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Infrainguinal arterial bypasses using dilated varicose veins selectively wrapped with prosthetic segments - late results
(Portuguese PDF version)

Didier Mellière,¹ Maria Claudia de Albuquerque,² Pascal Desgranges,³ Eric Allaire,⁴ Jean Pierre Becquemin⁵

1. Professor, University Hospital Center Henri Mondor, Créteil, France.
2. Resident physician, Vascular Surgery Service, University Hospital Center Henri Mondor, Créteil, France.
3. Professor, Vascular Surgery, University Hospital Center Henri Mondor, Créteil, France.
4. Vascular surgeon, University Hospital Center Henri Mondor, Créteil, France.
5. Professor and head of Vascular Surgery Service, University Hospital Center Henri Mondor, Créteil, France.

Correspondence:
Didier Mellière
Vascular Surgery
CHU Henri Mondor
94010 Créteil, France
E-mail: didier.melliere@laposte.net

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ABSTRACT

Objective: To answer the following questions: 1) is it necessary to excise and suture the dilatations before wrapping? 2) are the wrapped segments at risk of hyperplasia or stenosis? 3) are the non-wrapped areas at risk of dilatation and rupture?

Methods: Infrainguinal revascularization was performed in 12 patients (10 males, two females), aged 33-77 years (mean age = 68). Surgical indication was arteritis (n = 7), popliteal aneurysm (n = 4), or rupture of a Dacron graft (n = 1). Location of the bypass was femoro-popliteal (n = 8), femoro-infrapopliteal (n = 3) or popliteo-popliteal (n = 1). Position of the vein was ex situ, either reversed (n = 9) or non-reversed devalvulated (n = 3). The number of dilatations reinforced with a graft were one (n = 2), two (n = 3), three (n = 6) and four (n = 1). All reinforcements except one were made with PTFE grafts.

Results: Two vein bypasses occluded, one early due to distal bed deficit and the other one 4 years after the surgery. The other 10 grafts remained patent during the follow-up, which ranged from 1 to 11 years (mean = 4 years). Half of the patients demonstrated some degree of progressive deterioration of the distal bed. At the last control, two patients had a patent bypass in spite of a deserted run-off.

Conclusion: The results of this series show that long-term patency of the wrapped vein-bypasses look far better than those of prosthetic-grafts in this location described in the literature. The wrapping can be easily performed with a short thin wall PTFE graft. It is useless to reduce the dilatations before the wrapping by suture or resection - anastomosis. Wrapped segments will not develop hyperplastic stenosis. Unwrapped segments may enlarge moderately without a risk of rupture.

Key-words: arterial bypass, grafts, varicose veins.

J Vasc Br 2005;4(4):336-40

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There is a consensus, among all indications for infrainguinal bypasses, about the superiority of using veins rather than prostheses, which becomes more important when the anastomosis is more distal, below the knee, on the leg or ankle arteries. The mean 5-year patency rates of bypasses performed for the treatment of intermittent claudication, according to the TransAtlantic Inter-Society Consensus (TASC),¹ are 80% for those performed with veins, regardless of the level; 75% with PTFE above the knee and 65% with PTFE below the knee; in cases of femoropopliteal bypasses due to critical ischemia, such rates in meta-analysis are 66, 47 and 33%, respectively. The recommendation 92 stipulates that "an adequate long saphenous vein is the optimal conduit in femoral below-knee popliteal and distal bypass. In its absence, other good-quality vein should be used". Similarly, the Repères pour les Décisions en Chirurgie Vasculaire, edited by the French College of Vascular Surgery,² in the chapter "Stenosis or isolated occlusion of the superficial femoral artery in the condition of intermittent claudication, version 2000", indicates that different studies have demonstrated the superiority of venous bypasses. In the absence of an available saphenous vein, several authors have shown the importance of the bypasses performed, either with arm veins,^3,4 and/or with segments of anastomosed veins between themselves.⁵

