Carotid–carotid crossover bypass after mechanical thrombectomy for internal carotid artery occlusion due to plaque from stenosed innominate artery

Background: The treatment for internal carotid artery occlusion (ICAO) due to innominate artery stenosis is not well established. We herein describe a case of carotid–carotid crossover bypass and common carotid artery (CCA) ligation after mechanical thrombectomy for ICAO due to a plaque from the stenosed innominate artery. Case Description: A 70-year-old man was transferred to our hospital because of left-sided hemiparalysis. Head magnetic resonance imaging/angiography showed a cerebral infarction in the right middle cerebral artery area and the right ICAO due to a plaque from the stenosed innominate artery. Immediately, we performed mechanical thrombectomy and successfully attained partial revascularization (Thrombolysis in Cerebral Infarction Grade 2B). After a conference with cardiovascular group, we performed carotid–carotid crossover bypass and the right CCA ligation. The treatment was successful, and no complications occurred. Conclusion: Carotid–carotid crossover bypass and CCA ligation may be a better option for innominate artery stenosis in selected patients.

Fatal Case of a Contained Ruptured of the Infrarenal Aorta due to Simultaneous Primary Aortocaval Fistula and Aortoenteric Fistula

We report an extremely rare case of primary aortocaval fistula with simultaneous development of an aortoenteric fistula in a 68-year-old man. The patient developed under oral anticoagulation a spontaneous intracaval aortic rupture. An emergency intervention was performed with a covering of the fistula with an aorto-uniiliac stent graft and a femoro-femoral crossover bypass. One week later, the patient was transferred to our institution with the diagnosis of a psoas abscess and a suspected concomitant aortoenteric fistula. We performed a complete explantation of the endograft and implanted it after extensive debridement an aortobiiliac bypass, made of bovine pericardium. The postoperative course was complicated, first by bleeding from the left iliac anastomosis, and then by bleeding from the proximal aortic anastomosis. The entire graft was explanted and an axillo-femoral bypass was implanted. The patient then developed a multi-organ failure and died 3 months later. If possible, an extended surgical debridement and resection of all infected tissue with in situ reconstruction is the gold standard. However, with this therapy, there is still a high risk of reinfection. Long-term antibiotic management is mandatory.

Temporary extracorporeal femoro-femoral crossover bypass to treat critical limb ischemia due to occlusive femoral transaortic microaxial left ventricular assist device – a novel technique and case series

Objective The Impella transaortic microaxial left ventricular assist device (MLVAD) bears the risk of severe ipsilateral limb ischemia due to it´s percutaneous insertion through the common femoral artery (CFA). As long as the MLVAD is required for cardio-circulatory support, treatment options are limited. Therefore, we developed a temporary extracorporeal femoro-femoral crossover bypass to restore and maintain perfusion of the affected leg. Methods From October 2018, we treated all patients with severe limb ischemia due to the MLAVD with a femoro-femoral crossover bypass. For comparison, a consecutive cohort of patients undergoing placement of the MLAVD between January 2011 and July 2019 was identified. For those patients who experienced limb ischemia after Impella placement, data on age, gender, BMI and diabetes, underlying cardiac condition, duration of Impella pump in place, limb complications, limb salvage procedure, need for additional surgical procedure on the affected limb (e.g. fasciotomy) were recorded. The primary outcome is the feasibility and safety of our percutaneously established extracorporeal femoro-femoral crossover bypass. As secondary outcomes, we report overall 30 day mortality and limb salvage rates. Results Between January 2011 and July 2019, 25 of 245 (10.3%) patients developed a severe ipsilateral limb ischemia following the MLVAD placement. Until October 2018, 20 patients were treated conventionally (C-cohort) and since October 2018, five (consecutive) patients have been treated by an extracorporeal femoro-femoral cross over bypass (BP-Cohort). Following the BP-procedure, an immediate improvement of the perfusion was seen in all patients. The bypass remained in place during a median of 5 days. Limb salvage was documented in 100% of our patients and 30 days mortality was 60% in both groups. Conclusion This is the first case series reporting on this novel technique. We demonstrated that the percutaneous creation of an extracorporeal femoro-femoral crossover bypass is feasible, safe and effective and should therefore be promoted in the future.

