Preserved Renal Function in Kidney Transplantation over a Thrombosed Aortobifemoral Bypass Graft: The Role of Retrograde Flow and Early Thrombolysis

Aortobifemoral bypass (ABFB) thrombosis is not uncommon, and when the artery of a renal graft is implanted on a bypass the risk of graft loss is high. We report the case of a 48-year-old woman with a previous history of ABFB under antiplatelet therapy and a kidney allograft implanted on the vascular prosthesis, who presented with acute limb ischemia and severe renal impairment. Imaging techniques revealed a complete thrombosis of the proximal left arm of the ABFB. However, a faint retrograde flow over the graft was observed thanks to the recanalization of distal left bypass by collateral native arteries. This unusual situation not previously reported in a kidney transplant setting, together with an early diagnosis, allowed graft survival until an early local thrombolysis resolved the problem. Two years later, renal function remains normal.

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Advanced treatment of acute femoropopliteal bypass graft occlusion with Fogarty catheter guidance

Vascular ◽

10.1177/1708538113496238 ◽

2013 ◽

Vol 22 (4) ◽

pp. 262-266 ◽

Cited By ~ 1

Author(s):

Gokhan Albayrak ◽

Koray Aykut ◽

Mehmet Guzeloglu ◽

Aytac Gulcu ◽

Eyup Hazan

Keyword(s):

Bypass Graft ◽

Limb Ischemia ◽

Graft Patency ◽

Transluminal Angioplasty ◽

Acute Limb Ischemia ◽

Graft Occlusion ◽

Fogarty Catheter ◽

Femoropopliteal Bypass ◽

Conventional Angiography ◽

Stent Grafting

Purpose The guiding role of the Fogarty catheter was investigated among patients suffering from limb ischemia due to acute femoropopliteal bypass graft occlusion. Methods A total of 27 patients with a history of femoropopliteal bypass operation who was admitted with acute limb ischemia were enrolled in this retrospective study. In cases in which the Fogarty catheter could not be passed through the popliteal anastomosis, the popliteal region was explored and a new bypass or patch plasty was performed for the distal anastomosis. The cases in which the blood circulation was observed in the graft, but in which the Fogarty catheter balloon was stuck in the native vessels on the proximal and distal side of the graft and the balloon could be withdrawn by deflation, were referred to conventional angiography. The stenosis observed in native vessels was managed by endovascular stent grafting and/or balloon dilatation. Findings Graft patency was achieved in all patients. In 11 patients, conventional angiography was implemented following embolectomy. In these patients, all the occlusions found as significant on angiography were removed by percutaneous transluminal angioplasty. Conclusion Effective use of Fogarty catheter is safe in acute femoropopliteal bypass graft occlusions and in particular, in the planning of further treatment following thrombectomy.

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Acute Limb Ischemia

DeckerMed Surgery ◽

10.2310/surg.2100 ◽

2012 ◽

Author(s):

Jovan N. Markovic ◽

Cynthia K. Shortell

Keyword(s):

Clinical Evaluation ◽

Bypass Graft ◽

Limb Ischemia ◽

Heparin Therapy ◽

Common Symptom ◽

Acute Limb Ischemia ◽

Graft Occlusion ◽

Surgical Embolectomy

Acute limb ischemia (ALI) is one of the most challenging conditions in vascular surgery and carries a high risk of amputation and mortality when treatment is delayed. Limb ischemia occurs when there is abrupt interruption of blood supply to an extremity because of either embolic or in situ thrombotic arterial or bypass graft occlusion. The goals of management include limb salvage, minimization of morbidity, and prevention of death. However, given that no objective markers of limb viability are currently available, the initial determination of whether a limb is likely to be viable must be made on clinical grounds. An early clinical evaluation is crucial for the diagnosis and identification of the underlying etiology of the ALI. As ALI is a clinical diagnosis, this review describes all aspects of the clinical evaluation as essential: patient history, staging of limb ischemia, and investigative studies. Atheromatous embolization is also discussed in depth. The characteristic signs of ALI may be summarized as the “six p’s”: pulselessness, pain, pallor, poikilothermia, paresthesia, and paralysis. Pain is the most common symptom in an ischemic limb and progresses along with the ischemia. As ischemia continues to progress, severe pain can be replaced by anesthesia of the limb, which can confound the examiner. Thus, pain should be documented with regard to severity, localization, and progression. ALI therapies covered are heparin therapy, thrombolytic therapy, thrombectomy, and surgical embolectomy and revascularization. The pathophysiology of limb ischemia is related to the progression of tissue infarction and irreversible cell death. Compared with other organs and tissues (e.g., the brain and the heart), the extremities are relatively resistant to ischemia. However, the various tissue types of which an extremity is composed have different metabolic rates. This review has 2 figures, 6 tables, and 165 references.

