Primary suture-anastomosis of the Viabahnendoprosthesis to a native arterySriram Narayanan, MS, FRCS,a* Joseph Shalhoub, BSc, MBBS, MRCS,a*Narayan Karunanithy, MRCS, FRCR,b and Nick Burfitt, MRCS, FRCR,b London, United Kingdom

We describe the case of a ruptured woven polyester common femoral-to-popliteal artery bypass graft, in which the lack ofa suitable proximal landing zone precluded a totally endovascular approach to revascularization. The patient was treatedwith Viabahn endoprostheses (W. L. Gore & Associates, Flagstaff, Ariz), with the proximal end of the proximal Viabahnemerging from a graft arteriotomy and sutured directly end-to-side to the native common femoral artery. We believe thisis the first reported case of a sutured anastomosis of the Viabahn endoprosthesis to a native vessel. The surgical technique

is illustrated, and potential indications are discussed. (J Vasc Surg 2010;51:1297-9.)

The Viabahn endoprosthesis (W. L. Gore & Associates,Flagstaff, Ariz) is an expanded polytetrafluoroethylene linerattached to an external nitinol stent that is primarily used inthe treatment of occlusive disease of the iliofemoral arterialtree.1 Designed for endovascular deployment, the lack of aproximal landing zone in the artery in question may pre-clude the use of this device as a conduit for revasculariza-tion. We report a case in which direct suturing of theViabahn endoprosthesis to a native common femoral artery(CFA) allowed the device to be deployed, despite theabsence of a proximal landing zone, and present a descrip-tion of the suture technique.

CASE REPORT

An 89-year-old retired soldier, who had undergone a bypassfrom the right CFA to the above-knee popliteal artery 23 yearspreviously, presented with a painful, pulsatile, and rapidly expand-ing swelling (over weeks) in the medial aspect of his right thigh.The bypass conduit that had been used was a woven polyesterprosthesis with a long distal vein cuff. There were no symptoms orsigns of sepsis. All of his right lower limb pulses were present,although the popliteal and pedal pulses were reduced in volume.Ankle-brachial pressure indices were 0.62 at the anterior tibialartery and 0.64 at the posterior tibial artery.

Despite his age, comorbidities were limited to hypertension.The patient was independent in all activities of daily living andenjoyed an otherwise good quality of life. He was able to cycle inexcess of 2 miles per day on an exercise bicycle, which he stillinsisted on doing on the morning of his presentation.

From the Departments of Vascular Surgerya and Interventional Radiology,b

Charing Cross Hospital, Imperial College NHS Trust, Imperial CollegeLondon.

*These two authors share first authorship.Competition of interest: none.Reprint requests: Joseph Shalhoub, Department of Vascular Surgery, 4th

Floor, Charing Cross Hospital, Fulham Palace Rd, London W6 8RF, UK(e-mail: j.shalhoub@imperial.ac.uk).

The editors and reviewers of this article have no relevant financial relationshipsto disclose per the JVS policy that requires reviewers to decline review of anymanuscript for which they may have a competition of interest.

0741-5214/$36.00Copyright © 2010 by the Society for Vascular Surgery.

doi:10.1016/j.jvs.2009.12.045

Noninvasive imaging with duplex ultrasound (DUS) demon-strated a longitudinal 6- to 8-cm disruption in the middle portionof the material of the prosthetic bypass graft, with an extensivepseudoaneurysm along the entire length of the graft. Flow wasmaintained through the graft, with a monophasic signal present inthe distal popliteal artery. The DUS imaging also showed a tightstenosis of the proximal anastomosis extending onto the nativeCFA itself. This was confirmed on computed tomography angiog-raphy (CTA) and was thought to be technically unsuitable forpercutaneous stent deployment by antegrade or contralateralpuncture. CTA further confirmed the lack of adequate proximallanding zone.

TECHNICAL NOTE

The right CFA, proximal anastomosis, and prostheticgraft were exposed through a longitudinal incision. Anarteriotomy was made in the intact proximal graft, distal tothe stenotic segment but proximal to the ruptured middleportion of the graft. Through this graft arteriotomy, threeViabahn endoprostheses telescoped into each other weredeployed using a combination of direct vision and fluoros-copy. The distal end of the distal Viabahn stent was posi-tioned in the above-knee popliteal artery. The proximal endof the proximal Viabahn stent was brought out through thegraft arteriotomy, and a sutured end-to-side anastomosiswas formed between the endoprosthesis and the CFA using5-0 polypropylene suture (Fig).

The section of CFA between the Viabahn anastomosisand the existing CFA-graft anastomosis was ligated toprevent perfusion of the pseudoaneurysm from the rup-tured graft.

