President - egjvesegjves.com/uploads/issue_pdf/46b62754e34a3fff1f550ab92b2... · 2014. 3. 18. · Hasan Soliman Khaled Abdel Aal Mamdouh Kotb Mostafa Elekawy Saied Elmallah Tarek

President Ashraf Hidayet

Vice PresidentAyman Salem

Secretary General Atef Allam

TreasurerAli Morad

MembersAbo Bakr ElsedeikAhmed Saad El-DinAhmed TahaAlaa SharabyEhab Saad Hasan SolimanKhaled Abdel AalMamdouh KotbMostafa ElekawySaied ElmallahTarek Radwan

The Vascular Society of Egypt Executive Board 2009-2011

Nozha International Hospital Heliopolis, Cairo, EgyptTel: 00202 22664248/9Fax: 00202 22660717E-mail: [email protected] site: vsegypt.org

Egyptian Journal of Vascular & Endovascular Surgery

Editor-in-ChiefTarek Radwan

Co- EditorsAhmed Taha Atef Allam Ayman Salem Ehab Saad Khaled Abdel Aal Sherif Essam Honorary EditorsAhmed Sameh Hammam Amir Nasef Abo Bakr ElsedeikAbdel Kader Kotb Mohamed Elbatanony Nabil El-Mehairy

Editorial BoardAbdel Fattah IsmailAdel Husseini Ahmed EldorryAhmed Saad EldinAhmed SamiAlaa Sharaby Ali MoradAmr GadAshraf HidayetAli SabbourEmad HusseinEssam ElkadyHanan Hamed

International Editors

Founding Editor Nabil El Marasy

Hasan Abdel AatyHasan BakrHasan SolimanHatem Abdel AzeimHussein Kamal EldinKhalid HindawyMaged EldeebMahsob MoradMahmoud Abo ZidMamdouh KotbMohamed Abdo Ay EldinMohmed HosniMohamed R. Warda

Mohamed SharkawyMostafa Al LekawyMoneir MabroukOmar Elfarouk Rafat NagaRaouf HassanRashad BisharaReda GoharSaied Elmallah Sayed ElzayateShereif Shoulkami Tarek Abdel Azeim Yahia Sadek

Saad AlgarniSaudi Arabia

M. HenryNancy-France

Sayed AliDublin-Ireland

Please address all correspondence to:

Hany HafezEngland

Wayne YakesUSA

Editor-in ChiefTarek Radwan

36 Gisr Al Suez St.,Heliopolis, Cairo, Egypt

Tel. 02 24521561E-mail: [email protected]

PublisherMediagraphic Advertising Co.

6 A Ahmed Fakhry St., Makram Abeid, Cairo, Egypt

Tel.&Fax: 02 226711461Mob.: 011 5555889

E-mail: [email protected]

Egyptian Journal of Vascular & Endovascular SurgeryVolume 6 Number 1 March 2010

Contents

From The President of VSEAshraf Hidayet 5

From the Secretary General of VSEAtef Allm 6

From the New EditorsTarek Radwan FRCS 7

Vascular Complications After Kidney TransplantationTarek A. AbdelAzim MD FRCS 9

Below The Knee Angioplasty for Limb Salvage in DiabeticPatients with Critical Lower Limb IschemiaSherif Essam Tawfik, Sherif Omar & M. Maged El-Deeb .

15

A Scoring Angioplasty Balloon Catheter for the Management of Complex Tibial Arterial Lesions in Critical Lower Limb Ischaemia; a Prospective StudySherif Essam Tawfik& Hesham Adel Alaa-eldin 25

Closure Of The Saphenous Opening After Saphenofemoral Junction Disconnection: An Anatomical Barrier Against Postoperative NeovascularizationSherif Essam Tawfik&Hesham Adel Alaa-eldin

31

Straight Sapheno-Poplitral Arteriovenous Fistula: Mansoura ExeperiencenIbrahim Awad, M.D. 39

Surgical Strategies for Venous Anatomical Variations of Right Lobe Graft in Living Donor Liver Transplantation (LDLT); International Medical Center (IMC) ExperienceK. Amer, A. Foda, M. Mirghany, et.al.

43

Vascular ImagesTarek Radwan, Ahmed Farok, et.al. 51

5

Egy J Vasc Endovasc Surg Vol 6, No.1, March 2010

From The President of VSE

Dear Colleagues It is a great moment for me to write these few words in this respectable journal which I consider one of the great achievements of the Vascular Society of Egypt.

It is the result of the perfect cooperation of the board members of the society who represent all aspects of vascular surgery practice in Egypt. This journal is a symbol of great devotion of the previous and present editors in chief and editors.

I hope that this journal will be recognized internationally in the near future and I am sure it will be so as a result of the sincere efforts of every participant.

Ashraf Hidayet. President of VSE

6


From the Secretary General of VSE

Professors who made history of vascular surgery in Egypt

The family of vascular surgery had lost last year three active and effective mem-bers, Professor Kamal Eldin Houssin , Professor Adel Elham, and Professor Nabil Elmarasy. They had a massive impact on the history of vascular surgery in Egypt. Their pioneering and great effort in developing our career are not denied and should be an example for every member of the family. For the new generations who will not take the chance to meet them I say: although it is not possible to reproduce the ex-perience of being there listening to them personally, we are quite confident that the ideas and knowledge of those professors will have been transmitted through years and generations. Finally, I would like to thank Professor Adel Elhousainy , Professor of Vascular Sur-gery, Tanta University for his initiative and great idea about documentation of mile-stones of vascular surgery in Egypt. We call every vascular center in Egypt to write a comprehensive talk about milestones and history of start and developing vascular surgery in their places. Gathering of these talks will enable us to deliver a book about history of vascular surgery in Egypt.The rewards will be great, the new generation will deal with their career with more consciousness for better performance and ethical commitments putting in front of their eyes the wisdom “ who has no history has no future “ May ALLAH mercy their soles all.

Atef Allm Secretary General of VSE

7


From the New Editors

Dear Colleagues Since its appearance, the Egyptian Journal of Vascular & Endovascular Surgery has become the official publication of the Vascular Society of Egypt dealing with all as-pects of vascular surgery, medicine and research. This is due to the effort and leader-ship invested by the previous editors, namely the founding editor Dr Nabil Almarasy. It is also due to the outstanding contributions attracted by the Journal, and to the work of the editorial board members, and reviewers. As new editors, we are inspired by our predecessors, honored by our selection, and excited about the opportunities and challenges that lie ahead. We plan to continue many of the policies and procedures implemented by our predecessors. We are very pleased that our new board is coming with the start of the International Standard Serial Number (ISSN) for our Journal. A new section is introduced entitled “Vascular Images,” from which we will select an illustration for the cover of each issue. It will provide an interesting vascular im-age and an associated short educational summary, in a focused, case-report format. Appropriate images include clinical pictures, radiographs, pathology, anatomy, and operative findings,. Contributions for this section are now invited.As we enter our term as editors, we look forward to working with all members of the Vascular Society of Egypt to strengthen this Journal and maintain its position. As al-ways, we will appreciate your advice and assistance.

Tarek Radwan FRCS Editor in Chief

9


Vascular Complications After Kidney Transplantation

Tarek A. AbdelAzim MD FRCS

Professor of Vascular Surgery Ain Shams University

Introduction: The first renal transplantation was performed in 1954. The kidney remains the most frequent organ transplanted. A major breakthrough occurred with the release of cyclosporine in 1983; this drug helps to control transplant rejection. With improved surgical techniques and medical management of rejection, renal transplantation has become the treatment of choice for end-stage renal disease (ESRD).1-3 The use of immu-nosuppressive agents such as cyclosporine, OKT3, and FK506 has resulted in a 1-year survival rate for mis-matched cadaveric renal grafts of 80%. A 90% 1-year graft survival rate has been reported with non-identical grafts from living related donors and a 95% 1-year success rate for grafts with identical human lymphocyte antigen. The half-life of grafts from living related donors varies from 13-24 years. Other medical managements have further extended the functional life of renal transplants while ensuring a better quality of life for the trans-plant recipient.1-4 Despite high graft and recipient survival figures worldwide today, a variety of technical compli-cations can threaten the transplant in the postoperative period. Vascular complications are commonly related to technical problems in establishing vascular continuity or to damage that occurs during donor nephrectomy or preservation. Vascular complications occur in up to 3% of renal transplants. Thrombotic, hemorrhagic, stenotic, and embolic complications related to the transplanted kidney have been reported.3

Factors influencing the risk of complications:Age: As the experience with renal transplantation has grown, the age of patients who undergo renal transplan-tation has widened. In general, pediatric patients have a physical limitation in the size of the abdominal-pelvic spaces. Most children who receive renal transplants are small for their age because of chronic renal insuf-ficiency. Furthermore, the small size of the iliac vessels makes the vascular reconstruction more technically challenging. Anastomosing the renal artery to the common iliac artery or even to the aorta rather than the internal iliac artery is usually required in children with body weight under 20Kg.5,6 In older patients, the severity of vascular disease and the increased incidence of malignancy cause additional risks. Careful preoperative vascular assessment of the lower limbs in older patients is very important to avoid post operative extremity related ischemic complications.7

Sex: No important sex-related differences concern the complications of renal transplantation. The smaller ves-sel size in women however may slightly increase the risk of vascular occlusion.

