Femorofemoral bypass in unilateral iliac artery occlusion

Between January 1973 and January 1988, 188 patients with unilateral iliac artery occlusion were treated at The Middlesex and University College Hospitals, 185 for primary disease and three for blockage of a previous aortobifemoral graft. In the early part of the series, a variety of operations, including aortofemoral and iliofemoral bypass, and endarteriectomy, was used. Femorofemoral bypass was at first reserved for patients who were considered unfit for major surgery, but the results seemed so good that it was adopted as the procedure of choice. Latterly, percutaneous transluminal angioplasty became available, and the role of this is discussed. Over the 15-year period, 150 patients underwent femorofemoral bypass (all but two receiving a prosthetic graft). Of these, 90 per cent had disabling claudication and 8 per cent had critical ischaemia. There were six early deaths (within 30 days of operation) and five late deaths, and two surviving amputees; nine patients could not be traced. The remaining 128 patients have been assessed at intervals of from 3 to 92 months, both clinically and with Doppler studies. The cumulative patency was 86 per cent at 13 years, and all of these patients experienced subjective and haemodynamic improvement in the recipient limb. Eight grafts occluded in the early postoperative phase. In five patients there was deterioration in the donor limb; it is postulated that the effect was due to causes other than the operation. There were two serious postoperative complications due to technical error, one of which led to early above-knee amputation. These are presented in detail. In the light of this experience, the advantages and indications for femorofemoral bypass and the results to be expected from it have become clarified, and the technique standardized so that errors can be avoided. We suggest that femorofemoral bypass is now the operation of choice for unilateral iliac artery occlusion.     

Acute and chronic lower limb ischaemia

Limb ischaemia is a common clinical condition that causes considerable morbidity and mortality and represents a major drain on healthcare resources. Peripheral arterial disease (PAD) is the leading cause of both acute and chronic limb ischaemia. Chronic limb ischaemia may also be caused by non-atherosclerotic processes such as arterial entrapment, fibrosis or arteritis. Acute limb ischaemia may be also due to embolism, thrombosis or trauma. Duplex ultrasonography, computed tomography angiography and magnetic resonance angiography are now conventional forms of arterial imaging, with catheter angiography reserved for intervention. Risk factor modification is extremely important for all these patients, since many will also have significant coronary or cerebrovascular disease. Those with claudication often improve with structured exercise and if symptoms progress they may benefit from angioplasty or stenting. Arterial bypass remains the mainstay of treatment for patients with critical limb ischaemia if they are fit enough for surgery. Acute limb ischaemia is a surgical emergency and can be treated with surgical embolectomy or catheter-directed thrombolysis (depending on local expertise). Patients with irreversible limb ischaemia should be treated with primary amputation or palliation as appropriate.     

Infrapopliteal bypass grafts for severe ischaemia of the lower limb

A retrospective survey of 27 infrapopliteal bypass grafts performed for rest pain revealed a cumulative limb salvage rate of 65.3% with an overall operative mortality of 8%. When pre-operative angiography demonstrates a patent infrapopliteal artery, reversed saphenous vein bypass grafting offers a realistic alternative to primary amputation when femoropopliteal occlusion threatens limb viability.     

Acute and chronic ischaemia of the lower limb

Limb ischaemia is an important clinical problem due to the high prevalence of peripheral arterial disease (PAD) in the UK. The main risk factors are smoking and diabetes mellitus. In young patients, alternative diagnoses of embolus, thrombosis, arteritis, congenital anomaly, fibrosis and traumatic (including iatrogenic) arterial injury must be considered. Intermittent claudication, critical ischaemia and acute ischaemia are clinical diagnoses easily confirmed by ankle–brachial pressure index (ABPI) measurement. Non-invasive arterial assessment by duplex, magnetic resonance angiography and computed tomographic angiography are used to confirm the diagnosis and to plan intervention. Angiography is usually reserved for therapeutic intervention. Best medical therapy for PAD includes smoking cessation, aspirin, blood pressure control (angiotensin-converting enzyme inhibitors) and statin therapy. These interventions are proven to reduce heart attack and stroke. For claudicants, structured exercise classes improve maximum and pain-free walking distance; in addition, percutaneous angioplasty may be considered if they have a suitable lesion in the iliac, femoral or popliteal arteries. Patients with critical limb ischaemia require intervention to avoid limb loss; arterial reconstruction (angioplasty or bypass) is preferable to primary amputation, as preservation of mobility is an important determinant of quality of life. The acutely ‘threatened’ limb is a surgical emergency and requires immediate intervention, best performed in a specialized vascular unit.     

