Inverted T bypass: a solution for distal revascularization in the absence of an adequate autologous vein graft.
DOI:
https://doi.org/10.48750/acv.574Keywords:
Chronic Limb-Threatening Ischemia, Open revascularization, Infrapopliteal disease, Tibioperoneal disease, Peripheral arterial diseaseAbstract
Introduction: Peripheral arterial disease has become a worldwide problem, with chronic limb-threatening ischemia(CLTI) being its most extreme manifestation. Recently, endovascular strategies evolved and became the first approach in many revascularization procedures. However, infrapopliteal (IP) disease is still a therapeutic challange.1–3
This study aims to present a surgical technique, named inverted T bypass, that can be applied to patients with: an IP artery with poor collateralization to the foot, an inframalleolar artery with poor runoff and availability of only a short venous graft.4
Methods: A single-center retrospective analysis of all patients submitted to inverted T bypass. The end points of the present study were limb-based patency(LBP), primary patency(PP) and secondary patency(SP) rates, freedom from CLTI, recurrence of CLTI, freedom from major index limb amputation, amputation free-survival, and overall survival.
Results: A total of twenty-five patients with CLTI (68% male) with a median age of 77 years were submitted to 25 inverted T bypasses. The median follow-up was 25 months(interquartile range of 32). Twenty-one preoperative angiographies were performed. Severe femoropopliteal (FP) and IP anatomic patterns(GLASS FP and IP grade 4) were predominant(57% and 86%, respectively) with 100% of limbs classified as GLASS stage III. Three patients(12%) had previously failed endovascular treatment. LBP, PP and SP were, respectively, 75%, 75% and 79% at 1 year, and 61%, 61% and 64% at 2 years. After one year, 86% of the limbs were free from CLTI and 79% of them remained without recurrences during a follow-up of 2 years. Eighty-one percent of the patients were free from major index limb amputation at 2 years.
Conclusion: The inverted T bypass is a creative surgical solution for CLTI patients with poor runoff and lacking an adequate venous graft. The results are promising, rendering this technique a viable option for distal and ultra-distal revascularization in complex cases.
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References
Menard MT, Rosenfield K, Farber A. The BEST-CLI Trial: Implications of the Primary Results. European Journal of Vascular and Endovascular Surgery 2023:317–9. Doi: 10.1016/j.ejvs.2022.12.032.
Conte MS, Bradbury AW, Kolh P, White J V., Dick F, Fitridge R, et al. Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. European Journal of Vascular and Endovascular Surgery 2019;58(1):S1-S109.e33. Doi: 10.1016/j.ejvs.2019.05.006.
Sidawy AP, Perler BA. Rutherford’s Vascular Surgery and Endovascular Therapy. vol. 2. 10th ed. Elsevier; 2023.
Farber A, Menard MT, Conte MS, Kaufman JA, Powell RJ, Choudhry NK, et al. Surgery or Endovascular Therapy for Chronic Limb-Threatening Ischemia. New England Journal of Medicine 2022;387(25):2305–16. Doi: 10.1056/ nejmoa2207899.
Zhou B, Lu Y, Hajifathalian K, Bentham J, di Cesare M, Danaei G, et al. Worldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4·4 million participants. The Lancet 2016;387(10027):1513– 30. Doi: 10.1016/S0140-6736(16)00618-8.
Graziani L, Silvestro A, Bertone V, Manara E, Andreini R, Sigala A, et al. Vascular Involvement in Diabetic Subjects with Ischemic Foot Ulcer: A New Morphologic Categorization of Disease Severity. European Journal of Vascular and Endovascular Surgery 2007;33(4):453–60. Doi: 10.1016/j.ejvs.2006.11.022.
Diehm N, Shang A, Silvestro A, Do D-D, Dick F, Schmidli J, et al. Association of Cardiovascular Risk Factors with Pattern of Lower Limb Atherosclerosis in 2659 Patients Undergoing Angioplasty. European Journal of Vascular and Endovascular Surgery 2006;31(1):59–63. Doi: 10.1016/j.ejvs.2005.09.006.
Lauterbach SR, Torres GA, Andros G, Oblath RW. Inf ragenicular Polytetrafluoroethylene Bypass With Distal Vein Cuffs for Limb Salvage A Contemporary Series. vol. 140. 2005.