Anatomy: The vascular supply to the ureter of the transplanted kidney is critical as well. The traditional surgical means of harvesting the transplant kidney allows the selection of either the right or left kidney. In most cases, the left kidney is favored because the left renal vein is longer than the right. The introduction of a laparoscopic approach for donor nephrectomy has further emphasized the selection of the left kidney in most cases. Single renal arteries and veins are most common; however, the donor kidney can have multiple renal arteries arising

Review Article

Tarek A. AbdelAzim10


from the aorta from T12 to L4. Multiple renal arteries are noted in approximately 25-30% of renal grafts. While increasing the operating time, grafts with suc-cessfully anastomosed multiple renal arteries func-tion just as well as those with single arteries. Particu-lar attention has to be given to accessory lower pole arteries to avoid ureteric ischemic complications. The pre-transplantation donor evaluation must include an accurate assessment of the number and the location of multiple renal arteries.8,9

Pre-transplantation donor evaluations must include adequate evaluation for accessory renal arteries be-ginning from just below the diaphragm and proceed-ing distally to include both external iliac arteries. Arte-rial assessment should include the possibility of early renal artery branching. Preoperative assessment is best performed using a multidetector CT scanner with extensive post processing using multiplanar re-formatted images and 3D visualization.10

Renal veins can be multiple and present frequent anomalies. The most common venous anomalies include the retroaortic position of the main left renal vein, multiple veins, early branching of renal veins, and anomalies of the anastomosis between the re-nal veins and the lumbar and gonadal veins. In addi-tion to vascular variations, anomalies in the potential renal donor may include urologic collecting system duplication, single kidneys, crossed-fused kidneys, and hydronephrosis. Determining the suitability of a kidney for transplantation is complex; the renal trans-plantation surgeon must make the decision whether to use a kidney or not after discussion among all in-terested parties.8,9

Previous transplantation: Renal re-transplantation is generally associated with a higher risk of rejec-tion and graft failure. Most often first time transplants are done on the right side. Re-transplants done on the left side are generally not associated with an in-creased complications risk. Re-transplantation on the same side as in patients undergoing third transplan-tation however, tremendously increases the technical difficulty of the procedure as well as the complication rate.8

Hemorrhage Renal failure patients tend to have bleeding tenden-cy because of platelet dysfunction. This can contrib-ute to generalized oozing from the pelvic bed of the transplanted kidney as well as from the anastomotic suture line. Such bleeding is usually managed by compression and the occasional use of local hemo-static agents. A more serious form of intraoperative bleeding is that resulting from vascular injury during dissection of the recipient iliac vessels. Injury of one or more of the tributaries of the iliac vein can result in serious and occasionally life threatening bleeding. These tributaries are usually very fragile and can rap-idly retract into the bony pelvis making their control quite challenging. Extreme caution has to be taken together with meticulous dissection to avoid such in-juries. Reactionary hemorrhage within the early post-operative period can occur. The usual site is the vas-cular anastomosis arterial or venous. Less commonly slippage of a ligature off one of the small branches or tributaries may be responsible. Once suspected, prompt re-exploration is required for control of bleed-ing. Secondary hemorrhage as a result of infection eroding the suture line occurs usually two to three weeks following the procedure and can be severe and life threatening. Duplex ultrasound can be used to confirm the diagnosis but in case of hemodynamic instability prompt re-exploration should be carried out .11 Re-moval of the transplanted kidney is usually required to control bleeding is such cases. Attempts at repair-ing the infected suture line should be avoided as this almost always results in re-bleeding.

Renal Vascular ThrombosisThrombosis of renal allograft vascular anastomosis site is the most severe complication following re-nal transplantation. In the literature, renal allograft thrombosis is reported with different incidence rates, from 0.5-4%. This incidence tends to be significantly higher with cadaveric donors compared to living do-nors. Many factors are responsible for such differ-ence. Primary cadaveric graft damage by accident and further manipulations during cadaveric donor ne-phrectomy, preservation and perfusion are important factors compromising the quality of cadaveric renal

Vascular Complications After Kidney Transplantation 11


transplant outcome. Also, preoperative evaluation of cadaveric grafts is not as exact as in cases of living donor grafts (excretory urography, arteriography, etc). Transplantaion of kidneys with multiple renal arteries is also associated with a slightly higher incidence of thrombosis compared to kidneys with a single artery. This is probably related to the small size of the mul-tiple arteries as well as the longer time needed for the reconstruction. If diagnosed during surgery, vascular thrombosis is usually the result of a technical defect and requires immediate revision of the anastomosis. Re-cooling of the kidney during the procedure by re-application of ice packs and cold perfusion is neces-sary to prevent loss of viability from warm ischemia.Vascular thrombosis during the postoperative period is usually confirmed by duplex or angiography. (Figure 1) Unfortunately, by the time the diagnosis is confirmed, it is usually too late to salvage the kidney and in most cases the kidney is infarcted on exploration neces-sitating removal.11

Renal Artery StenosisTransplant renal artery stenosis (RAS) is seen in about 10% of patients after renal transplantation, and it is the most important form of treatable hypertension. In renal transplantation patients, RAS may occur as a complication of surgery, as a result of transplant rejection, or as intrinsic vascular disease; transplant RAS usually occurs in the first year after surgery and, rarely, after the third year. Patients usually present with hypertension and, occasionally, an elevated serum creatinine level. In addition to hypertension, RAS may also result in graft failure. The diagnosis is usually made by duplex ultraonography and / or an-giography (Figure 2). The primary treatment option is renal arterial angioplasty often with stent placement. Surgical repair of transplant renal artery stenosis has been described using both direct vascular repairs with a vein patch as well as with preserved cadaveric iliac artery grafts. Correction of the vascular stenosis has to be carried out early on before progression to complete occlusion and graft failure.12

Anastomotic pseudoaneurysmThe development of a pseudoaneurysm of a trans-

plant artery is a rare complication. Since actually ultrasonography is routinely used, a pseudoaneu-rysm can be easily detected. Color Doppler allows a differential diagnosis from hematoma, urinoma and lymphocele.11 This complication has been reported with both end-to-end and end-to-side reconstruc-tions. Unfortunately a pseudoaneurysm after renal transplant often carries a high risk of loss of the trans-plant. This is related to the difficulty and complexity of repair techniques with interposition of a vein graft is required.(Figure 3) A policy of watchful waiting may be adopted with small sized aneurysms.13,14

LymphoceleLymphocele collections may occur soon after renal transplantation or they may develop on a delayed ba-sis. Their incidence ranges from 3-12 %. Whether its origin is from the recipient or donor is rarely identified. A lymphocele may rarely result in urinary obstruction of the transplant or compromise blood flow. Cases of chylous ascites following renal transplantation have also been reported. Diagnosis is usually confirmed by ultrasonography or CT scan.11 Guided aspiration with fluid analysis may be needed to differentiate from urinomas. Mild cases are managed conservatively but large or persistent collections generally require fenestration of the cavity into the abdominal space or, more recently, laparoscopic fenestration. The ap-plication of the laparoscopic technique demands a full understanding of the surgical anatomy before the procedure is performed.

Post-biopsy renal allograft arteriovenous fistulaThis is another unusual complication following renal biopsy of the transplanted kindney. Puncture of small vessels within the renal parenchyma can result in a traumatic arteriovenous fistula. The diagnosis is usu-ally established by duplex ultrasonography. (Figure 4)Selective transcatheter embolization with coaxial or single-catheter techniques is very effective and safe for treating post-biopsy arteriovenous fistulas in renal transplants. The loss of renal parenchyma is minimal with no deterioration of allograft function in the early post-procedure period. The long-term survival of the renal allograft is also not affected by embolization. 15,16

Tarek A. AbdelAzim12


Figure 3. Technique of repair of anastomotic pseudoneure\ysm following renal transplantation

Figure 4. Duplex ultrasound scan showing post needle biopsy arteriovenous fistula

Figure 1. Angiogram showing complete thrombosis of the graft renal artery with non visualization of the transplanted kidney

Figure 2. Post-transplantation angiogram showing tight stenosis of the renal artery anastomotic site

Vascular Complications After Kidney Transplantation 13


References

1. Sener A, Cooper M. Live donor nephrectomy for kidney transplantation. Nat Clin Pract Urol 2008, 5: 203-102. Ott U, Busch M, Steinaer T et al. Renal retrans-plantation: a retrospective monocentric study. Trans-plant Proc 2008, 40:1345-83. Montgomery RA, Cooper M, Kraus E, et al. Renal transplantation at the Johns Hopkins Comprehensive Transplant Center. Clin Transpl 2003, 199-2134. Fernandez LG, Zudaire JJ, Isa WA, et al. Vascu-lar complications in 237 recipients of renal transplant from cadaver. Actas Urol Esp 1992, 16:292-55. Morita K, Iwami D, Hotta K, et al. Pediatric kidney transplantation is safe and available for patients with urological anomalies as well as those with primary renal diseases. Pediatr Transplant 2009, 13:200-56. Ruiz E, Cateriano JE, Lobos P, et al. Kidney trans-plantation in small children with live related donors: 20 years of experience. J Pediatr Urol 2006, 2:373-97. Snyder JJ, Kasiske BL, Malclean R. Peripheral arterial disease and renal transplantation. J Am Soc Nephrol 2006, 17: 2056-688. Kok NF, Dols LF Hunink MG et al. Complex vas-cular anatomy in live kidney donation: imaging and consequences for clinical outcome. Transplantation 2008, 85:1760-5

9. Santangelo M, Clemente M, De Rosa P et al. The finding of vascular and urinary anomalies in the har-vested kidney for transplantation. Transplant Proc 2007, 39:1797-910. Mazzucchi E, Souza AA, Nahas WC, et al. Surgi-cal complications after renal transplantation in grafts with multiple renal arteries. International Braz J Urol 2005, 31:125-3011. Tarzamni MK, Argani H, Nurifar M et al. Vascular complications and Doppler ultrasonographic finding after renal transplantation. Transplant Proc 2007, 39:1098-10212. Polka WG, Jezior D, Garcarek J, et al. Incidence and outcome of transplant renal artery stenosis: single center experience. Transplant Proc 2006, 38:131-213. Orlic P, Vukas D, Curuvija D et al. Pseudoaneu-rysm after renal transplantation. Acta Med Croatica 2008, 62 :86-914. Asztalos L, Olvaszto S, Fedor R, et al. Renal ar-tery aneurysm at the anastomosis after kidney trans-plantation. Transplant Proc 2006, 38:2915-815. Loffroy R, Guiu B, LambertA, et al. Management of post-biopsy renal allograft arteriovenous fistulas with selective arterial embolization: immediate and long-term outcomes. Clin Radiology 2008, 63:657:6516. Libicher M, Radeleff B, Grenacher L et al. Inter-ventional therapy of vascular complications following renal transplantation. Clin Transplant 2006, 20: 55-9

15


Below The Knee Angioplasty for Limb Salvage in Diabetic Patients with Critical Lower Limb Ischemia

Sherif Essam Tawfik, Sherif Omar & M. Maged El-Deeb

Department of Surgery, Faculty of Medicine, Ain Shams University

Introduction: It is well known that atherosclerotic involvement in diabetic patients with critical limb ischemia (CLI) mainly affects below-the-knee (BTK) arteries. But the therapeutic efficacy of percutaneous transluminal angioplasty (PTA) in such patients has not been clearly defined.

