Infrainguinal saphenous vein graft aneurysm and aortic aneurysm

Short-Term Results of Varicose Vein Graft Used for Lower-Limb Bypass Surgery

Objective: Due to the potential of thrombus blockage and aneurysm rupture, saphenous veins with varicose veins are not advised for use as bypass grafts. However, if no other autologous vein is accessible for use as a conduit in lower-limb bypass; varicose vein transplants may be employed. Few reports have studied the clinical results of lower-limb bypass using varicose vein grafts. We therefore investigated whether or not acceptable patency rates of varicose vein graft for lower-limb bypass could be achieved. Methods: We performed lower-limb bypass using varicose vein graft on nine limbs from June 2017 to May 2020 and conducted a retrospective analysis of prospectively collected data. Results: Early graft failure following bypass surgery using a varicose vein transplant was not detected, and major complications, such as acute graft occlusion or aneurysm dilatation, were not noted throughout the follow-up period. The primary and secondary patency of varicose vein graft was 70.0% and 100% at 3 years, respectively. Conclusion: The incidence of major problems of the varicose vein transplants does not seem to be higher than with conventional saphenous vein grafts. If there are no other appropriate autologous veins, a varicose vein graft may be useful as a conduit for bypass surgery.

Vein graft aneurysms following popliteal aneurysm repair are more common than we think

True infrainguinal vein graft aneurysms are reported infrequently in the literature. We sought to identify the true incidence of these graft aneurysms after popliteal aneurysm repair and identify factors which may increase the risk of such aneurysms developing. Using a prospectively compiled database, we identified patients who underwent a popliteal aneurysm repair between January 1996 and January 2011 at a single district general hospital. Patients were routinely followed up in a graft surveillance programme. Out of 45 patients requiring repair of a popliteal aneurysm over a 15-year period, four (8.8%) patients developed aneurysmal graft disease. Of the patients who developed graft aneurysms, all had aneurysmal disease at other sites compared with 18 (45.0%) patients who did not develop graft aneurysms. Patients with graft aneurysms had a mean of 1.60 aneurysms elsewhere compared to 0.58 in patients with non-aneurysmal grafts ( P = 0.005). True vein graft aneurysms occur in a significant number of patients following popliteal aneurysm repair. Our data would suggest this to be more likely in patients who have aneurysms elsewhere and therefore a predisposition to aneurysmal disease. It may be appropriate for patients with aneurysms at other sites to undergo more prolonged post-operative graft surveillance.

Mega-aneurysmal degeneration of a saphenous vein graft following infrainguinal bypass. A case report

True aneurysm formation in infrainguinal autologous vein grafts is rare. The authors report a case of a patient presenting with extensive aneurysmal degeneration of a femoropopliteal bypass vein graft 13 years after the original operation and 8 years after graft revision and thrombolysis for acute occlusion. Over a 2-year period, the vein graft aneurysm expanded from 2.7 to 4.5 cm maximal diameter. He underwent exclusion and partial resection of the vein graft aneurysm with placement of a new femoropopliteal bypass using reversed saphenous vein from the contralateral leg. Histopathologic examination of the aneurysm revealed intimal fibrosis, medial degeneration, and inflammation. This case and review of the literature suggests that true infrainguinal vein graft aneurysms occur infrequently and massive aneurysm degeneration is even more uncommon. Because of the rarity of true infrainguinal vein graft aneurysms, their etiology remains unclear.

[True aneurysms of venous autografts: report of nine cases and review of the literature]

