Case report of superficial femoral artery and popliteal artery aneurysm repair using brachial vein

Introduction

The ipsilateral greater saphenous vein (GSV) remains the gold standard conduit for lower extremity bypass surgery. If unavailable, other autogenous veins, including the contralateral GSV, short saphenous, basilic, and cephalic vein, have been used. ¹ A brachial vein can also be used as an adequate alternative; however, reports describing its use in this setting are limited. ² In this report, we describe a patient who underwent bypass grafting using his brachial vein when no other viable autogenous alternative conduits were available. The patient consented to having his case published.

Case report

We report the case of a 70-year-old man who presented to our emergency department with right calf pain and associated right lower extremity cold sensation, numbness, and toe weakness that developed earlier that morning. Upon arrival, the patient’s vital signs were stable. Physical examination revealed a cool right lower extremity with mild motor and sensory deficits, and a palpable mass was felt behind his right knee. His right popliteal, dorsalis pedis, and posterior tibial pulses were not palpable. Duplex ultrasound imaging of his right lower extremity revealed a right 2.5 cm acutely thrombosed superficial femoral artery (SFA) and popliteal artery aneurysms. The patient was immediately started on a heparin drip and was prepared for intervention.

In the operating room, angiography revealed a thrombosed right lower extremity SFA aneurysm and thrombus in the popliteal artery (Figure 1). After cannulating his right anterior tibial artery, we used the AngioJet® (Boston-Scientific, Marlborough, MA) system to perform suction thrombectomy and thrombolysis with its Power Pulse feature to administer 10 mg of tissue plasminogen activator (tPA) with 20 min dwell time, followed by balloon maceration to further break up the remaining thrombus. Completion angiography revealed residual thrombus within the SFA and popliteal arteries, and we decided to leave the lytic catheter in place. Upon completion of the procedure, the patient’s right calf was soft, and the patient was taken to the recovery room in stable condition.

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Figure 1.

Intraoperative photo of the large SFA and popliteal artery aneurysms.

Several hours after the operation, the patient reported new right leg pain. A hematoma had formed at his left groin puncture site. TPA was immediately stopped and manual pressure was held at his puncture site. At this time, the patient was also noted to have a tense right calf consistent with compartment syndrome, and he was taken back to the operating room. A calf fasciotomy was performed. Repeat angiogram of his right leg revealed patent SFA and popliteal artery with distal runoff extending to the anterior tibial and dorsalis pedis arteries.

On hospital day 6, the patient was taken back to the operating room for bypass surgery. The patient’s arms and legs were evaluated for a conduit using duplex ultrasound. The patient’s right brachial vein was the only autogenous conduit of adequate quality and caliber that could be used for the procedure. The patient underwent general anesthesia. The aneurysmal segment of the SFA extended up to the adductor canal. A bypass was created from his right SFA extending to his P2 segment of the popliteal artery as the aneurysm involved the P1 segment (Figure 2). Completion angiography revealed excellent runoff through the anterior tibial artery. The patient had a palpable dorsalis pedis pulse at the end of the procedure. The SFA and popliteal arteries were ligated from within the aneurysm sac. The patient tolerated the procedure well.

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Figure 2.

Intraoperative photo showing the brachial vein bypass.

Three- and six-month follow-up duplex demonstrated a patent bypass graft and no swelling was noted in the patient’s right arm.

Discussion

Despite advancements in endovascular procedures, open bypass surgery remains a highly effective revascularization technique for limb salvage in patients with peripheral arterial occlusive disease and popliteal artery aneurysms.

