Contralateral Greater Saphenous Vein Research Articles

Delayed Presentation of Popliteal Artery Injury after Salter-Harris III Proximal Tibia Fracture

Introduction. Proximal tibia physeal fractures in children are not very common but can be dangerous because they can harm popliteal fossa structures, especially the popliteal artery. Popliteal artery injuries (PAI) are most commonly the result of trauma to the lower extremity, including blunt force, hyperextension injuries, complex fractures, and knee dislocations that can compromise popliteal neurovascular structures. Case Presentation. A 14-year-old boy presents to the emergency department after being transferred from an outside hospital 24 hours after a left lower extremity hyperextension injury. Radiographs demonstrated a Salter-Harris III proximal tibia fracture with posterior displacement. ABIs were deferred due to palpable distal pulses and no evidence of compartment syndrome. Closed reduction and percutaneous pinning were planned to correct the fracture. Intraoperatively, it was discovered that knee extension decreased lower extremity perfusion while knee flexion returned perfusion. An angiography revealed a popliteal artery occlusion with no distal flow. Based on this, an above-knee to below-knee popliteal bypass using the contralateral great saphenous vein was performed followed by closed reduction and percutaneous pinning of the proximal tibia. Conclusion. Proximal tibia physeal injuries, especially the Salter-Harris III and IV injuries, warrant a high index of suspicion of popliteal artery injuries. Palpable pulses and delayed presentation in the distal lower extremity do not rule out a PAI because collateral flow to the anterior and posterior tibial arteries may mask signs of an avascular limb, highlighting the need for a thorough history and physical exam. The authors present this case to reaffirm the importance of an ankle-brachial index when evaluating hyperextension injuries with proximal tibial epiphyseal fractures.

Outcomes following ipsilateral great saphenous vein bypass for lower extremity arterial injuries

ObjectiveUse of autologous great saphenous vein (GSV) grafts for repair of extremity arterial injuries is well established. Contralateral great saphenous vein (cGSV) is traditionally used in the setting of lower extremity vascular injury given the risk of occult ipsilateral superficial and deep venous injury. We evaluated outcomes of ipsilateral GSV (iGSV) bypass in patients with lower extremity vascular trauma. MethodsPatient records at an ACS verified Level I urban trauma center between 2001 and 2019 were retrospectively reviewed. Patients who sustained lower extremity arterial injuries managed with autologous GSV bypass were included. Propensity-matched analysis compared the iGSV and cGSV groups. Primary graft patency was assessed via Kaplan-Meier analysis at 1-year and 3-years following the index operation. ResultsA total of 76 patients underwent autologous GSV bypass for lower extremity vascular injuries. 61 cases (80%) were secondary to penetrating trauma, and 15 patients (20%) underwent repair with iGSV bypass. Arteries injured in the iGSV group included popliteal (33.3%), common femoral (6.7%), superficial femoral (33.3%), and tibial (26.7%), while those in the cGSV group included common femoral (3.3%), superficial femoral (54.1%), and popliteal (42.6%). Reasons for using iGSV included trauma to the contralateral leg (26.7%), relative accessibility (33.3%), and other/unknown (40%). On unadjusted analysis, iGSV patients had a higher rate of 1-year amputation than cGSV patients (20% vs. 4.9%), but this was not statistically significant (P = 0.09). Propensity matched analysis also found no significant difference in 1-year major amputation (8.3% vs. 4.8%, P = 0.99). Regarding ambulatory status, iGSV patients had similar rates of independent ambulation (33.3% vs. 38.1%), need for assistive devices (58.3% vs. 57.1%), and use of a wheelchair (8.3% vs. 4.8%) compared cGSV patients at subsequent follow-up (P = 0.90). Kaplan-Meier analysis of bypass grafts revealed comparable primary patency rates for iGSV versus cGSV bypasses at 1-year (84% vs. 91%) and 3-years post-intervention (83% vs. 90%, P = 0.364). ConclusionIpsilateral GSV may be used as a durable conduit for bypass in cases of lower extremity arterial trauma where use of contralateral GSV is not feasible, with comparable long-term primary graft patency rates and ambulatory status.

Microsurgical Peritoneovenous Bypass for the Treatment of Recalcitrant Chylous Ascites.