INTRODUCTION The true aneurysm formation of the autogenous saphenous vein graft (ASVG) is a very rare complication after bypass surgery [1 -5]. In 1969 Pillet [1] first described a true fusiform aneurysm formation of the ASVG which had been used as a replacement of the iwured superficial femoral artery in 26-year-old male patient. We present nine cases. CASE!. A 71-year-old man with previous history of arterial hypertension and higher serum lipid level, was admitted with an asymptomatic pulsating swelling of the medial portion on the thigh. Five years ago the bellow knee F-P bypass with ASVG due to occlusive disease has been performed. The transfemoral angiography (Figure 1) showed patent graft with fusiform true aneurysm formation at its mid portion. This aneurysm has been replaced with PTFE graft. The pathohistological examination showed an atherosclerotic origin of the aneurysm. This patient died four years after operation due to myocardial infarction with patent graft. CASE 2. A 57-year-old female with previous history of arterial hypertension and higher serum lipid level, had an elective resection and replacement of the superficial femoral artery aneurysm. For the reconstruction an ASVG was used. The saphenous vein showed postflebitic changes. Four years later she was admitted with asymptomatic pulsating mass of the mid portion of the thigh. The control transfemoral angiography showed patent graft with fusiform aneurysm formation of its mid portion. After aneurismal resection, an above knee F-P bypass with 8 mm PTFE graft was performed. A pathohistological examination showed a partially degenerated elastic membrane with fragmentation and disruption, without atherosclerosis (Figure 2). During the follow up period an elective resection of the subclavian artery aneurysm as well as abdominal aortic aneurysm, were performed. CASE3. A subclavian artery aneurysm caused by TOS has been repaired with sapehnous vein graft at 40-year-old female patient with regular arterial tension and normal serum lipid level. The pathohistologycal examination showed an intimai fibroelastosis associated with intimai and medial connective tissue proliferation of the aneurysm. The atherosclerotic changes were absent. Four years later this patient has been admitted urgently with ischemia of the left hand, absent distala arterial pulses and with asymptomatic pulsating mass over the supradavicular area. The Duplex ultrasonography and angiography, showed aneurysm of the ASVG, associated with occlusion (embolism) of the brachial artery (Figure 3). This aneurysm has been replaced with 6 mm PTFE graft Transbrachial thrombembolectomy has been performed too. The pathohistological examination showed a non atherosclerotic origin of the ASVG aneurysm (Figure 4). Three years after secondary operation the PTFE graft is patent. Echocardiography of the same patient showed mitral valve prolaps, probably caused by connective tissue disorder. CASE 4. A 56-year-old female patient was admitted urgently, due to hemorrhagic shock and giant pulsating swelling over the popliteal space. The Duplex ultrasonography and transfemoral angiography showed ruptured popliteal artery aneurysm. This patient had arterial hypertension and higher lipid level. During the urgent operation using dorsal approach, an aneurysm has been replaced with ASVG. A pathohistological examination showed an atherosclerotic origin of the aneurysm. Ten days postoperatively due to bleeding from the wound, a new urgent surgical procedure was performed. Intraoperatively 1 cm long graft laceration was found, while postoperative bacteriological examination showed an infection caused by Staphylococcus Aureus. The graft has been removed, and new extraanatomic, subcutaneous bypass from the superficial femoral to anterior tibial artery using ASVG was performed. Three years later this patient was admitted urgently with giant pulsating mass and skin necrosis at the knee region, associated with hemorrhagic shock. The control angiography showed a ruptured aneurysm of the ASVG (Figures 5 and 6). The aneurysm was replaced with 6mm PTFE graft. The pathohistological examination showed an atherosclerotic origin of the aneurysm. Two year postoperatively, the new graft is patent. CASE 5. A 65-year-old man with previous history of arterial hypertension and high serum lipid level, was admitted with pulsating swelling and skin necrosis at the portion on the thigh. Nine years ago the bellow knee F-P bypass with cephalic vein due to occlusive disease has been performed. Transfemoral angiography showed patent graft associated with ruptured fusiform aneurysm at its mid portion. This aneurysm has been replaced with 6mm tubular PTFE graft. The postoperative patohistological examination showed an atherosclerotic changes at the resected aneurysm. This patient was followed two years, and graft is patent., CASE 6. A 62-year-old male patient was admitted urgently, with giant pulsating swelling over the popliteal space and hemorrhagic shock. The Duplex ultrasonography and angiography showed ruptured popliteal artery aneurysm. The patients had previous history of arterial hypertension and higher serum lipid level. The aneurysm has been replaced with ASVG. Pathohistological examination showed an atherosclerotic origin of the aneurysmal sac. Seven days postoperatively, a massive bleeding from the wound due to graft infection, occurred. New urgent operation showed complete graft abrupption at the site of proximal anastomosis, while postoperative bacteriological examination showed a presence of Staphylococcus Aureus. The graft was removed and new extraantomic, subcutaneous bypass from the superficial femoral to the anterior tibial artery with contralateral ASVG, was performed. The patient recovered very well. Five years latter this patient was admitted urgently with large painful pulsating mass in the thigh. The angiography showed and ASVG fusiform aneurysm. The aneurysm has been replaced with 6 mm PTFE graft. The pathohistological examination showed an atherosclerotic origin of the resected aneurysm (Figure 7). Two years after the operation, a new graft is patent. CASE 