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Aortic Graft Infection Secondary to Iatrogenic Transcolonic Graft Malposition

Vascular and Endovascular Surgery ◽

10.1177/1538574418764037 ◽

2018 ◽

Vol 52 (5) ◽

pp. 386-390

Author(s):

Jacqueline J. Blank ◽

Abby E. Rothstein ◽

Cheong Jun Lee ◽

Michael J. Malinowski ◽

Brian D. Lewis ◽

...

Keyword(s):

Vascular Surgery ◽

Bypass Graft ◽

Graft Infection ◽

Preoperative Imaging ◽

Sigmoid Colectomy ◽

Acute Limb Ischemia ◽

Bypass Grafting ◽

Aortic Graft ◽

Aortobifemoral Bypass ◽

Aortic Graft Infection

Aortic graft infections are a rare but devastating complication of aortic revascularization. Often infections occur due to contamination at the time of surgery. Iatrogenic misplacement of the limbs of an aortobifemoral graft is exceedingly rare, and principles of evaluation and treatment are not well defined. We report 2 cases of aortobifemoral bypass graft malposition through the colon. Case Report: Case 1 is a 54-year-old male who underwent aortobifemoral bypass grafting for acute limb ischemia. He had previously undergone a partial sigmoid colectomy for diverticulitis. Approximately 6 months after vascular surgery, he presented with an occult graft infection. Preoperative imaging and intraoperative findings were consistent with graft placement through the sigmoid colon. Case 2 is a 60-year-old male who underwent aortobifemoral bypass grafting due to a nonhealing wound after toe amputation. His postoperative course was complicated by pneumonia, bacteremia thought to be secondary to the pneumonia, general malaise, and persistent fevers. Approximately 10 weeks after the vascular surgery, he presented with imaging and intraoperative findings of graft malposition through the cecum. Conclusions: Aortic graft infection is usually caused by surgical contamination and presents as an indolent infection. Case 1 presented as such; Case 2 presented more acutely. Both grafts were iatrogenically misplaced through the colon at the index operation. The patients underwent extra-anatomic bypass and graft explantation and subsequently recovered.

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The Trellis Thrombectomy System in the Treatment of Acute Limb Ischemia

Journal of Endovascular Therapy ◽

10.1177/152660280301000223 ◽

2003 ◽

Vol 10 (2) ◽

pp. 317-321 ◽

Cited By ~ 8

Author(s):

Karthikeshwar Kasirajan ◽

Venkatesh G. Ramaiah ◽

Edward B. Diethrich

Keyword(s):

Thrombolytic Agent ◽

Bypass Graft ◽

Limb Ischemia ◽

Acute Limb Ischemia ◽

Graft Thrombosis ◽

Percutaneous Mechanical Thrombectomy ◽

Flow Restoration ◽

Drug Dispersion ◽

Thrombectomy Device ◽

Distal Occlusion

Purpose: To report the use of a new percutaneous mechanical thrombectomy device in the treatment of acute limb-threatening ischemia. Technique: The Trellis Thrombectomy System is a 7-F drug dispersion catheter that features a treatment segment isolated by proximal and distal occlusion balloons, which help prevent distal embolization and systemic release of the infused thrombolytic agent. After inflating the distal balloon, the thrombolytic agent is infused and held at the target site by inflation of the proximal balloon. An oscillating dispersion wire optimizes dispersal of the thrombolytic agent as the thrombus is mechanically fragmented. The liquefied thrombus is then aspirated. Four consecutive patients with acute lower extremity ischemia secondary to bypass graft thrombosis were treated with the Trellis thrombectomy catheter. Overall, 95% of thrombus was successfully removed from the treatment zone, with no device-related complications. Only one patient required adjunctive thrombolytic therapy after thrombectomy with the Trellis device. Conclusions: The Trellis thrombectomy device is a safe and effective technique to isolate the infused thrombolytic agent in association with mechanical fragmentation for rapid blood flow restoration.

