LEA 22. Totally Percutaneous Femoral-Popliteal Bypass: The Best of Both Worlds

Abstract

Endovascular techniques are now leading the revascularization of lower limbs, mainly because of the interest in a percutaneous approach. Despite huge progress, failure of recanalization may occur, or more often, recurrence darkens the evolution. In these cases, surgical bypasses are required, but they have a higher morbidity and mortality impact. We describe an innovative technique of femoral-popliteal bypass realized through a totally percutaneous approach and the early results of the initial study. From January to June 2018, six totally percutaneous bypasses (four male patients; age, 62-89 years [mean, 74.5 years]) were performed at the femoral-popliteal level: three above the knee and three below the knee. All the bypasses where prosthetic. Four patients had critical limb ischemia; two had severe claudication (50 m or less). Two patients had failure of previous endovascular revascularization, three had multibypass failure, and one had early iterative severe restenosis. In addition, three had adverse skin conditions for a surgical approach (multiple scars in two patients and lymphedema with inguinal surgical infection in one patient). Percutaneous puncture under ultrasound guidance allowed placement of three intravascular sheaths in the femoral, popliteal, and contralateral femoral positions, followed by extravascular and subfascial tracking of the guidewire and rendezvous technique, then deployment of covered self-expandable stents bypassing the occluded segment of the artery with respect to the profunda femoral artery as well as collaterals. In all the cases, technical success occurred, with clinical resolution of the critical limb ischemia or vascular symptoms and satisfactory blood flow through the stent graft. No death occurred, and there was no major complication. Local bruising or a small hematoma occurred in two patients, and there was quick recovery and stand-up at day 1 in all the cases. On early follow-up (1-7 months; mean, 4.1 months), primary patency remained in five patients. One occlusion occurred 45 days after implantation, needing in situ fibrinolysis (no technical defect but a poor runoff). Although this is an early and short-term study, it demonstrates the feasibility of totally percutaneous bypass, combining the main advantages of both endovascular and bypass revascularization. Further evaluation is required.