Rehman, Zia Ur

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eCommons@AKU Department of Surgery Department of Surgery 1-2020 Lateral sub-cutaneous route for anterior tibial artery revascularisation Zia Ur Rehman Follow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_surg  Part of the Cardiovascular Diseases Commons, and the Surgery Commons Sir,Below the knee revascularisations using venous graftsdecrease the risk of major amputations.1 Traditionally,anterior tibial artery (ATA) is revascularised via medialroute. In this graft is routed through adductor canal, thentunnelled posterior to knee between the femoral condyleand brought from medial incision to anterior compart-ment via a tunnel through the interosseus membrane.Lateral route is unconventional route to the ATA. It isrecommended in case of scarred or infected groin.2,3The conventional route is technically difficult, associatedwith higher risk of graft kinking and is difficult to monitor.4We report a case of successful ATA bypass using lateralsubcutaneous route.A 64-year woman was having right 4th toe gangrene andbilateral rest pain. She was bed bound for the last 4months due to this condition. Computed angiographyshowed diffusely diseased superficial femoral andpopliteal arteries with the ATA as the only outflow arteryin the leg. Angioplasty was unsuccessful because of thelong lesion. She was considered for femoro-distalbypass. At presentation, she had severe groin fungalinfection and was treated with antifungal medications.Patient had good volume, palpable, femoral arteries.Using profunda femoris artery as inflow, bypass wasperformed initially for the right leg with tissue loss.Profuda femoris artery and ATA were exposed throughstandard longitudinal incisions. Ipsilateral greatsaphenous vein (GSV) was harvested through skipincisions technique, avoiding infected areas and used inreverse fashion. Lateral subcutaneous route wascreated using a 36F chest tube. A counter incision wasrequired in the upper third thigh. She had moderatelydiseased, calcified ATA. Right common femoral andprofunda femoris arteries were having minimal plaqueand good pulsatile flow. End-to-side anastomoses of thegraft were created with profunda femoris and ATA andinline flow established up to the foot. Wounds wereclosed in layers. Patient had smooth recovery and wasdischarged on fifth postoperative day. The gangrenous4th toe auto-amputated at third week.After 4 weeks of first operation, she underwent revas-cularisation using same approach on the left side. Asmall abscess on the inner upper thigh noted at the timeof operation was drained, covered and separated fromthe intended operative field. The disease was muchmore on left femoral bifurcation. Femoral endar-terectomy was done. Ipsilateral GSV was used inreversed fashion; and it was also dissected by skipincisions avoiding the drained abscess site. She hadsmooth recovery from the procedure. Foot becamewarm and pink and her pain settled. She was walkingafter being bed bound for 4 months.  On follow-up visitat 3 months of initial operation, she was asymptomaticbut right graft had no pulsation. CT angiography (CTA)showed occluded right graft (Figure 1).  As she was nothaving any complaints, no intervention was offered.Lateral subcutaneous route is practical for scarred groins,active groin infection or thigh infection. Hoballah et al.first described lateral approach of ATA with subcutan-eous graft tunnelling with primary patency of 16% andsecondary patency of 86% at 1 year. They used thisroute for patients having medial infection, scarring fromprevious surgery, limited vein length, prior local radio-therapy and high-risk groins.5 Higher re-inter-ventions inthese patients were due to advanced form of diseaseand limited quality of veins available. Our thought processwas that a wound dehiscence on medial side can exposeunderlying graft, if placed on that side. This danger canpotentially be avoided by extra-anatomical routing thegraft away. In conventional route, the graft is deep and isnot palpable compared to lateral subcutaneous routewhere the graft is easily palpable. Physicians and evenpatients themselves can monitor for any decreased flowand detect developing stenosis earlier.Journal of the College of Physicians and Surgeons Pakistan 2020, Vol. 30 (1): 109-110 109LETTER TO THE EDITORLateral Sub-cutaneous Routefor Anterior Tibial ArteryRevascularisationFigure 1: Computed tomographic angiogram showing patent left femoro-anterior tibial vein bypass. The right bypass has occluded at 3 months butpatient had viable leg with no symptoms.The graft on right side remained patent for three monthsand salvaged that leg.Extra-anatomical route using the lateral subcutaneoustunnel is feasible for patients needing revascularisationof ATA.CONFLICT OF INTEREST:Authors declared no conflict of interest.AUTHOR’S CONTRIBUTION:ZUR: Substantial contributions to the conception or designof the work; the acquisition, analysis, or interpretation ofdata for the work; drafting the work or revising it criticallyfor important intellectual content; final approval of theversion to be published; agreement to be accountablefor all aspects of the work in ensuring that questionsrelated to the accuracy or integrity of any part of the workare appropriately investigated and resolved. REFERENCES1. Adam DJ, Beard JD, Cleveland T. Bypass versus angioplastyin severe ischemia of the leg (BASIL): Multicenter, randomisedcontrolled trial. Lancet 2005; 366:1925-34.2. Kontopodis N, Kafetzakis A. Profunda femoral to anterior tibialartery bypass to treat critical limb ischemia in a patient withnumerous prior arterial reconstructions. Eur J Vasc EndovascSurg 2016; 52:702.3. Benzing C, Fellomor PT. Lateral approach to the distal femoralartery in femoro-anterior-tibial bypass surgery. Eur J VascEndovasc Surg 2016; 52:267.4. Lee T, Ra HD, Park YJ, Park HS, Kim SJ. New routing alter-native for proximal anterior tibial artery bypasses in patientswith Buerger disease. J Vasc Surg 2011; 54:1839-41.5. Hoballah JJ, Chalmers RT, Sharp WJ. Lateral approach to thepopliteal and crural vessels for limb salvage. Cardiovasc Surg1996; 4:165-8.Letter to the editor110 Journal of the College of Physicians and Surgeons Pakistan 2020, Vol. 30 (1): 109-110Zia Ur RehmanDepartment of Surgery, The Aga Khan University Hospital,Karachi, PakistanCorrespondence to: Dr. Zia Ur Rehman, Section of VascularSurgery, Department of Surgery, The Aga Khan UniversityHospital, Karachi, Pakistan E-mail: ziaur.rehman@aku.eduReceived: March 08, 2019;   Revised: May 08, 2019;Accepted: May 18, 2019

Lateral sub-cutaneous route for anterior tibial artery revascularisation

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Lateral sub-cutaneous route for anterior tibial artery revascularisation

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