Distal Bypass Grafting Using the Basilic-Cephalic Loop Vein for Chronic Limb-Threatening Ischemia under Peripheral Nerve Blockades in a Patient with Severely-Reduced Heart Function and End-Stage Renal Disease

Abstract

A 51-year-old man with severe comorbidities required redo revascularization due to left chronic limb-threatening ischemia caused by a previous vein graft occlusion. The saphenous veins were not available due to previous surgeries. Femoro-posterior tibial artery bypass surgery was successfully performed using the basilic-cephalic loop vein under peripheral nerve blockades. This anesthesia allowed a series of surgical revascularizations without general anesthesia, and the postoperative courses were uneventful. The patient survived for 4 years with ambulatory status. In conclusion, loop graft can be an alternative single vein material for distal bypass when no saphenous veins are available.

Keywords: chronic limb-threatening ischemia; heart failure; nerve block anesthesia.

Fig. 1 Preoperative findings. Dipyridamole stress myocardial perfusion scintigraphy showing decreased accumulation in the apex and anterior–anteroseptal and inferior walls (A). Computed tomography angiography showing occlusion of the superficial femoral artery (SFA, arrow) as well as calcification of the popliteal and infrapopliteal arteries (arrowheads) (B). Intra-arterial digital subtraction angiography demonstrated no stenotic lesion of left iliac artery (C) and chronic total occlusion of SFA (D) and popliteal arteries (E). Left posterior tibial, peroneal, and plantar arteries were well visualized (F and G). A photograph of left foot with ulcers (H). Vein mapping ultrasound showing the availability of the right upper arm veins. Number means diameter (mm) (I).

Fig. 2 A series of operative findings of right basilic and cephalic vein loop grafting. Right interscalene brachial plexus block and left lower extremity nerve blockade were performed by anesthesiologists (A). Vein mapping, including the median cubital vein (MCV), by ultrasonography (arrow) (B). The veins were dissected with a skip incision manner, and valves of the basilic vein were destructed from MCV (C). Loop vein graft long enough for femorotibial bypass grafting (D). Proximal anastomosis to the deep femoral artery (E) and distal anastomosis to the posterior tibial artery (F).

Fig. 3 Intraoperative completion angiography and findings of reintervention. A proximal anastomosis was at the deep femoral artery (DFA) (A). Middle segment of the vein graft was shown. A small caliber segment was found (red square) but naturally expanded 7 months after the placement (B). The vein graft reached the posterior tibial artery (PTA), a distal anastomosis site (C). A proximal segment of vein graft and stenosis of PTA distal to the anastomosis site (arrowheads) were treated with plain old balloon angioplasty (D and E).