Pedal Bypass With Deep Venous Arterialization:
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1 Pedal Bypass With Deep Venous Arterialization: Long Term Result For Critical Limb Ischemia With Unreconstructable Distal Arteries Pramook Mutirangura Professor of Vascular Surgery Faculty of Medicine Siriraj Hospital Mahidol University Bangkok Thailand
2 No Disclosure
3 Critical limb ischemia
4 Unreconstructable distal artery Completely occluded & calcified pedal artery
5 Heavy calcification and severe stenosis of the pedal artery Calcified post. tibial a.
6 Conventional pedal artery bypass
7 Pedal bypass with deep venous arterialization (PBDVA) Principle of surgical technique Common femoral artery PTFE graft Common femoral vein Long saphenous vein proximal artery composite graft distal pedal vein
8 Critical limb ischemia Ankle pressure = 60 mmhg ABI = 0.4 Oxygen pressure = 16 mmhg
9 Preoperative assessment
10 Duplex ultrasonography: assessment of pedal vein 3 mm. posterior tibial vein
11 Duplex ultrasonography : proximal femoral artery
12 Pedal bypass with deep venous arterialization (PBDVA) Steps of the surgical procedure
13 PBDVA surgical technique The patient in supine position
14 PBDVA surgical technique Posterior tibial vein isolation
15 PBDVA surgical technique Proximal femoral artery isolation
16 PBDVA surgical technique Contralateral vein harvesting & graft tunnelling
17 PBDVA surgical technique Harvested long saphenous vein
18 PBDVA surgical technique Proximal vascular anastomosis
19 PBDVA surgical technique Anastomosis of composite graft
20 PBDVA surgical technique Composite graft
21 PBDVA surgical technique Blood flow through composite graft
22 PBDVA surgical technique Posterior tibial venotomy
23 PBDVA surgical technique Vascular dilator for destruction of valvular competency
24
25 PBDVA surgical technique Distal vascular anastomosis
26 PBDVA surgical technique Distal vascular anastomosis
27 PBDVA surgical technique Distal vascular anastomosis
28 PBDVA surgical technique Complete vascular anastomosis
29 VDO: intraoperative angiography
30 Intraoperative angiography
31 PBDVA surgical technique Closure of surgical wounds
32
33 Complete healing of ischemic ulcer Preoperative Postoperative
34 Preoperative Postoperative
35 Distal anastomosis (VDO) Preoperative CTA Postoperative CTA
36 Foot circulation Preoperative CTA Postoperative CTA
37 Transcutaneous oxygen pressure preoperative postoperative O 2 pressure = 16 mmhg O 2 pressure = 63 mmhg
38 Foot level <20 mmhg Poor healing mmhg Equivocal >40 mmhg Good healing
39 Postoperation 1 year Postoperation 5 years
40 Immediate postoperation Postoperation 5 years
41 Quality of life Postoperation : 1 year Postoperation : 5 year
42 Long term outcomes of PBDVA (n=40)
43 Hemodynamic changes in CLI treated by PBDVA
44 Postoperative duplex ultrasonography Immediate postoperation 5-year postoperation
45 Postoperative duplex ultrasonography Immediate postoperation 5-year postoperation
46
47
48 Lt. femoral artery PBDVA Lt. posterior tibial vein Preoperative Postoperative
49
50
51 PBDVA R. iliac a. R. posterior tibial v. Preoperative Postoperative 4 wks Postoperative 2 yrs
52 Long term outcome : good quality of life 6 year-follow-up
53 Conclusions PBDVA has been proved to enhance limb salvage in critical limb ischemia with unreconstructable distal artery. PBDVA could tremendously increase not only blood supply to the ischemic foot but also collateral circulation of the whole ischemic leg. This hemodynamic change could maintain healthy foot circulation and provide limb salvage in the long term followup.
54 1-4 December 2015 Bangkok, Thailand
55 Comparative study of venous arterialization and pedal bypass in a patient cohort with critical limb ischemia Pedal bypass (n = 19) Venous arterialization (n = 21) Early occlusion 23% 15% 1-year patency 75% 71% Limb salvage 47% 53% Equal limb salvage After pedal bypass surgery (good distal a.) After venous arterialization (poor distal a.) Schreve MA, et al., Annals of Vascular Surgery
56
57 Pedal Bypass With Deep Venous Arterialization: Long Term Result For Critical Limb Ischemia With Unreconstructable Distal Arteries Pramook Mutirangura Professor of Vascular Surgery Faculty of Medicine Siriraj Hospital Mahidol University Bangkok Thailand
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