In practice, vascular surgeons are frequently faced with the lack of appropriate veins in several situations: previous removal of the veins for varicose treatment, exeresis of veins for other bypasses, fibrous walls, insufficient diameter or presence of varicose veins. In this last case, it is not rare that the only usable vein presents one or several isolated dilatations, although the diameters of intermediate segments are adequate. There are three reasons to reject such veins: risk of rupture, risk associated with multiple resections-anastomoses, risk of stenosis in case of reduction by simple suture. On the contrary, would it be licit to use a vein whose located dilatations could be selectively wrapped with short prosthesis segments? In previous studies, satisfactory early results were obtained by using such wrapped veins, some of them selectively and others in their totality.⁶ Afterwards, it was verified that, when the venous dilatation are located, the selective wrapping seems to provide short-term results which are also more favorable than the total wrapping, since besides being easier to perform, there is a lower risk of vein lesion in the insertion in a short prosthetic segment.

In this study, the result of bypasses performed by the first author with veins whose dilatations had been wrapped by a short prosthesis segment was assessed, in order to answer the following questions: is it necessary to excise and suture the dilatations before wrapping? Does the wrapped area evolve to hyperplasia and stenosis? Are the non-wrapped areas at risk of dilatation and rupture?

PATIENTS AND METHODS

A retrospective descriptive study of a small series of cases was performed. From 1992 to 2001, the selective wrapping technique was used in 12 patients, 10 males and two females, aged between 36-71 years (median age = 68), who needed infrainguinal bypasses. Of these, eight had an obliterating arteriopathy: six suffered from invalidating intermittent claudication and resistant to the classical medical treatment, one presented pain at rest (stage III in Leriche and Fontaine's classification) and the last one presented eschars in the heel and toes. Two of them presented an associated occlusion of the femoral artery and an initial popliteal aneurysm. Only one had a distal run off that was considered normal: four had two occluded leg arteries, but kept a communicating axis at the plantar arch; three presented one or two arteries that progressively occluded; in the last patient, the distal bed was reduced to some thin collateral veins, which originated from the tibial-peroneal trunk. These patients' antecedents contained common diseases. The 36-year-old patient with critical ischemia had an associated family antecedent of arteritis and smoking (two packs/day).

Three other patients had a popliteal aneurysm: one was asymptomatic, but the arteriography showed occlusion of the anterior tibial artery; one had the aneurysm with partial thrombosis and his distal bed was limited to a peroneal artery; the last patient had been previously submitted to a bypass that occluded, causing an acute ischemia. This patient was submitted to thrombolysis, but evolved with persistence of several blood clots. He presented an associated contralateral popliteal aneurysm, with a surgical indication due to its dimensions. Finally, a patient who was multioperated due to arteritis had an associated false aneurysm at the Scarpa's triangle and a rupture of a femoropopliteal prosthesis above the knee in three sites, with a distal bed reduced to the peroneal artery.

The bypasses were femoropopliteal (n = 8), femoral arteries of the leg (n = 3) and popliteal-popliteal (n = 1). The anatomical conditions allowed the use of the reverse saphenous vein in nine cases and non-reversed devalvulated in three cases. In one patient one bypass was performed with arm veins (radial + cephalic) previously dilated due to the creation of an arteriovenous fistula. For all others, the great saphenous vein was used.

The techniques for dissecting the saphenous vein and the anastomoses had no particularities. The vein diameter ranged from 4 to 9 mm, presenting 5 mm in five cases. The veins were introduced inside the prosthetic wrapping and placed outside the knee bend area. These wrappings were performed only once with a Dacron segment (Cardial, France), seven times with the usual PTFE and, in the last four cases, with a 6-mm thin wall PTFE graft, used for carotid bypasses (Gore®). The length of the wrapping ranged from 2 to 6 cm, and the amount of segments used for the same vein was one (n = 2), two (n = 3), three (n = 6) or four (n = 1). In order to avoid the displacement of the wrapping over the vein during its passage inside the tunneler, one or both the extremities were attached to its adventitious by a stitch with a 7.0 wire. The success of the procedure was checked in the transoperative arteriography. All operated patients were examined 1 month after the surgery and 1 year later using the eco-Doppler. Next, all patients were advised to be submitted, every year, to an eco-Doppler control and to see a doctor in case of clinical problems or detected by the ultrasonography. The patients were contacted for the study and required to see a doctor or to bring the last eco-Doppler examination. The small number of patients does not authorize the use of statistical tests.

