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Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 84-86

Quaternary revascularization after three failed infra-inguinal bypasses

Department of Vascular and Endovascular Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India

Date of Submission23-Jan-2020
Date of Acceptance05-May-2020
Date of Web Publication20-Feb-2021

Correspondence Address:
Jithin Jagan Sebastian
Department of Vascular and Endovascular Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijves.ijves_10_20

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It is becoming increasingly commonplace to find patients with their third or fourth revascularization procedure. We present one such patient with thrice-failed infra-inguinal bypass, which was successfully revascularized. A 63-year-old diabetic, hypertensive with three failed infra-inguinal bypasses presented with forefoot gangrene. Computed tomography angiogram revealed a long-segment occlusion from the external iliac to the middle posterior tibial artery (PT). Hybrid approach was used to stent the proximal anastomotic site and open surgical bypass was carried out for the distal site. The forefoot healed after amputation with skin grafting. Failed infra-inguinal procedures usually present as long-segment, complex lesion, which require a hybrid approach for revascularization. Preoperative planning and reintervention are paramount in achieving suitable patency in this group of patients.

Keywords: Angioplasty, hybrid, infra-inguinal bypass, stenting

How to cite this article:
Sebastian JJ, Rajendra N, Ayyappan M K, Mathur K, Pawar P, Raju R. Quaternary revascularization after three failed infra-inguinal bypasses. Indian J Vasc Endovasc Surg 2021;8:84-6

How to cite this URL:
Sebastian JJ, Rajendra N, Ayyappan M K, Mathur K, Pawar P, Raju R. Quaternary revascularization after three failed infra-inguinal bypasses. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Feb 25];8:84-6. Available from:

  Introduction Top

Redo procedures after thrombosis of infra-inguinal graft are common. Complex, long-segment Trans-Atlantic Society Consensus (TASC)-D lesions are commonplace. Challenging is the task when multiple previous interventions have been attempted. A range of endovascular and open expertise is available to deal with these situations. Complex hybrid procedures combining both modalities seem to be the mainstay of treatment. Increasing expertise in the field has reduced the primary technical failure rate. These procedures form the only method of revascularization in such patients. We present a patient who had undergone three failed infra-inguinal bypasses and was successfully revascularized.

  Case Report Top

A 63-year-old male, diabetic and hypertensive, presented to the vascular outpatient department with left forefoot gangrene which had evolved over the past 3 weeks. The patient was in rest pain with an Ankle-Brachial Pressure Index (ABI) of 0.2. The patient had a history of multiple failed infra-inguinal bypasses.

In 2010, the patient developed critical limb ischemia of the same leg and underwent a left common femoral artery to proximal popliteal artery bypass with polytetrafluorethylene (PTFE). He had varicose veins on the ipsilateral leg which he got treated subsequently with radiofrequency ablation. The following year in 2012, he developed similar symptoms and presented late with toe gangrene. He then underwent a left common femoral-to-distal popliteal artery PTFE bypass in view of his disease progression. The patient was asymptomatic following the second surgery for a period of 5 years.

In early 2017, he presented with critical limb ischemia and underwent a common femoral-to-proximal popliteal-to-proximal PT sequential bypass. A year later, he presented with forefoot gangrene. On examination, he had absent pulses in the left leg with multiple scars of the previous surgeries. He had a superficial femoral artery occlusion on the contralateral side as well with an ABI of 0.9. The patient underwent a computed tomography angiogram, which showed a long-segment occlusion from the external iliac to the middle PT artery. Distal reformation of the PT artery was present. The progression of the disease leading to failure of the three infra-inguinal grafts is shown in [Figure 1].
Figure 1: Previous CT angiograms done in 2010, 2012, 2017 and the present CT angiogram (2018)

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The patient was planned for thrombectomy of the existing graft and a hybrid procedure to vascularize the proximal and distal ends. Intraoperatively, the most recent and the longest graft was identified and exposed in the middle thigh [Figure 2]. Thrombectomy was carried out with Fogarty catheter, and an angiogram was taken, which showed proximal and distal anastomotic stenosis. Angioplasty of the anastomotic sites was carried out, and good forward and backward bleed was identified. There was minimal improvement in the ABI to 0.5. The patient developed graft thrombosis on the 2nd postoperative day, and a redo procedure was planned. This time, an angiogram showed residual stenosis at the proximal and distal anastomotic sites. The outflow, middle PT artery was exposed and found to be patent reaching up to the ankle. It was decided to stent the proximal site with a vasculo-mimetic, self-expandable, 6 mm × 80 mm stent extending into the graft [Figure 3]. The distal graft was exposed, and a reversed saphenous vein graft was used to bypass the distal anastomotic site onto the mid PT artery [Figure 4]. Postoperatively, there was pulsatile flow in the PT artery at the ankle. The patient subsequently underwent a forefoot amputation [Figure 4]. The patient was discharged on dual antiplatelets and was on regular follow-up. The patient went on to have skin grafting done and the forefoot stump healed well. At 2 years, the graft is still patent.
Figure 2: Axial CT image showing three occluded bypasses in the mid-thigh

