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