下肢动脉硬化性闭塞症多节段复杂病变的杂交手术治疗

目的:探讨下肢动脉硬化闭塞症(ASO)多节段复杂病变的治疗手段及临床疗效。方法:采用杂交手术治疗ASO多节段复杂病变,患者21例,切开股总动脉行髂动脉Fogarty导管取栓术+髂动脉血管腔内成形术(PTA)+支架(STENT)2例,髂动脉PTA+STENT+股总动脉内膜切除术(TEA)4例,髂动脉PTA+STENT+股总动脉TEA+股动脉Fogarty导管取栓术1例,髂动脉PTA+STENT+股总动脉TEA+股腘动脉人造血管旁路移植术1例,髂动脉PTA+STENT+股总动脉TEA+股浅动脉PTA+STENT2例,髂动脉PTA+STENT+股总动脉TEA+膝下动脉PTA2例,髂动脉PTA+STENT+股总动脉TEA+股深动脉扩大成形术2例,股总股浅动脉TEA+股浅动脉PTA+STENT3例,股浅动脉TEA+腘动脉PTA+膝下动脉PTA3例,先行膝下动脉远端流出道的PTA治疗,而后同期进行股腘动脉人造血管移植术1例。结果:手术成功率为100%,未出现严重并发症,踝肱指数(ABI)复查由0.31升至0.66(正常值0.53～0.91)。分别于术后3,6,9个月及12个月进行Ⅰ期临床评估及彩色多普勒超声检查,1例11个月死于急性心肌梗死,2例再狭窄,1年通畅率90%(18/20)。结论:杂交手术治疗多节段复杂病变的下肢动脉硬化闭塞症患者安全、创伤小及通畅率高。     

Usefulness of femoro(ilio)-axillar bypass surgery for the treatment of subclavian steal syndrome caused by aortitis syndrome

Summary In two patients with subclavian steal syndrome associated with aortitis syndrome, retrograde bypass grafting from the femoral or common iliac artery to the axillary artery resulted in the disappearance of symptoms. One patient, a 37-year-old female, was treated with a bypass from the left femoral artery to the left axillary artery with a 10-mm ring-supported double velour knitted Dacron graft. The other patient, a 54-year-old female, with the complication of moderate aortic regurgitation, was treated with a bypass from the left common iliac artery to the left axillary artery with an 8-mm EPTFE graft. These bypass grafts were angiographically confirmed to be patent after the operation. When changes in graft flow in different body positions (supine, sitting, and standing) were examined, using a transcutaneous Doppler flow meter, 5 years after the operation, resting graft flow to the upper extremities showed no consistent changes among the three different positions and was maintained in a stable condition, regardless of the patients' positions. Furthermore, graft flow increased while the left arm exercised. This finding, together with the clinical efficacy, indicates that this mode of retrograde bypass grafting may be effective in some selected patients with this complicated syndrome.     

Superficial femoral artery autotransplantation for popliteal artery damage: a good solution?

We chose not to use a vein to bypass a popliteal artery lesion in four preferring to perform an autotransplantation of a proximal segment of the homolateral superficial femoral artery. The proximal arterial segment translated downstream being replaced by a synthetic graft. This approach was used to treat a popliteal aneurysm in two patients and cystic adventitiel disease in two others. The great saphenous was unfit for bypass in two patients. One patient died with a patent transplant nine Months after surgery due to an unrelated urological problem. The other three patients were alive and symptom free, at least forty-two Months after surgery. All three had a patent transplant despite obstruction of the proximal synthetic bypass in one patient. Provided that the outcome in a larger number of cases confirms these favourable results, we think that this technique offers an attractive alternative to venous bypass, at least whenever a venous graft cannot be used.     

How can we improve the prognosis of infrapopliteal bypasses?

