Femoral arteriyel sisteme gerçekleştirilen ekstra-anatomik bypass greftleme prosedürleri

Amaç: Tek taraflı aorto-iliak tıkanıklıklara yaklaşımda, özellikle yüksek riskli yaşlı olgularda, klasik vasküler bypass prosedürlerinin uygulanamadığı durumlarda, anatomik lokalizasyondaki vasküler kaynağın uygunsuzluğu ya da bu yaklaşımın yaratacağı risk varlığında ekstra-anatomik femoro-femoral (F-F) bypass alternatif bir cerrahi yöntem olarak seçilebilir. Ayrıca günümüzde, şiddetli alt ekstremite iskemisi olan yaşlı olgularda aksillofemoral (Ax-F) greft bypass sıklıkla uygulanmaktadır. Özellikle olguların yüksek risk grubunda olması veya anatomik problemlerin mevcudiyeti Ax-F bypassı uygun ve belki de tek alternatif haline getirmektedir. Gereç ve yöntem: Ocak 1997 - Ocak 2003 yılları arasında Alsancak Devlet Hastanesi Kalp ve Damar Cerrahisi Bölümünde alt ekstremite revaskülarizasyonu amacıyla 36 olguya F-F bypass greft ve aynı dönemde 19 olguya ekstraanatomik Ax-F bypass prosedürü uygulandı. Femoral arteriyal sisteme ekstra-anatomik bypass greftleme prosedürü uygulanan toplam 55 olgu retrospektif olarak incelendi. Bulgular: F-F bypass prosedürü uygulanan olguların yaş ortalaması 63,2 olup tümü erkekti. Olgular ortalama 6.6 gün sonra taburcu edildiler. Erken postoperatif dönemde hiçbir olguda revizyon işlemi gerekli olmadı. Tüm olgularda 8 mm'lik ringli PTFE greft materyali kullanıldı. Postoperatif geç dönemde 2 olgu kaybedilirken (birisi yaygın anterolateral MI, diğeri Grade IV Prostat Ca nedeniyle) diğer 34 olgunun izlemleri süresince greftleri patentti.Ax-F bypass uygulanan olgularımızın yaş ortalaması 61,8 olup hepsi erkekti. Ortalama 7,6 günde taburcu edildiler. Erken dönemde bu grupta da greft trombozu gözlenmedi, geç dönemde bu grupta iki olguda greft trombozuna cerrahi müdahalede bulunuldu. Tüm olgulara postoperatif izlemde enterik kaplı asetilsalisilik asit preparatı ile distal run-offunun periferik anjiyografisinde suboptimal tıkanıklık saptananlara ilaveten klopidogrel de verildi.Sonuç: Bu serideki düşük morbidite değerleri ve uygulanan prosedüre bağlı mortalite gözlenmemesi, yüksek riskli olgularda iskemik bacakların revaskülarizasyonunda, özellikle tek taraflı aorta-iliak tıkayıcı hastalıkta ekstra-anatomik F-F bypass uygu¬lamasının iyi bir alternatif yaklaşım olduğunu gözledik. Öte yanda Ax-F bypassın da endikasyonu iyi konulmuş olgularda, başarıyla ve güvenle kullanılabilecek anatomik rekonstrüksiyona alternatif bir yaklaşım olduğunu düşünmekteyiz.

Anahtar Kelimeler:

Arteriyel tıkayıcı hastalıklar, Femoral arter, Geriyedönük çalışma, Kalp damar cerrahi işlemleri, Transplantlar

Extraanatomical bypass grafting to femoral arterial system

Objective: In approach to unilateral aortoiliac obstructions, especially in elderly patients, when classical vascular procedures are inappropriate, with anatomically im¬proper inflow or with high risk, extra-anatomic femorofemoral bypass may be chosen as an alternative treatment modality. Recently, we applied axiUofemoral grafting in elderly patients with severe ischemia of lower extremity. Especially in presence of high risk or technical problems axiUofemoral bypass may become the proper and probably the only alternative. Material and method: Between January 1997 and January 2003, at the Department of Cardiovascular Surgery of Alsancak State Hospital, 36 patients underwent femorofemoral (F-F) bypass grafting and 19 patients underwent axiUofemoral bypass procedure in order to revascularize the lower extremity. A total number of 55 pa¬tients underwent extra-anatomic bypass grafting to femoral arterial system. These patients were investigated retrospectively. Results: The average age of patients who underwent F-F bypass procedure is 63.2 and all were male. Patients were discharged after 6.6 days in average. None of the patients required any revision procedure in early postoperative period. 8 mm ringed PTFE graft material was used in all cases. In late postoperative period 2 cases were lost (one of them due to diffuse anterolateral MI, the other due to Grade 4 prostate carcinoma), whereas the other 34 cases had patent grafts during the follow-up period.The average age of patients who underwent axiUofemoral (Ax-F) bypass procedure is 61.8 and all were male. Patients were discharged after 7.6 days in average. In late postoperative period interventions were carried out for graft thromboses. All cases received enteric coated acetylsalicylic acid preparates in postoperative period. If the distal run-off was suboptimal angiographically clopidogrel was added.Conclusion: Low values of morbidity and zero mortality in this series showed that in revascularization of ischemic legs among high risk groups, especially in unilateral aortoiliac obstructive disease extra-anatomic F-F bypass procedure is a good alter¬native approach. Also we showed that Ax-F bypass is a safe alternative to anatomical reconstruction.

