A Hybrid Technique Using a Viabahn Endoprosthesis for Graft Anastomosis to a Previously Stented Artery
Lauren A. Huntress, MD, Saum A. Rahimi, MD, Randy Shafritz, MD.
Rutgers-RWJMS, New Brunswick, NJ, USA.
DEMOGRAPHICS: A 57-year-old Caucasian female with a history of an aorto-bifemoral bypass for aorto-iliac occlusive disease (AOID) presented with an infected right limb necessitating removal and extra-anatomic revascularization. Herein, we present a hybrid anastomotic technique using a Viabahn Endoprosthesis (W.L. Gore) for graft anastomosis to a previously stented artery for an axillary-superficial femoral artery (SFA) bypass.
HISTORY: Her past medical history includes hepatitis C, HTN, COPD, 50 pack-per-day smoker, and severe PAD. Her past vascular surgical history includes a left femoral endarterectomy with bovine patch angioplasty and bare metal stenting of the right SFA extending into the distal common femoral artery (CFA). Two years later, she underwent an aorto-bifemoral bypass complicated by the development of a right groin seroma. Nine months later, she presented with bacteremia and an infected anastomotic pseudoaneurysm (PSA) with a draining sinus tract of the right groin. CTA confirmed a patent aorto-bifemoral bypass with an isolated, infected PSA of the right graft limb at the femoral anastomosis.
PLAN: Surgical resection of the right external iliac artery, graft limb, and CFA with ligation of the proximal profunda and SFA was performed prior to extra-anatomic revascularization. The profunda branched just distal to its origin, and was not a suitable bypass target. The previously stented SFA was patent and of normal caliber, so we proceeded with a right axillary to distal SFA bypass. Prior to performing the distal anastomosis, the SFA was re-lined with a Viabahn stent graft which served as an SFA endoprosthesis, and the axillary-SFA bypass was anastomosed end-to-end to the Viabahn graft.
DISCUSSION: Sutureless or hybrid anastomotic techniques have been previously described in the literature to circumvent difficult anastomoses. These include the Viabahn Open Revascularization Technique (VORTEC), the Sutureless Telescoping Anastomotic Technique (STAT), and most recently, the Viabahn Padova Sutureless (ViPS) technique. The use of these hybrid methods has shown high rates of technical success for visceral revascularization, however their application in the periphery remains largely unexplored. Deployment of a covered stent in a target artery facilitates graft-to-graft anastomoses, and avoids the difficulties associated with sewing graft-to-vessel, especially in the setting of a small, fragile, or heavily calcified recipient artery. To our knowledge, use of this hybrid technique has not been described for a graft anastomosis to a previously stented vessel.
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