Infrapopliteal bypasses are often used for critical ischemia, in patients older than 80, in diabetics patients in 20% of cases, and patients with end-stage renal disease in 10% of cases. The goal of this paper is to analyze the systemic factors, which contribute to the clinical results, the technical aspects, which improve the patency of the bypass, and the role of postoperative follow-up. Postoperative mortality in those patients ranges from 3 to 10%, depending on several factors: age, global cardiovascular diffusion, diabetes mellitus, end-stage renal disease. A complete evaluation of concomitant cardiovascular disease including coronary, renal and carotid disease is necessary to achieve the goal of reducing early and late mortality. Previous treatment of septic lesions of the foot is very important, before revascularisation. Technical aspects of infra-inguinal revascularisations modalities are based on a complete analysis by duplex scan, magnetic resonance imaging and intra-arterial angiography, with asynchronous subtractions and lateral view of the foot. With the duplex scan, the quality and the length of the homolateral or controlateral long saphenous vein can be previewed, allowing an appropriate choice among bypass modalities. A surgically safe portion, free of proximal hemodynamic lesions, must be chosen for the proximal anastomosis: common femoral artery, superficial femoral artery (SFA), popliteal artery or tibial artery. In patients with poor arterial distal run off, and high peripheral resistances (diabetic foot, end-stage renal disease, foot infections) the proximal anastomosis must be made as distal as possible, on the popliteal or tibial artery. In case involving a short lesion of the superficial femoral artery, a combined strategy with angioplasty and distal bypass is a safe therapeutic option. The distal anastomosis must be made on an artery in continuity with the foot, and the plantar arch. In diabetic patients, the best artery is often the pedal artery. The graft is preferentially venous, which is better than prosthetic bypass. The long saphenous vein can be used in situ or reversed, or transposed, reversed after valvular disruption, when the proximal anastomosis is made below the common femoral artery. At 3 years, the primary patency of prosthetic bypasses is between 30 and 50%. Several technical artifices, (external route) or venous artifice at the distal anastomosis site (venous patch, venous cuff) can be useful. A distal arteriovenous fistula improves the flow in the grafts, but increases the distal resistances. Free tissue transfer increases outflow, allowing treatment of major tissue loss of the foot. Postoperative therapy must include a systemic heparinisation, until the patient is able to have a muscular activity. Antiplatelet therapy with aspirin is warranted for venous grafts. For prosthetic by-pass, some studies have shown that coumadin therapy provides a benefit. These bypasses require a duplex scan follow-up at 1, 6, 12 months and then annually to search for stenosis of the venous grafts. If a significant hemodynamic lesion is found, a new procedure, via an endovascular or surgical approach can improve secondary patency. In cases of acute occlusions of the graft, an aggressive approach including thrombectomy, thrombolysis and distal angioplasty, can improve the patency. A global evaluation, with medical therapy, with antiplatelets, statins, diabetes control, annual evaluation of silent myocardial ischemia, and duplex scan follow-up of carotid artery disease, may improve the quality-of-life of these patients.     

The management of infected grafts in reconstructive vascular surgery

Aseptic bypass graft and graft-preserving open local treatment have proved to be the 2 suitable procedures for therapy of infected grafts in vascular surgery (stage III Szilagyi) with preservation of the limb extremity. After 685 reconstructive operations (1982 to 1984) for chronic arterial occlusive disease in the supraaortic as well as in the iliac and femoral segments, 9 infections involving the graft (1.31%) occurred. These infections were more common in superficial extra-anatomical bypass. The incidence of inguinal infection was 0.44%. In 2 cases an aseptic bypass with abandonment of the infected vascular segment and in 4 cases open local treatment of the infected graft proved successful in treating the infection and led to secondary wound healing. The transplant had to be abandoned and an amputation performed in 3 patients, one of whom died. That is to say, the infection was successfully treated (with respect to the original aim of the operation) in 66.7% of cases. The aforementioned methods do not represent alternative procedures: the aseptic bypass is considered in retroperitoneal and inguinal infections, whereas the open local treatment is used in cases of superficial extra-anatomical bypass grafts and in the infrainguinal and supraaortic artery segments. The success of the latter treatment, however, depends on several preconditions. In former years, loss of the limb extremity was almost unavoidable and, because of septicemia, the outcome often lethal. By applying the above-discussed principles of management this could be drastically improved.     

