1. Extra-anatomic Bypass – Alternative Operative Treatment
of Chronic Arterial Insufficiency of the Lower Extremities.
A Clinical Case.
N. Yordanova², M. Miteva², M. Tomov¹, G. Georgiev¹
¹ - Vascular Surgery, Multi-profile Hospital of Active Treatment – Rousse; ² - Medical University of Varna
Key words: chronic arterial insufficiency of the
lower limb, critical ischemia, Leriche’s syndrome,
extra-anatomic bypass.
Summary
We represent a clinical case of 55-year-old co-
morbid man with chronic arterial insufficiency of
the lower limb and critical ischemia,
angiographically proven Leriche’s syndrome
affecting an only lower extremity. The proper
operative treatment in this case was assessed to be
an extra-anatomic bypass.
Introduction
Leriche’s syndrome is a variation of chronic
arterial insufficiency of the lower extremities’
pathology. It is a chronic obliteration of the aortic
bifurcation and the two common iliac arteries. On
exhaustion of all conventional methods or
contraindications for their implementation, it is
necessary resorting to the so called extra-anatomic
bypasses. They are of large importance considering
avoidance of amputations or postponing these in
future. We introduce a clinical case of a 55-years
old man suffering and Leriche’s syndrome with a
realization of extra-anatomic bypass resulting in
great improvement of the lower extremity blood
flow.
Methods
On a consecutive hospitalization, the patient
presented typical symptoms of critical ischemia –
rest and night pains in left limb that were not
influenced by NSAIDs. An ulcer on the left foot
was present. O.N.N. suffers hypertensive heart
disease of III grade with hypertrophic
cardiomyopathy, diabetes mellitus type II with
polyneuropathy and dyslipidemia. All of the
diseases had a long-term prescription. He has
experienced myocardial infarction in the past. A
medical history of previous vascular interventions
was present.
On Doppler ultrasound examination lack of
pressure of the pedal arteries was found: а.
brachialis 110 mm Hg , а. dorsalis pedis sinistra –
0 mm Hg, a. tibialis post. – 0 mm Hg. Additionally,
Ankle-Brachial Index (ABI) is 0. A CT angiography
was made.
Left axillar artery was determined as an
appropriate donor and left femoral artery was an
appropriate recipient.
The reconstructive intervention was implemented
on 12/02/2015 - by-pass axillofemoralis sinistra
cum prosthesis MaxiFlo 8/70 mm. Ring. Drenaige.
After proximal (axillar) and distal (femoral)
approaches were realized, a ring prosthesis was
placed in the mid-axillary line to prevent kinking
of the graft with torso flexion or a kink over the
costal margin (figure 2). An enhancement of flow
in the recipient vessels was confirmed. Pulse of the
distal arteries of the left lower limb was found.
WBC RBC HB Hct PLT Gluc. Urea Creat. Total
protein
Prothro
mbine
time
INR
10.02. 11,1
g/l
3,4 g/l 94g/l 0,298 g/l 480 g/l 3,3 mmol/l 2,8 mmol/l 56 µmol/l 62 g/l 14,76 s. 1,15
11.02. 5,65 mmol/l
12.02. 8,4 g/l 3,46
g/l
89 g/l 0,290 g/l 451 g/l 5,13 mmol/l
13.02. 9,8 g/l 3,47
g/l
93 g/l 0,297 g/l 451 g/l
16.02. 7,2 g/l 3,36
g/l
83 g/l 0,287 g/l 312 g/l
18.02. 5,8 g/l 3,29
g/l
89 g/l 0,278 g/l 357 g/l
20.02. 6,1 g/l 3,26
g/l
85 g/l 0,280 g/l 380 g/l 65,20 s. 5,75
21.02. 23,08 s. 2,00
22.02. 20,97 s. 1,80
23.02. 6,4 g/l 2,89
g/l
86 g/l 0,247 g/l 323 g/l 27,10 s. 2,21
Table. 1 Para-clinical test of О.N.N. for the period 10/02/2015 – 23/02/2015
Results
Postoperatively, the patient’s condition
significantly improved with stable
hemodynamics and palpable pulse of left
popliteal artery. All complaints were
eliminated. The left foot ulcer started
healing. Physiotherapist stired him up to
activity. On discharge was found: RR а.
Brachialis sin. – 120 mm Hg; RR а.
Dorsalis pedis sin. – 60 mm Hg; RR a.
tibialis post. sin. – 80 mm Hg; ankle-
brachial index (ABI) – 0,66.
Conclusion
Extra-anatomic vascular reconstructions
are an alternative for salvage of the
extremity when treating CAILE with
critical ischemia in case of comorbid
patients with a great operative risk. As a
last option of treatment prior to
amputation, they give an opportunity of
improving patients’ quality of life and as
such, they should be considered when
indicated especially when it comes to
saving an only lower limb.
Theoretical facts
In 1923 Leriche published a series of observations of a syndrome occurring in
relatively young men, consisting of bilateral intermittent claudication, diminished or
absent femoral pulse, and sexual impotence. This syndrome has subsequently come to
bear his name – Leriche’s Syndrome. It is defined as localized aorto-illiac disease
(Type I), with occlusive lesions confined to the distal abdominal aorta, its bifurcation
and common iliac vessels (figure 1). In more than 90% of symptomatic patients,
disease will be more widespread, however. Approximately 25% will have disease
confined to the abdomen (Type II), and approximately 65% will have widespread
occlusive disease above and below the inguinal ligament (Type III).
References
1. Vascular Surgery, SIXTH EDITION, Robert B. Rutherford MD, FACS, FRCS (Glasg.)
2. Haimovici's Vascular Surgery, 6th Edition
3. The role of extraanatomic bypass in the management of bilateral aortoiliac occlusive disease, Schneider JR; Golan JF, Division of Vascular Surgery
4. Axillofemoral Bypass Graft — A Safe Alternative to Aortoiliac Reconstruction, John A. Mannick, M.D, and Donald C. Nabseth, M.D.
Figure 1. Angiography
Figure 2. Axillar access and tunneling on middle axillar line