New treatments for recalcitrant chylous ascites are needed to avoid sequelae associated with increased intraabdominal pressures, chyle loss, and diminished quality of life. An autologous microsurgical technique was developed to treat recalcitrant chylous ascites and restore normal physiology. A retrospective case series was performed for patients with recalcitrant chylous ascites surgically treated from 2018 to 2020. The authors included all patients with recalcitrant chylous ascites refractory to current standard-of-care interventions such as diet modifications, pharmacologic therapies, and peritoneovenous mechanical shunts. All were treated with microsurgical peritoneovenous bypass with a minimum follow-up of 12 months. Six patients were included over a 2-year period. Surgery was aborted for two patients (33%) with intraoperative venous reflux of the deep inferior epigastric vein, negative on preoperative ultrasound. One patient had a successful reoperation using the contralateral greater saphenous vein; the other elected for a chronic indwelling drain for chyle drainage. Among the five successful procedures (83%), ascites drainage decreased from a median preoperative volume of 1 L/day to postoperative volume of 0.06 L/day. Median hospital length of stay was 7 days (range, 212 to 194 days). Three patients had one complication each, including vancomycin-resistant Enterococcus , spontaneous bacterial peritonitis, and pulmonary embolism. All complications resolved with additional interventions. Median follow-up was 13.5 months (range, 12 to 27 months). Microsurgical peritoneovenous bypass was a reliable and reproducible autologous surgery for the treatment of recalcitrant chylous ascites at a minimum follow-up of 12 months. Therapeutic, IV.

Temporary vascular shunt for damage control surgery: case report

Background: Although rare, arterial limb injuries are cause of massive hemorrhage and consequently hypovolemic shock. Temporary vascular shunts have many benefits: not only do they allow for reperfu­sion, but they also afford time to transport a patient to a higher level of care. Methods: Case report Results: The authors present a case report of a 35-year-old man brought to the emergency department one hour after suffering a penetrating injury to the anterior right thigh. In the operative room a complete superficial femoral artery transection was detected so artery shunt was performed. In the immediate post-operative period, the patient was transferred to a specialized center where the final revascularization was accomplished by interposition of the contralateral great saphenous vein in reverse. Patient was discharged after a seven day hospital stay and follow up demonstrated viable and functional limb. Conclusions: Vascular shunt seems a good option in the early approach of arterial injuries in the absence of resources for definitive care, as it allows early revascularizations without compromising subsequent definitive revascularization after transfer to a specialized department.

The Upper-Arm Basilic-Cephalic Loop: A Valueable Alternative for Below-Knee Arterial Reconstruction.

Despite advances of endovascular interventions, bypass surgery remains the gold standard for treatment of long and complex arterial occlusions in the lower limb. Autologous vein is regarded superior to other options. As the graft of first choice, the great saphenous vein (GSV) is often not available due to previous bypass, stripping or poor quality. Other options like arm veins (AV) are important alternatives. As forearm portions of AVs are often unusable, a graft created from the upper arm basilic and cephalic veins provides a valuable alternative. We analyzed consecutive patients treated at an academic tertiary referral center between 01/1998 and 07/2018 using arm veins as the main peripheral bypass graft. Study endpoints were primary patency, secondary patency, limb salvage and survival. In the observed time period 2702 bypass procedures were performed at our institution for below-knee arterial reconstructions. Vein grafts used included the ipsilateral GSV (iGSV; n = 1937/71.7%), contralateral GSV (cGSV; 192/7.1%), small saphenous vein (SSV; 133/4.9%), prosthetic conduits (61/2.3%) and different configurations of AV (379/14%). In the majority of patients receiving AV grafts a complete continuous cephalic or basilic vein (CAV) was used (n = 292/77%). If it was not possible to use major parts of these 2 veins, either spliced arm vein grafts (SAV) (42/11%) or an upper arm basilic-cephalic loop graft (45/12%) were used. Median follow-up was 27 (interquartile range: 8-50) months. After 3 years secondary patency (CAV: 85%; SAV: 62%; loop: 66%; p = 0.125) and limb salvage rates (CAV: 79%, SAV: 68%; loop: 79%; p = 0.346) were similar between the 3 bypass options. The encouraging results of alternative AV configurations highlight their value in case the basilic or cephalic veins are not useable in continuity. Especially for infragenual redo-bypass procedures, these techniques should be considered to offer patients durable revascularization options.

