A Case of Concomitant Extra-Anatomic Bypass to Both Femoral Arteries with Central Repair in a Patient with Aortic Dissection Complicated Ischemia in the Lower Extremities / 日本心臓血管外科学会雑誌

We report a case of aortic arch replacement and extraanatomic bypass from a branched graft to both bifemoral arteries in a patient with aortic dissection complicated by ischemia in the lower extremities. A 61-year-old woman was found to have thrombosed type II aortic dissection by enhanced computed tomography (CT). Because she had no clinical symptoms, we chose conservative pharmacotherapy. A year later, she suddenly felt severe back pain and dyspnea. CT demonstrated type IIIb aortic dissection. She developed lower extremity ischemia because the true lumen in the abdominal aorta was severely compressed by the false lumen. Two weeks after onset, we planned a bilateral axillo-femoral bypass because the right lower limb ischemia had worsened, with severe pain. However, CT showed ascending aortic dissection. Hence, emergency graft replacement of aortic arch was required. A T-shaped graft was anastomosed to the bilateral femoral arteries, and was used as a delivery line during cardiopulmonary bypass. Although distal anastomosis of the arch was constructed only to the true lumen, leg ischemia persisted. Therefore, the T-shaped graft was connected to the branched graft used for antegrade systemic perfusion. We used INVOS as an indicator of intraoperative lower limb ischemia, which was useful for judging whether or not revascularization of lower extremity was achieved. After the operation, the bypass graft was patent, and ischemia in the lower extremities disappeared.

Aorto-bi-Femoral Bypass for Juxtarenal Aortic Occlusion in a Patient with Multiple Co- Morbidities: Report of a Challenging Case.

Aorto-bi-femoral bypass for aorto-iliac occlusive disease is a fairly common procedure in vascular surgical practice. The procedure, despite its extensive nature, is generally well tolerated particularly by those having an infrarenal type of aortic occlusion. Patients having a juxtarenal aortic occlusion require a considerably more expeditious surgery necessitating maneuvers to protect the renal arteries. Surgical risk increases significantly in those having multiple co-morbid conditions. We report here a successful case of aorto-bi-femoral bypass for juxtarenal aortic occlusion in a patient having multiple co-morbid conditions like ischemic heart disease, occluded right renal artery with chronic kidney disease, severe malnutrition, hypertension and chronic obstructive pulmonary disease

Aorto-bi-Femoral Bypass for Aorto-Iliac Occlusive Disease: Recent Experience at the National Institute of Cardiovascular Diseases (NICVD).

Background & Objectives: Aorto-bi-femoral bypass is one of the most important surgical strategies in vascular surgical practice. The procedure is employed in surgical revascularization for both stenotic and aneurysmal diseases involving the aorto-iliac segment. The present study was carried out to analyze our recent experiences with this procedure for aorto-iliac occlusive diseases (AIOD) at the National Institute of Cardiovascular Diseases (NICVD). Materials and Methods: Over a period of 3 years (April 2008 to March 2011), a total of 47 patients underwent aorto-bi-femoral or aorto-bisiliac bypass grafting for AIOD using a Y-graft prosthesis. The mean age of the patients was 46.4 years (range 25-75 years). Thirty eight of the patients were male and the remaining 9 were female. A retroperitoneal approach was used in 27 patients. In the remaining 20 patients, the operation was done using a transperitoneal approach. A Gelatin-coated Dacron Y-graft prosthesis was used in 43 (5 of which were silver-coated prosthesis) patients while PTFE (Polytetrafluoroethylene) prosthesis was used in the remaining 4 patients. The operation was carried out under epidural anesthesia with sedation in most cases. Results: The operation was well-tolerated in all patients. There was no intraoperative mortality in this series. Two patients died in the immediate post-operative period- one due to myocardial infarction and the other due to acute renal shut-down leading to renal failure accounting for a mortality rate of 4.3%. Wound infection and lymphorrhoea at the groin incision site were the two main immediate post-operative complications. There was no incidence of graft infection in this series. Twelve patients were available for post-operative follow-up up to 2 years. Out of them, 5 patients returned with occluded grafts 8-23 months after the operation. Three of these patients underwent graft excision with re-do Y-graft bypass. The remaining two were treated with extra-anatomic bypass (Axillobifemoral). Conclusions: Aorto-bi-femoral bypass is an effective surgical strategy for occlusive diseases involving the abdominal aorta and the iliac arteries. The procedure is well-tolerated with a low incidence of early post-procedural complications and graft failure. However, poor adherence of the patients to follow-up remains a significant obstacle for evaluating the long-term outcome of this procedure.

