Successful long-term limb salvage using cephalic and small saphenous vein grafts: A case report

Abstract

In this case report, we present a patient scheduled for operation due to critical leg ischemia in whom a bilateral great saphenous vein (GSV) had already been used during previous cardiac and peripheral vascular surgeries. The patient underwent femorofemoral crossover bypass from left to right with a small saphenous vein and right femoropopliteal bypass with cephalic vein (CV) during the same session. Distal pulses became palpable, and symptoms regressed dramatically following the operation. A control computed tomographic angiography scan revealed no signs of graft stenosis 32 months after the surgery. Despite the recent advances in synthetic graft materials, small saphenous and CVs should be remembered as alternative long-standing conduits in the absence of the GSV.

INTRODUCTION

The optimal graft for bypass surgery has been a matter of discussion for years. However, it is known that autogenous grafts are superior to synthetic materials.[1] While the great saphenous vein (GSV) has always been the first choice, in some cases where the GSV is unavailable, other superficial veins have been used as alternatives to synthetic grafts.[2] Today, cardiovascular surgical procedures have become quite diverse and widespread throughout the world. Consequently, the absence of GSV due to previous coronary artery bypass grafting, peripheral arterial surgery, vascular injury repair, or interventions for chronic venous insufficiency (e.g., endovenous ablation, stripping, etc.) is the main challenge faced by many vascular surgeons. Although the thin walls and narrow diameters of the superficial veins limit their use, in certain cases they may be an alternative to synthetic grafts.[3] Small saphenous vein (SSV) and upper extremity superficial veins (cephalic and basilic) are other autologous grafts, while umbilical and GSV homografts are preferred as nonautologous alternatives in patients with a missing GSV.

In this case report, we present an alternative autogenous vascular graft solution instead of synthetic conduits in a patient scheduled for operation due to critical leg ischemia whose bilateral GSV had already been used in the previous cardiac and peripheral vascular surgeries. Although the presence of the SSV and cephalic veins (CV) has been known for many years, for most surgeons, these do not come to mind as alternative conduits in the first place. By presenting this case, we aim to emphasize that these two mostly overlooked conduits can be used safely as an alternative, when necessary.

CASE REPORT

A 68-year-old male was referred to the department of vascular surgery after suffering from leg pain at rest. His physical examination revealed an ischemic ulcerated wound and chronic dystrophic changes on the first toe of his right foot. The patient had a surgical history of a right aorta–iliac artery bypass surgery with 7-mm polytetrafluoroethylene prosthesis and right femoropopliteal bypass using an autologous saphenous vein in the same session. The femoral and distal pulses were not palpable. The ankle systolic blood pressure was measured at 50 mm Hg, while the ankle-brachial index was measured at 0.75 for the right leg.

He was suffering from resting leg pain, and an ulcerated wound that had not healed despite maximal medical treatment, including cilostazol, acetylsalicylic acid, and clopidogrel. We planned a femorofemoral crossover from the left common femoral artery (CFA) to the right CFA and femoropopliteal bypass from the right CFA to the right popliteal artery based on the finding of digital subtraction angiography [Figure 1]. As bilateral GSVs were harvested during his previous peripheral and cardiac surgeries, we harvested the SSV from the left leg and the CV from the left arm. The SSV was used for the femorofemoral bypass, and the CV was used in the right femoropopliteal bypass. The distal pulses became palpable following the procedure.

Figure 1.

Preoperative digital subtraction angiography showed stenotic lesions in the lower extremity arteries

The patient was discharged home on the 4^th postoperative day without complications. He was prescribed antihypertensive, antihyperlipidemic medications in combination with warfarin and acetylsalicylic acid. The patient was also involved in a psychotherapy program to quit smoking. The ulcerated wound on the foot had totally healed 6 months after surgery, and mobility restrictions were alleviated by the 12^th month after treatment. During a postoperative 32-month follow-up control visit, a lower extremity computed tomographic angiography revealed patent venous grafts [Figures 2 and 3].

Figure 2.

Postoperative computed tomographic angiography showed the anterior view of the small saphenous vein graft used for the crossover bypass and the cephalic vein graft used for right femoropopliteal bypass

Figure 3.

Postoperative computed tomographic angiography showed the posterior view of the cephalic vein graft used for the right femoropopliteal bypass

DISCUSSION

The optimal treatment strategy for critical limb ischemia aims to prolong life while preventing amputation. According to the TASC-II classification, surgery is the treatment of choice for infra inguinal type D lesions.[4] Choosing the right conduit for use in surgical revascularization is crucial for optimal long-term results.

Early patency rates of synthetic grafts are similar to venous grafts; however, synthetic grafts have lower long-term patency rates.[5] GSVs are the first choice graft to be considered in peripheral vascular surgery, as they are superior to synthetic grafts; they are foldable, resistant to infection, less thrombogenic, suitable for manipulation, last longer, readily diffusible, and easier to obtain.[6] Nonetheless, GSV use is limited when the GSV has been used previously in other cardiovascular surgical attempts, which has happened in 40% of cases.[7] In this situation, other superficial veins are chosen instead of a synthetic graft. Although some studies have reported that the use of superficial veins in lower extremity reconstructions causes restriction and dilatation, others report successful outcomes following these operations.[1,8,9] There was no GSV available in our patient, due to previous cardiovascular operations, and synthetic grafts revealed very low patency. For these reasons, the SSV was used in the femorofemoral crossover bypass and the CV in the right femoropopliteal bypass.

Graft type is a major area of interest within the field of infra inguinal femoropopliteal bypass surgery. When considering the above knee bypasses, a meta-analysis showed better primary patency for autologous veins compared to synthetic grafts.[10] According to the guidelines, other autologous veins are preferable to synthetic grafts in the case of unavailable GSV in infrapopliteal revascularization (Grade C recommendation).[11] One key study comparing all autogenous arm superficial vein bypass grafts and prosthetic grafts is that by Faries et al., in which alternative autogenous vein grafts in patients without GSV were shown to be clearly better than prosthetic ones, in terms of patency rate and limb salvage.[12]

The small diameters of other superficial veins and their tendencies to aneurysm restrict their use, while the tendency to infection and higher stenosis rate makes synthetic grafts disadvantageous. Hence, some authors recommend the creation of a temporary arteriovenous shunting between the CV and the radial artery at the wrist level before a bypass operation, to arterialize the thin CV.[13] The possibility of preferring SSV and CV as autologous grafts, especially in infrainguinal bypass surgeries, should be kept in the minds of vascular surgeons to achieve higher patency rates and avoid the complications stemming from synthetic grafts.

Declaration of patient consent

The authors certify that they have obtained appropriate patient consent documentation, and the, the patient has given permission for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Applicable reporting guideline for case reports (CARE) was followed by the authors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Research quality and ethics statement

This case report did not require approval by the Institutional Review Board / Ethics Committee. The authors followed applicable EQUATOR Network (http://www.equator-network.org/) guidelines during the conduct of this research project.