Alternative Venous Conduits for Below Knee Bypass in the Absence of Ipsilateral Great Saphenous Vein

Vein is regarded superior to artificial graft in peripheral arterial bypass surgery. However, this option is often limited owing to previous use or removal of the ipsilateral greater saphenous vein (iGSV). In this case, the contralateral great saphenous vein (cGSV), the small saphenous vein (SSV), or arm veins (AV) are possible alternatives. Experience with all three grafts for below knee vein bypass is reported.

Alternative Venous Conduits for Below Knee Bypass in the Absence of Ipsilateral Great Saphenous Vein

Vein is regarded superior to artificial graft in peripheral arterial bypass surgery. However, this option is often limited owing to previous use or removal of the ipsilateral greater saphenous vein (iGSV). In this case, the contralateral great saphenous vein (cGSV), the small saphenous vein (SSV), or arm veins (AV) are possible alternatives. Experience with all three grafts for below knee vein bypass is reported. Consecutive patients treated at an academic tertiary referral centre between January 1998 and July 2018 using the cGSV, SSV, or AV as the main peripheral bypass graft were analysed. Study end points were primary patency, secondary patency, limb salvage, and survival. Over the observed time period, 2642 bypass operations for treatment of peripheral artery disease with below knee target arteries were performed at the authors' institution: 1937 procedures using the iGSV; 644 bypass procedures using the cGSV (n=186; 28.9%), SSV (n=101; 15.7%), or AV (n=357; 55.4%); and 61 procedures using a prosthetic graft. The median follow up period was 2.3 years (range 9 days-18.5 years). Thirty day mortality was 1.9% for the whole group and similar between the three groups. After five years, primary and secondary patency rates were comparable between the three groups. Secondary patency was 75% (95% confidence interval [CI] 66-83) in the cGSV and SSV groups, and 65% (95% CI 57-73) in the AV group (p=.47). Limb salvage and survival after five years were, respectively, 73% (95% CI 65-81) and 89% (95% CI 82-95) in the cGSV group, 79% (95% CI 69-89) and 87% (95% CI 79-95) in the SSV group, and 74% (95% CI 68-80) and 83% (77-89) in the AV group (p=.46). All three types of alternative autologous vein graft are equal regarding outcome parameters. Vascular surgeons should consider all autologous options if their preferred choice is not available.

Arm Vein versus Small Saphenous Vein for Lower Extremity Bypass in the Absence of Both Great Saphenous Veins

Bypass surgery remains the gold standard for long and complex arterial occlusions in the lower limb. The vein is regarded superior to prosthetic conduits in peripheral arterial bypass surgery. However, this option is often limited because of previous bypass, stripping, or poor quality of the ipsilateral and/or contralateral great saphenous vein (GSV). Under these circumstances, the arm vein (AV) and small saphenous vein (SSV) are the only alternative autologous vein grafts. We analyzed all consecutive patients treated at an academic tertiary referral center between January 1998 and July 2018 using either the AV or SSV as the main peripheral bypass graft. Study end points were primary patency, secondary patency, limb salvage, and survival. In total, 416 bypass procedures using exclusively AV (n=327) or SSV (n=89) were performed. There was a predominance of male gender. The majority of risk factors were evenly distributed between groups. The mean follow-up period was 2.3years (0.9 to 13.3years). Five-year primary and secondary patency rates were 39% (95% CI: 31-47%) and 67% (59-75%) for AV and 53% (41-66%) and 76% (67-86%) for SSV, respectively (P=0.2 and 0.25). The five-year limb salvage and survival rates were 71% (68-81%) and 84% (77-90%) for AV and 78% (67-88%) and 90% (82-98%) for SSV, respectively (P=0.52 and 0.11). Both AV and SSV are equally effective alternatives for peripheral bypass if no GSV is available. Although there was a trend toward better results with the SSV, there was no significant difference between the 2 options.