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Antithrombotic therapy for postinterventional management of peripheral arterial disease

American Journal of Health-System Pharmacy ◽

10.1093/ajhp/zxz315 ◽

2020 ◽

Vol 77 (4) ◽

pp. 269-276

Author(s):

Daria Zavgorodnyaya ◽

Tamara B Knight ◽

Mitchell J Daley ◽

Pedro G Teixeira

Keyword(s):

Peripheral Arterial Disease ◽

Antiplatelet Therapy ◽

Antithrombotic Therapy ◽

Bypass Graft ◽

Limb Ischemia ◽

Arterial Disease ◽

Acute Limb Ischemia ◽

Increased Risk ◽

Peripheral Arterial ◽

Quality Evidence

Abstract Purpose Evidence on the use of antithrombotic pharmacotherapy in patients undergoing revascularization of lower extremities for symptomatic peripheral arterial disease (PAD) is reviewed. Summary Individuals with PAD can experience leg pain, intermittent claudication, critical limb ischemia, and acute limb ischemia. In such patients, revascularization may be indicated to improve the quality of life and to prevent amputations. Antithrombotic therapy is often intensified in the postrevascularization period to prevent restenosis of the index artery and to counteract the prothrombotic state induced by the intervention. Therapeutic modalities include dual antiplatelet therapy (DAPT), anticoagulation, a combination of antiplatelet and anticoagulation therapy, and addition of cilostazol to single antiplatelet therapy. Subgroup analyses of data from randomized clinical trials provided low-quality evidence for the use of DAPT in patients with a below-knee prosthetic bypass graft and anticoagulation for those with a venous bypass graft. Cilostazol, when added to aspirin therapy, has been shown to prevent index vessel reocclusion after an endovascular intervention in patients at low risk for thrombosis in several small randomized trials. Conclusion There is a considerable paucity of high-quality evidence on the optimal antithrombotic regimen for patients undergoing lower extremity revascularization, with no particular therapy shown to consistently improve patient outcomes. The decision to initiate intensified antithrombotic therapy should include a close examination of its risk–benefit profile. The demonstrated benefit of such treatment is restricted to the prevention of index artery reocclusion, while an increased risk of bleeding may lead to significant morbidity and mortality.

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The association of opium dependence and postoperative complications following coronary artery bypass graft surgery: A propensity-matched study

Journal of Opioid Management ◽

10.5055/jom.2009.0036 ◽

2018 ◽

Vol 5 (6) ◽

pp. 365-372 ◽

Cited By ~ 7

Author(s):

Saeed Sadeghian, MD ◽

Abbasali Karimi, MD ◽

Samaneh Dowlatshahi, MD ◽

Seyed Hossein Ahmadi, MD ◽

Saeed Davoodi, MD ◽

...

Keyword(s):