Kreienberg PB, Darling RC, Chang BB, Paty PSK, Lloyd WE, Shah DM. Adjunctive techniques to improve patency of distal prosthetic bypass grafts: Polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs. J Vasc Surg 2000;31(4):696–701. Doi: 10.1067/mva.2000.104597.
Neville RF, Lidsky M, Capone A, Babrowicz J, Rahbar R, Sidawy AN. An Expanded Series of Distal Bypass Using the Distal Vein Patch Technique to Improve Prosthetic Graft Performance in Critical Limb Ischemia. European Journal of Vascular and Endovascular Surgery 2012;44(2):177–82. Doi: 10.1016/j. ejvs.2012.04.014.
Soares TR, Cabral G, Costa T, Tiago J, Gimenez J, Cunha e Sá D. Inverted T Bypass: A Solution for Distal Revascularisation in the Absence of an Adequate Autologous Vein Graft. European Journal of Vascular and Endovascular Surgery 2022:427–8. Doi: 10.1016/j.ejvs.2022.05.040.
Deutsch M, Meinhart J, Howanietz N, Fröschl A, Heine B, Moidl R, et al. The bridge graft: a new concept for infrapopliteal surgery. Eur J Vasc Endovasc Surg 2001;21(6):508–12. Doi: 10.1053/ejvs.2001.1361.
Mills JL, Conte MS, Armstrong DG, Pomposelli FB, Schanzer A, Sidawy AN, et al. The society for vascular surgery lower extremity threatened limb classification system: Risk stratification based on Wound, Ischemia, and foot Infection (WIfI). J Vasc Surg 2014;59(1):220--234.e2. Doi: 10.1016/j.jvs.2013.08.003.
Soares TR, Cabral G, Costa T, Tiago J, Gimenez J, Duarte A, et al. Heparin-Bonded Expanded Polytetrafluoroethylene Is a Solution for Infrapopliteal Revascularization in the Absence of an Adequate Autologous Vein Graft. Ann Vasc Surg 2023. Doi: 10.1016/j.avsg.2023.06.015.
Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF, Feldman HI, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med 2009;150(9):604–12. Doi: 10.7326/0003-4819-150-9-200905050-00006.
Dorigo W, Pulli R, Castelli P, Dorrucci V, Ferilli F, de Blasis G, et al. A multicenter comparison between autologous saphenous vein and heparin-bonded expanded polytetrafluoroethylene (ePTFE) graft in the treatment of critical limb ischemia in diabetics. J Vasc Surg 2011;54(5):1332–8. Doi: 10.1016/j. jvs.2011.05.046.
Almasri J, Adusumalli J, Asi N, Lakis S, Alsawas M, Prokop LJ, et al. A systematic review and meta-analysis of revascularization outcomes of infrainguinal chronic limb-threatening ischemia. European Journal of Vascular and Endovascular Surgery 2019;58(1):S110–9. Doi: 10.1016/j.ejvs.2019.04.013.
Albers M, Romiti M, Brochado-Neto FC, de Luccia N, Pereira CAB. Meta-analysis of popliteal-to-distal vein bypass grafts for critical ischemia. J Vasc Surg 2006;43(3):498-503.e2. Doi: 10.1016/j.jvs.2005.11.025.
Romiti M, Albers M, Brochado-Neto FC, Durazzo AES, Pereira CAB, de Luccia N. Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia. J Vasc Surg 2008;47(5):20–2. Doi: 10.1016/j.jvs.2008.01.005.
Lo RC, Darling J, Bensley RP, Giles KA, Dahlberg SE, Hamdan AD, et al. Outcomes following infrapopliteal angioplasty for critical limb ischemia. J Vasc Surg 2013;57(6):1455–64. Doi: 10.1016/j.jvs.2012.10.109.
Giles KA, Pomposelli FB, Hamdan AD, Blattman SB, Panossian H, Schermerhorn ML. Inf rapopliteal angioplasty for critical limb ischemia: Relation of TransAtlantic InterSociety Consensus class to outcome in 176 limbs. J Vasc Surg 2008;48(1):128–36. Doi: 10.1016/j.jvs.2008.02.027.