Aim: This study aims to assess the clinical success and the limb-salvage rates for infragenicular angioplasty as the initial treatment of critically ischemic lower limbs in diabetic patients.

Patients and methods: From December 2006 to October 2008, a consecutive series of 64 limbs in 54 diabetic patients with critical limb ischemia (Rutherford categories 4,5,6) were treated by primary infragenicular angi-oplasty. Our primary end points were immediate technical success, sustained clinical improvement, haemody-namic outcome, and limb salvage rate. Secondary end points were periprocedural complications and 30-day all cause mortality.

Results: The mean age of our 54 patients was 62 years (48-70 years). The initial technical success was achieved in 94% of procedures, with limb salvage rate of 100%, 95%, 89%, and 84% at 1, 3, 6, and 12 months respectively, haemodynamic improvement of 96%, 89%, 79%, and 60% at 1, 3, 6, and 12 months respectively, and sustained clinical improvement of 100%, 95%, 89%, and 84% at 1, 3, 6, and 12 months respectively,. The periprocedural adverse events occurred in 5 (7.8%) procedures, and the 30-day all cause mortality was 1/54 (1.85%).

Conclusion: Primary infragenicular angioplasty for limb salvage in the diabetic patient population represents an efficacious method to improve wound healing in critically ischemic limbs, taking into consideration the fragile nature and co-morbidities in such selected patient population.

Key words: Angioplasty; Below the knee arteries; Critical ischemia; Diabetic patients; Infragenicular; Tibial arteries.

Corresponding author: Sherif Essam TawfikDept. of Surgery, Faculty of Medicine, Ain Shams Univ.Tel.: +20101601731; fax: +20226177003.E-mail address: [email protected]

Sherif Essam Tawfik, Sherif Omar & M. Maged El-Deeb16


IntroductionIt is well known that atherosclerotic involvement in diabetic patients with critical limb ischemia (CLI) mainly affects below-the-knee (BTK) arteries,1 but the therapeutic efficacy of percutaneous transluminal angioplasty (PTA) in such patients has not been clearly defined.2 For this category of fragile patients world over, the features of the disease/morbidity, involving extended inflammation and tissue loss, make them somewhat reluctant to undergo re-vascularisation.3,4 However, increasing contemporary reports are to date proposing primary angioplasty as a feasible procedure in most diabetic subjects with optimal clinical results.5, 6, 7, 8

Studies of PTA in CLI have involved very heterogeneous patient populations, and this limits our knowledge of the value of PTA in particular patient subsets. Many of the published studies included diabetic and non-diabetic patients, different stages of ischaemia (claudication, rest pain, and tissue loss) and PTA of above-the-knee (ATK) and below-the-knee (BTK) vessels performed in the same setting.9, 10, 11, 12, 13, 14, 15

The purpose of this study was to assess the clinical success and the limb-salvage rates for infragenicular angioplasty as the initial treatment of critically ischemic lower limbs in diabetic patients.

Patients and MethodsFrom December 2006 to October 2008, 64 limbs in 54 diabetic patients were treated for critical limb ischemia at Ain Shams university hospitals. We included patients who satisfied the following parameters:(1)Patients who are known diabetics for more than 2 years; (2) Critical limb ischemia (Rutherford categories 4,5,6); (3) infragenicular arterial disease with collateral distal refilling of at least one of the foot vessels on pre-procedural imaging studies; (4) absence of concomitant supragenicular significant (>30%) arterial stenosis; (5) patients with serum creatinine >3.0 were excluded. Patient demographic data including risk factors were collected and tabulated. Clinical criteria including Rutherford category at baseline and during follow up were collected and analyzed. Lesion morphological criteria including lesion severity (occlusion or stenosis) and

length were recorded during the intra-procedural initial angiographic cineloop. Peri-procedural medications were acetylcysetine with good hydration at a rate of 0.5 ml/Kg/hr normal saline for 6 hrs before and after the procedure, intra-procedural 5000 units of unfractionated heparin. We used non ionic contrast medium (ultravist). Post procedure, we initiated therapeutic low molecular weight heparin (LMWH) anticoagulation for 48 hrs together with clopidogril loading dose (300mg), then statins (Atorvastatin; 20mg/day) and clopidogril (75mg/day) were to be continued on maintenance dose for 90 days. Procedural tools were invariably, a 6-F introducing sheath, a 4-F angiographic catheter (Vertebral, Cordis, USA), 0.035 hydrophilic guidewire (Terumo, Japan), and a 0.014 guidewire (PT2, Boston scientific, USA), long tibial balloons (amphirion deep, Invatec, Italy), stents when needed (Chromis deep, Invatec, Italy). Procedures were done in an ante grade approach under local anaesthesia in a dedicated vascular surgery room with a mobile C-arm with vascular imaging capabilities. Immediate technical success was defined as residual angiographic stenosis of

Below The Knee Angioplasty for Limb Salvage 17


disease (88.8%), and renal impairment with serum creatinine



Total Procedures n=64Lesion Characteristicsstenosis 42% (n=27)mean stenotic length 12cmocclusion 58% (n=37)mean occlusion length 17cmTarget vesselAnterior tibial 23% (n=15)Posterior tibial 35% (n=22)Peroneal 42% (n=27)

Table 3. Lesion characteristics

Table 2.Clinical criteria at baseline

Treated limbs n=64Rutherford 4 28% (n=18)Rutherford 5 35% (n=22)Rutherford 6 37% (n=24)

Figure 1. showing pre and post angioplasty of the peroneal artery

Table 1. Demographic data and risk factors

Total number of patients n=54Number of limbs n=64Males : Females 29:25Age (years) 62 (48-70)Hypertension 92.5% (n=50)Smoking 70% (n=38)Ischemic heart disease 88.8% (n=48)Renal impairment 26% (n=14)



Table 6. Periprocedural adverse events and 30 day mortality

groin haematoma n=4cardiac event n=1renal failure n=0

30 day mortality n=1

Table 7. Immediate clinical improvement

upward shift to Rutherford category ≤3 94% (n=60)improved (PVRs) 94% (n=60)

Figure 2. Kaplan-Meier curve showing sustained clinical improvement

Interval (months)

Number at risk at

the start of interval

Censored during interval

Number at risk at

the end of interval

Number who

reached an endpoint at the end of

interval

Proportion surviving this

interval

Cumulative survival at the end of interval

0-1 60 1 59 0 59/59 1.01-3 59 3 56 3 53/563-6 53 3 50 3 47/50

6-12 47 4 43 2 41/43

1.0*0.95=0.95

1.0*0.95*0.94=0.89

1.0*0.95*0.94*0.95=0.84

Table 8. Kaplan-Meier data of sustained clinical improvement

Table 4. Procedure technical characteristics

Total Procedures n=64Transluminal 31% (n=20)Subintimal 14% (n=9)Combined 55% (n=35)tibial stents 6% (n=4)

Total Procedures n=64immediate success 94% (n=60)stenosis (n=27/27) 100%occlusion (n=33/37) 89%

Table 5. Immediate technical success



Figure 3. Kaplan-Meier curve showing haemodynamic outcome

Table 9. Kaplan-Meier data of haemodynamic outcome

Interval (months)

Number at risk at



Number at risk at

the end of interval

Number who

reached an

endpoint at the end of interval

Proportion surviving

this interval Cumulative survival at the end of interval

0-1 60 1 59 2 57/59 0.9661-3 57 3 54 4 50/54 0.966*0.925=0.8933-6 50 3 47 5 42/47 0.966*0.925*0.893=0.7976-12 42 4 38 9 29/38 0.966*0.925*0.893*0.763= 0.6

Figure 2. Kaplan-Meier curve showing amputation free survival



Table 10. Kaplan-Meier data of amputation free survival

Interval (months)

Number at risk at



Number at risk at

the end of interval

Number who

reached an

endpoint at the end of

interval

Proportion surviving

this interval Cumulative survival at the end of interval

0-1 60 1 59 0 59/59 1.01-3 59 3 56 3 53/56 1.0*0.95=0.953-6 53 3 50 3 47/50 1.0*0.95*0.94=0.89

6-12 47 4 43 2 41/43 1.0*0.95*0.94*0.95=0.84

at 1, 3, 6, and 12 months respectively. (Table 10) shows the number of patients at risk at the beginning of each interval after exclusion of patients who were censored during follow up or those who reached the end point.

