Bypass to the Genicular Arteries for Revascularisation of the Lower Limb

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Eur J Vasc Endovasc Surg 20, 545–549 (2000) doi:10.1053/ejvs.2000.1236, available online at http://www.idealibrary.com on

F. C. Brochado Neto1, J. Gonzalez1, M. Cinelli Ju´ nior1 and M. Albers∗2

Vascular Surgery Section, 1Hospital do Servidor Pu´blico Estadual Francisco Morato de Oliveira and 2Hospital Municipal Doutor Carmino Caricchio, Sa˜o Paulo, SP, Brazil

Objective: to describe an initial experience with infrainguinal bypass grafts inserted distally in a genicular artery. Design: retrospective case series study. Subjects and methods: eleven patients with Grade III chronic limb ischaemia in whom arteriography showed femoropopliteal occlusive disease and at least one genicular branch suitable for receiving a bypass. Bypass grafts were done to the descending genicular artery (n=4) or the medial sural artery (n=6) using segments of autologous veins; one bypass was not completed. Results: primary graft patency and foot salvage rates were 73% at 1 month and 24 months of follow-up. Patient survival rate was 100% and 90%, respectively. Major amputation was required in two of three patients following early graft failure. Of the eight patients who had a patent graft, the Doppler ankle–brachial systolic pressure index showed no change in one patient, an increase of 0.13–0.66 in six patients, and was not measured in one patient. The former patient underwent a below-knee amputation whereas the other seven patients showed complete healing of their skin ulcers and sites of minor amputation. Conclusion: the genicular bypass is a useful alternative that may extend the limits of infrainguinal arterial reconstruction with autologous tissue and the potential for long-term patient beneﬁt.

Key Words: Arterial occlusive disease; Bypass grafts; Saphenous vein; Genicular bypass.

Introduction artery, develops after occlusion of the below-knee popliteal artery and becomes suitable for receiving a In addition to the progress in infrapopliteal bypass bypass when the entire popliteal artery finally oc- grafting to the most distal arteries and isolated tibial cludes. Although the importance of the perigeniculate artery segments,1–3 some attention has recently been collaterals as outflow vessels for the isolated popliteal given to perigeniculate collaterals as recipient vessels segment is well recognised,6–8 only one series of fem- for a bypass.4 The descending genicular artery (DGA), oral to genicular bypass grafts has been described.4 which is a branch of the superficial femoral artery at In the present report, we summarise a 4-year ex- the Hunter canal, is the highest inflow component of perience with this new alternative bypass. the perigeniculate collateral network (Fig. 1). The DGA subsequently bifurcates into a small musculoarticular 5 branch and a large saphenous branch. The latter Materials and Methods branch accompanies the saphenous nerve to the medial aspect of the knee and may grow in calibre to feed Patients the collateral system when there is chronic occlusion of the above-knee popliteal artery. Further occlusion Of 245 patients requiring a vein bypass graft to an or severe stenosis at the superficial femoral artery may infrapopliteal artery from September 1995 to July 1999, create the final conditions for a bypass to the DGA. eight men and three women aged 47 to 87 years Similarly, the medial sural artery (MSA), which ori- (median 65 years) underwent genicular bypass graft- ginates in the lower part of the above-knee popliteal ing. Of these 11 patients, four had diabetes mellitus, six had hypertension, three had heart disease, five ∗ Please address all correspondence to: M. Albers, Rua Ministro were smokers and all had Grade III chronic limb Godoí, 1584, AP 74, ZIP 05015-001 Saõ Paulo, Brazil. ischaemia.9 The ischaemic lesion was limited to the

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and in the above-knee popliteal artery in one patient. The remaining patient had multiple stenoses in the superficial femoral artery. The DGA in five patients and the MSA in the the six patients were identified and judged suitable for bypass. Other patent although diseased vessels included a peroneal artery in the lower third of the leg in three patients, a short isolated tibial segment in the middle third of the leg in three other patients, a dorsalis pedis in one patient, and a plantar artery in another patient. However, in three arteriograms only collaterals were found.

Contraindications to a conventional infrapopliteal bypass

The unfavourable arteriographic ﬁndings above dis- couraged a conventional tibial or pedal bypass in nine patients, six of whom also had an insufﬁcient length of available vein. Extensive skin lesions were the main problem in two patients, one of whom also had in- adequate veins.

