“Combining Endovascular and Bypass Surgery for Lower Extremity Vascular Reconstruction”

2023-05-27 21:30:00

▲ Below-the-knee bypass surgery plan. (Photo provided / Li Yingsheng)

Text / Li Yingsheng

What to do when the patient does not have a vein long enough for lower extremity bypass? A patient in his 70s encountered such a problem. Having been diabetic for many years, chronic wounds in her lower extremities gradually formed. Ultrasound examination revealed that the veins were atrophic and of poor quality, and only some of the veins could be used as arterial bypasses in the lower extremities. Therefore, after discussing with the patient, a composite operation was adopted to reconstruct the blood vessels of the lower extremities. The knee was treated with endovascular treatment, and the more serious part under the knee was bypassed. Finally, the patient’s wound was healed successfully.

Diabetic foot seems to be a simple wound problem, but it is actually a disease of lower extremity arterial obstruction. The mortality rate of this disease is extremely high. According to the statistics of the National Health Insurance Database, once a chronic wound occurs, the average remaining life of the patient is about 6 years. Unfortunately, if the wound worsens and leads to amputation, about 40% of patients will face amputation of the other foot, and the mortality rate after amputation is about 40% within 3 years. Generally speaking, among the complications caused by diabetes, chronic wounds are the most troublesome. To restore wounds, blood flow reconstruction plays a key role.

▲Image before balloon expansion of blood vessels on the knee. (Photo provided / Li Yingsheng)

The vein is not long enough for lower extremity vascular bypass surgery

Vascular bypass surgery of the lower extremities, confirmed by a large prospective literature as the best way to treat wounds, has become the standard of care. However, for patients whose veins are not of good quality, we can use compound surgery to leave the most difficult parts for bypass surgery and the relatively easy parts for catheter treatment. Catheter therapy, also known as endovascular therapy, is widely used in patients with diabetic feet, but has limited efficacy in treating the small vessels distal to the knee. Balloon dilatation means that the blood vessel is forcibly expanded, resulting in severe damage to the intima of the blood vessel, resulting in thickening of the intima, further leading to restenosis complications, and further deterioration of the wound; if the blood flow rate is low, thrombus may also form, resulting in Acute lower extremity ischemia.

The blood vessels of the lower extremities are reconstructed through composite surgery, the blood flow above the knee is treated with a catheter to open the blood flow, and then the distal blood vessels under the knee are bypassed to reconstruct the arterial blood flow of the entire lower extremity. This method can avoid as far as possible the injury of the intima of the distal small blood vessels under the knee, and can also avoid the large wound of traditional surgery. Each patient can be tailor-made treatment policy, please be sure to find a professional doctor for evaluation.

(The author is a cardiovascular surgeon at Linkou Chang Gung Hospital)

▲Image after balloon expansion of blood vessels on the knee. (Photo provided / Li Yingsheng)

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