DiscussionBypass surgery using outflow vessels in the distal ankle and foot is considered the standard of care in patients with CLI due to BTK-vessel disease.16

However, it needs a good vein conduit and at least one open foot artery, and is associated with 0.9% perioperative mortality, 3.0% myocardial infarction or acute congestive heart failure, and 6.6% early re-operation for graft thrombosis, postoperative bleeding or infection.17 For these reasons, infrapopliteal PTA is currently proposed as the primary treatment for CLI in patients with ischaemic diabetic foot.9,13,14,15,18 Although many published papers have described interesting findings concerning the efficacy of the endovascular treatment of peripheral artery disease, these studies have not involved carefully selected patient populations as diabetics or appropriately stratified the level of atherosclerotic involvement. Thus it was not clear whether the infragenicular PTA results in the diabetic patient population is genuine or simply the result of improved outflow due to concomitant above the knee procedures.19,20,21,22 We conducted our study on a selected patient population of diabetic patients with isolated infragenicular arterial disease causing critical limb ischemia in order to precisely evaluate the clinical outcomes of PTA in diabetic patients

with isolated BTK-vessel involvement. Our studied population consisted of a very homogeneous group of predominantly male patients with a mean age of 62 years, and a remarkable association of hypertension, and ischemic heart disease with infragenicular arterial involvement with a mean diseased stenotic length of 12cm and a mean occlusive segment length of 17cm. However, despite the severity of the disease, the successful endovascular procedures led to optimal follow-up outcomes. The limb salvage rate at one year was 84% despite a one year objective improvement of pulse volume recordings (PVRs) of 60%. This discrepancy probably reflects the fact that long-term complete patency of the treated vessel is less important in such patients than in those with coronary, carotid or renal arterial disease: the re-canalisation temporarily increases blood flow to the foot and has a positive effect in eradicating infection and healing ulcers and surgical wounds. As foot tissue healing reduces oxygen demand, less blood flow is generally required to maintain tissue integrity and keep the limb asymptomatic.10,23 Although this population of patients are technically challenging, our results support the role of PTA as the therapeutic option for CLI diabetic patients with infragenicular arterial disease. The main finding of our study is that Primary infragenicular angioplasty for limb salvage in the diabetic patient population represents an efficacious method to improve wound healing in critically ischemic limbs, and should be the first treatment option in all patients with CLI who would otherwise be offered distal bypass surgery or amputation, taking into consideration the fragile



nature and co-morbidities in such selected patient population.

References

1.Diehm N, Shan A, Silvestro A, Do DD, Dick F, Schmidli J, et al. Association of cardiovascular risk factors with pattern of lower limb atherosclerosis in 2659 patients undergoing angioplasty. Eur J Vasc Endovasc Surg. 2006;31:59–63.2.Capek P, McLean GK, Berkowitz HD. Femoropopliteal angioplasty. Factors influencing long-term success. Circulation. 1991;83(Suppl.2):I70–I80.3.Hafner J, Schaad I, Schneider E, Seifert B, Burg G, Cassina PC. Leg ulcers in peripheral arterial disease (arterial leg ulcers): impaired wound healing above the threshold of chronic critical limb ischemia. J Am Acad Dermatol. 2000;43(6):1001–1008.4.Calle-Pascual AL, Duran A, Diaz A, Monux G, Serrano FJ, de la Torre NG, et al. Comparison of peripheral reconstruction in diabetic and non-diabetic patients: a prospective clinic based study. Diabetes Res Clin Pract. 2001;53(2):129–136.5.Norgreen L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FGRon behalf of the TASC II Working Group. Inter-society consensus for the management of peripheral arterial disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(Suppl. 1):S32–S55.6.Haider SN, Kavanagh EG, Forlee M, Colgan MP, Madhavan P, Moore DJ, et al. Two-year outcome with preferential use of infra-inguinal angioplasty for critical ischemia. J Vasc Surg. 2006;43(3):504–512.7.Dick F, Diehm N, Galimanis A, Husmann M, Schmidli J, Baumgartner I. Surgical or endovascular revascularization in patients with critical limb ischemia: influence of diabetes mellitus on clinical outcome. J Vasc Surg. 2007;45:751–761.8.Lazaris AM, Tsiamis AC, Fishwick G, Bolia A, Bell PRF. Clinical outcome of primary infrainguinal subintimal angioplasty in diabetic patients with critical lower limb ischemia. J Endovasc Ther. 2004;11:447–453.9.Bosiers M, Hart JP, Deloose K, Verbist J, Peeters P. Endovascular therapy as the primary approach for

limb salvage in patients with critical limb ischemia: experience with 443 infrapopliteal procedures. Vascular. 2006;14(2):63–69.10.Soder HK, Manninen HI, Jaakkola P, Matsi PJ, Rasanen HT, Kaukanen E, et al. Prospective trial of infrapopliteal artery balloon angioplasty for critical limb ischemia: angiographic and clinical results. J Vasc Interv Radiol. 2000;11:1021–1031.11.Dorros G, Jaff MR, Murphy KJ, Mathiak L. The acute outcome of tibioperoneal vessel angioplasty in 417 cases with claudication and critical limb ischemia. Cathet Cardiovasc Diagn. 1998;45:251–256.12.Boyer L, Therre T, Garcier JM, Perez N, Ravel A, Privat C, et al. Infrapopliteal percutaneous transluminal angioplasty for limb salvage. Acta Radiol. 2000;41:73–77.13.Dorros G, Jaff MR, Dorros AM, Mathiak LM, He T. Tibioperoneal (outflow lesion) angioplasty can be used as primary treatment in 235 patients with critical limb ischemia: five-year follow-up. Circulation. 2001;104:2057–2062.14.Brillu C, Picquet J, Villapadierna F, Papon X, L’Hoste P, Jousset Y, et al. Percutaneous transluminal angioplasty for management of critical ischemia in arteries below the knee. Ann Vasc Surg. 2001;15:175–181.15. Schillinger M, Exner M, Mlekusch W, Haumer M, Rumpold H, Ahmadi R, et al. Endovascular revascularization below the knee: 6-month results and predictive value of c-reactive protein level. Radiology. 2003;227:419–425. 16.Aulivola B, Pomposelli FB. Dorsalis pedis, tarsal and plantar artery bypass. J Cardiovasc Surg 2004;45:203-12.17.Pomposelli FB, Kansal N, Hamdan AD, Belfield A, Sheahan M, Campbell DR, et al. A decade of experience with dorsalis pedis artery bypass: analysis of outcome in more than 1000 cases. J Vasc Surg 2003;37:307-15.18.Faglia E, Dalla Paola L, Clerici G, Clerissi J, Graziani L, Fusaro M, et al. Peripheral angioplasty as the first-choice revascularization procedure in diabetic patients with critical limb ischemia: prospective study of 993 consecutive patients hospitalized and followed between 1999 and 2003. Eur J Vasc Endovas Surg 2005;29:620-7.



19.Fraser SC, al-Kutoubi MA, Wolfe JH. Percutaneous transluminal angioplasty of the infrapopliteal vessels: the evidence. Radiology 1996;200:33.20.Karch LA, Mattos MA, Henretta JP, McLafferty RB, Ramsey DE, Hodgson KJ. Clinical failure after percutaneous transluminal angioplasty of the superficial femoral and popliteal arteries. J Vasc Surg 2000;31(5):880-7.21.Wolfle KD, Bruijnen H, Reeps C, Reutemann S, Wack C, Campbell P, et al. Tibioperoneal arterial lesions and critical foot ischaemia: successful

management by the use of short vein grafts and percutaneous transluminal angioplasty. Vasa 2000; 29(3):207-14.22.Conrad MF, Cambria RP, Stone DH, Brewster DC, Kwolek CJ, Watkins MT, et al. Intermediate results of percutaneous endovascular therapy of femoropopliteal occlusive disease: a contemporary series. J Vasc Surg 2006;44(4):762-923.Bakal CW, Cynamon J, Sprayregen S. Infrapopliteal percutaneous transluminal angioplasty: what we know. Radiology 1996;200:33-6.

25


A Scoring Angioplasty Balloon Catheter for the Management of Complex Tibial Arterial Lesions in Critical Lower Limb Ischaemia; a Prospective Study

Sherif Essam Tawfik, Hesham Adel Alaa-eldin


Introduction: Complex tibial lesions represent a challenging problem in a large proportion of patients present-ing with critical limb ischemia. In this particular subset of patients, heavily calcified and fibrocalcific lesions in the distal tibial tree, embodies an exigent problem for the success of the procedure.

Aim: To report our initial experience with the AngioSculptTM (ASC) scoring balloon catheter, which incorpo-rates a laser-cut highly flexible three nitinol spiral struts which encircle a semi-compliant conventional balloon catheter to create focal concentration of the dilating force leading to scoring (indenting) the surface of calcific plaques.

Patients and methods: Patients scheduled for angioplasty of the tibial vessels for critical limb ischemia, were included in our study. Primary end points were limb salvage rate, clinical improvement, and primary patency. Secondary end points were, technical success, difficulties, and complications associated with the use of the scoring balloon.

Results: Forty Eight patients underwent peripheral angioplasty procedures in our institute, of which 11 patients with complex lesions fulfilled the inclusion criteria. Mean lesion length was 35±12.2 mm, ostial lesion in 36.4% of patients. The AngiosculptTM balloon was used as sole therapy in all attempted tibial lesions. Limb salvage rate was 81.8%, Primary patency rate of the treated vessels was 63.6% at 6 months.

Conclusion: The AngiosculptTM scoring balloon is a highly effective solution for challenging tibial complex lesions, and is associated with a very high technical success with low complication rate.

Key words: Angioplasty; Angioscore; Angiosculpt; Below the knee arteries; Critical ischemia; Infragenicular; Scoring; Tibial arteries.