Angiographic evaluation of a carotid-subclavian bypass graft in a patient with subclavian artery stenosis and left internal mammary artery bypass graft

The incidence of coronary subclavian steal syndrome is estimated to be 0.4%. When revascularization is necessary, the preferred technique is the carotid-subclavian bypass graft. Failure of a carotid-subclavian graft is rare. We present a patient with subclavian stenosis who required reevaluation of both the carotid subclavian conduit and the left internal mammary bypass graft. A combined femoral and left brachial approach is recommended for evaluating the carotid-subclavian graft and left internal mammary artery graft in patients with bypassed subclavian artery stenosis and prior myocardial revascularization. © 1994 Wiley-Liss,Inc..     

Partial portal arterialization in complete en bloc resection of the hepatoduodenal ligament and left lobe of the liver for hepatic hilar cancer

The complete resection of the hepatoduodenal ligament is associated with enormous surgical invasion, which frequently results in postoperative hepatic dysfunction secondary to interruption of the reconstructed artery. We administered partial portal arterialization by anastomosis of the gastroduodenal artery to the portal vein without reconstruction of the hepatic artery in the complete resection of the hepatoduodenal ligament with resection of the left lobe of the liver in a patient with hilar bile duct carcinoma. After division of the proper hepatic artery, the gastroduodenal artery was anastomosed in an end-to-side fashion to the trunk of the portal vein. After division of the portal vein, to prevent ischemia, a single catheter bypass was inserted into a branch of the mesenteric vein and the another side of the catheter was attached to the hepatic end, of the portal vein. The portal vein was reconstructed with the superficial femoral vein graft. The blood supply to the remaining liver was interrupted for only 15 min during which the proximal end of the superficial femoral graft was anastomosed to the hepatic end of the portal vein. Postoperative liver function has been stabilized and his postoperative course is uneventful without portal hypertension. One month postoperatively, angiography through the vessels nourishing the raised jejunum visualized intrahepatic arteries.     

Repetitive intraoperative use of recombinant hirudin (Lepirudin) in peripheral vascular surgery with HITT

Heparin induced thrombocytopenia with thrombosis (HITT) is a rare but dangerous complication related to the application of unfractionated heparin or low molecular weight heparin. Due to an antibody dependent in vivo platelet activation, severe thromboembolic episodes may occur. We present the case of a patient with HITT following implantation of an aortobifemoral graft secondary to bilateral common iliac artery stenoses. An arterial clot developed and led to a partial occlusion of the graft to the right external iliac artery. Heparin was replaced by Lepirudin, a recombinant hirudin. A bolus of 0.4 mg/kg body weight was given, thereafter 0.15 mg/kg body weight per hour was administered continuously i.v. to maintain the aPTT 2- to 2.5-fold above the baseline value. The platelet count (minimum 47 G/l) normalised within two days. During thrombectomy of the right common femoral artery we used Lepirudin intraoperatively (bolus injection of 0.2 mg/kg body weight) to prevent any further platelet and coagulation activation during the clamping phase. Six months later the patient underwent two further bypass operations due to severe stenoses of both superficial femoral arteries. Due to the high risk of thromboembolism if HITT recurred, a bolus of 0.2 mg/kg body weight of Lepirudin was given during each intervention. No bleeding complications occurred. In addition Lepirudin appeared to decrease platelet consumption in the absence of active thrombosis. Direct thrombin inhibitors such as Lepirudin possess no heparin-like immunological properties and seem to have become the therapeutic "gold-standard" in patients with HITT. Our experience suggests that the repetitive intraoperative use of Lepirudin is safe and effective.     

