Femoro-Supragenicular Popliteal Bypass with a Bridging Stent Graft in a Diffusely Diseased Distal Target Popliteal Artery: Alternative to Below-Knee Popliteal Polytetrafluoroethylene Bypass

Abstract

Background: Lesions in distal target arteries hinder surgical bypass procedures in patients with peripheral arterial occlusive disease.

Methods: Between April 2012 and October 2015, 16 patients (18 limbs) with lifestyle-limiting claudication (n=12) or chronic critical limb ischemia (n=6) underwent femoral-above-knee (AK) polytetrafluoroethylene (PTFE) bypass grafts with a bridging stent graft placement between the distal target popliteal artery and the PTFE graft. Ring-supported PTFE grafts were used in all patients with no available vein for graft material. Follow-up evaluations assessed clinical symptoms, the ankle-brachial index, ultrasonographic imaging and/or computed tomography angiography, the primary patency rate, and complications.

Results: All procedures were successful. The mean follow-up was 12.6 months (range, 11 to 14 months), and there were no major complications. The median baseline ankle-brachial index of 0.4 (range, 0.2 to 0.55) significantly increased to 0.8 (range, 0.5 to 1.0) at 12 months (p<0.01). The primary patency rate at 12 months was 83.3%. The presenting symptoms resolved within 2 weeks.

Conclusion: In AK bypasses with a diffusely diseased distal target popliteal artery or when below-knee (BK) bypass surgery is impossible, this procedure could be clinically effective and safe when used as an alternative to femoral-BK bypass surgery.

Keywords: Arteries; Bypass; Graft; Stents.

Fig. 1

Femoral–above-knee bypass with placement of a bridging stent graft. Images from a 73-year-old man suffering from chronic critical limb ischemia. (A) Preoperative angiographic details of the above-knee popliteal artery. (B) Angiography performed by guiding the catheter through the PTFE graft shows a diffuse diseased popliteal artery after femoral–above knee bypass. (C) Recanalization of the focal occlusion and diseased popliteal artery was performed. (D) A Viabahn stent graft 5 mm in diameter was introduced over a guidewire into the distal target artery with proper landing under fluoroscopic and angiographic guidance after pre-dilatation angioplasty. (E) A balloon was used to mold the stent graft to achieve good apposition to the healthy popliteal artery wall and to the PTFE graft. (F) Final angiographic imaging after the femoral above-knee bypass with the hybrid procedure shows good patency of the graft and the Viabahn stent with preserved distal runoff. PTFE, polytetrafluoroethylene.

Fig. 2

A 77-year-old man with a skin wound at the below-knee bypass incision site who was treated with a femoral–above-knee bypass with placement of a bridging stent graft. (A) Computed tomography angiography shows occlusion of the right femoropopliteal artery and posterior tibial artery. (B) Angiography performed by guiding the catheter through the polytetrafluoroethylene graft shows the diffusely diseased popliteal artery after the femoral–above-knee bypass. (C) Recanalization of the diseased popliteal artery was performed. (D) Angioplasty was performed for pre-dilatation before placement of the bridging stent graft. (E) A Viabahn stent graft 5 mm in diameter was introduced over a guidewire into the distal target artery with proper landing under fluoroscopic and angiographic guidance. (F) The final angiographic imaging after the femoral–above-knee bypass with the hybrid procedure shows good patency of the graft and Viabahn stent with preserved distal runoff.

Fig. 3

Kaplan-Meier estimates of primary patency after femoral–above-knee bypass procedures with placement of a bridging stent graft.