26


IntroductionComplex tibial lesions represent a challenging problem in a large proportion of patients presenting with critical limb ischemia.1 For most vascular surgeons tibial lesions represent the most challenging territory for angioplasty either because it is a technically demanding procedure or because of clinical considerations as usually most of these patients are suffering from critical lower limb ischemia (CLI) with a high potential for limb loss.2,3 In this particular subset of patients with jeopardised limbs, tibial angioplasty has proven to be an efficient limb salvage procedure that can alleviate the need for a major surgical bypass procedure in such fragile group of patients.4,5,6,7 A substantial problem for the tibial angioplasty procedure is addressing the heavily calcified and fibrocalcific lesions in the distal tibial tree, which embodies an exigent problem for the success of the procedure. Thus there has been a great need for an angioplasty balloon that could address certain technical critical issues during the tibial angioplasty procedure, such as; low crossing profile balloon catheter for crossing tight lesions, high performance at low pressure with reduced local stress on the arterial wall to reduce neointimal hyperplasia, a uniform surface coverage with reduced balloon slippage to reduce the incidence of uncontrolled flow limiting dissections, as well as easy and quick balloon deflation and retrieval.The AngiosculptTM (ASC) scoring balloon catheter (AngioScore, Fremont, CA), incorporates a laser-cut highly flexible nitinol scoring element containing three spiral struts which encircle a semi-compliant conventional balloon catheter to create focal concentration of the dilating force along the edges of the scoring element. (Figure 1) This leads to more optimal luminal expansion compared to conventional balloon angioplasty, particularly in complex fibro-calcific lesions and may result in reduced barotrauma, less elastic recoil, and a lower incidence of uncontrolled dissections. The ASC is also designed to minimize device slippage and resultant vessel wall injury (i.e. ‘‘geographic miss’’) outside the intended treatment zone. We report our initial experience with the AngioSculptTM (ASC) scoring balloon catheter in the treatment of critical limb ischemia in 11 patients with challenging tibial lesions at the Western Vascular Institute, Galway University Hospital, Ireland.

Patients and MethodsFrom our pool of patients scheduled for percutaneous transluminal angioplasty of the infrapopliteal vessels for critical limb ischemia, without associated proximal lesions amenable for angioplasty and were classified

as Rutherford classification IV-VI, we included those who had challenging calcific lesions in our study.The selection of challenging calcific lesions was dependant on a preoperative duplex scan conducted in a dedicated vascular lab, which was further confirmed by intraoperative preliminary angiography and identification of areas of calcification incurring radio opacity under fluoroscopy. Lesion calcification was graded according to the presence of radio-opacities within the vascular wall at the site of the stenosis. The classification included none/ mild (no or minimal radio-opacities noted prior to contrast injection), moderate (multiple radio opacities noted prior to contrast injection), and severe (diffuse radio opacities noted on both sides of the arterial wall).Patient demographic data and pre-procedure baseline assessments of disease severity, including clinical classification of chronic limb ischemia based on the Rutherford Scale8 was recorded. Data regarding Lesion characteristics; vessels treated, lesion location, and lesion angulation, were collected. The ASC scoring balloon catheter was available in a rapid exchange delivery system with balloon diameter sizes 2.5, 3.0, and 3.5 mm and lengths of 15, and 20 mm. The size of the catheter was selected to approximate a 1:1 ratio to the reference vessel diameter to be treated. Under fluoroscopic control, a 0.014 guide wire was positioned beyond the target lesion and the ASC catheter advanced over the guide wire to the target lesion and was inflated to its nominal pressure for 2-3 minutes duration. Post dilatation angiography was done to evaluate the vessel diameter changes, recoil, dissection, or perforation.Primary end points were limb salvage rate, clinical improvement, and primary patency of the treated vessel segment by duplex scan over a period of six months follow up. Secondary end points were; 1 technical success judged by completion angio vessel diameter changes;2 technical difficulties, as the need for stenting, recoil, or balloon slippage “geographical miss”;3 technical complications as flow limiting dissection, thrombosis and perforation.

ResultsBetween April 2005 and December 2005, 48 patients underwent peripheral angioplasty procedures in our institute, of which 11 patients were included in this study for fulfilling the inclusion criteria. A total of 11

A Scoring Angioplasty Balloon Catheter 27


patients, with mean age of 75.4 years, five patients (45.5%) were females. Patients were treated for 11 lesions in the tibial vessels territory. Seven out of the eleven patients were diabetics. Six patients were treated for minor tissue loss (Rutherford classification V) and five patients were treated for major tissue loss or gangrene (Rutherford classification VI). All patients were on Aspirin, and statin prior to commencement of angioplasty procedures. Patients’ demographic data and risk factors are shown in (table 1). The AngiosculptTM balloon was successfully deployed and used as sole therapy in all attempted tibial lesions (Figure 2). Two out of the eleven patients had a previous bypass procedure; femoral to below knee popliteal bypass, and femoral to anterior-tibial bypass with a significant lesion in the tibial outflow vessel. Lesion morphology was complex, including moderate/severe calcification in all eleven patients, lesion length was 35±12.2 mm, ostial lesion in 4 (36.4%) patients. Lesion and vessel characteristics are shown in (Table 2) There were no technical difficulties encountered during the procedure, as all lesions responded to dilatation with no recoil or residual stenosis >20% of the reference vessel diameter. There was no significant device slippage “geographical miss” during the ASC inflation. Post-ASC technical complications in the form of dissections, was noted in only one (9%) lesion and was minor that it didn’t necessitate stenting. There were no perforations or instances of thrombosis encountered. During follow up, 6 patients had minor amputations as part of planned primary procedure. Limb salvage rate was 81.8%, with 2 major amputations during the follow up period for failure of symptomatic relief with intractable rest pain and spreading gangrene. Primary patency rate of the treated vessels was 63.6% (n=7) by duplex scan in our dedicated vascular lab. at 6 months follow up. The 30 day mortality was one patient with acute postoperative MI. Discussion: Patients presenting with infra-popliteal disease and CLI generally have severe multilevel and multivessel disease. It has been estimated that only 20–30% of such patients have an uncomplicated focal lesion with good distal run-off, and most are elderly with one or more comorbidities, which increases their surgical risk.9 As compared to conventional bypass surgery, PTA results in reduced

rates of morbidity and mortality, shorter hospital stays and lower costs, does not preclude subsequent surgery and is rapidly becoming the treatment of first choice for infra-popliteal occlusive disease, particularly in patient populations at high risk for surgery.10 The known inadequacies associated with standard PTA balloons, include difficulty in treating heavily calcified lesions and diffuse small vessel disease. The technique also is associated with frequent balloon slippage resulting in ‘‘geographic miss’’ and tissue recoil. The results often are unpredictable and have a high rate (≥30%) of uncontrolled dissections. The ASC scoring balloon catheter may be helpful in addressing some of the limitations associated with conventional balloon angioplasty. The mechanism of action by which the ASC achieves luminal expansion include both circumferential scoring of the plaque as well as the effects of balloon dilatation.11,12 This may result in less baro-trauma, fewer and less severe dissections, leading to more predictable results particularly in fibro-calcific lesions. The relatively low dissection rate observed in this study compared to the historical experience with conventional balloons supports this contention. Scoring (indenting) the plaque may also reduce the likelihood of elastic recoil, particularly in ostial lesions and bifurcations. The absence of slippage and avoidance of ‘‘geographic miss’’ during device deployment which is generally accepted as favorable in the coronary circulation may also be beneficial in this setting. The favorable acute angiographic results associated with the use of the ASC in coronary studies may be particularly desirable in the treatment of infra-popliteal disease where avoidance of stenting particularly with balloon expandable compressible stents is preferred. There have been several recent reports summarizing the short term clinical results with a number of other percutaneous technologies including Cutting Balloon, laser-assisted angioplasty, and excisional atherectomy13,14,15 in patients presenting with similar peripheral arterial diseases. The advantages of the ASC balloon over the cutting balloon are, no longitudinal atherotomes thus can be inflated safely at higher pressures; the cutting balloon can be used for concentric lesions but cannot be used for eccentric lesions; the cutting balloon cannot be used


28


for angulated lesions, for instance, ostial anterior tibial lesion. The results of this initial clinical evaluation of the ASC scoring balloon catheter in the treatment of complex infra-popliteal disease and CLI demonstrate that the device is effective in a broad range of lesion morphologies and is associated with a very low complication rate. The device was demonstrated to

be consistently deliverable throughout the affected

arteries and resistant to slippage during deployment.

This initial clinical experience with the ASC device in

patients with infra-popliteal disease will need to be

corroborated in larger multicenter studies that include

adequate long term clinical follow-up.

Figure 1. The AngiosculptTM scoring balloon

Figure 2. Pre and Post ASC angiography

Table 1. Demographic data and risk factors

Number of patients n=11Males : Females 6:5Age (years) 75.4(59-85)Diabetes 63.6%(n=7)Hypertension 36.4% (n=4)Smoking 54.5% (n=6)Rutherford V 54.5%(n=6)Rutherford VI 45.5%(n=5)

A Scoring Angioplasty Balloon Catheter 29


Table 2. lesion and vessel characteristics

Treated lesions n=11Mean lesion length (mm) 35±12.2

Moderate/severe calcifications 100% (n=11)Occlusive lesions 63.6%(n=7)Stenotic lesions 36.4%(n=4)

Ostial lesion 36.4% (n=4)Anterior tibial 45.5% (n=5)Peroneal/TPT 36.4% (n=4)Posterior tibial 18.2% (n=2)