Patency and Recurrence Rates of the Revision Using Distal Inflow Technique for High Flow Brachial Artery Based Arteriovenous Fistula

Introduction - High flow access (HFA; >2L/min or >1.5L/min with congestive complaints) is occasionally observed in the presence of a brachial artery based arteriovenous fistula (AVF).1 Several flow reducing techniques are available. Banding suffered from recurrence rates up to 50% within one year.2 Revision using distal inflow (RUDI) demonstrated a substantial flow reduction in the short term.3 Aim of this study was to report on the three-year patency and HFA recurrence rates of RUDI with interposition of the greater saphenous vein (GSV) in dialysis patients with a high flow access. Methods - Patients with a high flow elbow-based AVF scheduled for a RUDI procedure with use of the GSV between March 2011 and March 2017 in three facilities were followed for three years. Patency rates were defined as recommended by Sidawy.4 Recurrent high flow was defined as two consecutive high flow measurements (>2L/min) or signs of venous congestion or cardiac failure in presence of flows exceeding 1.5L/min. Patency and high flow recurrence were analysed using Kaplan-Meier analysis. Results - Twenty-one patients were studied (14 males, 54 ±3 years). RUDI was performed 44 ±12 months after the initial AVF construction. Peripheral arterial occlusive disease (5%) and diabetes mellitus (10%) were rarely observed while hypertension (52%) was more commonly present. Access flows decreased from 3220 ±204 mL/min preoperatively to 1150 ±88 mL/min postoperatively (P<0.001). Primary patency rates were 65% ±10, 54% ±12 and 54% ±12 after one, two and three years, respectively. Assisted patency rates were 79% ±9, 73% ±10 and 62% ±14, respectively. Secondary patency rates were 95% ±5, 95% ±5 and 76% ±14. In order to maintain access patency, twelve percutaneous transluminal angioplasties in eight and seven thrombectomies in four patients were conducted. Furthermore, two GSVs were replaced in a re-RUDI procedure (PTFE n=1; contralateral GSV n=1). HFA free survival was 74% ±10, 61% ±11 and 55% ±12 after one, two and three years. In the recurrence group, immediate postoperative access flow was higher when compared to the non-recurrence group (Flowrecurrence 1410 mL/min ±128, n=8 versus Flowno-recurrence 960mL/min ±87, n=11; P=0.012). The mean age in the recurrence group tended to be lower (Agerecurrence 46 ±4 years versus Ageno-recurrence 58 ±5years; P=0.082). Conclusion - A RUDI procedure with GSV interposition for HFA offers reasonably satisfactory patency rates after three years but requires maintenance. Recurrence free survival is higher when compared to rates described for banding. A relatively high immediate postoperative access flow is associated with recurrent high access flow.

The Lesser Saphenous Vein: An Underestimated Source for Autolougus Vein Bypass

Introduction - Vein is regarded superior to artificial graft in peripheral arterial bypass surgery. However, often this option is limited due to previous bypass, stripping, or poor quality of the ipsilateral greater saphenous vein (GSV). In this case the contralateral GSV or arm veins are preferred alternative vein grafts. The lesser saphenous vein (LSV) is a forgotten, but attractive alternative. There are only limited reports on the use of LSV as a bypass conduit available. We report our experience using LSV as part of an all autologous vein bypass policy.

Clinical Characteristics and Surgical Outcomes of Limb-Sparing Surgery with Vascular Reconstruction for Soft Tissue Sarcomas

The standard treatment for lower extremity soft tissue sarcoma (STS) is limb-sparing surgery. For a small subset of patients, concomitant vascular reconstruction may be required to preserve limb viability and function while completely excising the tumor with an adequate resection margin. The aim of this study was to evaluate the surgical outcomes and clinical characteristics of patients with STS of the extremities requiring vascular reconstructions. From January 2002 through December 2014, 13 patients with limb STS presenting with vascular invasion underwent surgical resection, followed by vascular reconstruction. The medical records such as demographics, histopathological findings, complications, success of vascular reconstruction, and clinical and oncological outcomes were retrospectively reviewed from a prospectively collected clinical database. With a mean follow-up period of 80.6months, a total of 24 vascular reconstruction procedures (1 only arterial, 1 only venous, and 11 both arterial and venous) were performed. Contralateral great saphenous vein graft was the conduit of choice for vascular replacement. Five graft thromboses were observed in 4 patients. Arterial occlusion occurred in two cases, and venous bypasses occluded in three patients. The overall five-year patency for arterial and venous reconstructions was 84.6% and 75.2%, respectively. The mean survival period of patients was 105.5months, with a 5-year disease-free survival rate and overall survival rate of 59.3% and 68.4%, respectively. Vascular resection and reconstruction for STSs of extremity can be safely performed with acceptable short- and long-term surgical and oncological outcomes. Regardless of the surgical procedure, amputation or limb-sparing surgery, the primary focus should be to adhere to strict oncological principles. In addition, because of the complexity of these tumors, an appropriate preoperative planning and meticulous multidisciplinary approach are also crucial.