Combined percutaneous transluminal angioplasty and extraanatomic bypass for symptomatic unilateral iliac artery occlusion with contralateral iliac artery stenosis

We have reviewed our experience with percutaneous transluminal angioplasty of contralateral iliac stenosis and extraanatomic bypass of the occluded iliac artery. Twenty-two men and nine women with a mean age of 65 years (range 46 to 84) presented with symptomatic iliac occlusive disease. Twenty-four (77%) had disabling claudication, four (13%) rest pain, and three (10%) ischemic tissue loss. Six (19%) had undergone previous vascular reconstructive procedures. All had an occluded iliac artery on the symptomatic side and greater than 50% stenosis of the contralateral iliac artery. Percutaneous transluminal angioplasty of the iliac stenosis was done prior to extraanatomic bypass, using polytetrafluoroethylene. There were six late deaths after discharge. The only significant complication was a femoral artery thrombosis which was corrected when the bypass graft was performed. Cumulative primary graft patency was 89% at one year and 81% at three years. The crossover graft occluded in six patients, five within 48 months of surgery, and one after nine years. One of these occluded grafts was salvaged by thrombectomy, for a secondary patency rate of 85% at three years. Two patients required aortobifemoral bypass, one an iliobifemoral bypass and one an ilioprofunda bypass. One patient operated upon for rest pain came to below-knee amputation. Mean resting ankle/brachial systolic pressure index increased significantly on the side of the iliac occlusion from 0.35 ±0.21 to 0.70 ± 0.20 (p < 0.05, paired t test) after the combined procedure. There was no significant difference in the mean resting ankle/brachial systolic pressure index on the contralateral side (0.60 ± 0.22 to 0.65 ± 0.27, ns). Combined iliac percutaneous transluminal angioplasty and femorofemoral bypass is a safe alternative to aortobifemoral bypass for selected patients with aortoiliac arterial occlusive disease. Presented at the Royal Australasian College of Surgeons, General Scientific Meeting, May 1989, Melbourne, Australia.     

Transluminal iliac angioplasty with distal bypass surgery in patients with critical limb ischaemia

Transluminal balloon angioplasty of the iliac artery was combined with a distal bypass graft procedure in 25 patients with critical ischaemia of the lower limb. Eleven patients had angioplasty in the operating theatre before a vascular graft and the remaining 14 patients had percutaneous transluminal angioplasty performed in the X-ray department before bypass surgery. The distal bypass grafts were 20 femoropopliteal and five femorofemoral grafts. Two patients died in the immediate postoperative period. Follow-up of patients ranged from 2 to 26 months with a graft patency of 63% at 12 months and 50% at 24 months but successful limb salvage rate of 75% at 12 and 24 months. Six patients required major amputations for failure of limb salvage. Transluminal iliac angioplasty is a valuable adjunct to distal bypass surgery by improving arterial inflow without the requirement for major aorto iliac surgery.     

Iliofemoral bypass surgery for lower limb ischaemia. A follow-up of 62 patients

This study evaluates iliofemoral bypass reconstruction in limb-salvage, graft patency, and appearance of contralateral symptoms. The study included 62 consecutive iliofemoral bypass reconstructions during 1980-82. The indication for surgery was disabling intermittent claudication in 19% of the patients and severe ischaemia in 81%. At follow-up 42 patients were examined, 16 were dead and 4 were lost to follow-up. The primary mortality was 5%. At 3 years postoperatively the survival rate was 78%, ipsilateral limb-salvage 88%, graft patency 83%, and patency of the contralateral iliofemoral segment 92%. During the follow-up period reconstructive vascular surgery on the contralateral aortoiliac segment was performed in only 3 patients. The results of the iliofemoral bypass reconstruction in this study were comparable to the results of aortic bifurcation grafts, and the patency of the contralateral iliofemoral segment was higher than might have been expected. The iliofemoral bypass reconstruction seems to be useful for patients with unilateral affection of the iliofemoral segment, for limb-salvage concerning patients in poor general condition, and for patients who have had a contralateral amputation.     

Treatment of unilateral iliac artery disease by femorofemoral bypass grafting.

Between Jan. 1, 1970 and June 30, 1977, 50 men and 23 women underwent femorofemoral bypass grafting. The average age of the group was 64.7 years. The procedure was performed for disabling claudication in 50 patients and for limb threatening ischemia in 23. Knitted Dacron grafts were used in all but two patients. The operative mortality was 4.1% and the late mortality 21.9%. There were six complications related to the prostheses, three infected grafts and three false aneurysms. Thrombosis of the graft occurred in 15 patients; the graft was successfully revised in 2. The cumulative 5-year patency rate determined by life-table methods was 73.4%. The causes of failure appeared to be well defined and unilateral iliac artery disease. The donor iliac artery, poor runoff through a diseases deep femoral artery on the recipient side and infection of the graft. This study indicates that femoro-femoral bypass has a definite place in the management of patients with unilateral iliac artery disease. The procedure can be performed on selected patients with a low operative mortality and an acceptable patency rate.     

