Exposure of the anterior tibial artery by medial popliteal extension

Transcription

1 Exposure of the anterior tibial artery by medial popliteal extension J. G. Sladen, FRCS(C), G. Kougeer, FRCS(C), and J. D. S. Reid, FRCS(C), Vancouver) British Columbia) Canada This report describes exploration of the proximal anterior tibial artery by extension of the standard below-knee approach to the popliteal artery. The anterior tibial artery is "poplitea1ized," giving excellent access to perform an anastomosis. The proximal medial approach depends on precise arteriography and is particularly suited to the in situ saphenous vein bypass and redo surgery. Advantages over previously described exposures include a shorter graft, ease of graft alignment, protection of the peroneal nerve, and the absence of a lateral counterincision. This exposure has been used on 12 of 14 anterior tibial grafts during the past 2 years. (J VAse SURG 1994;19: ) The length of available good vein is often the limiting factor in infrainguinal reconstruction. This is particularly true for the increasing number of patients who are admitted for redo surgery. The anterior tibial artery (ATA) can be exposed through number of interesting approaches l - 5 and the usual exposure between the muscles of the anterior compartments. 6 Proximal medial exposure, described here, allows a shorter graft and ease of graft alignment. It is usually possible if the ATA is the best vessel available for bypass (Fig. 1). TECHNIQUE The below-knee popliteal incision is extended distally approximately 10 cm, avoiding the saphenous vein if present. The soleus muscle is divided directly from its tibial origin and reflected posteriorly. The distal popliteal artery is identified by reflecting the popliteal vein posteriorly. The origin of the ATA is exposed and is seen disappearing behind the posterior tibial muscle and interosseous membrane. The small muscular veins are divided, and the From St. Paul's Hospital, University of British Columbia, Vancouver. Presented at the Fourteenth Annual Meeting of the Canadian Society for Vascular Surgery, Ottawa, Ontario, Canada, Sept , Reprint requests: Dr. J. G. Sladen, MD, FRCS(C), Burrard St., Vancouver, British Columbia, V6Z 2E8, Canada. Copyright 1994 by The Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter /94/$ /1/50394 Fig. 1. Precise angiogram of proximal ATA; ideal situation for medial exposure of xr A. 717

2 718 Sladen, Kougeer, and Reid April 1994 Anterior tibial a Soleusm. Common tibial a & v Tibialis posterior m. Fig. 2. Diagram demonstrates incision of interosseous membrane. Fig. 3. Photograph of medial exposure of ATA at operation, still tethered by muscular and recurrent arterial branches. tibial vein is usually ligated as it covers the exposure. The tibialis posterior muscle is divided close to the tibia, exposing the interosseous membrane. The membrane is divided with Pott's angled scissors or between the tips of a fine right-angled clamp, for 3 to 6 cm (Fig. 2). The ATA lies immediately deep to the membrane. A vessel loop passed around the origin of the AT A provides gentle traction while the artery is freed from its bed by dividing one or two small muscular branches and the larger recurrent branch if necessary. The proximal 6 cm of ATA is displaced medially, resulting in a straight "poplitealized" artery that is easily accessible for either endto-end or end-to-side anastomosis (Fig. 3). The AT A is allowed to fall back into its bed when the anastomosis is completed, but its angle of takeoff is usually somewhat straightened (Fig. 4). Use of a William's disc retractor with a 4.5 cm blade

3 Volume 19, Number 4 Sladen, Kougeer, and Reid 719 Fig. 4. A, Preoperative arteriogram shows diseased popliteal artery and occluded origin of ATA. B, Postoperative arteriogram in same patient. In situ, superficial femoral vein composite graft has been anastomosed into "poplitealized" anterior tibial vein. improves the exposure by hooking the sharp prong under the tibia and retracting the muscle with the blade (Fig. 5). ANATOMY Ten limbs were dissected both medially and laterally at postmortem examination to display the anatomy (Fig. 6). Each limb had a duplicated anterior tibial vein. Proximally the peroneal nerve is well lateral to the ATA but approaches the artery approximately 7 cm distal to the interosseous foramen (Fig. 7). It is avoided during medial exposure by moving the artery posteromedially. Completely removing the muscles from the tibia, rather than leaving a fringe of muscle along the bone, improves the exposure. EXPERIENCE Medial proximal exposure of the ATA has been used in 121imbs (11 patients) during a 2-year period from October 1, 1990 until September 30, Seven of the grafts were in situ saphenous vein, two were arm veins, one was superficial femoral vein, and two were composite redo grafts. Three operations were revisions for disease distal to an existing anastomosis. One patient died during operation, and one died during follow-up; both died of heart disease. Color-