Patency and clinical success 22years after the Palma procedure.

Surgical reconstruction for chronic iliofemoral venous occlusive disease is rarely performed. These interventions are fraught with frequent early graft occlusions with the best results achieved with autologous venous conduits. Suprapubic great saphenous vein (GSV) transposition to bypass the occluded iliofemoral vein (IFV) with the contralateral GSV was described by Palma and Esperon with a reported patency of 70% to 85% at 3to 7-year follow-ups. Questions have been raised about longterm patency, and functional and clinical success that can be achieved with a relatively small conduit compared with the size of an iliac vein. We present a case of a patient who underwent a Palma procedure for chronic left IFV occlusion 22 years ago. The patient consented to publish this report. A 20-year-old woman presented in 1990 with symptoms of exertional pain and swelling consistent with chronic venous insufficiency without skin changes or ulcers. Two years previously she had postpartum deep venous thrombosis, treated with heparin and warfarin. A venogram showed left IFV occlusion with extensive collaterals. A Palma procedure, femorofemoral GSV transposition using the right GSV was performed (A). She was maintained with lifelong oral anticoagulation and advised to wear elastic stockings. At the 12-year follow-up, a mildly symptomatic 2.5-cm right saphenous vein aneurysm at the saphenofemoral junction was identified and a portion of the wall was excised (B). At the 22-year follow-up, the patient had minimal symptoms with no edema, skin changes, or varicosities. A computed tomography venogram showed a patent Palma graft with rapid flow, and diameter that was equal to that of the right common iliac vein, and no evidence of stenosis or aneurysm (C and D/Cover). This case shows an excellent result two decades after the Palma procedure and supports its use in select patients. Results tend to be the best in patients with good inflow, no significant infrainguinal obstruction or incompetence, and a saphenous vein size >5 mm. In our experience with 25 patients a 78% patency at 5 years was shown. Long-term dilation of the vein is possible and can provide good outflow. The Palma procedure continues to be our first treatment option for patients with symptomatic unilateral iliac vein occlusion, who are not candidates for, or in whom endovascular treatment has failed.

Arm Veins versus Contralateral Greater Saphenous Veins for Lower Extremity Bypass Reconstruction: Preliminary Data of a Randomized Study

The aim of this randomized study was to determine whether arm vein (AV) or contralateral greater saphenous vein (CGSV) is the better alternative vein source for lower extremity bypass reconstruction. Consecutive patients with absent ipsilateral greater saphenous vein undergoing lower extremity revascularization were allocated to group A (AV bypass) or B (CGSV bypass). From 6, 2010, to 11, 2013, 64 patients (32 each group) were randomized. In all, 29 of 93 patients had to be excluded for various reasons. Median age was 76 years vs. 71 years (P = 0.01) for group A and B patients. There were no statistically significant differences regarding gender, cardiovascular risk factors, redo bypass procedures (P = 0.77), below-knee bypass procedures (P = 0.61), median bypass length (P = 0.6), and median length of incision on ipsilateral leg to perform anastomoses (P = 0.2) between group A and B patients, respectively. Incisions for vein harvest were longer in group A (P = 0.003). Overall surgical site infections (SSIs, P = 1.0) and SSI from vein harvest (P = 1.0) were equally distributed. No patient was lost to follow-up (17 vs. 18 months, P = 0.74). There was no statistically significant difference regarding primary (P = 0.77) and secondary (P = 0.25) patency rates at 1 year (group A: 52% vs. group B: 54% and group A: 72% vs. group B: 61%) and at 2 years (52% vs. 48% and 64% vs. 61%), respectively. There were 4 vs. 6 major amputations (P = 0.23) and 5 vs. 2 deaths (P = 0.1) in groups A and B during follow-up. Preliminary results suggest that both AV and CGSV may serve as a secondary vein bypass graft equally well.