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Figure 3: Vasculo mimetic stent across the proximal anastomotic site

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Figure 4: Mid-thigh access site, distal bypass, healing forefoot stump, preoperative foot image (clockwise)

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  Discussion Top

Redo procedures of infra-inguinal bypasses is a challenging task. Advances in endovascular therapy have made it possible to deal with these extensive TASC-D lesions. In the era of redo procedures for secondary patency, 25% of these patients present with multilevel extensive lesions.[1]

Hybrid procedures are the solution in treating these complicated cases. It can be done as a single or staged procedure to address the iliac and infrainguinal components. The inflow and the outflow tracts must be addressed in such a situation.[2] In our case, as both the inflow and outflow showed disease progression, angioplasty was done. Redo juxta anastomotic disease usually requires a stent or further adjunctive procedures after angioplasty.

The proximal anastomotic site was adjacent to the inguinal ligament, hence a woven nitinol stent was used proximally when angioplasty failed. Stenting in the tibial artery has similar patency rates to angioplasty.[3] Angioplasty had failed earlier, hence a bypass of the posterior tibial anastomosis was carried out. Both the inflow and outflow tracts must be kept in mind while planning the procedure.

Major amputations are inevitable in these patients, and salvage of these limbs is usually not attempted. The mortality and morbidity associated with these complex procedures is high at 19% and 61%, respectively, in open surgeries.[2] Dougherty et al.[4] reported a much lower morbidity and mortality at 11% and 1.4%, respectively, for hybrid procedures. Dosluoglu et al.[5] in a retrospective series comparing hybrid interventions to open and endovascular showed hybrid to have lower morbidity and mortality than open but higher than the endovascular group.

The patency of these procedures has been questioned especially for TASC-D lesions. Lantis et al.[6] reported 95% patency in femoral and popliteal interventions but have excluded TASC-D lesions. Covered iliac stents have shown a patency of 87% versus 53% in bare metal stents.[7] Our stent had to cross the inguinal ligament, hence a flexible woven nitinol stent was used.

Proximal and distal endoluminal reconstruction is associated with lower patency compared to either proximal or distal endovascular methods.[8] Proximal endovascular approach and distal open approach seem to have better patency than endovascular interventions at both ends. Our patient had three femoral bypass grafts in the thigh over a period, which subsequently thrombosed due to intimal hyperplasia and as the disease progressed. Similar patients with multiple redo procedures in future will require a hybrid approach to deal with these long occlusions as described above.

  Conclusion Top

Third- or fourth-time redo bypasses usually present with TASC-D lesions. These long-segment infrainguinal redo procedures require complex single or multistage hybrid procedures for revascularization. Planning and reintervention is paramount in this group of patients to achieve acceptable patency rates of limb salvage.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Moneta GL, Yeager RA, Taylor LM Jr., Porter JM. Hemodynamic assessment of combined aortoiliac/femoropopliteal occlusive disease and selection of single or multilevel revascularization. Semin Vasc Surg 1994;7:3-10.  Back to cited text no. 1
Harward TR, Ingegno MD, Carlton L, Flynn TC, Seeger JM. Limb-threatening ischemia due to multilevel arterial occlusive disease. Simultaneous or staged inflow/outflow revascularization. Ann Surg 1995;221:498-503.  Back to cited text no. 2
Hsu CC, Kwan GN, Singh D, Rophael JA?, Anthony C, van Driel ML. Angioplasty versus stenting for infrapopliteal arterial lesions in chronic limb-threatening ischaemia. Cochrane Database Syst Rev 2018;12:CD009195.  Back to cited text no. 3
Dougherty MJ, Young LP, Calligaro KD. One hundred twenty-five concomitant endovascular and open procedures for lower extremity arterial disease. J Vasc Surg 2003;37:316-22.  Back to cited text no. 4
Dosluoglu HH, Lall P, Cherr GS, Harris LM, Dryjski ML. Role of simple and complex hybrid revascularization procedures for symptomatic lower extremity occlusive disease. J Vasc Surg 2010;51:1425-350.  Back to cited text no. 5
Lantis J, Jensen M, Benvenisty A, Mendes D, Gendics C, Todd G. Outcomes of combined superficial femoral endovascular revascularization and popliteal to distal bypass for patients with tissue loss. Ann Vasc Surg 2008;22:366-71.  Back to cited text no. 6
Chang RW, Goodney PP, Baek JH, Nolan BW, Rzucidlo EM, Powell RJ. Long-term results of combined common femoral endarterectomy and iliac stenting/stent grafting for occlusive disease. J Vasc Surg 2008;48:362-7.  Back to cited text no. 7
Antoniou GA, Sfyroeras GS, Karathanos C, Achouhan H, Koutsias S, Vretzakis G, et al. Hybrid endovascular and open treatment of severe multilevel lower extremity arterial disease. Eur J Vasc Endovasc Surg 2009;38:616-22.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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