The extraanatomic by-pass in vascular surgery

Abstract

Introduction: The term “extraanatomic” is used to outline vascular grafts, the paths of which lie through regions completely different from the arteries they by-pass. Although modern vascular surgery upholds several extraanatomic by-pass procedures, the precise indications for these surgical interventions, as well as the selection of patients and the proper surgical technique, have not been completely set yet. Purpose and objectives: The study aims to assess the specific indications for extraanatomic by-pass, the proper surgical technique and patient selection. Materials and methods: 13 extraanatomical by-passes were performed during the period of 2010-2014. All patients fell into 3 groups: -Critical inferior limb ischaemia associated with advanced cardio-vascular and pulmonary pathology (n=6): all patients underwent femuro- or ilio-femural cross-overs. -Suppurative processes (n=3): all patients underwentfemuro-femural or ilio-femural cross-overs. -Vascular trauma (n=4) associated with damage and infection of adjacent tissues: 2 crossovers (1 ilieo-femural and 1 femuro-femural) in case of ilio-femural axis damage, 1 femuro-popliteal bypass (graft placed subcutaneusly), 1 suprafascialbrachio-brachial by-pass. Results: The results highly depend on the vascular bed patency. Patients in critical limb ischaemia with obliterant atherosclerotic background, advanced cardiovascular and pulmonary diseases or those with suppurative processes are prone to a poor vascular bed. In the first 2 groups, 1 femurofemural by-passthrombosed in the immediate postoperative period (amputation was required), 2 of them remained patent up to 6 months, 2 of them up to 1 year and the other 4 cross-overs more than 1 year. In the third group, all by-passes remained patent during all follow-up period (up to 8 years). Conclusions: Extraanatomical by-passes serve as an alternative to classical revascularization in certain groups of patients. These procedures are especially indicated in patients with contaminated vascular grafts or suppurative processes. Another group of patients are those with advanced cardio-vascular and pulmonary diseases. Axilo-femural and femuro-femural by-passes being far less traumatic than their aortofemural counterpart (although hemodynamically less favorable) are indicated in arteriopathic patients to save limbs in critical ischaemia, but not to treat intermittent claudication. In patients with vascular trauma associated with infected wounds, the extraanatomical by-pass is the procedure of choice.