Successful percutaneous stenting of a right gastroepiploic coronary bypass graft using monorail delivery system: a case report.

The right gastroepiploic artery (RGEA) is being successfully used as an arterial conduit in a selected group of patients undergoing coronary artery bypass graft surgery. However, myocardial ischemia may result due to spasm, occlusion, and stenosis of this graft. The anastamosis site at distal right coronary artery (RCA) or posterior descending artery (PDA) is the most common location for stenosis of an in situ gastroepiploic coronary bypass graft. Balloon angioplasty of such stenoses has been reported with optimal short-term results. Stent deployment would decrease the restenosis rate, so that repeat procedures could be minimized for these technically challenging lesions. We describe a case of successful deployment of a stent with monorail delivery system at the anastamotic site stenosis of an in situ gastroepiploic right coronary artery bypass graft. This percutaneous coronary intervention could prevent redo coronary artery bypass graft surgery. Cathet. Cardiovasc. Intervent. 49:197-199, 2000.     

Principles of surgery of the deep femoral artery in arteritis of the lower extremities]

The role of the deep femoral artery has too often been ignored in the assessment of arteritis of the lower limb. This anatomical distribution, which seems to be restricted to the thig, has left pride of place to the superficial artery as being responsible for intermittent claudication. In fact the deep femoral artery represents an exceptional and privileged route for anastomosis that is capable of replacing almost perfectly an obstructed superficial femoral artery and also in a more limited way femoro-popliteal arteries with extensive obstructions. The authors estimate that the deep femoral artery represents a true physiological bypass for a thrombosed superficial femoral artery on which a lumbar sympathectomy has a particularly remarkable action. It is important, in order to obtain as good a result as possible, that the flow in the deep femoral artery should be good, which presupposes complete freedom of the iliac axis and good permeability of the trunk of the artery, begining at its ostium. Surgery of the deep femoral artery is short or lon angioplastic surgery depending on the type of lesion, usually involving a venous patch. The surgical approach is straightforward. Whe it is used for isolated lesions or as the last stage of aorto-iliac surgery, delicate angioplasty of the deep femoral artery is a perfectly feasible operation which the authors believe should take its place, in association with lumbar sympathectomy, in the restoration of the superficial femoral artery.     

Laser Angioplasty of Totally Occluded Superficial Femoral Arteries Via a Percutaneous Popliteal Approach

Percutaneous laser hot-tip recanalization of totally occluded superficial femoral arteries has previously been dependent on access to the superficial femoral artery via the common femoral artery. Certain subsets of disease do not permit this approach and thus make patients ineligible for this nonsurgical option. In order to extend the benefits of laser angioplasty to these patients, we have investigated the applicability of percutaneous popliteal artery puncture as an access point from which superficial femoral artery percutaneous laser balloon angioplasty can be performed. Twenty-one procedures were performed on 20 patients with total superficial femoral artery occlusions. Eighteen had successful recanalization (85%). All 18 recanalized vessels were patent at 3 weeks post procedure. Minor complications which did not require surgical or medical intervention occurred in nine patients. We concluded that a percutaneous popliteal approach to laser angioplasty of a totally occluded superficial femoral artery can be safe and effective in selected patients.     

Off-pump reconstruction of pseudoaneurysm of the descending thoracic aorta.

We report 2 cases of postoperative pseudoaneurysm of the descending thoracic aorta, repaired successfully by temporary bypass graft without extracorporeal bypass. One patient presented with a large recurrent pseudoaneurysm that developed 30 years after ligation of a patent ductus arteriosus. The other patient presented with a pseudoaneurysm 18 years after thoracic aortic reconstruction for a traumatic aneurysm. In both cases, a temporary bypass graft was created from a major branch of the aortic arch to the femoral artery prior to definitive reconstruction. The postoperative course was uncomplicated by organ dysfunction or neurologic deficit. Creation of a temporary bypass graft can avoid the need for cardiopulmonary bypass in selected patients. By avoiding heparin use, blood loss is decreased, especially when dense pulmonary adhesions from previous surgery are present.     