Anastomotic technique. The proximal end of theViabahn endoprosthesis has a serrated edge, in keepingwith the stent architecture. Suturing the end of the stent tothe side of a native vessel without prior consideration of thiscan result in a nonhemostatic anastomosis. It is importantthat the “trough points” of the distal endoprosthesis liewithin the lumen of the native vessel. In addition, thespacing between two adjacent stent rows of the graft is suchthat a needle with excessive curvature (�3/8 of a circle)does not pass through easily. Our technique (Fig, A)

therefore had two key features:

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● Continuous sutures were placed between the secondand third stent rows, passing from within to without inthe native vessel. Undertaking the anastomosis in twohalves, using two separate lengths of suture, allowedthe prosthesis to be parachuted down and telescopedinto the native vessel, with the “trough points” of thefirst stent lying intraluminally within the CFA.

● Monofilament nonabsorbable polypropylene sutureswith 3/8-circle needles (Prolene 8860H; Ethicon Inc,Somerville, NJ) at either end allowed passage of theneedle smoothly between the second and third stentrows without being restricted by the nitinol frameworkof the endoprosthesis.

A postoperative CTA at day 8 revealed no significantkinking or excessive angulation of the stents, no in-stentstenosis, and no endoleak. The surgical anastomosis waswidely patent (Fig, C). The patient remained in the hospitalfor 17 days postoperatively to allow for rehabilitation.Follow-up at 4 weeks after discharge confirmed a completefunctional recovery and a patent graft on clinical and Dopp-

Right common femoral artery

Viabahn endoprosthesis

2nd and 3rd Stent Rows 3/8 Circle

Needles

A

B

Right common femoral artery

Viabahn endoprosthesis

Woven polyester graft

Viabahn to native artery

suture anatomosis

Cranial Caudal

Fig. A, This drawing shows the suture technique usendoprosthesis to the native right common femoral arterline lay between the second and third stent rows of the enthe Viabahn endoprosthesis emerging from the woven podirect end-to-side suture anastomosis onto the native rigreconstruction of the postoperative computed tomograpthe patent overlapping Viabahn endoprostheses distally

ler assessment. There is no current evidence to guide fol-

low-up in this context; however, we intend to survey withserial DUS scans at 3 and 6 months, and annually thereaf-ter.

DISCUSSION

To our knowledge, this is the first description of adirectly sutured anastomosis between the Viabahn endo-prosthesis and a native vessel. Sutureless anastomotic tech-niques have been described, although these have beenend-to-end anastomoses. The Viabahn Open Revasculari-sation TECnique (VORTEC) was first used to facilitaterenal revascularization2 and has subsequently been usedduring aortic debranching.3 Such a technique was also anoption for our patient, whereby an end-to-side anastomosisbetween the native CFA and a synthetic graft could beformed and the Viabahn endoprosthesis deployed into thatsynthetic graft.

Other options included a new bypass from the CFA tothe above-knee popliteal artery, however we anticipateddifficulty and potential blood loss with dissecting through a

Right common femoral artery

Viabahn to native artery

suture anatomosis

Areas of verlap of two

Viabahn doprostheses

Diseased native superficial

femoral artery

the end-to-side suture anastomosis of the Viabahnnote, a 3/8-circle needle was used, and the graft sutureosthesis, as shown. B, Intraoperative photograph showser graft (caudally), its short extraluminal course, and the

mon femoral artery (cranially). C, A three-dimensionaln shows the patent sutured end-to-side anastomosis andthe previous woven polyester bypass graft.

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large false aneurysm to locate the above-knee popliteal

JOURNAL OF VASCULAR SURGERYVolume 51, Number 5 Narayanan et al 1299

artery, and a below-knee bypass, again a more extensiveprocedure in an octogenarian.

It is noteworthy that nonspatulated end-to-side anas-tomoses have the potential to result in energy loss and flowdisturbances. However, the suture technique describedhere provides an additional option in difficult operativesituations.

CONCLUSIONS

A hybrid technique of endovascular deployment of thestent with surgical anastomosis proximally, as in our case, orwith the surgical anastomosis distally, can be used when atotally endovascular approach is precluded by difficultchronic total occlusions of native vessels, failure of guide-wires to pass, or lack of proximal or distal landing zones.The surgical anastomosis to the side of a native vessel can be

performed after endarterectomy of an impassable occlu-

sion, proximal or distal to an occlusion or an unsuitablelanding zone. Adherence to the two anastomotic principlesoutlined here allows for a safe and hemostatically secureanastomosis.

REFERENCES

1. Geraghty PJ. Covered stenting of the superficial femoral artery using theViabahn stent-graft. Perspect Vasc Surg Endovasc Ther 2006;18:39-43.

2. Lachat M, Mayer D, Criado FJ, Pfammatter T, Rancic Z, Genoni M,et al. New technique to facilitate renal revascularization with use oftelescoping self-expanding stent grafts: VORTEC. Vascular 2008;16:69-72.

3. Rancic Z, Pfammatter T, Lachat M, Frauenfelder T, Veith FJ, Mayer D.Floating aortic arch thrombus involving the supraaortic trunks: successfultreatment with supra-aortic debranching and antegrade endograft im-plantation. J Vasc Surg 2009;50:1177-80.

Submitted Nov 7, 2009; accepted Dec 14, 2009.