Surgical technique

The construction of a genicular bypass is technically simple and has been described.4 The targeted genicular branch is located by following the occluded parent artery downwards and is then dissected free for about 2–3 cm. Muscle or tendon splitting may be needed to expose the MSA, but not the DGA. In this series, a Fig. 1. When the popliteal artery occludes, the perigeniculate single venous segment was harvested from a great collateral network may develop at expense of the descending genicular artery (1), which bifurcates into a musculoarticular saphenous vein in five patients and a cephalic vein in branch (2) and a saphenous branch (3), or the medial sural artery three patients. A spliced venous conduit was used by (4). combining the lesser saphenous vein, the basilic vein, and the superficial femoral vein in one patient and toes in eight limbs, but also involved other sites of the the cephalic and basilic veins in another patient; one foot and leg in three patients. Secondary infection was bypass to a small calibre DGA was not completed. a further complication in five limbs. In addition, five of Since non-reversed vein bypasses were used in the 10 the 11 patients had previous failed arterial procedures completed reconstuctions, the proximal anastomosis (three bypasses, one thrombectomy and one an- was constructed first to allow vein dilatation with gioplasty). The ankle–brachial Doppler systolic blood normothermic blood under arterial blood pressure. pressure index (ABI) could not be assessed in one limb This anastomosis was done at the common femoral because of extensive ulceration in the leg and foot, artery (five MSA bypasses, three DGA bypasses), the was zero in five limbs as a consequence of inaudible superficial femoral artery (one DGA bypass) or the sounds, and ranged from 0.21 to 0.40 in the remaining above-knee popliteal artery (one MSA bypass). five limbs. After completing valve incision with valvulotomes, a pulsating dilated conduit was obtained and brought through a subsartorial plane to the level of the selected Preoperative arteriography genicular artery. Vessel loops or delicate bulldog clamps were applied for arterial control and flow Conventional arteriography revealed total arterial oc- arrest. Under magnification, an end-to-side ana- clusion in the superficial femoral artery in nine patients stomosis was done between the graft and the genicular

Eur J Vasc Endovasc Surg Vol 20, December 2000 Genicular Bypass Graft 547 artery using 7-0 polypropylene running suture. Com- pletion arteriograms were never obtained. Post- operatively, antibiotics and common analgesic drugs were prescribed routinely. In the long-term, acetyl-salicylic acid was used, and other antiplatelet drugs, anticoagulants, and haem- orrheologic agents were never prescribed.

Assessment of results

During the first 3 months after hospital discharge, visits to the outpatient clinic were planned on an individual basis, taking into account the necessary wound care. Subsequent visits occurred at intervals of 3 months during the first year of follow-up and every 6 months thereafter. None of the 11 patients was lost to follow-up and all were reassessed until the occurrence of graft failure, death or the end of the available observation period. Graft patency was assessed by pulse palpation over the graft and the ABI was measured and compared to the respective preoperative values. Postoperative arteriograms were obtained at different times because the revascularisation achieved was incomplete, the overall clinical improvement was moderate, the healing of ischaemic skin lesions or local amputation was delayed, and ultrasound equipment was not available for non- Fig. 2. Postoperative arteriogram showing a patent 7-cm long invasive monitoring. Any change in clinical status was popliteal-to-medial sural artery saphenous vein bypass graft. also assessed. The recommended standard criteria of The Inter- Foot salvage and patient survival national Society for Cardiovascular Surgery and the Society for Vascular Surgery were strictly observed in At 1 month and 24 months of follow-up, the cumulative all these evaluations.9 rate was 73±11% and 73±38% for foot preservation and 100% and 90±12% for survival, respectively. The foot was kept intact in three patients and was partially preserved in five patients who underwent a successful toe amputation. Three patients ultimately required a Results major (two below-knee, one above-knee) amputation.

Graft patency

In one patient, the intended bypass to a small DGA Clinical results was not completed and both of the grafts constructed with spliced veins occluded in the ﬁrst postoperative Major amputation was done in the two patients whose day. Another graft occluded at 39 months of follow- composite grafts occluded earlier, but was not required up. Using the Kaplan–Meier product-limit method, the for the one patient with an incomplete bypass. As cumulative primary graft patency rate was 73±11% at there were no early deaths, eight patients left hospital 1 month and 73±17% at 12 months and 24 months. with a patent single-vein bypass graft and were fol- Figure 2 shows the postoperative arteriogram of a 7- lowed-up for a median time of 19 months (range 6 to cm long popliteal-to-MSA bypass, the shortest graft 43 months). One of these patients showed no clinical in this series. improvement following a DGA cephalic vein bypass

Eur J Vasc Endovasc Surg Vol 20, December 2000 548 F. C. Brochado Neto et al.

thus clinically and haemodynamically successful ac- cording to objective criteria.9 The remaining patient was also a clinical success, but it was not possible to assess his ABI. The outcome for the 11 patients is shown in Table 1.

