Management of Failed Infrainguinal Arterial Bypass Surgery
Khaled Abdel Sattar El-Dieb;
Abstract
According to the current study, diabetes mellitus is a major independent risk factor for late graft failure and affects the outcome of subsequent management.
One of the best approaches for limb salvage in case of failed bypass graft occurred in the late phase is a secondary bypass (autogenous vein or synthetic), as it has better patency (but less than the initial bypass), however, it has a major effect on the morbidity or mortality of patients. Moreover, performing the distal anastomosis may be troublesome, due to fibrosis and the need to extend the graft more distally in smaller vessels.
Another contemporary successful approach is native SFA angioplasty and stenting, which has comparable patency to that of secondary bypass, additionally, it has little or no effect on the morbidity and mortality of patients. It is noteworthy to mention its technical difficulty due to the need of stenting of the whole SFA from just proximal to the proximal anastomosis and just distal to the distal anastomosis, provided the absence of an inflow or outflow disease.
As regard to cases of surgical thrombectomy and CDT (here, thrombectomy is akin to thrombolysis in thrombus removal), intraoperative completion angiography and angioplasty of the anastomosis or proximal or distal native arteries, assisted in the fair patency rates, but still have inferior results regarding patency to secondary bypass and native SFA angioplasty.
As for the use of postoperative antithrombotic drugs, using ASA and clopidogrel is superior to using ASA only in terms of maintaining postoperative conduit functionality, with little risk of bleeding at the operative site and the long-term bleeding complication.
Eventually, each patient must have his own management plan tailored in respect to various factors such as the surgeon’s preference and competence, patient’s preference, presentation of the patient, patient’s comorbid diseases, suspected functional outcome of the patient and the availability of equipment.
One of the best approaches for limb salvage in case of failed bypass graft occurred in the late phase is a secondary bypass (autogenous vein or synthetic), as it has better patency (but less than the initial bypass), however, it has a major effect on the morbidity or mortality of patients. Moreover, performing the distal anastomosis may be troublesome, due to fibrosis and the need to extend the graft more distally in smaller vessels.
Another contemporary successful approach is native SFA angioplasty and stenting, which has comparable patency to that of secondary bypass, additionally, it has little or no effect on the morbidity and mortality of patients. It is noteworthy to mention its technical difficulty due to the need of stenting of the whole SFA from just proximal to the proximal anastomosis and just distal to the distal anastomosis, provided the absence of an inflow or outflow disease.
As regard to cases of surgical thrombectomy and CDT (here, thrombectomy is akin to thrombolysis in thrombus removal), intraoperative completion angiography and angioplasty of the anastomosis or proximal or distal native arteries, assisted in the fair patency rates, but still have inferior results regarding patency to secondary bypass and native SFA angioplasty.
As for the use of postoperative antithrombotic drugs, using ASA and clopidogrel is superior to using ASA only in terms of maintaining postoperative conduit functionality, with little risk of bleeding at the operative site and the long-term bleeding complication.
Eventually, each patient must have his own management plan tailored in respect to various factors such as the surgeon’s preference and competence, patient’s preference, presentation of the patient, patient’s comorbid diseases, suspected functional outcome of the patient and the availability of equipment.
Other data
| Title | Management of Failed Infrainguinal Arterial Bypass Surgery | Other Titles | علاج إنسداد التوصيل الشرياني ما تحت القربة | Authors | Khaled Abdel Sattar El-Dieb | Issue Date | 2016 |
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