TPT, tibio-peroneal trunk

References1.Diehm N, Shan A, Silvestro A, Do DD, Dick F, Schmidli J, et al. Association of cardiovascular risk factors with pattern of lower limb atherosclerosis in 2659 patients undergoing angioplasty. Eur J Vasc Endovasc Surg. 2006;31:59–63.2.Hafner J, Schaad I, Schneider E, Seifert B, Burg G, Cassina PC. Leg ulcers in peripheral arterial disease (arterial leg ulcers): impaired wound healing above the threshold of chronic critical limb ischemia. J Am Acad Dermatol. 2000;43(6):1001–1008.3.Calle-Pascual AL, Duran A, Diaz A, Monux G, Serrano FJ, de la Torre NG, et al. Comparison of peripheral reconstruction in diabetic and non-diabetic patients: a prospective clinic based study. Diabetes Res Clin Pract. 2001;53(2):129–136.4.Norgreen L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FGRon behalf of the TASC II Working Group. Inter-society consensus for the management of peripheral arterial disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(Suppl. 1):S32–S55.5.Haider SN, Kavanagh EG, Forlee M, Colgan MP, Madhavan P, Moore DJ, et al. Two-year outcome with preferential use of infra-inguinal angioplasty for critical ischemia. J Vasc Surg. 2006;43(3):504–512.6.Dick F, Diehm N, Galimanis A, Husmann M, Schmidli J, Baumgartner I. Surgical or endovascular revascularization in patients with critical limb ischemia: influence of diabetes mellitus on clinical outcome. J Vasc Surg. 2007;45:751–761.7.Lazaris AM, Tsiamis AC, Fishwick G, Bolia A,

Bell PRF. Clinical outcome of primary infrainguinal subintimal angioplasty in diabetic patients with critical lower limb ischemia. J Endovasc Ther. 2004;11:447–453.8.Rutherford RB, Baker JD, Ernst C, et al. Recommended standards for reports dealing with lower extremity ischemia: Revised version. J Vasc Surg 1997;26:517–538.9.Heuser R, Henry M. Textbook of Peripheral Vascular Interventions. London: Taylor & Francis Group; 2004. 555 p.10.BASIL trial participants. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): Multicentre, randomized controlled trial. Lancet 2005;366:1925–1934.11.Gershony G, Virmani R, Lotan C, et al. A novel angioplasty catheter for the treatment of complex CAD: AngioSculpt. Am J Cardiol 2003;92:166L.12.Ferreira EJ, Vaz VD, Abizaid A, et al. A novel scoring catheter balloon (AngioSculpt) for the treatment of complex coronary lesions: An intravascular ultrasound study. Am J Cardiol 2004; 94:195E–196E.13.Ansel GM, Sample NS, Botti CF, et al. Cutting balloon angioplasty of the popliteal and infrapopliteal vessels for symptomatic limb ischemia. Catheter Cardiovasc Interv 2004;61:1–4.14.Laird JR, Zeller T, Gray BH, et al. Limb salvage following laser-assisted angioplasty for critical limb ischemia: Results of the LACI multicenter trial. J Endovasc Ther 2006; 13:1–11.15.Kandzari DE, Kiesz RS, Allie D, et al. Procedural and clinical outcomes with catheter-based plaque excision in critical limb ischemia. J Endovasc Ther 2006;13:12–22.

31


Closure Of The Saphenous Opening After Saphenofemoral Junction Disconnection: An Anatomical Barrier Against Postoperative Neovascularization



Introduction: Neovascularisation at the sapheno-femoral junction (SFJ) ligation site in the groin may occur within one year after great saphenous vein (GSV) surgery. Several anatomical and prosthetic barrier tech-niques have been proposed to prevent this evolution.

Aim: To test the hypothesis that the construction of an anatomical barrier by simple closure of the saphenous opening might decrease the incidence and extent of postoperative neovascularisation at the SFJ.

Patients and methods: From October 2006 to October 2008, we included 112 patients with 130 limbs pre-senting with primary varicose veins. The test (group A) patients, had the edges of the saphenous opening closed after SFJ disconnection. Follow up was done by duplex scan to detect neovascular serpentine veins at the groin.

Results: Our patients mean age was 30.2 years. According to preoperative CEAP classification we had 76 limbs classified as C2, and 54 limbs classified as C3. Both groups were initially matched regarding the Venous Disability Score (VDS). There was a significant difference (p=0.025) between the 2 groups at 1 year duplex follow up with 2 patients in the test group (group A) with groin neovascularization versus 12 patients in the control group (group B).

Conclusion: This study suggests a potential benefit of closure of the saphenous opening after SFJ ligation in the groin, a technique applied to contain postoperative neovascularisation at the ligated GSV stump.

Key words: Neovascularization; Saphenofemoral.



32


IntroductionRecurrent varices after surgery (REVAS) is a common, complex, and costly problem for both the patient and the surgeon who treats them.1 Some causes of recurrence are obvious: insufficient understanding of venous anatomy and hemodynamics, inadequate preoperative assessment, and incorrect or insufficient surgery. However, recurrence at the SFJ cannot always be explained by technical inadequacy of the original surgical intervention. Its development has also been attributed to neovascularization in the granulation tissue around the ligated stump.2 Neovascularisation at the level of the ligated sapheno-femoral junction (SFJ) is now recognized as one of the important pathophysiological mechanisms leading to recurrence of varicose veins.3-6 Neovascularization is defined as new blood vessel formation (angiogenesis) occurring in the surrounding tissue which may be induced by diffusible chemical factors (angiogenic factors). In the particular context of varicose recurrence after Great Saphenous vein (GSV) surgery, the term neovascularization describes a phenomenon of formation of new venous channels between the saphenous stump on the common femoral vein (CFV) and the residual GSV or its tributaries.7 Duplex-based prospective studies revealed some degree of neovascularization represented by typical serpentine tributaries arising from the ligated SFJ in up to 14% of operated limbs at one year after flush saphenofemoral or saphenopopliteal junction ligation.8 To contain such neovascularisation and hence prevent recurrence from the groin the use of a prosthetic or anatomical barrier to cover the ligated saphenous stump has been proposed.9-19 However, implantation of foreign material may lead to postoperative complications.20 Therefore systematic use of a prosthetic patch in the groin after SFJ ligation remains a questionable issue. Construction of a simple anatomical barrier without implantation of foreign material might offer a valuable alternative. The easiest approach to construct such anatomical barrier consists of closure of the saphenous opening once the SFJ has been ligated. The saphenous opening, in the groin is the deep facial defect traversed by the GSV at its termination before it joins the common femoral vein (CFV). For this study we hypothesised that the construction of an

anatomical barrier by simple closure of the saphenous opening might decrease the incidence and extent of postoperative neovascularisation at the SFJ. For the sake of critical evaluation of this anatomical barrier technique, we conducted this comparative study to compare a group of patients with the anatomical barrier technique to another cohort of patients without the anatomical barrier technique after SFJ disconnection.

Patients and MethodsOver a period of 24 months from October 2006 to October 2008, we included 112 patients with 130 limbs presenting with primary varicose veins to Ain Shams University Hospitals, and Nasr city health insurance hospital. They were assigned in consecutive order into group A (closure of saphenous opening) or group B (no closure of saphenous opening). In case of bilaterality, the 2 limbs were assigned to 2 different treatment groups. We included patients with primary varicose veins due to incompetent SFJ, diagnosed on clinical grounds and documented by venous duplex scan.Our inclusion criteria based on CEAP classification included:1.Patients without extensive clinical symptoms consistent with C2 and C3 categories (varicose veins with or without edema but without skin changes).2.Etiological classification Ep (primary varicose veins).3.Anatomical classification As (affecting the superficial system).4.Pathophysiological classification Pr (reflux).Patients were clinically evaluated preoperatively with the Venous Disability Score (VDS) (Table 1) together with duplex mapping with special emphasis on the SFJ to point out any anatomical variations at the SFJ (e.g. double saphenous). Patients with bilateral varicose veins were operated upon with 3 months interval between both legs. Surgical procedure was standardized as transverse groin incision at site of SFJ which was marked preoperatively by duplex scan. Identification of GSV at its termination into the common femoral vein, and ligation of tributaries ending at the SFJ. Over sewing of the SFJ stump by a

Closure of the Fossa Ovalis after Saphenofemoral Disconnection 33


33

nonabsorbable Prolene taper point 3-0 monofilament suture. For group A patients, meticulous identification and careful closure of the edges of the saphenous opening by 2-3 interrupted nonabsorbable Prolene taper point 3-0 monofilament suture was the differentiating step.(Figure1) Then for both groups, surgery proceeded afterwards by closure of the membranous layer of the subcutaneous tissue before skin closure. Then proceeding with stab avulsions for the leg varicosities, and finally GSV stripping to the knee level. Postoperatively the patient used elastic stockings for 3 weeks. All patients were given subcutaneous Clexane (Enoxaparine sodium) 20 mg once daily starting from the night before surgery and for 1 postoperative day. Follow up was scheduled at 2 months and 12 months postoperatively for clinical assessment by Venous Disability Score (VDS), and duplex evaluation for the sake of identification of neovascular serpentine tributaries at the groin together with quantification of these tributaries according to its size into G0 (no serpentine tributaries), G1 (tiny serpentine veins 2mm diameter). Duplex was done by two dedicated operators following the above mentioned simple quantification protocol. Complications in the early postoperative period or during follow up were documented.

ResultsA total of 112 patients with 130 limbs were included. There were 94 patients with unilateral disease and 18 patients with bilateral lower limb affection. We had 74 males and 38 females. Their mean age was 30.2 years. According to preoperative CEAP classification we had 76 limbs classified as C2, and 54 limbs classified as C3. On initial evaluation, the Venous Disability Score (VDS) was 1 for 30 affected limbs, and VDS of 2 for 65 of the affected limbs, and VDS of 3 for 35 of the affected limbs. The characteristics of patients and limbs are represented in (Table 2). The VDS score shown in table 3, shows that both groups were matching regarding the VDS at initial presentation, but there was a significant difference at 1 year follow up (p=0.024) with group A patients having a lower Venous Disability Score (VDS) than

group B patients. At 1 year follow up, we had 7 patients lost for follow up, one of them with bilateral lower limb affection, 2 patients with unilateral lower limb affection from group A, and 4 patients with unilateral lower limb affection from group B. This left us with 62 limbs in group A, and 60 limbs in group B.Regarding duplex follow up for groin neovascularization at 2 months there was no detectable serpentine neovascular venous channels detected in both groups. However, there was a highly significant difference (p=0.025) between the 2 groups at 1 year duplex follow up for groin neovascularization. There were 2 limbs with grade 1 neovascularization in group A, while there were 4 limbs with grade 1 and 8 limbs with grade 2 neovascularization in group B. This data is represented in (Table 4). Regarding the 18 patients who had bilateral disease, where each limb was allocated to a different treatment group, we did a subgroup analysis for them to see the difference in duplex detected neovascularization at 1 year. One of the 18 patients was lost to follow up, and table 5 shows that there was a significant difference (p=0.033) regarding groin neovascularization at 1 year, between the limbs allocated to the two treatment groups in this subgroup of patients with bilateral disease. In the early post operative period there were few minor complications in the form of 6 groin wound infection, 2 of them in group A, and 4 in group B. No Saphenous nerve injury reported. Bruising along the track of GSV stripping was not considered as a complication as it invariably disappeared at a maximum period of 3 weeks.

