The Sutureless Anastamosis: A technique for the treatment of circumferential calcification

BACKGROUND Peripheral arterial bypass surgery involving outflow target vessels with circumferential calcification is challenging and may prevent completion of a safe anastamosis. We describe a unique sutureless anastomosis that may be suitable for the treatment of patients with diffuse, circumferential calcification precluding conventional sutured anastomosis.
METHODS The patient was a 72 year old man with left leg rest pain. He had diabetes, hypertension, hypercholesterolemia and obesity. He stopped smoking 5 years ago but was restricted by limited pulmonary reserve. He had a prior aortobifemoral bypass graft (AFBG) for AAA and a patent synthetic right fem-pop graft. On the left side, the SFA was occluded at the origin and the there was reconstitution of the above-knee popliteal artery and three vessel runoff. There was diffuse, heavy, circumferential calcification involving the CFA, SFA and popliteal arteries. At operation, a short segment of the occluded mid-SFA was exposed. A 2-cm endarterectomy was performed to create an access site to the SFA. Through this side window, a glide wire and glide catheter were used to recanalize the distal SFA and confirm re-entry into the popliteal artery. The distal SFA and proximal popliteal arteries were sequentially dilated to accommodate an 8mm Viabahn endograft. The proximal end of the endograft emerged directly out of the sidewall of the occluded mid-SFA and was sutured to a segment of 8mm ringed PTFE. Through a separate groin incision, the PTFE graft was sutured to the previous limb of the AFBG.
RESULTS There were no early postoperative complications. At late follow-up, he was symptom-free and had strong pedal pulses and an ABI=1.03.
CONCLUSIONS This sutureless technique may be appropriate in selected situations in which a conventional sutured anastomosis is technically impossible due to heavy calcification or where exposure of the distal landing zone is limited.