Catheter-based revascularization of the hepatic artery to treat coronary steal from a gastroepiploic artery bypass graft

During diagnostic cardiac catheterization for symptoms of progressive angina, a high-grade ostial stenosis of an aberrant hepatic artery was identified. The common hepatic artery, which originated directly from the aorta rather than the celiac artery, supplied an in situ gastroepiploic artery bypass graft to the distal right coronary artery. Reduced flow within the bypass graft was observed consistent with a steal phenomenon from the coronary artery. This report describes successful angioplasty and stenting of the hepatic artery to salvage the gastroepiploic bypass graft and resolve the patient s ischemic symptoms.     

Value of axillofemoral bypass in the elderly

The aim of this retrospective study was to assess the merits of axillofemoral bypass in elderly patients. 69 axillofemoral grafts were laid from 1981 to 1985 in 56 patients, all older than 70. They always were aimed at limb salvage due to aortoiliac obliterating lesions (the indications of sepsis of aorto-bifemoral prostheses have been excluded). 13 patients have had an axillo-bifemoral graft and 43 an unilateral axillofemoral graft. The lower anastomosis involved the common femoral artery in 30 cases, the deep femoral artery in 39. The patients were followed up for 1 to 74 months, with an average of 24 months. The operative mortality was of 10 cases (17%). During the first postoperative month, 3 major amputations were required. The cumulated survival rate at 60 months was of 18%, with the primary and secondary patency rates at 60 months being of 46% and 71%, respectively. We conclude that axillofemoral bypass is perfectly adapted to this population of elderly subjects, in whom a direct aortic approach is counterindicated.     

Stanford A型主动脉夹层手术中股动脉插管的应用

目的 :探讨经股动脉插管行主动脉夹层动脉瘤手术的应用。方法 :88例StanfordA型主动脉夹层动脉瘤经股动脉插管建立体外循环进行手术 ,其中 2 6例深低温停循环。结果 :8例 (9. 1% )在术中出现假腔灌注 ;4例 (4. 5 % )脑部并发症 (2例广泛脑缺氧 ,2例脑栓塞 ) ,2例死亡 ,1例不清醒 ,1例偏瘫 ;6例 (8. 0 % )皮肤切口延迟愈合 ,局部感染 1例 (1.3% )。术后插管侧无下肢缺血或股动脉血栓形成。结论 :经股动脉插管行体外循环或左心转流手术治疗主动脉夹层动脉瘤的方法是有效的。采用经人工血管行股动脉插管可有效的降低了股动脉狭窄、血栓形成和下肢缺血的并发症发生率 ;股动脉插管主动脉逆行灌注造成的假腔灌注和脑部并发症在本组发生率虽较低 ,但后果严重。     

Claudication pain in the left arm of a coronary artery bypass graft patient using crutches: Coronary subclavian steal syndrome - a case report

A 77-year-old male former smoker with hypercholesterolemia and diabetes, who underwent coronary artery bypass graft surgery three years before admission and right carotid endarterectomy four years before admission, presented with recent-onset exertional chest pain. His medical history revealed that the chest pain was preceded by gradually worsening exertional claudication pain in his left arm when he was using crutches. The chest pain was similar to the pain he experienced before the coronary artery bypass graft surgery was performed. Coronary angiography and bypass graft imaging showed significant stenosis of the left subclavian artery proximal to the origin of the left internal mammary artery bypass, decreased flow in the left internal mammary artery with partial retrograde filling from the left anterior descending artery, and severe narrowing of the left vertebral artery with preserved centrifugal flow. Percutaneous stent implantation into the left subclavian artery was performed together with proximal balloon angioplasty of the left vertebral artery. The patient has been symptom free since the stent implantation.     