Coronary Artery ◽

Coronary Artery Bypass ◽

Artery Bypass ◽

Bypass Graft ◽

Public Health Problem ◽

Limb Ischemia ◽

Acute Limb Ischemia ◽

Preoperative Risk Factors ◽

Post Operation ◽

Matched Study

Objective: Opium is an overwhelming public health problem in some countries. Different studies have suggested this drug as a risk factor for cardiovascular disease. Although the effect of opium on immune system, lung disease, nephropathy, stroke, and cardiac arrhythmia has been found in different studies, its effect on postoperation complications is not clear yet. The authors conducted this study to assess the effect of opium on post operation in hospital complications among patients who underwent coronary artery bypass graft.Design: The authors retrospectively analyzed the data in this study.Setting: This study has been done at Tehran Heart Center.Patients: A total of 4,398 patients who had undergone isolated CABG were studied.Main outcome measure: Patients who fulfilled the DSM-IV-TR criteria for opium dependence (by smoking) were enrolled as Opium Dependent Patients. Also outcome variables were: Perioperative MI, septicemia, UTI, TIA, continuous coma, prolonged ventilation, pulmonary embolism, renal failure, acute limb ischemia, heart block, AF, mortality.Results: The prevalence of opium dependence was 15.6 percent among patients. The authors used a propensity matched model to analyze the relationship between opium and post operation complications. The authors adjusted opium and non-opium dependent patients in all of the baseline preoperative risk factors, so all of the matched patients were same and there was no bias in assessment.Conclusion: Opium dependent patients had significantly longer resource utilization. However, no significant relationship was found between opium dependence and other cardiac and non cardiac in hospital complications.

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Isolated pharmaco-mechanical thrombectomy (IPMT) for the endovascular treatment of acute axillofemoral graft occlusion

Vascular Medicine ◽

10.1177/1358863x13477233 ◽

2013 ◽

Vol 18 (1) ◽

pp. 27-31 ◽

Cited By ~ 1

Author(s):

Siddharth Wayangankar ◽

Jigar Patel ◽

Thomas A Hennebry

Keyword(s):

Mechanical Thrombectomy ◽

Bypass Graft ◽

Limb Ischemia ◽

Anastomotic Site ◽

Acute Limb Ischemia ◽

Graft Occlusion ◽

Distal Embolization ◽

Clot Burden ◽

Endovascular Devices

Since the long-term patency of axillofemoral (AXF) grafts is inferior to aorto-bifemoral (ABF) grafts, limb salvage procedures are crucial in this group of patients. Emerging endovascular devices have helped in the successful restoration of flow for acute limb ischemia in both native arteries as well as bypass grafts. One such device, the Trellis™ thrombectomy system is being used more frequently in this setting. The device has previously been used in veins, native arteries, and rarely in aortofemoral grafts. We present its first successful use for the treatment of occluded AXF bypass graft. The use of this device helped to isolate the treatment zone in the occluded graft, which allowed the use of a lower dose of thrombolytics, less systemic release of thrombolytics, and less distal embolization. Resolution of extensive clot burden was achieved and, with subsequent stenting of the graft at the distal anastomotic site, arterial flow to the leg through the AXF graft was restored and a revision surgery was avoided.

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Occluded Infrainguinal Bypass Graft: Potential Source of Limb-Threatening Emboli

Vascular ◽

10.2310/6670.2006.00029 ◽

2006 ◽

Vol 14 (3) ◽

pp. 156-160

Author(s):

Ankur Chandra ◽

Niren Angle

Keyword(s):

Bypass Graft ◽

Limb Ischemia ◽

Treatment Modalities ◽

Acute Ischemia ◽

Acute Limb Ischemia ◽

Graft Occlusion ◽

Graft Thrombosis ◽

Peripheral Embolization ◽

Surgical Bypass ◽

Peripheral Arterial

Surgical bypass represents one of the chief treatment modalities for peripheral arterial occlusive disease. Despite improving techniques, graft occlusion accounts for the majority of these bypass failures. Once occluded, however, these grafts are thought to rarely pose a threat for future ischemic events. This report describes two patients with previously thrombosed grafts who subsequently presented with limb-threatening ischemia owing to peripheral embolization from the graft. Two patients with occluded grafts presented with ipsilateral limb-threatening acute ischemia. Both of these patients developed severe acute limb-threatening ischemia weeks to months after known graft thrombosis. Arteriography revealed peripheral embolization in each case. Both patients were operated on for disconnection of the thrombosed graft from the native circulation and have been free of recurrent symptoms. The occluded graft, although generally innocuous, can be a source of peripheral emboli, resulting in peripheral embolization and acute limb ischemia. Both patients in this report developed limb-threatening ischemia owing to embolization from the cul-de-sac of occluded prosthetic grafts. Due to the rarity of the condition and its associated morbidity and mortality, awareness and recognition of this phenomenon are critical. Operative disconnection is recommended if the embolism occurs downstream of the graft and no other embolic source can be identified.