Clinical Outcome of Limb-Salvage Surgery After Wide Resection of Sarcoma and Femoral Vessel Reconstruction

Malignant sarcomas of the femur present major challenges in their management. Radical resection of sarcoma frequently requires concomitant major femoral vessel resection and reconstruction. We describe the clinical outcomes of vascular reconstruction, the long-term patency of vascular repair, and complications involved, and also discuss possible solutions to the problems associated with this procedure. In the past 15 years, 15 patients underwent wide resection of sarcoma of the femur with curative intent, including vascular reconstruction of the femoral arteries and/or veins. Arterial reconstruction was performed in 14 patients. In 12 patients, femoropopliteal reconstruction was performed with a contralateral great saphenous vein graft. In two cases involving femoroinguinal reconstruction, expanded polytetrafluoroethylene grafts were used because of unacceptable discrepancy. Myocutaneous flaps were used for covering of soft-tissue in 12 patients. One patient developed a local recurrence and eight died because of their tumor. Seven patients remained completely free of recurrence after a mean follow-up time of 69 months. One case showed gradual deterioration with ischemic pain in the affected lower extremity requiring amputation. The remaining 14 cases showed sufficient vascularity primarily. Complications after surgery were noted in nine cases, with the most common being leg edema in five cases, wound infection in three, and lymphatic fistula in two. The average Musculoskeletal Tumor Society score at the final assessment was 24 points (80%). For patients with sarcoma involving major vessels in the lower limb, wide resection followed by vascular reconstruction provides long-term local control and limb salvage with acceptable function. The complication rate from extensive resection and associated vascular reconstruction is high. The great saphenous vein graft produced results that were superior to prosthetic graft. Aggressive use of musculocutaneous flap transfers may help to minimize complications and reduce postoperative severe edema.

Technical Factors in Lower-Extremity Vein Bypass Surgery: How Can We Improve Outcomes?

Lower-extremity vein bypass surgery has been a standard operation in the armamentarium of vascular surgeons for more than 4 decades. Yet there remains surprising heterogeneity in the utilization, techniques, and outcomes associated with this procedure in current practice. Despite improvements in surgical technique and careful postoperative surveillance, vein graft failure remains a significant clinical problem affecting up to 50% of patients within 5 years. Experience, clinical judgment, creativity, and technical precision are required to optimize long-term results. Many factors, including patient-specific comorbidities, and variable biologic responses in the venous conduit, influence the ultimate outcome. Technical factors, however, play a dominant role in determining clinical success. Multiple single-center reports, and more recent multicenter trials, have clearly demonstrated that conduit selection and quality is the most critical element. An adequate caliber (>/=3.5 mm), good quality great saphenous vein is the optimal graft for infrainguinal bypass. Contralateral great saphenous vein, arm vein, and lesser saphenous vein are the next most desirable conduits. Graft configuration (reversed, nonreversed, or in situ) appears to have little influence on outcomes per se. Shorter grafts have improved patency. Inflow can be improved by surgical or endovascular means if necessary, and distal-origin grafts perform as well as those originating from the common femoral artery. The selected outflow vessel should supply unimpeded runoff to the foot, conserve conduit length, and allow for adequate soft-tissue coverage of the graft and a simplified surgical exposure. This review summarizes the data linking technical factors with graft patency, highlighting the importance of surgical judgment and operative planning in the current practice of infrainguinal bypass surgery.

A Novel Vascular Reconstruction Technique for Limb Salvage Surgery Using Temporary Bypass Tubes