Non-anastomotic midgraft stenosis of a knitted Dacron graft after arterial reconstruction. Report of a case.

Midgraft stenosis of the prosthesis after bypass surgery has seldom been reported. A man presented with an ischemic ulcer of the left foot. He had undergone bilateral femoropopliteal bypass surgery as well as left-sided iliofemoral bypass surgery with a knitted Dacron graft. The graft in his left thigh was occluded. A knitted Dacron conduit with 8-mm diameter was interposed between the iliofemoral bypass graft and the left profunda femoris artery, and graft-popliteal jumping bypass surgery was added. The postoperative angiogram showed a short-segmental severe stenosis of the interposed graft neighboring the proximal anastomosis. Repeat surgery showed that the stenotic lesion was located separately from the anastomosis. This midgraft stenosis was considered to consist of dissection of pseudointima associated with the intraoperative procedures. In cases of repeat surgery around the inguinal ligament, procedures should be performed with great care.     

Symptomatic true aneurysm of a venous bypass with compression of the right atrium

A symptomatic true aneurysm of a saphenous vein graft to the right coronary artery in a female patient twelve years after bypass surgery is presented. Beating heart surgery included resection of the aneurysmatic saphenous vein graft, reconstruction of the right atrium and coronary artery bypass grafting to the right coronary artery. The symptoms of aneurysms of vein grafts, the diagnostic procedures and the surgical treatment are discussed.     

Perioperative rupture of the LIMA graft leading to cardiogenic shock,emergency angiography,and stenting with a polytetrafluoroethylene‐covered stent

A 58‐year‐old man underwent an elective coronary bypass graft for severe four‐vessel stenosis. Cardiogenic shock developed just after coronary bypass grafting with a left internal mammary artery (LIMA) to left anterior descending (LAD) artery and superficial venous graft to 1^st and 2^nd obtuse marginal (OM1/OM2) arteries the posterior descending artery (PDA) was too small to graft. Despite significant inotropes and an intra‐aortic balloon pump, the patient deteriorated in intensive care unit with cardiogenic shock and ventricular arrhythmia. Urgent coronary angiography revealed a rupture or torn LIMA graft with extravasation of contrast into the left pleural cavity. There was no distal LIMA to LAD flow probably due to graft thrombosis. Revascularisation was performed on the severe ostial native LAD stenosis with a drug eluting stent. The rupture graft was then stented with a polytetrafluoroethylene‐covered stent, which stopped the bleeding, and latter, led to total graft thrombosis. The patient improved significantly and supportive inotropes could be weaned down. At 11 month follow‐up, the patient had mild left ventricular dysfunction, widely patent ostial LAD stent and thrombosed LIMA graft. © 2011 Wiley Periodicals, Inc.     

Innovative use of self‐expanded polytetrafluoroethylene endoprosthesis for percutaneous endovascular interventions

VIABAHN® endoprosthesis (Gore & Associates, Flagstaff, AZ), a nitinol self‐expanding polytetrafluoroethylene (PTFE) lined stent, has demonstrated utility for percutaneous treatment of chronic occlusive disease involving the superficial femoral artery. In a case series communication we aimed to describe the feasibility of a PTFE‐lined stent for percutaneous treatment of conditions other than chronic occlusive disease. We report the successful use of PTFE‐endoprosthesis to percutaneously treat several vascular conditions, including arterio–venous fistula closure, reconstruction of a distal limb of an aorto–femoral endoprosthesis aneurysm, femoral artery perforation repair, and an exclusion of large saphenous vein graft aorto–coronary bypass aneurysm. This case series illustrates the feasibility of the “off‐label” use of self‐expanded PTFE endoprosthesis to percutaneously treat several conditions, which would otherwise require “open” surgical reconstructions. © 2011 Wiley Periodicals, Inc.