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Endovascular approach for acute limb ischemia without thrombolytic therapy

Therapeutic Advances in Cardiovascular Disease ◽

10.1177/1753944720924575 ◽

2020 ◽

Vol 14 ◽

pp. 175394472092457

Author(s):

Keisuke Fukuda ◽

Yoshiaki Yokoi

Keyword(s):

Mortality Rate ◽

Endovascular Therapy ◽

Thrombolytic Agent ◽

Artery Bypass ◽

Bypass Graft ◽

Limb Ischemia ◽

Acute Limb Ischemia ◽

Surgical Revascularization ◽

Technical Success Rate ◽

Kaplan Meier

Background: Endovascular therapy for acute lower limb ischemia (ALLI) has developed and demonstrated safety and efficacy. The purpose of this study was to assess clinical outcomes in patients treated for ALLI with conventional endovascular or surgical revascularization. Method: This study was a retrospective single-center review. Consecutive patients with ALLI treated with conventional endovascular revascularization (ER) without thrombolytic agent or surgical revascularization (SR) between 2008 and 2014 were investigated. The 1 year and 3 year amputation rate and mortality rate were assessed by time-to-event methods, including Kaplan–Meier estimation. Result: A total of 64 limbs in 62 patients with ALLI due to thromboembolism or thrombosis of a native artery, bypass graft, or previous stented vessel were included. The majority of limbs (90.9%) presented with Rutherford clinical categories 1 to 2 ischemia. Technical success rate was 95.5% in ER and 92.9% in SR group ( p = 0.547). Overall amputation rates were 9.1% in ER versus 9.5% in SR after 1 year ( p = 0.971) and 9.1% in ER versus 11.9% in SR after 3 year ( p = 0.742). Overall mortality rates were 15% in ER versus 7.1% in SR after 1 year ( p = 0.491) and 15% in ER versus 11.2% in SR after 3 year ( p = 0.878). Conclusion: Endovascular or surgical revascularization of ALLI resulted in comparable outcomes in limb salvage and mortality rate at 1 year and 3 year. Conventional endovascular therapy without thrombolytic agent such as stenting, balloon angioplasty, or catheter-directed thrombosuction may be considered as a treatment option for ALLI.

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Regional Thrombolytic Therapy and Stent Implantation in an Acutely Occluded Aortobifemoral Bypass Graft

Journal of Endovascular Therapy ◽

10.1177/152660280301000118 ◽

2003 ◽

Vol 10 (1) ◽

pp. 86-89 ◽

Cited By ~ 1

Author(s):

Angelo Anzuini ◽

Roberto Chiesa ◽

Flavio Airoldi ◽

Giorgio Gimelli ◽

Efrem Civilini ◽

...

Keyword(s):

Stent Implantation ◽

Bypass Graft ◽

Limb Ischemia ◽

Aortobifemoral Bypass ◽

Total Occlusion ◽

Graft Thrombosis ◽

Catheterization Laboratory ◽

Local Thrombolysis ◽

Complete Lysis ◽

Repeat Angiography

Purpose: To present a case highlighting the efficacy of local thrombolysis followed by stent implantation in acute occlusion of an aortobifemoral bypass graft. Case Report: A 47-year-old man was referred to our catheterization laboratory for acute bilateral limb ischemia occurring 18 hours after an aortobifemoral bypass procedure. Angiography documented total occlusion due to massive thrombosis of the grafts. After 24 hours of local thrombolysis, repeat angiography showed complete lysis of the thrombus and an intimal flap in the abdominal aorta. A Palmaz stent was successfully implanted to cover the flap and restore adequate flow. At 1 year, the patient remains asymptomatic, and angiography showed patency of both the stent and the grafts. Conclusions: Based on this patient's response, local thrombolysis followed by stenting may be a safe and effective alternative to reoperation for the treatment of acute graft thrombosis caused by an intimal aortic flap. More experience with this approach is necessary to determine if this is an acceptable and effective mode of treatment.

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