Sural Artery Bypass in Buerger's Disease

Sural Artery Bypass in Buerger’s Disease: Report of a Case

Harunobu Matsumoto, MD,1 Eisuke Yamamoto, MD,1 Chiaki Kamiya, MD,1 Emi Miura, MD,1 Tadashi Kitaoka, MD,1 Jun Suzuki, MD, PhD,1 Kota Yamamoto, MD, PhD,1 Juno Deguchi, MD, PhD,1 Morihiro Higashi, MD, PhD,2 Jun-ichi Tamaru, MD, PhD,2 and Osamu Sato, MD, PhD1

A 72 year-old man was admitted to the hospital to receive treatment for resting pain and an ulcer, which had developed on an amputation stump, 4 months after he had undergone a thrombectomy, below-the-knee popliteal-dorsal pedis artery bypass of his left leg, and digital amputation of his 2nd toe. Angiography demonstrated diffuse arterial and bypass occlusion in his left leg that did not include a sural artery, which was the main collateral. Therefore, the patient underwent reversed saphenous vein bypass from the common femoral artery to the medial sural artery. His leg pain disappeared, and the ulcer healed promptly.

Keywords: sural artery bypass, perigenicular artery bypass, collateral artery bypass

Introduction Case Report

evascularization is the primary option in the manage- A 72 year-old man, who had smoked for fifty years, Rment of critical limb ischemia. Previous studies have was diagnosed with diabetes mellitus. He had suffered described bypass to the perigeniculate collateral arteries the thrombophlebitis of his left leg one year earlier and as an option for limb salvage in selected patients, such was admitted to the hospital to receive treatment for as in cases of extensive disease, previous failed endo- or coldness, cyanosis and severe rest pain in his leg and a open vascular attempts, lack of the usual crural arterial painful ulcer, measuring approximately 8 mm in diam- runoffs or autogenous substitutes being common scenar- eter, which had developed on the amputation stump of ios.1–7) However, the use of this bypass has been restricted the left 2nd toe. He had undergone thrombectomy of his to a few groups of vascular surgeons. This report presents left leg 5 months earlier and left below-the-knee popliteal one case of a successful sural artery bypass in a patient to dorsal pedis artery bypass using a reversed saphenous with Buerger’s disease, who presented with rest pain in vein graft and amputation of the left 2nd toe 4 months the leg due to occlusion of the previous distal bypass. earlier. His ankle-brachial pressure index was immeasurable. Electrocardiogram showed sinus rhythm and no ischemic changes. Computer tomography showed no embolic sources, no peripheral aneurysms nor evidence of popliteal entrapment. Angiography demonstrated diffuse 1Department of Vascular Surgery, Saitama Medical Center, arterial occlusion, occlusion of the superficial femoral Saitama Medical University, Kawagoe, Saitama, Japan artery, popliteal artery and crural artery of his leg and the 2Department of Pathology, Saitama Medical Center, Saitama bypass graft. However, the sural artery was dilated, and it Medical University, Kawagoe, Saitama, Japan was the main collateral to the calf (Fig. 1). He underwent Received: November 18, 2011; Accepted: January 21, 2012 arterial bypass from the common femoral artery to the Corresponding author: Harunobu Matsumoto, MD. Department medial sural artery with a reversed contralateral saphe- of Vascular Surgery, Saitama Medical Center, Saitama Medical nous vein graft to treat the ischemic lower extremity. The University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan Tel: +81-49-228-3462, Fax: +81-49-228-3462 medial sural artery was exposed via a medial approach. E-mail: [email protected] The skin incision was a classic medial below-the-knee

Annals of Vascular Diseases Vol.5, No.2 (2012) 199 Matsumoto H, et al.

Fig. 1 Pre-operative angiogram. The left superficial femoral, popliteal and crural arteries were occluded. A dilated sural artery (arrow) was the main collateral to the lower leg.

popliteal incision extended to the proximal site along pneumatic tourniquet to control bleeding, minimizing the posterior edge of the semitendinosus muscle. The crural extent of sural artery exposure and decreasing the risk fascia was incised posteriorly toward the proximal site of clamp injury (Fig. 2). Histopathological finding of the along the semimembranosus and semitendinosus muscle superficial femoral artery was supportive for Buerger’s and peeled carefully from the surface of the medial head disease, as it showed mild inflammatory changes in tu- of the gastrocnemius muscle. The medial sural artery was nia media and intimal thickening associated with fresh exposed from its origin from the popliteal artery into the thrombosis. medial head of the gastrocnemius muscle surrounded by The patient’s postoperative course was uneventful. a venous plexus. There were two medial sural arteries Though his postoperative ankle-brachial pressure index and both of them were similar in size to the usual pero- was still immeasurable, his foot became warm, and his neal artery. One of them was going into the medial head leg pain disappeared. Postoperative angiography showed of the gastrocnemius muscle deeply, so we decided the a patent bypass graft and good collateral blood flow to other one as a target vessel that seemed easier to anasto- the calf muscle (Fig. 3). The patient was discharged 16 mose in technically. The wall was not fragile, and there days following surgery. The ulcer shrunk promptly and were no atherosclerotic changes. The distal anastomosis healed two months after surgery. was performed with 6–0 polypropylene sutures using a

