Transobturator aorto-profunda femoral artery bypass using the direct medial thigh approach

We present a novel technique for aorto-profunda femoral artery bypass using both the obturator foramen and the direct medial thigh approach to the profunda femoral artery in a patient with an infected femoral graft and limb-threatening ischemia. This patient has undergone multiple bypass grafts to salvage function of his lower extremities, but these standard anatomic and extra-anatomic bypasses had failed because of graft infections. The technique as well as the surgical anatomy are described. The combination of the transobturator aorto-profunda femoral artery bypass and the direct medial approach to the profunda femoral artery is technically feasible, provides adequate outflow for limb salvage in selected patients with good collateral arteries, offers acceptable long-term patency, and is particularly useful when the groin is hostile to dissection or graft material and the superficial femoral and popliteal arteries are occluded.     

Rare origin of the inferior epigastric and medial circumflex femoral arteries arising from a common trunk

A case of unilateral anomalous arterial supply of the lower limb and the anterior abdominal wall is presented. In this case, inferior epigastric artery arose from a common trunk with the medial circumflex femoral artery. The common trunk arose from the femoral artery. The inferior epigastric artery reached the anterior abdominal wall by passing deep to the inguinal ligament. The medial circumflex artery ran between the femoral artery and vein within the femoral triangle. A possible ontogenetic explanation is provided for this situation. Awareness of the variations in anatomy of the inferior epigastric and femoral arteries is important for angiographers and the surgeon who operates in this region. Received: 28 October 1999 / Accepted: 10 July 2000     

Reoperation and coarctation of the aorta: the need for lifelong surveillance

BACKGROUND: We report a series of reoperations in 23 patients who had undergone previous aortic coarctation repair. METHODS: The medical records of these patients were reviewed, and the patients were followed up by telephone interview. Mean age at reoperation was 25 years. There was a mean of 18 years between initial coarctation repair and reoperation. Indications for reoperation included recoarctation (9 patients), aortic aneurysm (8), aortobronchial fistulas with exsanguinating hemorrhage (2), subaortic stenosis (1), ruptured thoracic aneurysm (1), ruptured sinus of Valsalva aneurysm (1), and supramitral stenosing ring (1). RESULTS: There were no specific intraoperative complications. Three patients required reexploration for bleeding. An acutely ischemic lower limb developed in 1 patient secondary to a common femoral artery embolus, which necessitated embolectomy. CONCLUSIONS: Reoperation for postcoarctation repair patients can be performed with good results. Sudden life-threatening hemorrhage due to aortobronchial fistulas in patients having undergone Dacron patch aortoplasty, as well as long-term obstructive phenomena seen anywhere along the left ventricular outflow tract, make lifelong surveillance of these patients mandatory.     

Arrest of the growth plate after arterial cannulation in infancy

Seven children who had partial arrest of the growth plate after neonatal arterial cannulation, developed obvious skeletal changes in adolescence. Cannulation of the femoral artery produced ischaemia which led to four cases of ipsilateral shortening of the lower limb and one of partial arrest of the proximal femoral physis with subsequent coxa valga. The two arrests in the upper limb affected the humerus, ulna and radius, and the radius alone, after cannulation of the brachial and radial arteries, respectively. These late effects of cannulation are not widely appreciated, and may occur as a result of thrombosis rather than extravasation.     

Nerve injury in lower limb vascular surgery.

OBJECTIVE: Nerve injury is one of the most common complications of varicose vein surgery and is a frequent cause for litigation but its incidence following lower limb arterial surgery has not been well documented. This study was undertaken to determine the incidence of nerve injury following lower limb arterial surgery. This was addressed in relation to long saphenous or femoral vein harvesting, or re-operative surgery. MATERIALS AND METHODS: A total of one hundred patients who had undergone lower limb arterial reconstruction in the previous five years were invited to participate in this study. Seventy-eight patients responded, of which 44 patients (66 operated legs) agreed to participate. They underwent neurological assessment of the lower limbs. RESULTS: 66.7% of limbs had objective evidence of sensory deficit following lower limb arterial surgery but none had motor deficit. Redo surgery or superficial femoral vein harvest had no influence on the incidence of nerve injury. Below knee incisions had a higher incidence of nerve injury than other approaches. Long saphenous vein harvest significantly increased the rate of nerve injury. CONCLUSIONS: There is a high incidence of sensory nerve damage following lower limb arterial surgery. In the present climate of increasing litigation it is important to know the likely incidence of post-operative nerve damage so that patients can be counselled appropriately during the process of obtaining informed consent.     