Keywords:

Arterial Occlusive Diseases, Femoral Artery, Retrospective Studies, Cardiovascular Surgical Procedures, Transplants,

PDF

___

1.Cechura M, Treska V, Krizan J, Certik B, Kunscher V, Sulc R. Extraanatomic bypass surgery for peripheral arterial vascular disease-is it still justified? Zentralbl Chir 2002; 127: 760-763.
2.Freeman NE, Leed FH. Operations on large arteries. Calif Med 1952; 77: 229-239.
3.Takafumi M, Morris DK, Toshihiro O, et al. Femorofemoral bypass: An analysis of 53 femorofemoral grafts. J Vasc Surg 1999; 33: 401-403.
4.Lewis CD. A subclavian artery as a means of blood supply to the lower half of the body. Br J Surg 1961; 48: 574-579.
5.Passman MA, Taylor LM, Jr, Moneta GL, Porter JM. Axillofemoral bypass. In Whittimore AD, editor: ad-vances in vascular surgery, vol 3, St Louis, Mosby, Inc 1995.
6.Sauwage LR, Wood SJ. Unilateral axillary bilateral femoral bifurcation graft: a procedure for the poor risk patient with aortoiliac disease. Surgery 1966;60: 573-577.
7.Giordanengo F, Lazaridis J, Boneschi M, Giuffrida F. Current role of extraanatomical revascularization of the lower limbs. Minerva Cardioangiol 1993;41: 249-253.
8.Ye J, Wang Y, Fan L, et al. Extra-anatomy axillary or femoro-femoral bypass grafting for the treatment of aortailiac occlusive disease. Zhonghua Wai Ke Za Zhi 1998; 36: 457-458.
9.Cechura M, Treska V, Krizan J, Certik B, Kunscher V, Sulc R. Extraanatomic bypass surgery for peripheral arterial vascular disease-is it still justified? Zentral Chir 2002; 127: 760-763.
10.Johnston KW, Rae M, et al. Five-years results of a prospective study of percutaneous transluminal angi-oplasty. Ann Surg 1987; 206: 403-413.
11.Nolan KD, Benjamin ME, Murphy TJ. Femorofemoral bypass for aortofemoral graft limb occlusion: A ten year experience. J Vasc Surg 1994; 19: 851-857.
12.Brouwer JHM, Biemans MCR, Donders CPH. Longterm results of 44 crossover bypasses. J Carndriovasc Surg 1988; 29: 290-295.
13.Testini M, Todisco C, Greco L, et al. Femoro-femoral graft after unilateral obstruction of aorta-bifemoral bypass. Minerva Cardioangiol 1998; 46: 15-19.
14.Hiamovici H, Ascer E. Extra-anatomic bypass, Haimovici’s Vascular Surgery 4. edition; 1996; 688-699.
15.Ehrenfeld WK, Harris JD, Wylie EJ. Vascular steal phenomenon. An experimental study. Am J Surg 1968; 116: 192-197.
16.Lau H, Cheng SW, Hui J. Eighteen-year experience with femoro-femoral bypass. Aust N Z J Surg 2000; 70: 275-278.
17.Brief DK, Brener J, Wilson S, Veith FJ. Vascular surgery principles and practice. New York: Mc Graw-Hill: 412: 17, 1987.
18.Mingoli A, Sapienza P, Feldhaus RJ, et al. Femorofemoral bypass grafts: Factors influencing long-term patency rate and outcome. Surgery 2001; 129: 451-458.
19.Kalman PG, Hosang M, Jhonston KW, Walker PM. Unilateral iliac disease: The role of iliofemoral bypass. J Vasc Surg 1987; 6: 139-143.
20.Thompson-Fawcett M, Moon M, Hands L, Collin J. The significance of donor leg distal runoff in femo-rofemoral bypass grafting. Aust NZ J. Surg 1998; 68: 493-497.
21.Ascer E, Veith FJ, Gupta SK, et al. Six year experience with expanded polytetrafluoroethylene arterial grafts for limb salvage. J Cardiovasc Surg 1985; 26: 468-472.
22.Stabilini L, Brigli G, La Paglia V, et al. Axillo-femoral bypass in the treatment of aorta prosthesis infection. A special case. Minerva Chir 1994; 49: 1019-1023.
23.Passman MA, Taylor LM, Moneta GL, et al. Comparison of axillofemoral and aortofemoral bypass for aortoiliac occlusive disease. J Vasc Surg 1996; 23: 263-271.
24.Carrel T, Pasic M, Niederhauser U, Turina M. Extraanatomic thoraco-bifemoral bypass: an excellent alter-native to in-situ reconstruction for repeat revascu-larization of the lower limbs. Schweiz Med Wochenschr 1994; 124: 961-971.
25.Von Segesser LK, Vogt P, Genoni M, Lachat M, Turina M. The infected aorta. J Card Surg 1997; 12: 256-260.
26.Shin CS, Chaudhry AG. The hemodynamics of extraanatomic bypass grafts. Surg Gynecol Obstet 1979; 148: 567-570.
27.Abid A, Denguir R, Kaouel K, et al. Revascularization of the lower limbs with extra-anatomic shunts. Report of 80 cases. J Mal Vasc 2001; 26: 307-313.
28.Harris EJ Jr, Tailor LM Jr, Mc Connel DB, Moneta GL, Yeager RA, Porter JM. Clinical results of axillofemoral bypass using externally supported polytetrafluoro-ethylene. J Vasc Surg 1990; 12: 416-420.
29.Pevec WC, Holcroft JW, Blaisdell FW. Ligation and extraanatomic arterial reconstruction for the treatment of aneurysms of the abdominal aorta. J Vasc Surg 1994; 20: 6296-6236.
30.Schwartz RA, Nichols WK, Silver D. Is thrombosis of the infrarenal abdominal aortic aneurysm an acceptable alternative? J Vasc Surg 1986; 3: 448-455.
31.Ward RE, Holcroft JW, Conti S, et al. New concepts in the use of axillobifemoral bypass grafts. Arch Surg 1983; 118: 573-576.