Femorofemoral bypass for unilateral iliac artery occlusion in the presence of bilateral superficial femoral artery occlusions

The femorofemoral bypass has become a popular technique of reconstruction for unilateral iliac artery occlusion because of low morbidity and excellent long-term patency. A "steal phenomenon" is infrequently seen, but even in relatively sedentary patients with limb-threatening ischemia femorofemoral grafting has been associated with severe donor limb ischemia in occasional instances. This report describes five high risk elderly patients who underwent femorofemoral bypass for limb-threatening ischemia due to unilateral iliac artery occlusion in association with bilateral superficial femoral artery occlusions. All patients underwent successful bypass as judged by relief of rest pain and healing of ulcerations. Despite a pre-operative resting donor limb mean ankle/brachial index of .45, there was no deterioration of donor limb perfusion when patients were followed for a mean of 15.6 months. It is concluded that femorofemoral bypass is the procedure of choice for limb salvage in poor risk patients with adequate donor limb inflow regardless of the degree of outflow occlusive disease.     

Percutaneous transluminal angioplasty for lower limb ischaemia

Forty successful percutaneous transluminal angioplasties (PTA) were performed in the iliac and femoropopliteal segments of 33 patients with lower limb ischaemia. There was immediate symptomatic relief in 37 limbs (92 per cent) although 7 relapsed and 5 patients required reconstructive arterial surgery within a month of PTA. Objective testing showed that the longer term relapse rate (median follow-up 12 months) was low (10 per cent). Despite a significant incidence of early complications and relapse, PTA provided a good long term result in the majority of patients treated.     

腋-股动脉旁路移植救治慢性重症下肢缺血

目的 探讨腋-股动脉转流救治慢性重症下肢缺血的疗效。方法 回顾性分析1995年1月至2002年11月的63例主髂动脉闭塞患者行腋-单股和腋-双股动脉人工血管旁路移植的临床资料。结果 44例出院时静息痛消失，19例患者间歇跛行消失，平均踝/肱比从术前的0、18(0-0．49)提高到0．68(0．29～1．04)。本组肢体救治率87．4％，截肢率7．9％。3例死亡，手术死亡率是4．7％。1、3、5年通畅率分别为93．2％、79．8％、64．1％。结论 因主髂动脉闭塞导致慢性重症下肢缺血的高危患者，通过腋-股动脉人工血管旁路移植可有效的挽救肢体和生命。     

Superior mesenteric artery bypass for chronic mesenteric ischaemia: a DGH experience

This article evaluates the results of single vessel bypass surgery for symptomatic chronic mesenteric ischaemia (CMI) in 6 patients undergoing a total of 8 superior mesenteric artery (SMA) bypass operations, all with good post-operative symptom relief. Post-prandial pain and weight loss was present in 5 out of 6 patients. Epigastric bruit was present in only two patients and 4 out of 6 patients had diarrhoea. The patients had varying degrees of peripheral vascular disease, ischaemic heart disease and hypertension. All patients had occlusion of the SMA on angiography and bypassing the occluded segment resulted in disappearance of the symptoms and weight gain. The vascular graft was sutured end to side to the front of the infra-renal aorta and end to side to the SMA, distal to the origin of the middle colic artery. Two patients had recurrence of symptoms due to graft occlusion at 3 and 4 years, respectively; they were successfully treated with repeat SMA bypass. There were no major complications or deaths related to the procedure in this study; one patient developed an incisional hernia requiring elective repair. Thus, early restoration of SMA circulation by bypass grafting in patients with CMI is sufficient to alleviate symptoms and prevent intestinal infarction with its high mortality rate.     

Subintimal angioplasty in lower limb ischaemia

Subintimal angioplasty has been suggested as a treatment option for occlusive disease and has become an established practice in some centres, reducing their operative workload considerably. Others have concerns about the safety and durability of the procedure. This review will focus on the evidence for the use of subintimal angioplasty in lower limb occlusive disease. A systematic review of the literature from a Medline search has been carried out. Despite a paucity of trial data, subintimal angioplasty is now an established technique for the treatment of lower limb occlusive disease. The results for femoro-popliteal disease are well documented, with excellent technical and clinical success rates and low complication rates. The results for iliac disease are less well documented and demand caution. For infra-popliteal disease with critical ischaemia, the technique is again safe with good short and long-term results in a group of patients in whom distal bypass surgery is often risky. Subintimal angioplasty has a definite learning curve and those wishing to take it up should visit an experienced centre first. To achieve widespread acceptance it is likely to require large scale randomised controlled trials.     