Nifedipine in patients with peripheral vascular disease

The calcium antagonist nifedipine has been studied in a group of patients with intermittent claudication. In a long-term double blind, placebo controlled trial in 27 patients there was no effect on exercise tolerance as measured by pedal ergometry and only a limited improvement in symptom score on double dose nifedipine. Common femoral artery volumetric blood flow (measured by duplex ultrasound) was unaffected. The acute effects on blood flow were also studied, with a mean increase of 23% in common femoral artery blood flow 30 min after sublingual nifedipine. The administration of nifedipine to patients with peripheral vascular disease will not adversely affect claudication symptoms, and may result in an acute improvement in lower limb blood flow. Nifedipine is a suitable antihypertensive in patients who suffer from intermittent claudication.     

Acute limb ischemia and fracture of the pelvic ring: a case report

We report the case of traffic accident victim who suffered multiple injuries after being ejected from the vehicle. The patient suffered blunt trauma of the pelvis followed by acute ischemia of the lower limb. The initial work-up revealed minimally displaced fractures of the right and left obturator rings and the left sacral wing, as well as a non-displaced fracture of the anterior wall of the acetabulum. Computed tomography eliminated a compressive retroperitoneal hematoma. The mechanism of the injury was direct blunt trauma rupturing an atheroma plaque which led to thrombosis of the left common femoral artery. Thrombectomy three hours 30 minutes after onset of ischemia enabled complete sensorial and motor recovery. Awareness of this unusual type of injury can be helpful in conducting a rigorous physical examination to ensure rapid diagnosis and treatment.     

Adjunctive uses of the radial artery for emergency infrapopliteal bypass in patients presenting with acute limb-threatening ischemia

Although the radial artery has proven to be a reliable conduit for arterial bypass procedures in cardiac surgery, its use in lower extremity revascularization has been limited due to its length. In patients who have undergone multiple cardiovascular procedures, venous conduit options can be limited, and infrapopliteal bypass with prosthesis has been shown to yield poor patency rates. In this report, the authors describe 3 different uses of the radial artery in patients with acute limb-threatening ischemia in the redo setting, which resulted in limb salvage.     

Limb conservation in extremity soft tissue sarcomas with vascular involvement

Background:

The major neurovascular involvement and large primary tumors are indication of amputation. The present study is an attempt to explore the feasibility of a limb salvage surgery in extremity sarcoma cases with major vessel involvement. Oncological outcomes and surgery-related morbidities are compared with those reported in literature.

Materials and Methods:

A retrospective review of all limb salvage surgeries done in our department between 2005 and 2008 was done and four cases of extremity sarcoma of lower limb involving femoral vessels analyzed. Interpretation of data from these cases, along with review of literature, is done.

Results:

In all these cases a wide monobloc excision was done adhering to oncological principles. This required resection of superficial femoral artery alone in two cases, resection of superficial femoral artery along with common femoral vein and femoral nerve in another, and of common femoral vein alone in yet another. Reconstruction was done in all these cases with reversed long saphenous vein graft. Histopathology of resected margins was free of tumor in all the four patients. One patient developed local recurrence and one developed distant metastsis. Two were disease free for one year with good functional limb, one has been disease-free for three years and another was disease-free at two years, after which he defaulted further follow-up. One patient developed arterial blowout which required ligation of common femoral artery which resulted in gangrene of the limb. He underwent amputation.

Conclusion:

Major neurovascular involvement in extremity sarcoma is not considered a contraindication for limb salvage surgery. Review of literature also supports our view. Post-operative wound related complications are more in this group of patients. However, long term functional outcome is good. Literature suggests a good long term local control after vascular resection and reconstruction.     

A simple technique of distal limb perfusion during prolonged femoro-femoral cannulation

OBJECTIVE: Cannulation of the femoral vessels for cardiopulmonary support is a common approach for many cardiac procedures as well as access of choice for many emergency bypass systems such as extracorporeal membrane oxygenation. A serious complication of prolonged femoral cannulation remains the ischemic injury of the distal limb. SUBJECTS: To minimize the incidence of ischemia in the cannulated leg, we have begun to provide antegrade femoral blood flow by placing a vascular introducer percutaneously distal to the arterial cannula into the superficial femoral artery and connecting it to the side port of the arterial line. CONCLUSION: This technique of distal limb perfusion was found to be safe and effective in preventing lower limb ischemia for patients with prolonged femoral cannulation for extracorporeal circulatory support.     

