Br. J. Surg. Vol. 63 (1976) 562-564
‘Hitch-hike’ grafts for limb salvage in peripheral arterial disease B. P. BLISS A N D N. F O N S E K A * SUMMARY
A technique of arterial reconstruction suitable f o r patients with extensive arterial occlusions and for previous failed arterial surgery is described, The ‘hitchhike’ graft consists of a proximal limb of 6-mm velour Dacron prosthesis and a distal limb of autogenous vein. The intermediate prosthesis-to-vein anastomosis is made into an endarterectomized segment of upper popliteal artery. The results in the first 16 limbs are described. Eleven grafts are functioning from 2 to 14 months after operation and 5 of these have functioned for more than I year, The advantages of the technique are: long arterial occlusions may be bridged; autogenous vein is used to cross the knee joint; good measured blood flows may be demonstrated at operation; acceptable patency rates may be obtained up to 1 year.
The proximal anastomosis may be made end to side into the common femoral artery or more proximally into the iliac arteries or abdominal aorta, using an extraperitoneal approach where necessary. The distal anastomosis may be made end to side into the popliteal artery below the knee or more distally into
PATIENTS with gangrene or pregangrene of the lower limb and extensive arterial occlusions often present a major technical problem. Many have poor, narrow, long saphenous veins. Others have had one or more failed arterial operations in which the long saphenous veins have been used. Composite procedures to overcome these problems have been reported from time to time (Dale et al., 1962; Cockett and Maurice, 1963; Linton and Wilde, 1970) but the success rate has generally been poor. In 1971 De Laurentis and Friedmann described 3 cases treated with a double bypass procedure. They used an 8-mm Dacron tube proximally, implanted into an open or endarterectomized segment of the proximal popliteal artery, from which a second bypass of reversed saphenous vein was taken across the knee joint to the distal popliteal artery. We have adapted the principle of this double bypass and found it to be a useful procedure in treating severely ischaemic limbs with extensive occlusions. This paper presents the preliminary results in a series of 16 limbs.
Methods Operation The ‘hitch-hike’ graft (Fig. 1) consists of a proximal limb of 6-mm internal velour Dacron prosthesis and a distal limb of autogenous vein (saphenous, basilic or cephalic). The intermediate anastomosis is made into a short endarterectomized segment of upper popliteal artery. Fig. 2 shows the preparation of the popliteal segment and Fig. 3 the technique of anastomosis. The name ‘hitch-hike’ graft was coined to describe the way in which the two graft elements ‘ride off’ the endarterectomized popliteal segment. 562
Fig. 1. The ‘hitch-hike’ graft.
the tibia1 or peroneal arteries in the calf. We have found that the radial/cephalic or radial/basilic veins have sufficient calibre and length to extend from the upper popliteal artery to the middle or lower third of the leg. We use these veins when the long saphenous vein has been used for a previous procedure. The advantages of this technique are:
* University Department of Surgery, Charing Cross Hospital, London. Present address of B. P. Bliss: Devonport Hospital, Plymouth.
Limb salvage in peripheral arterial disease 1. It overcomes the problem of disproportion in size when a Dacron prosthesis is anastomosed end to end to autogenous vein. 2. It improves the fixation of the anastomosis and prevents rotation stresses which may narrow the venous limb of the graft. 3. It allows long lengths of occluded artery to be bypassed. 4. It enables the widest part of a poor saphenous vein to be used to traverse the knee joint.
Patients To date a total of 16 limbs in 15 patients (12 males and 3 females) have been treated. The length of followup (in August 1975) in 8 cases is more than 1 year and in the remainder 2-9 months. The indications for the ‘hitch-hike’ procedure are shown in Table I. Twelve patients had gangrene or pregangrene. Ten patients had had failed direct arterial surgery. Six patients had long saphenous veins which were inadequate to bridge their long arterial occlusions. The sites of the proximal and distal anastomoses are shown in Tables 11 and 111 respectively. Six patients had a graft extending from one of the iliac arteries proximally to the posterior tibial or peroneal distally, and one patient had a graft from the aorta to the distal popliteal. The site of origin of the autogenous vein segment used is shown in Table IV. Thirteen of the patients had blood flow and resistance measurements made during the operation after the completion of the graft, and 5 patients had Doppler ankle pressure measurements both pre- and postoperatively.
Fig. 2. Preparation of the popliteal artery for the ‘hitch-hike’.
Table I: INDICATIONS FOR ‘HITCH-HIKE’ GRAFT Inadequate Failed long previous saphenous reconstruction vein Gangrene or pregangrene (12)* 7’ 5 ‘Incaoacitatina’ claudication (4)
* Includes 3 patients
3
-
1
who were already unilateral amputees.