Discussion This study aimed at evaluation of closure of saphenous opening after SFJ ligation as an anatomical barrier to reduce the incidence of groin neovascularization. The study revealed an incidence of postoperative neovascularisation at the SFJ of 3.2% after one year compared to 20% in the no closure group. Very few studies have addressed the potential usefulness of anatomical barriers to contain postoperative neovascularisation and lower the postoperative recurrence rate. The majority of these studies date from before the era of duplex scanning, which makes


34


Table 1. Venous Disability Score (VDS)

Table 2. Characteristics of patients and limbs

Table 3. VDS follow up at 1 year

(a) (b)

Figure 1. (a) SFJ before disconnection traversing the saphenous opening, (b) Prolene stitch going through the edges of the saphenous opening after SFJ disconnection

0 Asymptomatic1 Symptomatic but able to carry out usual activities*

without compressive therapy2 Can carry out usual activities* only with

compression and/or limb elevation3 Unable to carry out usual activities* even with

compression and/or limb elevation

Patients n=112Limbs n=130Age 30.2 (+/- 8.1)

Women 38 (34%)Bilateral disease 18 (16%)C2 classification 76 (58.5%)C3 classification 54 (41.5%)

VDS =1 30VDS=2 65VDS=3 35

*Usual activities = patient’s activities before onset of disability from venous disease

Group A Group B P

valueVDS 0 1 2 3 0 1 2 3initial 13 36 16 17 29 19 0.46

12 months 53 9 41 19 0.024



comparison difficult. Glass10, 12 studied the effects of closure of the cribriform fascia on the incidence of clinical recurrence after SFJ ligation and multiple ligations of the GSV (without stripping). At least 4 years after the initial operation, recurrence from the previous SFJ ligation site was confirmed at surgical re-exploration in 25% of 141 limbs initially operated without closure of the cribriform fascia and in 3% of 127 limbs operated with closure of this fascia. Thomson 11 suggested closing the saphenous opening by raising a flap of fascia from the fascial tunnel of the GSV and folding it cephalad to be stitched in place around the opening. Reviewing the results of 137 such consecutive operations, he found only two recurrences (however no postoperative time interval was mentioned). Many years before, the construction of an alternative anatomical barrier designed to prevent recurrence after an efficiently performed high ligation had been suggested.9 The technique was slightly more complicated and required a more extensive dissection in the groin. It consisted of suturing a flap of pectineus fascia over the common femoral vein and ligated GSV stump to the femoral sheath and margins of the saphenous opening. In 1978 Sheppard, had reported ‘encouraging results’ with this type of intervention.9 Concerning the use of a silicone implant and closure of the cribriform fascia, there had been promising results with this technique.16,18

Unfortunately this technique resulted in some short- and long-term complications potentially related to the foreign material used: not only some early and late postoperative infections and lymphatic problems, but

also some cases of venous thromboembolism and of abnormal scar tissue reaction causing a symptomatic stenosis of the common femoral vein.20 In our study, the fact that follow-up period was for one year, is considered short in terms of recurrence as clinically visible or palpable recurrent varicose veins usually become apparent only after three to five years. However, early ultrasound scanning after one year permits early detection of ‘duplex-recurrence’, which appears as different degrees of neovascular veins at the site of the previous SFJ ligation.3, 8, 21 Duplex-based prospective studies revealed some degree of neovascularization represented by typical serpentine tributaries arising from the ligated SFJ in up to 14% of operated limbs at one year after flush saphenofemoral or saphenopopliteal junction ligation.8 It has been shown that these early postoperative duplex findings help to predict which patients will develop recurrence and potentially require re-operation (or alternative treatment) in the long term.21, 22 To avoid postoperative neovascularisation, alternative techniques with the aim of obliterating the GSV (endovenous procedures with radiofrequency or laser energy) without groin dissection have shown promising results.23, 24, 25 After radiofrequency obliteration of the GSV duplex ultrasound scans confirmed the absence of neovascular veins in the groin.26, 27 The obvious advantage of these techniques consists in the fact that there is no groin incision and hence no surgical trauma, which is a potential trigger for neovascularisation. In addition, in the majority of cases the superficial epigastric vein remains patent after endovenous

Table 4. groin neovascularization at 2 and 12 months follow up

Table 5. groin neovascularization for the bilateral disease subgroup

Group A Group B P valueNeovasc. 0 1 2 0 1 22 months 65 65

12 months 60 2 48 4 8 0.025

Group A Group B P valueNeovasc. 0 1 2 0 1 212 months 17 13 4 0.033


36


obliteration of the GSV, with the advantage of not disturbing drainage of the abdominal wall, in this way avoiding an additional trigger for neovascularisation.5 However, technical equipment for endovenous procedures is not yet available in all surgical centres, as these devices and the catheters used are quite expensive.28 In such patients, well performed surgery will still offer a valuable alternative. Closing the saphenous opening after SFJ ligation in these cases might reduce postoperative neovascularisation in the groin and hence recurrence of varicose veins. The use of VDS score in our study was intended to measure the patients’ symptomatic response after surgery in each group independently. However, the fact that there was a significant difference at 1 year follow up (p=0.024) with group A patients having a lower Venous Disability Score (VDS) than group B patients, cannot be explained by the sole duplex finding of groin neovascularization. Thus a larger study with a larger sample, clinical severity scoring, and “quality of life” assessment, is probably needed to evaluate the effect of this modified surgical technique on the symptomatic outcome and quality of life. In conclusion, this study suggests a potential benefit of closure of the saphenous opening after SFJ ligation in the groin, a technique applied to contain postoperative neovascularisation at the ligated GSV stump. This simple technical is an adjunctive measure to reduce the incidence of recurrence in those patients who still undergo ‘classic’ varicose veins operations.

References

1.Michel Perrin. Classification and treatment of recurrent varicose veins. In: John J Bergan, ed. The Vein Book. Elsevier ; 2007. p.299-3072.De Maeseneer MG. The role of postoperative neovascularisation in recurrence of varicose veins: From historical background to today’s evidence, Acta Chir Belg. 2004. 104: 283–289.3.Jones L, Braithwaite BD, Selwyn D, Cooke S, Earnshaw JJ. Neovascularisation is the principal cause of varicose vein recurrence: results of a randomised trial of stripping the long saphenous vein. Eur J Vasc Endovasc Surg. 1996;12:442–445. 4.De Maeseneer MG, Tielliu IF, Van Schil PE,

De Hert SG, Eyskens EJ. Clinical relevance of neovascularisation on duplex ultrasound in the long term follow up after varicose vein operation. Phlebology. 1999;14:118–122.5.Fischer R, Chandler JG, De Maeseneer MG, Frings N, Lefebvre-Vilardebo M, Earnshaw JJ, et al. The unresolved problem of recurrent saphenofemoral reflux. J Am Coll Surg. 2002;195:80–94.6.Van Rij AM, Jones GT, Hill GB, Hons BS, Jiang P. Neovascularization and recurrent varicose veins: more histologic and ultrasound evidence. J Vasc Surg. 2004;40:296–302.7.De Maeseneer MG. Neovascularization: An adverse response to proper groin dissection. In: John J Bergan, ed. The Vein Book. Elsevier ; 2007. p.239-2458.De Maeseneer MG, Ongena KP, Van den Brande F, Van Schil PE, De Hert SG, Eyskens EJ. Duplex ultrasound assessment of neovascularization after sapheno-femoral or sapheno-popliteal junction ligation, Phlebology. 1997. 12: 64–68.9.Sheppard M. A procedure for the prevention of recurrent saphenofemoral incompetence. Aust NZ J Surg. 1978;48:322–326. 10.Glass GM. Prevention of recurrent saphenofemoral incompetence after surgery for varicose veins. Br J Surg. 1989;76:1210. 11.Thomson H. Saphenous vein stripping and quality of outcome. Br J Surg. 1997;84:424–425.12.Glass GM. Prevention of sapheno-femoral and sapheno-popliteal recurrence of varicose veins by forming a partition to contain neovascularization. Phlebology. 1998;13:3–9.13.Earnshaw JJ, Davies B, Harradine K, Heather BP. Preliminary results of PTFE patch saphenoplasty to prevent neovascularization leading to recurrent varicose veins. Phlebology. 1998;13:10–13.14.Gibbs PJ, Foy DM, Darke SG. Reoperation for recurrent saphenofemoral incompetence: a prospective randomised trial using a reflected flap of pectineus fascia. Eur J Vasc Endovasc Surg. 1999;18:494–498.15.Bhatti TS, Whitman B, Harradine K, Cooke SG, Heather BP, Earnshaw JJ. Causes of re-recurrence after polytetrafluoroethylene patch saphenoplasty for recurrent varicose veins. Br J Surg. 2000;87:1356–1360.16.De Maeseneer MG, Giuliani DR, Van Schil PE, De Hert SG. Can interposition of a silicone implant after



