New concept in vascular surgery: Percutaneous Bypass, applications and perspectives
Seance of wednesday 07 february 2024 (Communications libres)
DOI number : 10.26299/36c4-kp58/emem.2024.05.03
Abstract
Aim: To describe the original and innovative technique in vascular surgery of totally percutaneous bypass using the extravascular placement of a covered stent.
Material and method: At the femoropopliteal level, the procedure requires the placement of three introducers, respectively in the contralateral common femoral artery, the proximal superficial femoral artery (SFA), and the ipsilateral distal SFA. A guide is introduced through the contralateral introducer, exits the arterial lumen through the femoral introducer then returns to the popliteal artery via the ipsilateral intro, after extravascular tunneling. Two self-expanding PTFe-coated stents are then deployed from the ostium of the SFA to the distal SFA. This technique thus makes it possible to avoid surgical approaches, vascular sutures, and interruption of blood flow by clamping. Furthermore, the technique could be extrapolated to other territories, such as the abdominal aorta (MISCAB technique), the upper limb or hemodialysis access routes, all based on this new surgical concept.
Results: We first report a study based on the first 30 cases of percutaneous femoropopliteal bypasses, performed between 2018 and 2021 on 28 patients aged 71 +/- 3 years, suffering from severe claudication Rutherford 3 n= 16 (53 %) or critical ischemia Rutherford 4-6 n= 14 (47%), and in whom open or endoluminal repair was not feasible and/or had failed. The immediate results were excellent, with no deaths, one occlusion successfully treated by thrombolysis, no local complications requiring reoperation, and no lack of healing. The average follow-up was 25.54 months (3 months - 48 months). At 12 and 50 months, the KM survival curve was 95% and 85%, primary patency 78% and 70%, secondary patency 80% and 75%, assisted secondary patency 90% and 90%, and the absence of amputation. 98% and 98%, i.e. comparable results in terms of permeability to traditional surgical bypasses, but without complications linked to the approach (for which the literature reports an average overall rate of 20% or more). These figures seem to be confirmed with the current study now accumulating 65 femoropopliteal bypasses carried out at the end of 2023. At the aortic level, 7 procedures were successfully carried out and patency maintained over a follow-up of 1 to 3 years.
Conclusion: In patients with long lesions and/or failed endovascular approaches, this technique has the advantage of being completely percutaneous, without vascular suture and without clamping, leading to a clear reduction in impact and the morbidity of the intervention, with satisfactory initial results. If these favorable results are confirmed by larger series and longer follow-up, percutaneous extravascular bypass, based on an innovative concept, will represent a new weapon of choice for arterial repair.
Material and method: At the femoropopliteal level, the procedure requires the placement of three introducers, respectively in the contralateral common femoral artery, the proximal superficial femoral artery (SFA), and the ipsilateral distal SFA. A guide is introduced through the contralateral introducer, exits the arterial lumen through the femoral introducer then returns to the popliteal artery via the ipsilateral intro, after extravascular tunneling. Two self-expanding PTFe-coated stents are then deployed from the ostium of the SFA to the distal SFA. This technique thus makes it possible to avoid surgical approaches, vascular sutures, and interruption of blood flow by clamping. Furthermore, the technique could be extrapolated to other territories, such as the abdominal aorta (MISCAB technique), the upper limb or hemodialysis access routes, all based on this new surgical concept.
Results: We first report a study based on the first 30 cases of percutaneous femoropopliteal bypasses, performed between 2018 and 2021 on 28 patients aged 71 +/- 3 years, suffering from severe claudication Rutherford 3 n= 16 (53 %) or critical ischemia Rutherford 4-6 n= 14 (47%), and in whom open or endoluminal repair was not feasible and/or had failed. The immediate results were excellent, with no deaths, one occlusion successfully treated by thrombolysis, no local complications requiring reoperation, and no lack of healing. The average follow-up was 25.54 months (3 months - 48 months). At 12 and 50 months, the KM survival curve was 95% and 85%, primary patency 78% and 70%, secondary patency 80% and 75%, assisted secondary patency 90% and 90%, and the absence of amputation. 98% and 98%, i.e. comparable results in terms of permeability to traditional surgical bypasses, but without complications linked to the approach (for which the literature reports an average overall rate of 20% or more). These figures seem to be confirmed with the current study now accumulating 65 femoropopliteal bypasses carried out at the end of 2023. At the aortic level, 7 procedures were successfully carried out and patency maintained over a follow-up of 1 to 3 years.
Conclusion: In patients with long lesions and/or failed endovascular approaches, this technique has the advantage of being completely percutaneous, without vascular suture and without clamping, leading to a clear reduction in impact and the morbidity of the intervention, with satisfactory initial results. If these favorable results are confirmed by larger series and longer follow-up, percutaneous extravascular bypass, based on an innovative concept, will represent a new weapon of choice for arterial repair.