Discussion

The same degree of technical expertise is required for the construction of a genicular bypass and a standard infrapopliteal bypass. However, the former is shorter, does not cross the knee joint, and avoids incisions in the leg. In addition, the genicular bypass keeps the crural arteries intact and preserves the venous pool better. Genicular arteries are also free of calcification, spared of extensive atherosclerotic changes, and similar in size to an average peroneal artery.4 The genicular bypasses were done because of different combinations of advanced arterial disease, pre- viously failed reconstructions, insufficient length of available vein, and spreading infection in the affected limb. The non-reversed vein configuration was ad- opted in this series to take advantage of a better size-match at the anastomoses and also because bi- directional flow reduces stasis in the graft when runoff is poor.1 For the same reasons, non-reversed vein grafts have been preferred for the revascularisation of plantar 1,3 Fig. 3. Postoperative arteriogram showing a patent descending arteries and isolated tibial segments. genicular artery cephalic vein bypass graft. The saphenous branch The use of a genicular bypass provided a less ag- of the descending genicular artery is not patent. Haemodynamicc gressive arterial reconstruction when a standard infra- failure led to a below-knee amputation. popliteal bypass was unfeasible or was not a sensible choice. Other authors also elected an incomplete re- because the saphenous branch of the DGA occluded vascularisation procedure, even when a more distal (Fig. 3). This individual underwent leg amputation, bypass was applicable.7 Since the musculoarticular achieved walking rehabilitation with a prosthesis, and branch of the DGA may have a negligible haemo- died in the 80th month of follow-up with a still patent dynamic role, it is debatable whether or not a graft graft. inserted in this vessel favours the healing of a leg The other seven patients, who had a total of two amputation. cephalic and five saphenous vein bypass grafts, no On haemodynamic grounds, the genicular bypass longer had pain at rest, showed complete healing of allows only partial revascularisation and may be their skin ulcers and sites of minor amputation and equivalent to a bypass to a short isolated popliteal remained alive during follow-up. segment with a single outflow branch connected to a compromised leg vasculature. Although they represent a high resistance runoff system, the peri- Haemodynamic results geniculate collaterals have a useful transport cap- acity. This was indicated by a mean early One of the four patients with clinical failure had a postoperative ABI of 0.59 in this study and 0.71 patent graft, but his ABI of 0.27 remained unchanged in another series.4 For isolated popliteal and tibial postoperatively indicating haemodynamic failure. Six arteries, the mean ABI has been reported as 0.63 and of the other seven patients had a patent graft, showed 0.75, respectively.3,7 While the genicular collateral an increase of 0.13–0.66 in the ABI, had a postoperative pathway may reach as far as the distal third of the ABI of 0.50–0.66 (median 0.61, mean 0.59), and were leg, the highest value for the early postoperative ABI

Eur J Vasc Endovasc Surg Vol 20, December 2000 Genicular Bypass Graft 549

Table 1. Outcomes for 11 patients with a genicular bypass.

Patient Age DM Pre- Post- Genicular Vein Outcome Follow-up ABI ABI artery graft (months)

168+ — — MSA CV Thrombosis/healed 39 2 56 0.27 0.27 DGA CV Graft patent/BKA/died 8 3 63 0.32 0.61 MSA GSV Graft patent/healed 43 465+ 0.21 0.60 MSA GSV Graft patent/healed 29 575+ 0.25 0.50 DGA CV Graft patent/healed 26 6 61 0 0 MSA SF/BV/LS Thrombosis/AKA 1 7 79 0 0 MSA CV/BV Thrombosis/AKA 1 8 56 0 0.64 DGA GSV Graft patent/healed 12 9 47 0 0 None None No graft/healed 1 10 54 0 0.66 MSA GSV Graft patent/healed 9 11 87 + 0.40 0.53 DGA GSV Graft patent/healed 6