Figure 1 - Bypass with vein presenting four small dilatations. The superior anastomosis was concluded. Two dilatations were wrapped, and the other two are distally indicated by the dissection clamp

 

Figure 2 - The four dilatations were wrapped

 

RESULTS

The bypass performed to save the limb of a 36-year-old man quickly occluded. This patient was amputated. The inferior anastomosis was performed in the terminal popliteal artery, despite being quite infiltrated. The transoperative arteriography showed that the tibial-peroneal trunk was reduced to a filiform lumen. Due to this fact, we lowered a guide wire until the anterior tibial artery and dilated the tibial-peroneal trunk with a 3-mm balloon. However, we could not succeed to introduce the balloon inside the anterior tibial artery. The occlusion of the bypass was due to the lack of run-off, and not to the wrapping technique.

The other 11 bypasses were followed up over a period of 13 to 133 months, with an average of 47 months. Three operated patients died due to unrelated causes, two 1 year after the surgery and one 2 years later, with patent bypasses. The eight patients who survived were followed up, respectively, for 1 year (n = 1), 4 years (n = 4), 5 years (n = 1), 6 years (n = 1) and 11 years (n = 1). One bypass occluded after 4 years, which led to the leg amputation (this patient was previously submitted to a lower limb revascularization to repair a popliteal aneurysm; this first bypass thrombosed and was partially repermeabilized by fibrinolysis, but with persistant clots in the distal bed). All other bypasses remained patent. One of them presented a stenosis of the proximal anastomosis 6 months after the surgery, which was treated by the interposition of a short prosthetic segment, bearing no relation with the wrapped vein. Another bypass suffered a global dilatation, 1 mm in average.

We did not observe stenoses of the wrapped segment, nor significant dilatations of intermediate zones, but half the operated patients developed a progressive deterioration of the distal bed. At the last control, two of the patent bypasses presented a deserted run-off.

DISCUSSION

The first long bypass with inverted saphenous vein was performed by J. Kunlin in 1948, using a vein that presented a varicose dilatation; it remained patent until the patient's death, 28 years later. The ectasia remained stable and was treated by resection-suture 14 years later, when an aorto-bifemoral prosthesis was inserted. After 20 years, the venous bypass dilated itself, in average, 1/3 of its diameter; after 27 years, it had atheromatous plaques noticed during a reintervention for repairing a false aneurysm of the superior anastomosis.⁷

The aneurysmal dilatation of venous bypasses is a rare complication,^8-13 which can evolve to a rupture.^12,13 In our experience, when the dilatation is detected in time, it can always be treated by complete replacement, if the whole vein is dilated, or by partial replacement or simple external wrapping, if the dilatation is segmental. The average time for the development of dilatation is 7 years.⁸ The causes are still not clear. They are thought to be secondary to atheromas^9,11 (despite the tissues of these dilatations not being frequently different from the rest of the bypass),¹⁴ to smoking and to the existence of an aneurysmal disease. Loftus et al. verified, in a prospective study, the development of 42% of venous aneurysms in bypasses for the repair of popliteal artery aneurysms versus 2% in those due to critical ischemia.¹⁰ We could particularly fear this evolution when the vein used for the bypass presents one or several varices whose wall usually gets thinner, and may lead to a fragility of the whole venous wall. Nevertheless, we have never observed this complication, which was not seen in three other studies: Moritz et al., who used nine short and partial wrappings,¹⁵ Soury et al., who had only one case,¹⁶ and Neufang et al., who studied the evolution of 35 bypasses over an average period of 28 months; all patients had varicose veins treated by short PTFE wrappings.¹⁷