复合血管序贯式旁路移植术治疗慢性肢体缺血的临床分析

目的:探讨复合血管序贯式下肢动脉旁路术治疗慢性下肢缺血的效果。方法:回顾性分析3年内采用复合式血管序贯式动脉血管重建的25例慢性下肢缺血患者的临床资料。复合血管由聚四氟乙烯（PTFE）人工血管及自体静脉组合而成。PTFE近心端与股总动脉吻合，远端与孤立腘动脉吻合；自体静脉从PTFE血管远端发出并与小腿的胫或腓动脉吻合。结果:自体静脉远端吻合口止于胫前动脉5例，胫后动脉8例，腓动脉12例。术后1，2，3年累积通畅率分别为78%， 72%， 61%。二期累积通畅率分别为83%，77%，68%。救肢率分别为83%，83%，73%。结论:复合血管序贯旁路术治疗慢性肢体缺血远期通畅率较高，具有较好的救肢效果，是解决自体静脉不足的合理选择。     

Management of iatrogenic lower limb ischaemia in children.

An acutely ischaemic lower limb following femoral artery cannulation in children is a problem infrequently encountered by plastic surgeons in the UK. When such a case presented to us, we performed a search of published literature to guide us to the optimum treatment. This included methods for extraperitoneal exposure of the common iliac artery and vein. We describe the surgical technique that we used to salvage an acutely ischaemic lower limb following femoral puncture and a review of the literature.     

Blunt trauma of the common femoral artery.

Blunt vascular trauma in children is relatively rare and usually occurs in combination with fractures. Direct blunt trauma of the common femoral artery can lead to complete obstruction of the artery. In children, this obstruction may cause difference in limb growth. The authors describe a case of traumatic intimal rupture of the common femoral artery in an 11-year-old child after a fall from a bicycle. There have been a few reports of blunt trauma to the common femoral artery in children. The patient described had immediate symptoms of ischemia. Prompt reconstruction of the common femoral artery resulted in full recovery. Principles of arterial reconstruction in children are generally the same as in adults. The use of artificial grafts is to be avoided. Follow-up term is unclear as well as the use of anticoagulation therapy.     

An evaluation of resting arterial ischemia models in the rat hind limb

Techniques for using the rat hind limb as a model of pure arterial ischemia at rest have not been well defined. Because the rat has no profunda femoral artery, numerous collateral pathways exist to the hind limb, and femoral artery ligation is not an effective method of inducing arterial ischemia. After several anatomic studies, a two stage operation to produce arterial ischemia in the left hind limb was devised. The first stage involved surgical interruption of collateral and re-entrant vessels, and the second stage involved femoral artery ligation. Using Xenon 133 clearance as an estimate of blood flow, reduction in flow to 14, 24, and 37% of the simultaneously measured value in the right hind limb was obtained at 2 hours, 2 days, and 5 days post ligation. Oxygen extraction in the left hind limb doubled both at 2 hours and at 2 days post ligation. Histological evaluation of the anterior compartment musculature after 5 days demonstrated loss of nuclei, degenerating contractile elements, edema, and inflammatory infiltrate. Evaluation of rats that had undergone isolated femoral artery ligation showed a 66% reduction in flow 2 hours after ligation, but no reduction in flow at 5 days, no increase in oxygen extraction, and only nuclear changes on histological exam at five days.     

合并下肢多处骨折的股动脉损伤的诊疗体会

目的探讨合并下肢多处骨折的股动脉损伤的临床诊断及治疗效果。方法手术治疗15例下肢多发性骨折伴股动脉损伤患者,从解剖、诊断及手术治疗等方面总结经验。结果15例患肢均成活。术后肢体肿胀约2周消退9例,自觉存在反复轻度肿胀5例。术后1-3个月出现了不同程度足踝和（或）足趾屈曲挛缩畸形,5例早期行康复治疗后畸形改善,6例后期行肌腱延长及踝关节松解,4例行屈肌腱延长术。随访8-2个月,所有病例均恢复行走功能,足底感觉完全恢复。结论下肢多发骨折伴发股血管损伤一般位于收肌裂孔附近,需手术探查血管移植修复;对〉24h甚至6d的股动脉损伤患者积极手术修复仍可挽救部分功能。     

An unexpected anatomical variant of the femoral artery in a patient with acute lower limb ischemia: case report

We report a case of acute embolic ischemia of the right lower limb in a patient with unexpected intraoperative anatomic variant of femoral artery. In this anomaly, the deep femoral artery arises from the external iliac artery, 2 cm above the inguinal ligament, runs with a parallel course with the superficial femoral artery, and placed between the branches of femoral nerve. In consideration of the difficulty to achieve extensive and optimal control of the external iliac artery with the femoral approach, a retrograde embolectomy of the iliac artery by two separate arteriotomies on the deep and superficial femoral arteries were successfully performed. The literature reviewed about this anomalies. In these unexpected intraoperative cases a ductile and ingenious approach seems to be mandatory to perform a safe operation with low systemic impact.     