4 720 Sladen, KiJugeer, and Reid April 1994 Fig. 5. Williams disc retractor improves exposure from medial approach and is useful in most tibial exposures. Anterior tibial a., Vl & V2 Popliteal V2 ~ ~,.: ~opliteal a & Vl >j~i I' Interosseous membran~:>c ": l,/(j ~ \ Ant. recurrent,::, ': 'Ii!: ' - ~ I ~.. tibial a. ' " " ' ', :-F"-----'-'---'=-'" Fig. 6. Schematic diagram summarizes anatomy observed during postmortem dissections. flow duplex scanning has been used for graft surveillance with an average follow-up of 18 months and a minimum follow-up of 6 months. Two grafts have been revised for stenosis of the body of the graft, and one has been revised for neointimal stenosis just distal to the tibial anastomosis. This graft was revised by exploring the ATA directly from an anterolateral approach through unscarred tissue between the anterior tibial and long peroneal muscles. Two grafts thrombosed and were treated by thrombolysis with urokinase; one of these failed after revision. There was no evidence of stenosis at the AT A anastomosis in either of these reconstructions. COMMENT Familiarity with the various approaches to the tibial arteries opens up useful alternatives for distal bypass, particularly in the redo situation as reviewed by Veith et al. 7 Classically the AT A is exposed from an anterolateral approach through the anterior compartment. 5 With the increase in redo and revisionary vascular surgery, available length of good vein has become a critical consideration. Before the experience reported here, we had extended a below-knee popliteal graft to the proximal AT A by excising the head of the fibula. 2,8 This gave excellent exposure but was followed by footdrop that was slow to resolve

5 Volume 19, Number 4 staden, Knugeer, and Reid 721 Fig. 7. Postmortem dissection of proximal anterior compartment in right leg. Peroneal nerve approaches AT A about 7 cm below interosseous foramen. and kindled our interest in an alternative approach. The medial approach to the mid ATA gives adequate exposure,4 particularly if combined with posteriormedial displacement of the artery as described by Dardik et al. 5 This exposure allows good alignment for in situ vein grafts but requires a long graft. When the disease is appropriate, we prefer to expose the proximal AT A by extension of the standard medial below-knee popliteal exposure described by Szilagyi et al. 6 The site of the anastomosis depends on precise visualization of the proximal AT A on angiography (Fig. 1). The origin and upper 6 cm of the artery are exposed and "poplitealized," giving excellent access for an anastomosis. Disease present near the ATA recurrent artery is easily bypassed by extending the exposure. We always ligate the small muscle branches, but we prefer to save the recurrent branch if possible. However, the ATA is divided rather than jeopardize the exposure if the leg is large and the ATA is deep. The recurrent branch has been sacrificed in about half of these limbs and seems to be well tolerated as judged by graft patency and velocity on color-flow duplex examination results. The peroneal nerve is safe because the artery is moved posteromedially away from it. There has been no incident of nerve injury. During follow-up, only one problem has involved the ATA anastomosis, and there is no evidence of stenosis at present in any of the patent grafts. The projqmal medial approach allows a shorter graft with good alignment and avoids a counter incision. It was used on 12 of 14 grafts terminating in the ATA during the last 2 years. We have found proximal medial exposure of the AT A to be a very useful approach when the AT A is the dominant tibial vessel and the popliteal artery is occluded or badly diseased. REFERENCES 1. Tyson RR, Reichle FA. Technique of femorotibial bypass. Surgery 1970;68: Dardik H, Dardik I, Veith FJ. Exposure of the tibial peroneal arteries by a single lateral approach. Surgery 1974;75: Danese CA, Singer A. Lateral approach to the popliteal artery trifurcation. Surgery 1968;63: Gillot C. Medial approach to the anterior tibial artery. Press Med 1986;21: Dardik H, Elias S, Miller N, et al. Medial approach to the anterior tibial artery. J VAse SURG 1985;5: Szilagyi DE, Whitcomb JG, Smith RF. Anteromedial approach to the popliteal artery for femoropopliteal arterial grafting. Arch Surg 1959;78: Veith FJ, Gupta SK, Ascer E, et al. Improved strategies for secondary operations on infrainguinal arteries. Ann Vasc Surg 1990;4: Veith FJ, Ascer E, Gupta SK, Wengerter KR. Lateral approach to the popliteal artery. J VAse SURG 1987;6: Submitted April 19, 1993; accepted July 27, 1993.