Another potential complication would be the development of a hyperplastic stenosis at the level of wrapped areas. In an experimental study with sheep, Moritz et al.¹⁵ did not observe stenoses. On the contrary, by comparing femoropopliteal bypasses performed with femoral veins and others with jugular veins which were previously introduced in a tubular net of wide pores Dacron, they verified that there was a less important hyperplasia in the second group. The same authors, in a series of 19 bypasses in humans, noted only one case of graft stenosis in an area unwrapped by the net. It was not observed by Soury et al.,¹⁶ Neufang et al.,¹⁷ neither by us. While the vein arterialization always causes a certain degree of hyperplasia, it seems that the total wrapping by a Dacron net would reduce hyperplasia, since it reduces the opposing forces to the venous wall.¹⁵ Moritz et al. noticed an increase in the density of the vasa vasorum over the Dacron net. In a study previously made with animals, Karayannacos et al. showed that the prosthesis porosity is essential, as a parietal widening appeared when the prosthesis was not porous.¹⁸ However, as Neufang et al.,¹⁷ we used PTFE and did not observe stenoses, possibly because the wrapped segments were sufficiently short to allow the development of the vasa vasorum.

One may criticize our study due to the brevity of the average follow-up, which was a little less than 4 years, and due to the small number of cases. With regard to the duration of the observation, it was enough to evaluate the risk of hyperplasia, since in most cases it is developed during the first year. However, it was too short to analyze the aneurysmal degeneration, but if this complication occurred, it could be easily discovered by a periodic clinical examination and eco-Doppler. The repair is easy and may be performed occasionally under local anesthesia. As to the small number of cases, it is compensated by the fact that our observation is added to that made by Neufang et al., whose study had three times more cases than ours. In their study,¹⁷ the primary and secondary patencies of the bypasses with wrapped veins followed-up for 4 years were, respectively, 66 and 82%. Such results seem to be clearly higher than those concerning prosthetic bypasses described in the literature. This is explained by the conservation of the parietal compliance and of the antithrombogenicity of the intima.

Six details deserve attention: 1) it is useless to resect or reduce the dilatations by suture, contrarily to what was proposed by other authors;¹⁶ the exceeding tissue supports itself on the prosthetic wrapping with no problems; Moritz et al.¹⁵ verified that we can reduce, without complications, the vein diameter in 50% with the wrapping; 2) at the wrapping level, the origin of the large collateral veins must be resected, in order to avoid a stricture of the lumen, whereas the small collateral veins may be ligated with a thin wire. 3) the vein must be placed in such a manner that the wrapping is not at the level of the knee bend, which is located a few centimeters above the articular interline; 4) the most adequate prosthesis for short wrappings seems to be the thin wall PTFE, which we can easily dilate to the desirable diameter with the help of a small clamp; for long wrappings, it is better to use a prosthetic net with wide pores, such as the ProVena, manufactured by B. Braun Vascular Systems (Bethlehem, PA, USA); 5) In order to avoid the displacement of the wrapping material over the vein during its passage inside the tunneler, the extremities must be attached to its adventitious by a 7.0 wire; 6) next, it is prudent to observe these bypasses annually using eco-Doppler for the whole life. This technique can also be used for in situ bypasses, through a lateral cut in the prosthesis and a suture with a few separate stitches.

In Neufang's et al. series,¹⁷ of a total of 932 infrainguinal bypasses, 3.8% were benefited by such technique, thus avoiding a prosthetic bypass.

CONCLUSION

The presence of some dilatations over a vein whose caliber is globally adequate does not justify its rejection when there is no other vein available. The patency of these wrapped veins is higher than that of bypasses that are exclusively prosthetic. This notion should be known by those who perform arterial surgery, but also by surgeons and angiologists who deal with varicose veins.

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