7. A 78-year-old man with previous history of arterial hypertension and higher serum lipid level, has been admitted with an asymptomatic pulsating swelling of the medial portion on the thigh. Seven years ago the bellow knee F-P bypass with ASVG and exclusion of the poplietal artery aneurysm was performed. The Duplex ultrasonography and angiography showed a fusiform true aneurysm formation at the mid portion of the patent graft. The aneurysm has been replaced with femoro-anterior tibial artery bypass procedure using 6 mm PTFE graft. The pathohistological examination showed an atherosclerotic origin of the aneurysm. This patient died five days after the operation due to myocardial infarction with patent graft. CASE 8. A 65-year-old male with previous history of arterial hypertension and higher serum lipid level, had an elective replacement of the popliteal artery aneurysm. For the reconstruction a PTFE graft was used. Two years postoperativelly this graft occluded due to changes on the crural arteries. From these reasons a new bypass from the superficial femoral to anterior tibial artery with saphenous vein graft, was performed. Nine years later she was admitted with painful pulsating mass of the mid portion of the thigh. The Duplex ultrasonography and transfemoral angiography showed patent graft with fusiform aneurysm formation of its mid portion. The ASVG aneurysm was replaced with 8 mm Dacron graft. A pathohistological examination showed atherosclerotic origin of the ASVG aneurysm. One year latter this graft is patent. CASE 9. A 65-year-old male with previous history of arterial hypertension and higher serum lipid level, has been admitted due to disabling claudications discomfort caused by aorto-iliac occlusive disease. Nine years earlier a right sided aorto-renal bypass with ASVG was performed due to occlusive disease and renovascular hypertension. An translumbar aortography showed occlusion of the aortic bifurcation associated with fusiform aneurysm formation of ASVG (Figures 8, 9 and 10). During the same operation an aorto-bifemoral bypass and repairing of ASVG aneurysm with Dacron grafts, were performed. A pathohistological examination showed atherosclerotic origin of the ASVG aneurysm. One year latter both grafts are patent. DISCUSSION The table 1 shows 45 true aneurysmal formation at ASVG after F-P bypass surgery in cases with occlusive diseases [1-25]. In his famous paper Szilagyi [3] reported a study of the biologic fate of ASVG in 260 patients with F-P bypass procedures, and he found 10 (3.8%) aneurysms. In 1973 De Weese [5] found 4 (1.2%) ASVG aneurysms after 350 F-P reconstructions, while in 1975 Vanttinen [6] found 1 (0.9%) such case after these procedures. In 1987 Yuanagyia [26], and in 1989 Martin [27] described cases of ASVG aneurysmal formation after subclavian artery aneurysm replacement. Yanagyia's patient had a Behcet disease. We also had one case of ASVG aneurysm after subclavian artery aneurysm repair, manifested with hand ischemia due to distal embolization. Gemperle[12]in 1986 decribed ASVG aneurysm which developed 18 years after replacement of the injured brachial artery. Carrasaquilla [28] has in 1972 described a case of ASVG aneurysm formation after replacement of the common carotid artery, while in 1998 Tekeuchi et al [29] described a case of an ASVG aneurysm after subclavian to vertebral artery bypass due to stenotic lesions of the both vertebral arteries. Four years later a giant ASVG aneurysm was found, and successfully resected. In 1990 Peer et al [30] reported two ASVG aneurysms seven and eight years after popliteal artery aneurysm replacement. In 1991 Kogel et al [31] described one such case 10 years after primary operation. In 1997 Loftus [32] described 10 new cases of the ASVG aneurysms after popliteal artery aneurysm repair. We had two such cases developed three and five years after primary operation. In three of our cases ASVG aneurysm showed an atherosclerotic origin, while in 3 non atherosclerotic. The exact mechanism of aneurysm degeneration of the ASVG in arterial position is unknown. There is likely a combination of factors including: - mechanical trauma during vein harvesting and operation [9,30]; - weakness at branching sites in the vein [2,9]; - potential weakness in the vicinity of the venous valves due to absence of the circular muscle cuff in the media of the vessel wall [5]; - infection [16]; - trauma caused by bony structures near the graft [18,30]; - arteritis [13,14,26, 27, 30]; - atherosclerosis [2,3,5-11,18,19,21,24,25]; - hemodinamic factors from the arterial pressure [23]; - transmural ischemie injury of the vein wall due to disrupting of the vasa vasorum after removing of the vein segments [28,29,33]; Brody cold this fenomen ?devascularization of the venous graft" [34]; - diffuse nature of this process in patients with multiple aneurysmal changes [20,32] (our cases 2,3,4,6 and 8); - using of the cephalic [9], or superficial femoral vein [1] (case 7); - changed veins (one of our cases). The use of in situ bypass technique for arterial reconstruction would theoretically, minimize endothelial trauma by reducing operative manipulation, preserving vasa vasorum, and eliminating the pressure induced endothelial desquamation that has been associated with mechanical destination of reversed vein graft during their harvest. However, Sassoust [15] in 1986 reported 5 cases of true aneuryms of the ASVG after in situ F-P bypass. After Sassoust's new cases of ASVG aneurysm following F-P in situ bypass surgery were reported [22-24]. CONCLUSION Early ASVG aneurysm formation occurring six months after surgery has been found to be the result of preexisting unrecognized vein wall weakness or injury at the time of harvest, while aneurysm discovered 5 or more years postoperatively, were atherosclerotic in nature. The aneurysms of the ASVG are frequent, at patients with multiple aneurysms of natural arteries. The ASVG aneurysms require active surgical treatment. Then autologous vein grafts are not ?material of choice" for replacement of aneurysmally changed ASVG after peripheral vascular reconstructions.