Sir: The techniques and concepts of limb salvage for soft-tissue sarcoma of the lower limb involving major vessels have been substantially developed in recent years.1–3 We present a novel vascular reconstruction technique for limb salvage surgery using temporary bypass tubes. A temporary bypass tube (Anthron; Toray Industries, Tokyo, Japan) has been designed for use before excision of soft-tissue sarcoma involving major vessels in the extremities. The tube is constructed of polyvinylchloride coated with a heparinized hydrophilic polymer (Anthron).4 The rate of heparin release from the polymer is 10–2 U/cm2/minute, sufficient to prevent intracatheter coagulation without requiring administration of systemic anticoagulants. Both ends of the tube are tapered to facilitate insertion of the bypass tube into vessels. Nambisan and Karakoisis2 showed the standard steps in extensive resection of sarcoma of the extremity involving major vessels. After proximal and distal exposure of the vessels, dissection around the muscles to be removed along with the tumor is undertaken, and the origins and insertions of these muscles are divided. The last step in resection, following heparinization, is to clamp and divide the vessels proximally and distally. We used to perform the operation in the same manner described by Nambisan and Karakoisis.2 However, we encountered several cases in which control of hemorrhage from soft tissue surrounding the tumor was difficult. We therefore attempted to use temporary bypass tubes before and during extirpation of the whole tumor (Fig. 1). This procedure provided an almost bloodless field during dissection. This bypass procedure using an Anthron tube served as a pneumatic tourniquet to which we have become accustomed, facilitating reductions in hemorrhage, easy dissection, and time savings. Finally, this maneuver provides a lower incidence of infection, which can be quite high during extensive resections that require prolonged surgery. However, the tube courses beyond the operative field, and the natural warp of the tube serves to keep the tube away from the tumor still connected around abundant soft tissue. This facilitates handling during tumor dissection. After extirpation of the tumor keeping with bypass, the contralateral greater saphenous vein is harvested. Vascular defects are reconstructed using vein grafts (Fig. 2). During vein harvesting and graft preparation, there was no concern regarding limb ischemia.Fig. 1.: A large liposarcoma in the anterior region of the right thigh (asterisk). Anthron bypass tubes were substituted for the superficial femoral artery (single arrowhead) and vein (double arrowheads).Fig. 2.: After extirpation of the tumor keeping with bypass, the contralateral greater saphenous vein is harvested. Vascular defects of the superficial femoral artery vein were reconstructed using vein grafts.The tapered type tube can maintain blood flow at 230 ml/minute under a 20-cm H2O blood pressure discrepancy. Given the high blood flow through the femoral artery, holding the inserted tube and vessels by anchoring them with thick silk sutures and clamping them with bulldog forceps is a key step to achieving success in this procedure. No thrombus formation in the catheter was detected after use and no complications attributable to the catheter were observed. Limb salvage surgery using the Anthron bypass tube facilitates reductions in ischemia time, operation time, and infection rate. We have proposed a new technique with which to obtain a bloodless operative field in the proximal extremity using the bypass tube. This technique appears useful for resecting tumors with adequate surgical margins and achieving local control of the disease. Noriaki Kikuchi, M.D., Ph.D. Division of Plastic and Reconstructive Surgery Department of Orthopaedic Surgery Toshihisa Osanai, M.D., Ph.D. Department of Orthopaedic Surgery Takashi Tsuchiya, M.D., Ph.D. Department of Orthopaedic Surgery Yamagata University School of Medicine Hiroshi Orui, M.D., Ph.D. National Sanatorium of Yamagata Clinic Toshihiko Ogino, M.D., Ph.D. Department of Orthopaedic Surgery Yamagata University School of Medicine Yamagata, Japan

Redo Pedal Bypass Surgery after Pedal Graft Failure: Gain or Gadget?

Pedal bypass failure is not always associated with limb loss. Management of critical limb ischemia after failure is controversial. The aim of this study is to evaluate the results of redo bypass procedures to foot arteries in the absence of alternative tibial outflow arteries. Data of patients undergoing redo pedal bypass within a 14-year period were reviewed. The outcome after redo pedal bypass in patients whose original pedal bypass failed within 30 days versus those in patients whose original pedal bypass failed more than 30 days after the original pedal bypass were reviewed. Society for Vascular Surgery reporting standards were applied. Out of 335 pedal bypass grafts, 22 (6.6%) pedal redo bypass procedures were identified in 20 patients performed after previous pedal graft failure: 64% were male, mean age 67.7 +/- 9.5 years, diabetes 90.9%, hypertension 90.9%, coronary disease 68.2%, renal disease 18.2%. Seven patients were operated for early failure and 15 for late failure (median 193 days). The graft conduit at the first operation was ipsilateral greater saphenous vein (GSV) in 18 (81.8%), alternative vein in three (13.6%), and one expanded polytetrafluoroethylene. Redo graft conduits were as follows: ipsilateral GSV in nine (40.9%), arm vein in six (27.3%), contralateral GSV in two (9.1%), "other veins" in two (9.1%), and homologous artery in three (13.6%). The same target artery was used in 81.8%, at the initial site in 54.5% and more distally in 27.3%. Redo revascularization for early failure was successful only once. Median follow-up after late redo was 23.7 months. Seven redo grafts performed after late pedal graft failure failed after a median of 115 days. The availability of adequate autologous conduit is the limiting factor for redo procedures. Lack of alternative outflow sites adds to the difficulty of target artery dissection. Redo pedal bypass surgery after early pedal bypass failure is associated with very poor patency and limb salvage. Acceptable patency and extension of limb salvage can be achieved with redo procedures for late pedal bypass failure.