Subintimal angioplasty in lower limb ischaemia

Subintimal angioplasty has been around for 18 years but has become popular only in the last 2 to 3 years, following a number of publications from various centres in Europe and the USA. After its initial successes in the femoropopliteal segment, the techniques has been extended to the infrapopliteal segment. Recanalization of long tibial occlusions and the possibility of reconstituting the trifurcation has proved to be most useful in the treatment of patients with critical limb ischaemia. Primary success rates of between 80 and 90% can be expected in the infrainguinal and the infrapopliteal segment. Patencies of 64% at 5 years in the superficial femoral artery for claudication has been reported. Limb salvage rates have been consistently high at around 85 to 90% at 1 year. Subintimal angioplasty has proved to be a useful and inexpensive way to treat intermittent claudication. For critical limb ischaemia, it has proved to be very effective.     

Femoro-femoral arterial bypass is an effective and durable treatment for symptomatic unilateral iliac artery occlusion

AIMS: This study was designed to determine the effectiveness of femoro-femoral arterial bypass (FFB) operation at hospital discharge and 1 year after operation, and to determine the role of long saphenous vein (LSV) as a conduit. METHODS AND RESULTS: A retrospective review was undertaken of 161 consecutive patients (median age, 66 years; range, 44-97 years) who had femoro-femoral grafts during the 12 years from July 1987 to March 1999. The indication for operation was claudication in 66 patients and critical ischaemia in 95. A synthetic graft was used in 123 patients and LSV in 38. Six patients with LSV had a previously infected synthetic graft and 2 a previously occluded synthetic graft. In-hospital operative mortality was 13 (8.1%). One year postoperatively, known mortality was 29, fifteen patients were lost to follow-up putting 1-year mortality at 18.0-27.3%. Eight of these had LSV as the conduit. At discharge from hospital, the median improvement in the ankle brachial pressure index was 0.3 (range, 0-1.0) overall, and 0.32 for patients with LSV (range 0-1.0). Among the 117 known survivors at 1 year, secondary graft patency was 107 confirmed by Doppler or duplex (91.5%) overall, and 25 (89.3%) for LSV; 100 (85.5%) maintained symptomatic improvement, 11 (9.4%) were experiencing no benefit and 6 (5.1%) were worse, of whom 2 had undergone amputation. In patients in whom LSV was used, 22 (78.8%) remained symptomatically improved, 3 (10.7%) experienced no benefit, 3 deteriorated and one had an amputation. CONCLUSIONS: One year following FFB, at least 18.0% of patients were dead. Among possible survivors to 1-year, graft patency was at least 78.8% and at least 75.8% remained clinically improved. FFB is effective in the treatment of unilateral iliac artery occlusion. LSV is as effective as a synthetic conduit.     

Oedema in the lower limb of patients with chronic critical limb ischaemia (CLI).

OBJECTIVE: approximately 70% of patients with chronic critical limb ischaemia (CLI) show clinical signs of oedema in the distal leg and foot. The primary aim of the present investigation was to quantify this oedema. In addition we investigated whether oedema formation could be due to deep venous thrombosis (DVT). METHODS: fifteen patients with unilateral CLI and oedema were studied, four males and 11 females, with a mean age of 77+/-10.3 years. Water displacement volumetry (WDV) was used to measure limb volume. Colour duplex ultrasound (CDU) and venous occlusion plethysmography (VOP) were applied to exclude functionally significant DVT. Blood chemistry was analysed to screen for some causative factors of generalised oedema formation. RESULTS: the mean volume of the limbs with CLI was 9% greater than the contralateral limbs (1279+/-325 ml vs. 1179+/-298 ml). None of the patients had functionally significant DVT. The mean plasma albumin concentration was reduced at 28.5+/-6.6 g/l. CONCLUSION: a significantly reduced plasma albumin concentration cannot be regarded as a causative factor, since the oedema is unilateral. The aetiology of oedema formation is probably multifactorial, and further investigations are under progress to elucidate relevant pathogenetic factors.     

Acute and chronic limb ischaemia

Acute (ALI) and chronic limb ischaemic (CLI) make up a major part of the workload of vascular surgeons and carry considerable morbidity and mortality. Peripheral artery disease (PAD) is the major cause of these conditions. Diagnosis of these conditions involves proper use of imaging including duplex ultrasound, computed tomography angiography (CTA), magnetic resonance angiography (MRA), as well as invasive techniques like digital subtraction angiography (DSA). Management ranges from conservative techniques, the mainstay of management in intermittent claudication (IC), with medical optimization, through to endovascular and open revascularization techniques in CLI and ALI. Finally where no revascularization options exist, primary amputation or palliation must be considered.