DM: diabetes mellitus, Pre-ABI: Pre-operative ABI, Post-ABI: Post-operative ABI, CV: cephalic vein, GSV: great saphenous vein, SF: superficial femoral vein, BV: basilic vein, LS: lesser saphenous vein, BKA: below-knee amputation, AKA: above-knee amputation. in this study was 0.66. Since the postoperative ABI References was always lower than 0.90, the patients were qual- ified as moderately improved rather than markedly 1Andros G. Bypass to the plantar arteries. In: Bergan JJ, Yao JST (eds). Techniques in arterial surgery. Philadelphia: WB Saunders, improved, based on a recommended scale intended 1990: 157–168. to measure change in clinical status.9 2Ascer E, Veith FJ, Gupta SK. Bypasses to plantar arteries and other tibial branches: An extended approach to limb salvage? J The primary cumulative graft patency rate at 24 Vasc Surg 1988; 8: 434–441. months was 73%, but would increase to 80% if the 3Belkin M, Welch HJ, Mackey WC, O’Donnell TF Jr. Clinical single incompleted bypass were excluded. This result and hemodynamic results of bypass to isolated tibial artery segments for ischemic ulceration of the foot. Am J Surg 1992; suggests that the genicular bypass is a useful procedure 164: 281–285. and agrees with the 1-year primary cumulative patency 4Barral X, Salari GR, Toursarkissian B et al. Bypass to the rate of 77% reported by Barral et al.4 for 22 bypasses. perigeniculate collateral vessels. A useful technique for limb salvage: Preliminary report on 22 patients. J Vasc Surg 1998; 27: The 24-month cumulative foot salvage rate of 73% 928–937. was the result of two early graft occlusions and one 5Colborn GL, Lumsden AB, Taylor BS, Skandalakis JE. The surgical anatomy of the popliteal artery. Am Surg 1994; 60: haemodynamic failure, a complication with an in- 238–246. cidence of 5%–30% in bypasses to isolated artery seg- 6Mannick JA, Jackson BT, Coffman JD, Hume DM. Success of ment.3,7,8 bypass vein grafts in patients with isolated popliteal artery segments. Surgery 1967; 61: 17–25. While the standard infrapopliteal bypass remains 7Brewster DC, Charlesworth PM, Monahan JE, Abbott WM, preferable under usual circumstances, a more liberal Darling RC. Isolated popliteal segment v tibial bypass. Arch use of the genicular bypass may be justified in suitable Surg 1984; 119: 775–779. 8Veith FJ, Gupta SK, Daly V. Femoropopliteal bypass to the patients. Compared to the 7-cm long MSA bypass isolated popliteal segment: Is polytetrafluoroethylene graft ac- inserted in one patient (Fig. 2), a peroneal bypass ceptable? Surgery 1981; 89: 296–303. 9Rutherford RB, Baker JD, Ernst C et al. Recommended stand- would require more incisions, muscle splitting or fib- ards for reports dealing with lower extremity ischemia. J Vasc ular resection, tunnelling, a longer vein segment, the Surg 1997; 26: 517–538. crossing of the knee joint, and, at least ideally, two 10 Gooden MA, Gentile AT, Demas CP, Berman SS, Mills JL. Salvage of femoropedal bypass graft complicated by interval surgical teams working simultaneously to save time gangrene and vein graft blowout using a flow-through radial and effort. Finally, the expected 24-month patency rate forearm fasciocutaneous free flap. J Vasc Surg 1997; 26: 711–714. for such a bypass does not exceed 70%.13 11 Dardik H, Pecoraro J, Wolodiger F et al. Interval gangrene of the lower extremity: A complication of vascular surgery. J Vasc In broad agreement with the findings of a previous Surg 1991; 13: 412–415. report,4 this study shows that the genicular bypass 12 Memsic L, Busutill RW, Machleder H et al. Interval gangrene occurring after successful lower-extremity revascularization. may extend the limits of arterial reconstruction with Arch Surg 1987; 122: 1060–1063. autologous tissue and enhance the potential for long- 13 Abou-Zamzam Jr A, Moneta GL, Lee RW et al. Peroneal bypass term patient benefit at no additional cost. Further is equivalent to inframalleolar bypass for ischemic pedal gangrene. Arch Surg 1996; 131: 894–899. experience is required to confirm these favourable prospects. Accepted 25 October 2000

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