Treatment of popliteal arterial aneurysm using a superficial femoral artery autograft

The usefulness of aggressive surgical management of popliteal arterial aneurysm is now widely accepted. Reconstruction is usually performed using either prosthesis or saphenous vein autograft. Autografts are preferable but not always possible because of problems of availability and congruence. An alternative conduit for cases involving lesions spanning the articular midline of the knee is the superficial femoral artery. From 1993 to 1998, we used superficial femoral artery autografts to treat a total of 18 aneurysms in 12 patients. All patients were male with a mean age of 66 years (range, 42 to 75). Fourteen aneurysms were treated during elective procedures, including four in combination with aortic repair. The remaining four were treated on an emergency basis. Exposure was achieved via the internal medial route in all cases. Treatment consisted of exclusion or aneurysmorraphy. The mean length of the autograft harvested from the ipsilateral thigh was 10.2 cm (range, 6-18). The harvested graft was replaced by a PTFE prosthesis. Our results show that superficial femoral artery autografts are a suitable alternative for two indications: for patients with small aneurysms located in the middle of the popliteal artery, since autografts provide excellent congruence, and for patients with no other useable donor vein or concurrent deep venous thrombosis.

Prevalence of true vein graft aneurysms: implications for aneurysm pathogenesis

BACKGROUND

Circumstantial evidence suggests that arterial aneurysms have a different cause than atherosclerosis and may form part of a generalized dilating diathesis. The aim of this study was to compare the rates of spontaneous aneurysm formation in vein grafts performed either for popliteal aneurysms or for occlusive disease. The hypothesis was that if arterial aneurysms form a part of a systemic process, then the rates of vein graft aneurysms should be higher for patients with popliteal aneurysms than for patients with lower limb ischemia caused by atherosclerosis.

METHODS

Infrainguinal vein grafting procedures performed from 1990 to 1995 were entered into a prospective audit and graft surveillance program. Aneurysmal change was defined as a focal increase in the graft diameter of 1.5 cm or greater, excluding false aneurysms and dilatations after graft angioplasty.

RESULTS

During the study period, 221 grafting procedures were performed in 200 patients with occlusive disease and 24 grafting procedures were performed in 21 patients with popliteal aneurysms. Graft surveillance revealed spontaneous aneurysm formation in 10 of the 24 bypass grafts (42%) for popliteal aneurysms but in only 4 of the 221 grafting procedures (2%) that were performed for chronic lower limb ischemia.

CONCLUSION

This study provides further evidence that aneurysmal disease is a systemic process, and this finding has clinical implications for the treatment of popliteal aneurysms.

Infrainguinal aneurysm formation in arterialized autologous saphenous vein grafts

True aneurysm formation in arterialized autologous veins is an unusual complication. We studied a patient with 2 aneurysms occurring in the mid and distal portion of an in situ femoropopliteal bypass. The first aneurysm led to graft occlusion 4 years after the primary intervention, requiring replacement of the ectatic graft segment. The graft was still patent when the patient was examined 7 years after the primary intervention and 3 years after the first aneurysm. In the mid portion of the graft, a true aneurysm measuring 5 by 8 cm had developed. The aneurysm was replaced by a reversed segment of the contralateral greater saphenous vein. Recovery was uneventful. Advanced atherosclerotic changes with extensive intimal fibroplasia, subendothelial cholesterol deposits, and ulcerations were revealed by means of histopathology of the aneurysm wall. Atherosclerosis is considered to be the main cause of aneurysm formation in vein grafts, but a review of the literature suggests the additional etiopathogenic factors should be further investigated.