200 Annals of Vascular Diseases Vol.5, No.2 (2012) Sural Artery Bypass in Buerger’s Disease

Fig. 2 Intra-opetative findings. a a: The medial sural artery surrounded by a venous plexus (arrow) was exposed, arising b from the popliteal artery and passing into the Fig. 3 Post-operative angiogram. medial head of the gastrocnemius muscle. The bypass graft (arrow) was patent, and good b: A reversed saphenous vein graft (arrow) blood flow to the calf muscle was confirmed. was anastomosed end-to-side to the medial sural artery using 6-0 polypropylene sutures.

Discussion arteries is also described as an option for limb salvage in selected patients. Shindo et al. first reported a case of Perigeniculate arteries are important collateral ves- successful sural artery bypass for a patient with critical sels in the lower leg, in patients with occlusion of the limb ischemia due to Buerger’s disease in 1995.1) popliteal artery. Mannick et al. first reported that limb Two important collateral vessels are used for peri- salvage could be achieved in patients with an isolated geniculate artery bypass, the highest genicular artery (“blind”) popliteal artery segment (IPAS) by performing and the medial sural artery. The medial sural artery is a femoropopliteal bypass with a reversed saphenous vein one of the perigeniculate collateral vessels, and it arises in 1967.8) This procedure has been favored for patients from the posterior wall of the popliteal artery at the knee with critical limb ischemia (CLI). Ballotta et al. reported joint. de Latour et al.3) reported that sural arteries present that revascularizations to an IPAS can achieve acceptable several advantages as distal anastomosis sites for lower results in terms of patency and limb salvage, with 3 year limb bypass grafts. First, grafts to these arteries can cumulative patency and limb salvage rates of 76% and be shorter, measuring between 25 and 35 centimeters, 82%, respectively, even when there is no infrapopliteal in length. Short conduit length not only improves graft runoff vessel.9) Bypass to the perigeniculate collateral quality but also increases circulatory velocity by reducing