COMPARATIVE STUDY OF FEMORO-FEMORAL CROSSOVER BYPASS AND AORTO-UNIFEMORAL BYPASS

Iliac artery occlusions can produce Chronic limb-threatening ischemia and these patients need early revascularization procedures for their limb salvage which is usually established by Aorto-unifemoral bypass. But in patients with poor general conditions femoro-femoral crossover bypass is an alternate option. Ours is Comparative study of Femoro-femoral crossover bypass and Aorto-unifemoral bypass in patients with Iliac occlusion and Chronic limb-threatening ischemia. Total of 22 patients were included in which femorofemoral bypass performed in 10 patients and Aorto-unifemoral bypass in 12 patients. Indications for femorofemoral bypass were poor cardiac/respiratory functions and old age with poor performance. Stable patients were subjected to Aorto-unifemoral bypass. Patency rates and limb salvage rate were 100% with no perioperative mortality in both of these procedures. This shows femorofemoral bypass is an effective revascularization procedure in patients with Iliac occlusion and Chronic limb-threatening ischemia with associated poor general conditions.

Temporary extracorporeal femoro-femoral crossover bypass to treat critical limb ischemia due to occlusive femoral transaortic microaxial left ventricular assist device – A novel technique and case series

Background The Impella transaortic microaxial left ventricular assist device (MLVAD) is a temporary circulatory support (TCS). It's percutaneous insertion through the common femoral artery (CFA) bears the risk of severe ipsilateral limb ischemia. As long as the MLVAD is required for cardio - circulatory support, treatment options are limited. To approach this problem, we developed a temporary extracorporeal femoral - femoral crossover bypass to restore and maintain perfusion of the affected leg.The aim of this report is to introduce our novel technique and present results of a case series of accordingly treated patients.Methods From October 2018, we treated all patients with severe limb ischemia due to the MLAVD with a femoral - femoral crossover bypass and collected their data prospectively. For comparison, all consecutive patients undergoing placement of the MLAVD between January 2011 and July 2019 were identified retrospectively.The primary outcome of the study is the feasibility and safety of our percutaneously established extracorporeal femoral - femoral crossover bypass. As secondary endpoints, we report overall 30 - day mortality and limb salvage rates.Results Between January 2011 and July 2019, 25 of 245 (10.3%) patients developed a severe limb ischemia of the ipsilateral leg following the MLVAD placement.Until October 2018, 20 patients were treated conventionally (C - cohort) and since October 2018, five (consecutive) patients have been treated by an extracorporeal femoral - femoral cross over bypass (BP - Cohort).Following the BP - procedure, an immediate improvement of the perfusion of the affected limb was seen clinically and on Duplex ultrasound in all patients. 20% of the BP - cohort needed additional surgical salvage procedures compared to 25% of the C - Cohort. Limb salvage was documented in 100% of our patients and 30 days mortality was 60% in both groups.Conclusion This is the first case series reporting on a novel technique of limb salvage in patients with severe limb ischemia due to an MLVAD. We demonstrated that the percutaneous creation of an extracorporeal crossover bypass is feasible, safe and effective and should therefore be promoted.

Eine außergewöhnliche Therapie der Vena-iliaca-externa-Hypoplasie bei einer Patientin mit Klippel-Trénaunay-Syndrom – ein Fallbericht

ZusammenfassungDas Klippel-Trénaunay-Syndrom (KTS) ist eine seltene und komplexe Fehlbildung. Sie zeigt die typische Trias aus vaskulärer Malformation, Knochen- und Weichteilhypertrophie sowie venöser Varikosis. Die Systemmanifestationen werden in einem individuell variablen Muster beobachtet. Eine isolierte angeborene Hypoplasie des venösen Systems tritt jedoch in den seltensten Fällen auf. Aus diesem Grund spielt die Früherkennung eine wichtige Rolle für die weitere Behandlungsplanung. So können durch rechtzeitige Behandlung schwere Krankheitsverläufe oder Spätfolgen vermieden werden. Eine isolierte angeborene Hypoplasie ist extrem selten und prädisponiert insbesondere im jungen Erwachsenenalter für Becken- oder Beinvenenthrombosen. Bei dieser Krankheit wird selten eine chirurgische Rekonstruktion durchgeführt.Wir beschreiben einen sehr seltenen Fall einer 60-jährigen Frau mit KTS, die vor 28 Jahren einen venösen Crossover-Bypass (Palma) mittels Vena saphena magna bei Hypoplasie der Vena iliaca externa rechts erhalten hat. Das Ziel des vorliegenden Berichts ist das klinische Erscheinungsbild, den diagnostischen Prozess und das Krankheitsmanagement vorzustellen sowie eine Literaturübersicht zum operativen Behandlungsverfahren darzustellen.