Ann Vasc Dis Vol.5, No.2; 2012; pp 199–203 ©2012 Annals of Vascular Diseases doi: 10.3400/avd.cr.11.00090 Case Report 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 immea- surable. 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 col- lateral 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.