortoiliac Occlusive Disease

Congratulations to Dr. Moqueet Qureshi who gave the best presentation at the January journal club. It was a close one as all the presentations were excellent analyses of their papers. This months journal club presenters are:

Dr. Daniel Lopez: paper link -Humphries et al. Outcomes of covered versus bare metal balloon expandable stents for aortoiliac occlusive disease. JVS 2014;60:337-44.

Dr. John Weber: paper link -Aihara et al. Long term outcomes of endovascular therapy for aortoiliac bifurcation lesions in the Real-AI Registry. J Endovasc Ther 2014;21:25-33.

Dr. Michael O’Neil: paper link -Vallabhaneni et al. Iliac artery recanalization of chronic occlusions to facilitate endovascular aneurysm repair. JVS 2012;56:1549-54.

The Journal Club will start at 6:30pm, congregating at 6pm for conversation, dinner and beverages, at the Foundation House, Cleveland Clinic and Foundation.

Categories
PAD techniques TEVAR

External iliac remote endarterectomy in lieu of a conduit for TEVAR

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The patient had diffuse atherosclerosis with small luminal area even in areas without calcified plaque. It predicted inaccessibility for the 22 French sheath required to deliver the 32mm C-TAG device to be placed for a symptomatic type B thoracic aortic dissection associated with a small but expanding proximal aneurysm.

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My options included direct aortic puncture, an aortofemoral conduit, or an endoconduit. The aorta was heavily calcified and the bifurcation was narrowed by circumferential plaque down to 6-7mm at its narrowest and the left iliac had a severe narrowing due to this plaque. The common femoral artery was severely diseased with a lumen diameter of 4mm due to heavily calcified plaque.

I have come to favor direct aortic puncture over conduits, but the heavily calcified aorta and the absence of safe areas to clamp made me think about other options. My experience with endoconduits has been limited to revising problems of endoconduits from elsewhere, but others report it as a feasible option.

The problem with a long artery narrowed with irregular plaque and even intimal thickening is that it will readily expand to accommodate a large sheath but removing it involves the frictional resistance of the whole artery and typically the “iliac on a stick” avulsion involves the whole length of external iliac artery, likely because the common iliac is anchored by the aortoiliac plaque, the smaller diameter of the EIA, and the longer more tortuous path offering greater resistance in the EIA compared to the aorto-common iliac segment.

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Remote endarterectomy, a technique involving endarterectomizing an artery through a single arteriotomy, offers the possibility of increasing the lumen of even a mildly diseased artery and reducing the frictional coefficient, assuming the remnant smooth adventitia is less resistant than rough irregular intimal plaque.

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The plan was to expose the right common femoral artery and endarterectomize it and gain wire access from the R. CFA. A wire would be placed on the left iliofemoral system to protect it for later kissing iliac stents. A right EIA remote endarterectomy would be performed, and then the right aorto-common iliac segment would be balloon dilated to 8mm.

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The operation went as planned. The external iliac plaque was removed in a single piece from the EIA origin.

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Arteriography showed the right EIA to be free of intimal disease, and dilators and ultimately the 22F sheath went in easily.

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The TEVAR also went uneventully -the left subclavian which had a prior common carotid to subclavian bypass, was covered and the aneurysm and flap were excluded from the left CCA to the celiac axis.

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The most difficult part of the operation was removing the sheath, as is usually the case with a tight iliac, but the friction point was largely at the common iliac and not the external iliac. No artery could be seen extruding with the sheath at the groin while steady tension was applied to the sheath under fluoro. The aortic bifurcation was repaired with kissing iliac stent. The patient recovered well and her chest pain resolved.

I have done this for EVAR, including reopening occluded external iliac arteries, and even for a 26F access for TAVR, avoiding the need for placement of a conduit in selected patients.

Addendum: in followup, I had the chance to check up on the repair -the EIA remained large and patent.

before after