Cross Pubic Femoro-femoral Artery Bypass with Great Saphenous Vein / 대한혈관외과학회지

PURPOSE: The purpose of this study was to evaluate the great saphenous vein (GSV) as a conduit for crossover femoro-femoral bypass. Generally the conduit for crossover femoro-femoral bypass is a synthetic material because of the acceptable long-term patency and low complication rates. But, as the average life expectancy becomes extended, a better patency rate becomes more important. In this study, we compared the patency rates and hemodynamic results between crossover femoro-femoral bypass operations with GSVs and those with synthetic grafts. METHODS: From 1998 to 2008, 119 femoro-femoral bypass operations were done. Among them, 38 femoro-femoral bypass used GSV as a conduit (group I) and 79 operations used expanded polytetrafluoroethylene (group II). Two cases used arm veins and we excluded those cases. RESULTS: The 3 year primary patency rate of total cases was 75.1%, 93.7% in group I and 66.1% in group II. There were no statistical differences in hemodynamic results such as peak systolic velocity, volume flow and ankle/brachial systolic pressure index between the two groups. CONCLUSION: The 3 year primary patency rate of group I was better than that of group II. However there were no differences in hemodynamic changes. So GSV is recommended as a conduit for crossover femoro-femoral bypass especially in young patients who are eager to have longer patency rates after surgery instead of less invasive endovascular therapy.

Effects of Patients' Position on Blood Pressure and Heart Rate during Spinal Anesthesia for Axillo-femoral Bypass Surgery / 대한마취과학회지

BACKGROUND: Hypotension is one of the most common complications from the spinal anesthesia frequently used for surgery on the lower abdomen or extremities. It might be important in prognostic improvements to maintain cardiovascular homeostasis in elderly or patients with cardiovascular diseases. This study evaluated the effect of the patients' position on the preservation of cardiovascular stability when elderly patients suffering from hypertension undergo surgery for an axillo-femoral arterial bypass. METHODS: 24 patients with hypertension undergoing an elective axillo-femoral bypass surgery were examined. The patients were randomly allocated into two groups (Lateral 20 min group: patients with lateral position for 20 min after spinal anesthesia; Supine group: patients with the supine position immediately after spinal anesthesia). The observers recorded the hemodynamic variables, as well as the loss of sensation on both sides. RESULTS: Considering the changes in the arterial blood pressure and heart rate from the baseline values, patients in the supine group showed a greater decrease in arterial blood pressure and heart rate (P < 0.05). In the lateral 20 min group, there was a lower block level of cold sensation that reflected the sympathetic blockade at the non-operated site (P < 0.05). CONCLUSIONS: The lateral decubitus position for 20 min after spinal anesthesia can contribute to the maintenance of cardiovascular stability during unilateral axillo-femoral bypass surgery in elderly patients with hypertension.

Femoro-femoral Cardiopulmonary Bypass during Tracheal Reconstruction Surgery: A case report / 대한마취과학회지

A 45 year-old-women with tracheal stenosis due to an endotracheal tumor was scheduled for tracheal reconstruction surgery. The stenotic lesion was located 1 cm above the carina, and was length of 4 cm and had a narrowest internal diameter of 0.4 cm. The length of such a stenotic segment and its narrowest internal diameter may pose lung ventilation problems before or during tumor resection, which may preclude a successful outcome. Thus, during tracheal reconstruction surgery a femoro-femoral partial cardiopulmonary bypass, self respiration, and pulmonary artery ligation were used. These measures improved oxygenation and cardiovascular stability, and tracheal reconstruction was successfully performed without complication.

