Comment améliorer le pronostic des pontages infrapoplités ?

Composite femoro-tibial bypass as alternative solution in complicated revascolarization: Case report

Introduction

Peripheral Arterial Disease (PAD) in diabetic patients is a significant cause of Morbility. Long arterial occlusion in patient previously treated can require unusual and complex solution. Herein we report a case of complicated bypass in diabetic patient with history of bypass for bilateral popliteal aneurysm.

Presentation of case

A 51-year-old male, smoker, with hypertension and diabetes mellitus was referred to our hospital for rest pain in left limb and peripheral cyanosis. Ultrasound doppler (US) showed an occlusion after common femoral artery with patency of Anterior-tibial artery (ATA) two centimeters after the origin. The unavailability of adequate autologous conduit necessitated an alternative solution and was chosen a composite femoro-anterior tibial artery bypass with successive ATA angioplasty to ensure the patency of graft.

Discussion

The autogenous vein is the preferred conduit in below-knee vascular reconstructions but in redo-procedures in the absence of vein, synthetic or biologic vascular prostheses must be considered as graft material. In these cases tibial angioplasty can improve the outflow and the patency.

Conclusion

Composite Femoro-ATA bypass with tibial angioplasty is an alternative technique for critically ischemic legs with limited autologous vein material. In our experience this approach was safe and effective.

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Damage of microcirculation can be due to major amputation with an incidence of 30.7%.

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Long arterial occlusion in patient previously treated can require complex solution.

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In this case we have chosen a composite femoro-anterior tibial artery bypass.

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Composite Fem-ATA bypass with tibial angioplasty is an alternative technique in CLI.

Evaluating intimal hyperplasia under clinical conditions

OBJECTIVES

Open arterial revascularization using venous segments is frequently associated with the development of intimal hyperplasia (IH), leading to severe restenosis and graft failure. The lack of treatment to prevent this pathology is a major problem. Therefore, we generated a new porcine model, which closely mimics the clinical development of human IH, to test the therapeutic potential of candidate drugs.

METHODS

A patch of jugular vein was sutured to the right common carotid artery of pigs, to expose the vein to haemodynamic conditions of the arterial bed. Four weeks after surgery, the operated vessels which received no further treatment (the control group) were compared with (i) contralateral, non-operated vessels (the healthy group); (ii) vessels of pigs that received a perivascular application of a drug-free microparticle gel (the placebo group) and (iii) vessels of pigs that perioperatively received the same gel loaded with 10-mg atorvastatin (the atorvastatin group).

RESULTS

When compared with non-operated vessels, all operated segments displayed a sizable IH which was thicker in the venous patch than in the host artery. These alterations were associated with a thickening of the intima layer of both vessels in the absence of inflammation. The intima/media ratio has been significantly increased by 2000-fold in the vein patches. Perivascular application of atorvastatin did not prevent IH formation. However, the drug increased the adventitial neovascularization in the operated vessels.

CONCLUSIONS

The novel porcine model allows for monitoring IH formation under haemodynamic conditions which mimic clinical situations. It should facilitate the screening of innovative treatments to prevent restenosis.

[New progress in the treatment of chronic wound of diabetic foot]

Diabetic foot is one of the serious complications of diabetic patients. It is caused by diabetes combined with different degrees of lower extremity vascular lesions and neuropathy, and the wound can not heal for a long time. The serious results can cause bone marrow infection, bone destruction, and have high disability and death rate. At present, there are various treatment methods for diabetic foot chronic wound. On the basis of internal medicine controlling blood sugar, anti infection, lowering blood lipid, improving microcirculation and nourishment nerve, the surgical method is adopted, including the debridement of the necrosis in a short time to prevent the infection from spreading; maggot biological debridement and ozone chemical debridement will promote the growth of granulation tissue while controlling infection. Skin grafting, skin flap transplantation, skin distraction closure can be used to repair soft tissue defects, or fat transplantation, platelet-rich plasma, and rich blood are used for the refractory wound after infection control. In patients with diabetic foot, the reconstruction of lower limb blood supply is beneficial to the recovery of chronic ischemic wounds. It is feasible to improve the blood supply of the lower extremities, improve the blood supply of the lower extremity artery bypass grafting, and improve the microcirculation of the peripheral vessels around the lower extremities. Lower extremity vascular bypass pressure perfusion therapy for vascular network expansion, tibia lateral moving technique for lower limb microcirculation reconstruction. For diabetic foot ulcer caused by peripheral neuropathy, such as Charcot foot, while the application of external fixator, total contact cast technology of affected foot for reducing treatment to promote wound healing; the preparation of orthopedic shoes can play a maximum protective effect on the healing of diabetic foot wound healing.