Deep Circumflex Iliac Artery as an Inflow Alternative for Lower Limb Bypass: Report of a Case

Abstract

Introduction: The common femoral artery (CFA) is the most favourable inflow in all types of lower limb bypass procedures. However, sometimes, the CFA cannot be used in patients with critical limb ischaemia owing to obstruction, severe calcification or previous dissection. Here, we describe how iliopopliteal bypass was successfully performed by using a reversed saphenous vein graft in a patient with total occlusion of the CFA, superficial femoral artery (SFA) and deep femoral artery (DFA) and an entirely stented external iliac artery (EIA). The deep circumflex iliac artery (DCIA), which is an artery in the pelvis that runs along the iliac crest of the pelvic bone, was used as a source of inflow. Methods: A 62-year-old man with a severely ischaemic left foot was admitted to our hospital. His third and fifth toes were necrotised with pain at rest. Computed tomography revealed complete occlusion of the left CFA, SFA and DFA with severe calcification. Additionally, the left EIA had been entirely stented at another hospital 2 years previously. Arteriography revealed that the distal site of the stent in the EIA was at the border of the CFA and that the left CFA, SFA and DFA were occluded with severe calcification. The left DCIA was the only patent artery. Results: Lower limb bypass surgery was performed. The left EIA, CFA, SFA and DFA were exposed. The left EIA was totally stented, and the CFA, SFA and DFA showed severe calcification. There was no place to clamp the EIA. Even with occlusion of the EIA with a balloon, there would have been no space to anastomose the CIA. The left DCIA was 10 mm in diameter and was well pulsating, and it evolved as a collateral artery. Considering the occlusion condition, we selected the DCIA as a source of inflow. Subsequently, the left greater saphenous vein was exposed from the saphenofemoral junction to the ankle. The popliteal artery was exposed below the knee, and confirmed to be suitable for anastomosis. After systemic heparinisation, a 3.5-mm saphenous vein graft was anastomosed to the left DCIA in an end-to-side fashion with a continuous 7-0 polypropylene suture. The distal end of the saphenous vein graft was anastomosed to the distal zone of the left popliteal artery in an end-to-side fashion with a continuous 6-0 polypropylene suture. After completion of distal anastomosis, good pulsation was observed in the dorsalis pedis artery. Postoperative three-dimensional computed tomography revealed that bypass grafts were patent and that peripheral blood flow remarkably increased (Graphic). Although the third and fifth toes remained necrotised, the rest of the left foot became warm and the pain disappeared. The patient is currently undergoing a course of physiotherapy to help him perform activities of daily living. Conclusion: The CFA has been recognised and accepted as an important inflow source in lower limb bypass procedures. However, in clinical situations where the CFA, SFA and DFA cannot be used owing to obstruction, severe calcification or previous dissection, as in the present case, the DCIA evolving as a collateral artery can be considered as an effective alternative inflow in lower limb bypass.