Experiences on Endovascular Aortouniiliac Repair Combined with Cross-Femoral Bypass Grafting for Abdominal Aortic Aneurysm / 中国微创外科杂志

Objective To evaluate the efficacy of endovascular aortouniiliac repair (EVAR) combined with cross-femoral bypass grafting (CFBG) for the treatment of abdominal aortic aneurysm (AAA). Methods From May 1997 to February 2007, 8 patients with AAA, in whom bifurcated stent-graft could not be used because of complex iliac anatomy, were treated with EVAR using AUI stent-graft combined with CFBG. The endoleak, ischemic syndromes,patency of the bypasses, and blood supply of the lower limbs were observed after the operation. Results There were no perioperative mortalities in this series. One patient died of myocardial infarction 15 months after the operation. Three patients developed primary endoleak, and was cure spontaneously 1, 3, and 6 months postoperation. The 8 patients were followed up for a mean of 24 months (3-72 months), during which the patency rate of cross-femoral bypass was 100%. One year after the operation, 1 patient developed mild anastomotic stoma stenosis without ischemia of the lower limbs, but no limb ischemia. Conclusion In patients with complex iliac anatomy unfavorable for bifurcated endografting, EVAR using AUI combined with CFBG is safe and effective.

A Case of Two-staged Operation for Stanford Type B Dissecting Aneurysms with Acute Renal Failure / 日本心臓血管外科学会雑誌

A 59-year-old man was admitted for treatment of Stanford type B acute dissecting aneurysm with acute renal failure. He had begun hemodialysis one month after onset, because digital subtraction angiography (DSA) revealed that the truelumen was narrowed by a dilated false channel just above the renal artery. Initially axillo-femoral bypass was performed to treat renal failure, and the patients was easily weaned from hemodialysis. Eight months after the first operation, descending thoracic aorta replacement was performed. The patient is doing well one year after operation. In conclusion, axillo-femoral bypass yielded good results because our patient recovered from renal failure and could undergo radical operation safely. Axillo-femoral bypass allowed evaluation of the hemodynamic study before radical operation.

2 Cases of Aortoiliac Disease Treated with Strecker Stent Followed by Femoro-Femoral Bypass Graft

In the treatment of aortoiliac disease, two methods could be considered. One is percutaneous transluminal angioplasty, and the other is bypass graft. However sometimes two methods could be combined in high risk patients with a lengthy unilateral occlusion of one iliac artery and less extensive obstruction of the contralateral one, since higher risk aortofemoral bypass surgery may be obviated by femoro-femoral bypass graft after percutaneous treatment of the less diseased iliac artery. We report two cases of arortoiliac disease treated with Strecker stent followed by femoro-femoral bypass graft.

2 Cases of Aortoiliac Disease Treated with Strecker Stent Followed by Femoro-Femoral Bypass Graft

In the treatment of aortoiliac disease, two methods could be considered. One is percutaneous transluminal angioplasty, and the other is bypass graft. However sometimes two methods could be combined in high risk patients with a lengthy unilateral occlusion of one iliac artery and less extensive obstruction of the contralateral one, since higher risk aortofemoral bypass surgery may be obviated by femoro-femoral bypass graft after percutaneous treatment of the less diseased iliac artery. We report two cases of arortoiliac disease treated with Strecker stent followed by femoro-femoral bypass graft.

Ruptured Dacron Prosthesis by Blunt Trauma 8 Years after Implantation for Axillo-femoral Bypass / 日本心臓血管外科学会雑誌

A case of a 77-year-old man is reported, who developed late rupture of the knitted Darcon velour graft by blunt trauma 8 years after implantation for axillo-femoral bypass. Dacron fiber deterioration, which led the graft to fragility, might have played a main role in the clinical setting. This case clearly emphasizes that with its possibility to be deteriorated life-long care and follow up should be taken for the patients who undergo arterial reconstructive surgery using Dacron prostheses.