sapheno-femoral ligation prevent recurrent varicose veins?. Eur J Vasc Endovasc Surg. 2002;24:445–449.17.Creton D. Surgery for recurrent sapheno-femoral incompetence using expanded polytetrafluoroethylene patch interposition in front of the femoral vein: long term outcome in 119 extremities. Phlebology. 2002;16:93–97.18.De Maeseneer MG, Vandenbroeck CP, Van Schil PE. Silicone patch saphenoplasty to prevent repeat recurrence after surgery to treat recurrent saphenofemoral incompetence: long-term follow-up study. J Vasc Surg. 2004;40:98–105.19.van Rij AM, Hill G, Christie R, Jones GT, Amer M, Thomson IAT, et al. Prevention of recurrence after saphenofemoral ligation: a randomised trial of mechanical inhibition of neovascularisation: early results. Int Angiol. 2006;25(Suppl. 1):150.20.De Maeseneer MG, Vandenbroeck CP, Lauwers PR, Hendriks JM, De Hert SG, Van Schil PE. Early and late complications of silicone patch saphenoplasty at the saphenofemoral junction. J Vasc Surg. 2006;44:1285–1290.21.van Rij AM, Jiang P, Solomon C, Christie RA, Hill GB. Recurrence after varicose vein surgery: A prospective long-term clinical study with duplex ultrasound scanning and air plethysmography. J Vasc Surg. 2003;38:935–943.22.De Maeseneer MG, Vandenbroeck CP, Hendriks JM, Lauwers PR, Van Schil PE. Accuracy of duplex evaluation one year after varicose vein surgery

to predict recurrence at the sapheno-femoral junction after five years. Eur J Vasc Endovasc Surg. 2005;29:308–312.23.Min RJ, Khilnani N, Zimmet SE. Endovenous laser treatment of saphenous vein reflux: long-term results. J Vasc Interv Radiol. 2003;14:991–996.24.Merchant RF, Pichot O. Closure Study Group. Long-term outcomes of endovenous radiofrequency obliteration of saphenous reflux as a treatment for superficial venous insufficiency. J Vasc Surg. 2005;42:502–509. 25.Agus GB, Mancini SIEWG. The first 1000 cases of Italian Endovenous-laser Working Group (IEWG). Ratioanale, and long-term outcomes for the 1999–2003 period. Int Angiol. 2006;25:209–215.26.Pichot O, Kabnick LS, Creton D, Merchant RF, Schuller-Petrovic S, Chandler JG. Duplex ultrasound scan findings two years after great saphenous vein radiofrequency endovenous obliteration. J Vasc Surg. 2004;39:189–195.27.Kianifard B, Holdstock JM, Whiteley MS. Radiofrequency ablation (VNUS closure) does not cause neo-vascularisation at the groin at one year: results of a case controlled study. Surgeon. 2006;4:71–74.28.Rautio T, Ohinmaa A, Perälä J, Ohtonen P, Heikkinen T, Wiik H, et al. Endovenous obliteration versus conventional stripping operation in the treatment of primary varicose veins: A randomized controlled trial with comparison of the costs. J Vasc Surg. 2002;35:958–965.

39


Straight Sapheno-Poplitral Arteriovenous Fistula: Mansoura Exeperience

Ibrahim Awad, M.D.

Department of General Surgery Mansoura University Hospitasl. Faculty of Medicine.

Introduction: Secondary to exhaust upper limb veins and costly synthetic access, alternate autogenous sites need to be revisited .This study presents the technique and the results of straight autogenous arteriovenous fistula (AVF) between the popliteal artery and great saphenous vein (GSV). Patients and methods: A prospective study was performed of 13 men and 7 women with a mean age of 52.75, duplex exam was done as a routine. The straight saphenous vein anastomosed to the popliteal artery in an end -to-side fashion.

Results: Twenty patients with end stage renal disease (ESRD) underwent this technique, Systemic Lupus Erthrymatosus (SLE) and relative hypotension were the most important risk factors. Two patients developed early edema, 6 fistulae failed with thrombosis and 3 failed with infected pseudaneurysm that needed fistulae ligation. The cumulative primary patency rate at 1year was75% and at 2 years was 55%.

Conclusion: Straight sapheno-popliteal (S-P) AVF gave encouraging results as an alternative access site especially in hypotensive patients.

Key words: fistula; great saphenous vein; sapheno-popliteal and relative hypotension.

Corresponding author: Ibrahim Awad Department of General Surgery Mansoura University Hospitasl. Faculty of Medicine.Mansoura University Gomhoria st., Mansoura. P.O Box 35516. EgyptE.mail: dr_ [email protected]

Ibrahim Awad

40


IntroductionThe primary use of autogenous AV fistulae for chronic hemodialysis access is recommended by the National Kideny Foundation-Dialysis Outcomes Quality Intiative (NKF- DOQI) practice guidelines.(1)

Autogenous fistulae are less prone to recurrent stenosis,thrombosis,or infection and have increased average patancy.(2) Increased longevity of patients with chronic renal failure exhausts the superfiscial upper limb viens related to the proliferation in use of AVF.(3) the lower limb is an alternative access site and may be used for a saphenous vein loop fistula between great saphenous vein anastomosed in an end -to-side fashion to the common femoral artery(4)

or to the popliteal artery.(5)This report describes the technique and the results of AVF between the popliteal artery and GSV.

Patients & methodsPatients included in this study were those with end stage renal disease (ESRD) requiring haemodialysis access with no suitable superfiscial upper limb viens. Routine duplex exam of the lower limb was done in all patients to assess arterial inflow,vien patency, diameter and duplication. Those with GSV varicosity,diameter < 3mm ,ileofemoral throtmbosis or arterial stenosis were execluded from this study.

TechniqueUnder spinal anesthesia the patient was layed down supine with abducted externally rotated thigh and flexed knee. Two incisions 12cm each were made over the course of the GSV in the thigh. Vein harvest was completed with division of all tributaries between 4-0 silk, vein flushing with heparinized saline was done to detect a misplaced sutuer, relieve vessel spasm or remove any clot (Figure1). Exposuer of the popliteal artery at its exit from the subsartorial canal was done from the lower incision ,retraction of the sartorious downward facilitated the exposure. Creation of an anterolateral subcutaneous tunnel passed lateral to vastus medialis, then a 5mm tension-free anastomosis was made by end-to-side fashion (Figure 2).

The deep fascia was sutured by interupted 3-0 absorbable sutures, the skin wounds were sutured using 3-0 non-absorbable sutuers. Anticoagulants were given as a routine for those with SLE. A period of 6weeks was allowed prior to the usage of the access for hemodialysis (Figure 3). Patients were followed up regularly every 3 months or when complications occur with cooperation with the nephrologists and dialysis nurses about the access complications and patient’s compliance.

ResultsFrom October 2005 to January 2007, 20patients with ESRD underwent this technique (13 males(65%),7 females(35%),age ranged 31-73,1 ± standard deviation 11.89). SLE (3 patients 15%) and relative hypotension(7 patients 35%) were the most important risk factors. The follow up period ranged from 1-25 months,with a mean of 15.8 months.The patients in this study had undergone AVF reconstruction 4.15 times on average. This technique was the 2nd fistula as an access in 3 patients ,the 3rd in 5 patients,the 4th in 6 patients ,the 5th in 3 patients, the 6th in 2 patients and the 9th in 1 patient. The cumulative primary patency rate at 1year was 75%. and at 2 years was 55%. Early post operative edema devoloped in 2 patients(10%) which resolved conservatively,no lymph leak ,no early thrombosis or infection. Thrombosis devoloped in 6 fistulas (30%)and resulted in fistula failure ,infected pseudaneurysm devoloped in 3 fistulas(15%) that required fistula ligation. No secondary procedures were done to extend patency of failed fistulas. No persistant venous hypertension ,high output cardiac failure or arterial steal. No operative deaths occurred ,but one patient died during follow –up with functioning fistula due to unrelated cause and was considered lost to follow-up (Table 1).

DiscussionArteriovenous fistulae are recognized as the gold standard of hemodialysis access because of superior long-term patency and lower infection and intervention rates when compared with prosthetic conduits.(6,7)

Straight Sapheno-Poplitral Arteriovenous Fistula Mansoura Exeperience 41


Figure 1. Vein flushing and tunnel planning . Figure 2. End to side anastomosis

Figure 3. The access after 15 months of dialysis.

Table 1. Pre and post operative variabls:

Variabls Number % SDPre operative variablesAge(years) 52.75 11.89SexMale 13 65Female 7 35Relative hypotension 7 35SLE 3 15No. of AVF 4.15 1.66Duration of AVF 4.3 3.13Post operative variablesEarly oedema 2 10Thrombosis 6 30Aneurysm 2 10Primary patency rate First year 15 75Second year 11 55Follow up (months) 15.8 6.38

Ibrahim Awad

42


In our countery the synthetic bridge fistulas are more costly and have higher rates of infection (about30%) than are reported in western studies. (8) The over all number of potential access sites in the upper limb is limited and revision of failed grafts may ultimately cost more than placement of new ones at other sites(9); hence, the GSV offers an additional source of autogenous vein.(10) In this study those with vein varicosity or ileofemoral thrombosis were excluded to avoid aneurysmal dilatation or venous hypertension respectively, also those with inflow problems to avoid steal. This type of fistula is created by dissecting, mobilizing and tunneling the GSV in the thigh. Creation of AVFin the lower limb will save one anastomosis over upper limb saphenous conduit access(11) and also improve fistula maturation and flow owing to relatively large caliber and high flow rate of the popliteal artery (12),in this study it is an advantage in hypotensive patients.The anastomosis of

Documents

President - egjvesegjves.com/uploads/issue_pdf/46b62754e34a3fff1f550ab92b2... · 2014. 3. 18. · Hasan Soliman Khaled Abdel Aal Mamdouh Kotb Mostafa Elekawy Saied Elmallah Tarek