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Case Reports
. 2018 Jul 18:2018:bcr2017223749.
doi: 10.1136/bcr-2017-223749.

Case of lower limb revascularisation using composite sequential bypass graft with a 'diamond' intermediate anastomosis

Cherry Cheung  1 , Ailin Rogers  1 , Morgan Peter McMonagle  1   2
Affiliations
Case Reports

Case of lower limb revascularisation using composite sequential bypass graft with a 'diamond' intermediate anastomosis

Cherry Cheung et al. BMJ Case Rep. .

Abstract

In patients with critical infracrural disease, autologous saphenous vein grafting offers the best reported conduit patency and limb salvage rates but is only feasible in approximately 30% of patients due to the lack of available or suitable vein. In the absence of a suitable length of available vein, various composite grafting techniques have been explored with the aim to improve graft longevity, maximise native vein use and improve overall clinical outcomes, including limb salvage rates. We report a case of a 66-year-old man with critical limb ischaemia and a history of venous disease, where a complex composite sequential bypass graft combining both native vein and synthetic graft, incorporated into a novel intermediate anastomotic technique in a 'diamond' configuration, offered promising results in limb salvage. This case highlights the key steps and advantages in this novel technique.

Keywords: general surgery; vascular surgery.

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Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1
Preoperative magnetic resonance angiography of the lower limb showing (A) adequate inflow, (B) complete occlusion of the right superficial femoral and popliteal arteries (arrow) and replacement with collaterals, and (C) two-vessel run-off on the right (anterior and posterior tibial arteries).
Figure 2
Figure 2
Right groin dissection with the common femoral artery controlled.
Figure 3
Figure 3
End-to-side proximal anastomosis of the expanded polytetrafluoroethylene (ePTFE) graft to the right common femoral artery.
Figure 4
Figure 4
Harvested long saphenous vein with tributaries controlled.
Figure 5
Figure 5
Longitudinal popliteal arteriotomy at the medial popliteal dissection. ePTFE, expanded polytetrafluoroethylene.
Figure 6
Figure 6
Proximal end of the diamond anastomosis with the expanded polytetrafluoroethylene graft in place.
Figure 7
Figure 7
Harvested autologous vein graft anastomoses to the lower end of the popliteal arteriotomy to complete the diamond anastomosis.
Figure 8
Figure 8
Completed diamond anastomosis.
Figure 9
Figure 9
Autologous vein graft tunnelled to the calf dissection to be anastomosed to the posterior tibial artery.
Figure 10
Figure 10
Medial calf dissection showing the posterior tibial artery controlled.
Figure 11
Figure 11
Distal end of the autologous vein graft anastomosed to the posterior tibial artery.
Figure 12
Figure 12
Graphical representation of diamond anastomosis at the popliteal arteriotomy showing the proximal polytetrafluoroethylene (PTFE) graft and distal vein anastomoses.
See this image and copyright information in PMC

References

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