Table 11: SITE OF PROXIMAL ANASTOMOSIS Artery: Superficial femoral Number of grafts: 1 Common femoral 5 External iliac 7 Common iliac 2 Lower abdominal aorta 1
D. 5. (R) w. 0. E. T. D.5. (L) P. G.
‘Hitch-hike’ grafts for limb salvage in peripheral arterial disease B. P. BLISS A N D N. F O N S E K A * SUMMARY
A technique of arterial reconstruction suitable f o r patients with extensive arterial occlusions and for previous failed arterial surgery is described, The ‘hitchhike’ graft consists of a proximal limb of 6-mm velour Dacron prosthesis and a distal limb of autogenous vein. The intermediate prosthesis-to-vein anastomosis is made into an endarterectomized segment of upper popliteal artery. The results in the first 16 limbs are described. Eleven grafts are functioning from 2 to 14 months after operation and 5 of these have functioned for more than I year, The advantages of the technique are: long arterial occlusions may be bridged; autogenous vein is used to cross the knee joint; good measured blood flows may be demonstrated at operation; acceptable patency rates may be obtained up to 1 year.
The proximal anastomosis may be made end to side into the common femoral artery or more proximally into the iliac arteries or abdominal aorta, using an extraperitoneal approach where necessary. The distal anastomosis may be made end to side into the popliteal artery below the knee or more distally into
PATIENTS with gangrene or pregangrene of the lower limb and extensive arterial occlusions often present a major technical problem. Many have poor, narrow, long saphenous veins. Others have had one or more failed arterial operations in which the long saphenous veins have been used. Composite procedures to overcome these problems have been reported from time to time (Dale et al., 1962; Cockett and Maurice, 1963; Linton and Wilde, 1970) but the success rate has generally been poor. In 1971 De Laurentis and Friedmann described 3 cases treated with a double bypass procedure. They used an 8-mm Dacron tube proximally, implanted into an open or endarterectomized segment of the proximal popliteal artery, from which a second bypass of reversed saphenous vein was taken across the knee joint to the distal popliteal artery. We have adapted the principle of this double bypass and found it to be a useful procedure in treating severely ischaemic limbs with extensive occlusions. This paper presents the preliminary results in a series of 16 limbs.
Methods Operation The ‘hitch-hike’ graft (Fig. 1) consists of a proximal limb of 6-mm internal velour Dacron prosthesis and a distal limb of autogenous vein (saphenous, basilic or cephalic). The intermediate anastomosis is made into a short endarterectomized segment of upper popliteal artery. Fig. 2 shows the preparation of the popliteal segment and Fig. 3 the technique of anastomosis. The name ‘hitch-hike’ graft was coined to describe the way in which the two graft elements ‘ride off’ the endarterectomized popliteal segment. 562
Fig. 1. The ‘hitch-hike’ graft.
the tibia1 or peroneal arteries in the calf. We have found that the radial/cephalic or radial/basilic veins have sufficient calibre and length to extend from the upper popliteal artery to the middle or lower third of the leg. We use these veins when the long saphenous vein has been used for a previous procedure. The advantages of this technique are:
* University Department of Surgery, Charing Cross Hospital, London. Present address of B. P. Bliss: Devonport Hospital, Plymouth.
Limb salvage in peripheral arterial disease 1. It overcomes the problem of disproportion in size when a Dacron prosthesis is anastomosed end to end to autogenous vein. 2. It improves the fixation of the anastomosis and prevents rotation stresses which may narrow the venous limb of the graft. 3. It allows long lengths of occluded artery to be bypassed. 4. It enables the widest part of a poor saphenous vein to be used to traverse the knee joint.
Patients To date a total of 16 limbs in 15 patients (12 males and 3 females) have been treated. The length of followup (in August 1975) in 8 cases is more than 1 year and in the remainder 2-9 months. The indications for the ‘hitch-hike’ procedure are shown in Table I. Twelve patients had gangrene or pregangrene. Ten patients had had failed direct arterial surgery. Six patients had long saphenous veins which were inadequate to bridge their long arterial occlusions. The sites of the proximal and distal anastomoses are shown in Tables 11 and 111 respectively. Six patients had a graft extending from one of the iliac arteries proximally to the posterior tibial or peroneal distally, and one patient had a graft from the aorta to the distal popliteal. The site of origin of the autogenous vein segment used is shown in Table IV. Thirteen of the patients had blood flow and resistance measurements made during the operation after the completion of the graft, and 5 patients had Doppler ankle pressure measurements both pre- and postoperatively.
Fig. 2. Preparation of the popliteal artery for the ‘hitch-hike’.
Table I: INDICATIONS FOR ‘HITCH-HIKE’ GRAFT Inadequate Failed long previous saphenous reconstruction vein Gangrene or pregangrene (12)* 7’ 5 ‘Incaoacitatina’ claudication (4)
* Includes 3 patients
3
-
1
who were already unilateral amputees.
Table 11: SITE OF PROXIMAL ANASTOMOSIS Artery: Superficial femoral Number of grafts: 1 Common femoral 5 External iliac 7 Common iliac 2 Lower abdominal aorta 1
D. 5. (R) w. 0. E. T. D.5. (L) P. G.