Annals of Vascular Diseases Vol.5, No.2 (2012) 201 Matsumoto H, et al. flow resistance. The second advantage is the availabil- nosus muscle after the crural fascia was peeled carefully ity of a good quality recipient artery. Like the internal from the surface of the medial head of the gastrocnemius thoracic artery, the perigeniculate collateral arteries are muscle to expose the medial sural artery surrounded by usually disease-free. This feature is especially important a venous plexus passing into the medial head of gastroc- in patients with diabetes and renal insufficiency who nemius muscle. Though a longer below-the-knee incision often have calcified vessels. The third advantage of the was needed in comparison to the approach reported by perigeniculate collateral arteries is their mean diameter, Barral et al., the current procedure made it relatively i.e., 2–2.5 mm, comparable to that of the lower leg arter- easy to evaluate the orientation and was an acceptable ies. Brochado Neto et al. reported perigeniculate artery procedure indeed for surgeons with little experience with bypasses were performed to treat different combinations perigeniculate artery bypass. of advanced arterial disease, previously failed reconstruc- The collateral artery originally has a small diameter tions, insufficient length of the available vein, and spread- that increases in size with time to replace the occluded ing infection in the affected limb.4) De Latour et al.3) and main arterial tree, but the wall seemed relatively thin in De Luccia et al.6) reported that perigeniculate collateral the current case. Regular vascular clamps could easily artery bypasses can achieve acceptable results, in terms of damage this fragile vascular wall. Therefore, a pneumatic patency and limb salvage rates, with 3 year primary, sec- tourniquet was used to control the bleeding during the ondary patency, and limb salvage rates of 64.7%–74.7%, distal anastomosis. A pneumatic tourniquet substitutes 69.9%–83.4% and 73.5%–90.2%, respectively. for vascular clamps to preserve the integrity of the ves- Exposure of the sural artery through the medial ap- sel because it gently and firmly occluded the arteries. It proach seemed difficult because the mid portion of the is also useful in the collateral artery bypass because it popliteal artery is not usually used as a distal site of provides an unhindered operative field. anastomosis in a femoro-popliteal artery bypass. Barral There are only few previous reports of sural artery et al. described the surgical procedure for sural artery by- bypasses, so the efficacy of this bypass still remains pass.2) They used a slightly lower incision in comparison uncertain. We had no way to predict the efficiency of the to the classic medial above-the-knee popliteal incision for bypass preoperatively. Skin perfusion pressure (SPP) is exposure of the sural artery. The sural arteries arise from one of the useful tools for evaluating outcome of isch- the posterior aspect of the mid-popliteal artery, approxi- emic foot ulcer with conservative therapy, as Urabe et mately 1 to 2 cm above the interarticular line. There is al. reported.10) It seemed that SPP may be one of the as- both a medial and a lateral sural artery, and they feed the sisted predictors of quality of the perfusion of the sural respective heads of the gastrocnemius muscle, traveling artery bypass before the ulcer recurrence. Barral et al. with the sural branches of the tibial nerve. Barral et al. reported that bypass to a perigeniculate vessel alone may used the medial artery, which is surrounded by a venous not be sufficient to allow tissue healing in the patient with plexus that is carefully freed down to the level at which extensive foot necrosis,2) and such patients may require the artery descends into the gastrocnemius muscle.2) This a more distal bypass to achieve limb salvage. However, muscle can be mobilized and divided for 1 to 2 cm to al- the perigenicular artery bypass can be a valid option for low the exposure of an additional 3 to 4 cm of artery. One limb salvage in selected patients with no calcification in of the advantages of this procedure is that this allows the the diseased arteries. surgeon to completely avoid below-the-knee incisions, which are more likely to present wound-healing difficul- Conclusion ties. Another advantage is that there is no need to divide any muscles by this procedure, because it is important This report presented a case of a successful sural ar- to avoid injury of any collateral vessels. However, expo- tery bypass in a patient with critical limb ischemia due sure of the above-the-knee popliteal artery through the to Buerger’s disease. A sural artery bypass is a treatment posterior path of the sartorius muscle is unusual because option for critical limb ischemia in selected patients with the classical approach is through the anterior path of the minimal arterial calcification, particularly those who are sartorius muscle. The current procedure used a classic poor candidates for conventional surgical or endovascular medial below-the-knee popliteal incision extended to the revascularization. proximal site along the posterior edge of the semitendi-

202 Annals of Vascular Diseases Vol.5, No.2 (2012) Sural Artery Bypass in Buerger’s Disease

References medial genicular artery for limb salvage. J Vasc Surg 2009; 50: 1196. [Medline] [CrossRef] 1) Shindo S, Kamiya K, Suzuki O, et al. Collateral artery 6) De Luccia N, Sassaki P, Durazzo A, et al. Limb salvage bypass in Buerger’s disease: report of a novel proce- using bypass to the perigeniculate arteries. Eur J Vasc dure. Surg Today 1995; 25: 92-5. [Medline] [CrossRef] Endovasc Surg 2011; 42: 374-8. [Medline] [CrossRef] 2) Barral X, Salari GR, Tousarkissian B, et al. Bypass 7) Yamamoto K, Sugimoto M, Kodama A, et al. Sural to the perigeniculate collateral vessels. A useful artery bypass: a case report. Jpn J Vasc Surg 2010; 19: technique for limb salvage: Preliminary report on 557-60. (in Japanese) 22 patients. J Vasc Surg 1998; 27: 928-35. [Medline] 8) Mannick JA, Jackson BT, Coffman JD, et al. Success [CrossRef] of bypass vein grafts in patients with isolated popliteal 3) de Latour B, Nourissat G, Duprey A, et al. Bypass to artery segments. Surgery 1967; 61: 17-25. [Medline] the perigeniculate collateral arteries: mid-term results. 9) Ballotta E, Da Giau G, Gruppo M, et al. Revasculariza- Eur J Vasc Endovasc Surg 2008; 35: 473-9. [Medline] tion to an isolated (“blind”) popliteal artery segment: [CrossRef] a viable procedure for critical limb ischemia. Surgery 4) Brochado Neto FC, Gonzalez J, Cinelli M Jr, et al. 2009; 145: 426-34. [Medline] [CrossRef] Bypass to the genicular arteries for revascularisation 10) Urabe G, Yamamoto K, Onozuka A, et al. Skin perfu- of the lower limb. Eur J Vasc Endovasc Surg 2000; 20: sion pressure is a useful tool for evaluating outcome of 545-9. [Medline] [CrossRef] ischemic foot ulcers with conservative therapy. Ann 5) De Luccia N, Appolonio F, Santo FR. Vascular images. Vasc Dis 2009; 2: 21-6. [CrossRef] Arm vein bypass from distal deep femoral to superior

Annals of Vascular Diseases Vol.5, No.2 (2012) 203