Abstract
Introduction and importance
The number of patients with chronic limb-threatening ischemia has increased in recent years. Herein, we report a rare case of angioplasty with a bovine pericardial patch in a patient with severe stenosis of the common femoral artery.
Case presentation
We report a case of a 73-year-old female with intermittent claudication. Ankle-brachial index (ABI) measurements showed a significant decrease of 0.52 on the left, and angiography revealed total occlusion on the left common femoral artery (CFA). Considering additional skin incisions, postoperative wound infection, and potential graft sampling, endarterectomy of the left CFA and patch angioplasty with the bovine pericardium (XenoSure®) were performed. The operative computed tomography showed no stenosis and the ABI improved from 0.52 to 1.15. Additionally, no stenosis, calcification, or dilatation was observed during the follow-up one year after the operation.
Clinical discussion
Various types of peripheral arterial repair were performed after endarterectomy. Autologous vein grafts and vascular prostheses are frequently used considering the background of each patient. Using bovine pericardium over other devices has several advantages, including no additional skin incisions to obtain the patches, resistance to infection, no oozing from the device itself, less bleeding from the suture site, and ease of hemostasis after the puncture under additional endovascular treatment. This case may be a good implication when deciding which device to use in complicated patients.
Conclusion
This case provides valuable insight into successful patch angioplasty after endarterectomy without any complications, highlighting the utility of XenoSure® in the treatment of this disease.
Keywords: Patch angioplasty, XenoSure®, Endarterectomy
Highlights
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Angioplasty with Bovine Pericardium XenoSure® is rarely reported.
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Using bovine pericardium over other devices has several surgical advantages.
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Angioplasty with XenoSure® may be a good implication in complicated patients.
1. Introduction
The number of patients with chronic limb-threatening ischemia (CLTI), which has a high risk of lower limb ischemia, tissue defects, neuropathy, and infection and requires clinical intervention, has increased in recent years due to the aging population and due to improvement in prognosis of dialysis patients [1]. Herein, we report a rare case of angioplasty with a bovine pericardial patch in a patient with severe stenosis of the common femoral artery. This work has been reported in line with the SCARE 2020 criteria [2].
2. Presentation of case
A 73-year-old female presented with intermittent claudication that had begun 1 year before. The patient had a medical history of hypertension, dyslipidemia, cerebral infarction, and atrial fibrillation. In addition, the patient was allergic to the contrast agent. An initial plain computed tomography (CT) scan revealed mild calcification of the left common femoral artery (CFA) and no apparent stenosis of the CFA and superficial femoral artery (SFA) (Fig. 1A). However, ankle-brachial index (ABI) measurements showed a significant decrease of 0.52 on the left, and angiography of the lower extremity revealed total occlusion with a total length of 8 mm on the left CFA (Fig. 1B). Considering additional skin incisions, postoperative wound infection, and potential graft sampling, we adopted a policy in which endarterectomy of the left CFA should be performed, and patch angioplasty with the bovine pericardium could then be conducted if sufficient blood vessel diameter could not be obtained.
Fig. 1.
Pre-, intra-, and postoperative findings.
(A) Preoperative plain computed tomography (CT) scan. (B) Preoperative angiography of the lower extremity could reveal total occlusion with a total length of 8 mm on the left common femoral artery (CFA). (C) Intraoperative findings. (D) Postoperative CT. CFA, common femoral artery; SFA, superficial femoral artery.
The procedure was performed under general anesthesia. A skin incision of 6 cm was made in the left inguinal region, and the left CFA was exposed. After incision of the CFA, severe intimal thickening and narrowing of the lumen were confirmed. Endarterectomy was performed from the CFA just below the inguinal ligament to the SFA and deep femoral artery bifurcation. After intimal fixation on the proximal and peripheral sides of the endarterectomy, patch angioplasty with bovine pericardium (XenoSure®) was performed with #5-0 polypropylene sutures (Fig. 1C). Edoxaban was continued as the postoperative medication in addition to an antiplatelet agent, Aspirin. The operative CT showed no stenosis and the ABI improved from 0.52 to 1.15. Additionally, no stenosis, calcification, or dilatation of the site was observed during the follow-up one year after the operation (Fig. 1D).
3. Discussion
Various types of peripheral arterial repair were performed after endarterectomy. Among them, the postoperative patency after direct suturing or patch angioplasty was good, and some reports showed that the postoperative 5-year patency was >90 % [3], [4]. Nevertheless, the level of evidence within these reports is fragmentary, owing to the lack of large-scale cohort studies on the selection of patch devices. For that reason, autologous vein grafts, such as a great saphenous vein, or vascular prostheses, such as expanded polytetrafluoroethylene, are frequently used considering the background of each patient, such as patients with impending coronary artery bypass grafting or at high risk of severe infection. Importantly, some studies have reported early outcomes of wound complications after angioplasty using each device. Some clinical studies on wound complications in cases with arterial patches, vein patches, and vascular prostheses showed that wound infection, hematoma, and lymph leak accounted for 7.6–17.1 %, 1.7–9.0 %, and 5.4–7.6 %, respectively [4], [5]. In a recent study on the improvement of wound complications with patch angioplasty with bovine pericardium (XenoSure®) and vascular prostheses, wound infection and lymph leak accounted for 7.7 % and 1.5 %, respectively, giving the impression that freedom from wound complications was slightly improved [3]. Although a direct comparison cannot be made, one report showed that patch angioplasty with bovine pericardium (XenoSure®) after carotid endarterectomy could facilitate bleeding management and reduce the morbidity of the postoperative aneurysm [6]. Furthermore, using bovine pericardium over other devices has several advantages, including no additional skin incisions to obtain the patches, resistance to infection, no oozing from the device itself, less bleeding from the suture site, and ease of hemostasis after the puncture under additional endovascular treatment [6]. Nevertheless, there have been few reports thus far investigating the long-term outcomes of bovine pericardium for patch angioplasty in patients with severe stenosis of CFA. Thus, there remains a significant need for long-term surgical outcomes, but this case may be a good implication when deciding which device to use in complicated patients.
4. Conclusion
This case provides valuable insight into successful patch angioplasty after endarterectomy without any complications, highlighting the utility of XenoSure® in the treatment of this disease.
Patient consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
Ethical approval
Ethical approval was not required for this case report in our institution.
Funding
The authors declare that they have no funding for our research.
Author contribution
Dr. Hiroo Uehara — collecting the data, reviewing patient notes, writing articles, and approving final submission.
Dr. Masateru Uchiyama — corresponding author; collecting the data, writing articles, reviewing patient notes, writing articles, analyzing images, and approving final submission.
Dr. Tomohiro Imazuru — analyzing images, writing articles, and approving final submission.
Dr. Tomoki Shimokawa — analyzing images, writing articles, and approving final submission.
Guarantor
Dr. Masateru Uchiyama.
Research registration number
N/A (this device is not the first time in man).
Declaration of competing interest
The authors declare that they have no conflict of interest, financial, personal, or otherwise which could influence bias.
Contributor Information
Hiroo Uehara, Email: h.uehara@med.teikyo-u.ac.jp.
Masateru Uchiyama, Email: mautiya@med.teikyo-u.ac.jp.
Tomohiro Imazuru, Email: imazuru@med.teikyo-u.ac.jp.
Tomoki Shimokawa, Email: tshimo@med.teikyo-u.ac.jp.
References
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