Sequelae after limb-sparing surgery with major vascular resection for tumor of the lower extremity

PURPOSE: Limb-sparing procedures have recently replaced amputations as the treatment for tumors invading major vessels of the lower extremity. Major arteries must be reconstructed for limb salvage. The veins are not usually reconstructed. This study was undertaken to investigate the sequelae such as chronic venous disease after venous resection for tumors. METHODS: Ten patients who underwent limb-sparing surgery for a tumor of the lower extremity or retroperitoneum that required major vascular resection were studied. The median follow-up period was 48 months. After combined resection of a major artery and vein, arterial reconstruction was performed. The veins were not reconstructed. The resected veins included the inferior vena cava (n = 2), the external iliac and common femoral veins (n = 3), the superficial femoral vein (n = 3), and the popliteal vein (n = 2). The main outcome measures were clinical classification of chronic venous disease in 10 patients and air plethysmography in seven patients. RESULTS: Clinical classification was C(0A) in 6 patients, C(3A) in 1 patient, C(3S) in 2 patients, and C(4S) in 1 patient. Venous claudication with uncontrollable edema was observed in two patients with C(3S) disease. Pain and itching with inflammatory skin changes were observed in one patient with C(4S) disease. These three patients had undergone resection of the femoral vein, including the deep femoral vein along with proximal adductor muscles. Air plethysmography revealed that the ejection fraction was significantly lower and the residual volume fraction was significantly higher in the three patients with symptoms than in symptom-free patients. CONCLUSIONS: Significant chronic venous disease was observed in the patients who underwent combined resection of the femoral vein, the deep femoral vein, and the adductor muscles for a tumor.     

下肢慢性缺血合并急性血栓形成的外科治疗

目的 探讨治疗下肢慢性缺血合并急性血栓形成的最佳外科治疗手段.方法 回顾性分析2000年1月～2010年10月我科收治的26例下肢慢性缺血合并急性血栓形成患者的临床资料,比较单纯采用股动脉切开导管取栓术组(10例)与股-腘动脉切开取栓联合动脉重建手术组(16例)的疗效.结果随访时间1～114个月,单纯股动脉切开术组中的...     

Kissing stents in the common femoral artery bifurcation for critical limb ischemia: technical description and report of three cases

The purpose of this article is to describe three cases of kissing stent placement in the common femoral artery bifurcation in patients unsuitable for open endarterectomy and patch plasty. In three patients with critical limb ischemia, caused by primary atherosclerotic disease or dissection-related injury when performing a lower extremity intervention, a technique of kissing stents was used to treat the flow-obstructing lesion in the common femoral artery bifurcation. Technical success was uniform, and during follow-up (4.5-8 months), all patients showed improved symptoms, wound healing, and duplex ultrasonography-verified patency of the stents. Kissing stents in the common femoral artery bifurcation are a feasible treatment option in patients with limited mobililty or contraindications to open repair. The short-term results seem promising, but longer follow-up and an increased number of patients will be needed to assess the durability of the reconstruction.     

Obturator bypass: a classic approach for the treatment of contemporary groin infection

As the number of cardiac and interventional radiologic procedures has risen, the frequency with which surgeons are called to treat groin complications has increased. Infectious groin problems that often involve foreign prosthetic material or remnants of percutaneous femoral closure devices are particularly challenging and require control of bleeding, removal of foreign material, wide debridement, and sometimes arterial resection. Management of the consequential limb ischemia in such cases is controversial. The purpose of this study is to review the utility of extra-anatomic common femoral bypass through the obturator foramen (obturator bypass) as a method of treating limb ischemia after arterial groin infection. From July 1992 through June 2001 a total of 12 patients (six male) presented with severe vascular infections of the groin and underwent obturator bypass. Infections occurred as a consequence of an isolated vascular graft infection (nine) or after a percutaneous interventional femoral access procedure (three). Patients presented with systemic sepsis and a draining sinus (six), infected pseudoaneurysm (two), or hemorrhage (four). Treatment included debridement of the groin wound, sartorius muscle flap coverage of the femoral vessels, antibiotics and synthetic (eight polytetrafluoroethylene and four Dacron) obturator bypass via a lower abdominal extraperitoneal incision from an aortobifemoral bypass graft limb to the superficial femoral artery (six), native iliac to femoral artery (three), iliac to popliteal artery (two), and aortobifemoral bypass limb to the popliteal artery (one). Graft patency and limb salvage were assessed by Kaplan-Meier life table analysis. There were two (17%) deaths (multisystem organ failure at postoperative days 9 and 6) and four major complications (25%) requiring reoperation in the first 30 days. Ten patients (83%) survived, healed their groin wounds, and are infection free. With a mean follow-up of 37 months graft patency and limb salvage at 60 months were 80 and 60 per cent, respectively. There were no late graft infections. We conclude that the obturator bypass is an effective and durable means of revascularization in the presence of the septic groin. This procedure belongs in the armamentarium of all surgeons managing these complications.