Technical modifications in endoscopic vein harvest techniques facilitate their use in lower extremity limb salvage procedures

We describe and report our results using endoscopic vein harvest (EVH) for lower extremity arterial bypass procedures, following the implementation of technical modifications specific to patients undergoing limb salvage procedures. We underwent training in EVH, followed by implementation of the technique in patients requiring limb salvage for lower extremity ischemia and aneurysms. After technical modifications in the technique were developed for limb salvage, we reviewed our experience in all patients who underwent minimally invasive distal bypass with EVH. Technical modifications include limited arterial dissection before vein harvest, the use of proximal and distal leg incisions for both exposure of arterial vessels and saphenous vein harvest, improved hemostasis techniques in the vein graft tunnel, avoidance of compression wraps to the ipsilateral harvest tunnel, complete removal of the vein with either reversed or nonreversed graft placement, and use of the endoscopic tunnel for conduit placement. Thirteen patients (14 limbs) have undergone minimally invasive distal bypass since technical modifications were implemented. Indications for EVH were rest pain (n = 12; 85.7%) and tissue loss (n = 8; 57.1%). Veins harvested were the ipsilateral great saphenous vein (n = 10; 71.4%), contralateral great saphenous vein (n = 2; 14.3%), and short saphenous vein (n = 2; 14.3%). No venous injuries occurred during endoscopic harvest, and all were used for bypass. Thirty-day primary and primary assisted patency rates were 85.7% and 92.9%, respectively. The limb salvage rate was 100%. Two patients developed postoperative hematomas, one early and one late, as a result of anticoagulation for cardiac comorbidities. Both patients required reoperation for successful re-establishment of patency. There were no perioperative deaths and no postoperative wound infections or complications. Two patients required a later prosthetic bypass, and two required a vein graft angioplasty. Complete wound healing was achieved in 75% of patients with preoperative tissue loss. Technical modifications in endoscopic saphenous vein harvest techniques facilitate their use in lower extremity limb salvage procedures. Vascular surgeons should become familiar with these techniques to minimize vein harvest wound complications and extend the options for limb salvage conduits, including use of both the ipsilateral and contralateral saphenous vein and the short saphenous vein. Meticulous hemostasis within the tunnel after endoscopic conduit harvest and avoidance of postoperative anticoagulation should help to prevent postoperative hematoma formation and early graft occlusion.

Aplasia of Great Saphenous Vein: A Case Report

A case of complete aplasia of the great saphenous vein (GSV) is described. A 60 year-old woman presented with signs and symptoms of chronic venous disease (CVD) to the vascular laboratory. The patient was examined using duplex ultrasound (DU) and was found to have aplasia of the GSV in her left leg from the lower calf to sapheno-femoral junction (SFJ). The contralateral GSV had segmental aplasia.

Distal Bypass for Limb Salvage: Should the Contralateral Great Saphenous Vein Be Harvested?

The great saphenous vein (GSV) is unusable in 20% of cases. The best alternative in these cases is the GSV of the contralateral lower limb (CLL). However, many surgeons are reluctant to harvest the contralateral GSV for fear that it might be needed for future treatment of critical ischemia in the CLL. The purpose of this retrospective study was to observe the long-term behavior of the CLL and to identify prognostic factors for the development of critical ischemia as a basis for contraindicating harvest of the contralateral GSV. The study was conducted in patients who underwent distal bypass for trophic manifestations between January 1995 and December 1997. Patients who had a history of contralateral bypass using the GSV or major amputation were not included. Eighty-one of the 86 patient records could be analyzed with a minimum follow-up of 5 years. Survival was 59% and 40% at 2 and 5 years, respectively. Statistical analysis focused on age, risk factors, trophic manifestations on the CLL, ankle-brachial index, and arteriographic findings. After 5 years of follow-up, seven of the 81 patients (8.6%) required contralateral long bypass. Presence of contralateral trophic manifestations at the time of initial bypass was the only statistically significant prognostic factor for requirement of contralateral long bypass (p < 0.01). These findings support harvesting of the contralateral GSV for lower limb salvage. The risk that long contralateral bypass will be required is low except in patients with contralateral trophic manifestations.