Southern Association for Vascular surgery

October 15, 2007

THE "Patchula" BYPASS: A VIABLE OPTION FOR THE PATIENT WITHOUT AUTOGENOUS CONDUIT AND SEVERE DISTAL OCCLUSIVE DISEASE

Richard F Neville, Benzon Dy*, William King*, Niten Singh*
Georgetown University, Washington, DC

Background: The addition of a distal arteriovenous fistula (dAVF) to improve patency in lower extremity bypass is well described. We have previously illustrated the technique of enhancing a distal vein patch bypass (DVP) with a dAVF ("patch-ula") for those patients with no autogenous conduit and severely disadvantaged arterial runoff. This report describes the results of our initial patient cohort using this patchula bypass for limb salvage.
Methods: From May 2002 to May 2007, 270 tibial bypasses were performed. A retrospective review revealed 95 bypasses using DVP as the conduit including 30 with the addition of a dAVF (patchula). Patient demographics included; 16 males, 14 females, diabetes mellitus (20, 66.7%), and chronic renal failure (6, 20%). All patients had limb threatening ischemia manifest as rest pain and/or tissue loss with 20 cases (66.7%) referred after failed prior revascularization; 11 failed bypasses and 9 failed endovascular interventions. The recipient artery was an isolated tibial segment, or, a severely diseased sole vessel runoff not ordinarily deemed suitable for bypass. At surgery, a common channel AVF was created between the recipient tibial artery and corresponding tibial vein prior to construction of the DVP. All patients were discharged on coumadin. Follow-up ranged from 1-60 months with graft function evaluated by pulse exam and Duplex graft surveillance. Primary patency and limb salvage ± SE were determined by life-table analysis using Rutherford criteria.
Results: The proximal anastomosis originated from the external iliac (7, 23.3%), CFA (13, 43.3%), or SFA (10, 33.3%). Recipient arteries included the anterior tibial (12,40%), posterior tibial (9,30%), or peroneal (9,30%). Venous hypertension in the bypassed limb was occasionally noted, but not considered problematic. Perioperative graft failure occurred in 1 patient with a total of 6 graft failures leading to 6 major amputations (1 AKA, 5 BKA). One patent graft was excised due to infection. Primary patency and limb salvage rates are noted below.

	6 month	12 months	18 months	24 months	+ 24 months
Primary patency	78.3% + 6.8% N = 29	78.3% + 10.5% N = 12	62.6% + 11.1% N = 12	62.6% + 15.6% N = 6	N = 3
Limb Salvage	78.7% + 6.7% N = 29	78.7% + 10.1% N = 13	78.7% + 10.1% N = 13	57.7% + 12.5% N = 9	N = 4

Conclusion: This early experience describes a modification of the DVP technique in patients with threatened limb loss and severely disadvantaged tibial runoff. The addition of an AVF may reduce outflow resistance thereby contributing to higher flow rates and improved graft patency. Further investigation and is warranted as the "patchula" technique may result in acceptable graft patency and limb salvage for those patients with no other alternative than amputation.

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