In addition to adequate inflow and outflow vessels, one of the greatest determinants of successful bypass can be attributed to the integrity and type of conduit used. ³ The ideal conduit is one that is flexible and compliant, yet durable enough to withstand hemodynamic changes, and must be biocompatible with its conjoining arteries. A poorly chosen conduit can accelerate graft complications such as stenosis, occlusion, and infection, which may lead to graft failure and ultimately, amputation. ⁴

Autogenous conduits, more specifically veins, are considered the preferred choice for lower extremity bypass surgery. When compared to prosthetic grafts, venous bypass grafts have been shown to yield superior long-term patency and limb salvage, especially when performed below the knee. ¹ However, the use of venous conduits is not without challenges. With many opportunities for vascular injury, harvesting a vein naturally demands more time and effort, as the slightest wall injury could initiate sequelae leading to graft failure. To identify a usable vein, preoperative vein mapping using ultrasound has become the standard of care. Ultrasound enables surgeons to visualize which veins are of adequate length, diameter, and quality. Additionally, surgeons can map out the course of a potential vein in preparation for its harvest.

Because of its accessibility, durability, and long-term patency rates, the ipsilateral GSV has been established as the gold standard conduit for bypass procedures. However, nearly 40% of patients requiring lower extremity bypass do not have an adequate one available, often due to inadequate caliber or absence—ablated, stripped, or used in prior bypass surgery. ⁵ In these circumstances, surgeons must look towards either utilizing a prosthetic graft or more preferably, harvesting an alternative, viable vein from the patient. The contralateral GSV is often regarded as the next best choice due to its length and proven long-term durability. ⁶ If unavailable, the short saphenous vein, a vein harvested from the patient’s arm, or a spliced autogenous venous conduit may be considered.

Arm veins have been recognized as efficacious conduits for lower extremity bypass grafting when the ipsilateral GSV is unavailable. Previous studies have shown that arm veins have comparable long-term patency rates to contralateral GSV conduits and superior long-term patency rates compared to prosthetic grafts, particularly when used as a conduit extending below the knee.^7,8 However, most of the existing research on arm vein bypass grafts appears to exclusively focus on the use of cephalic and basilic vein conduits.^7,9 In this case, our patient’s superficial arm veins were unusable. Instead, the patient’s right brachial vein was the only healthy vein of adequate diameter and length that could be used as a single-segment conduit to bypass the patient’s SFA and popliteal aneurysms. This less frequently harvested alternative is often considered a last-resort option due increased risk of complications associated with harvesting a deep vein. Dissecting and mobilizing a brachial vein can prove technically challenging as a surgeon must work within the deep fascia of the arm and avoid injuring neighboring structures such as the brachial artery and the median and musculocutaneous nerves. We highlight that when evaluating potential autogenous conduits of the arm, cephalic and basilic veins should be considered first. These superficial veins are easier to dissect with minimal risk of injury compared to the brachial vein’s deep anatomical course within the arm.

Studies including brachial vein bypass grafts in their datasets are limited, and the complication rates of its harvest are not well-established^2,10 The use of brachial veins in the creation of brachial artery-brachial vein arteriovenous fistulas, however, has been described. A review by Kotsis et al. reported that the most common complication of brachial vein superficialization in AVF creation was venous hypertension/forearm edema (2.3%–43.6%). Others perioperative complications included, wound infection (0%–11.7%), hematoma/wound dehiscence (3.5%–29.4%), thrombosis (9.5–35.2%), and steal syndrome (2.3%–17.6%).¹¹

Before proceeding with brachial vein harvest, we considered these risks with alternative and potentially safer options such as using a prosthetic graft or endovascular stenting. While synthetic conduits are already of adequate size, shape, and can be easily prepared for bypass, their inferior patency rates to autogenous conduits and increased life-long risk of developing a prosthetic graft infection make them a less desirable choice.^1,12 Additionally, our patient required a bypass that would extend past his knee joint, a known anatomical limitation of prosthetic grafts that are less effective than autogenous. ¹ We also considered endovascular approach: a technique considered favorable in patients with high perioperative risk for surgery. However, our patient’s life expectancy was exceptional; he was a former competitive athlete and continued to live a very active lifestyle as he presented to us in excellent physical shape. We felt he would benefit from the durability of surgical repair and would avoid the higher risks of reintervention and graft thrombosis associated with endovascular repair. ¹³ Furthermore, our patient had single vessel runoff, which is associated with lower patency rates in endovascular stenting. For these reasons, we determined that pursuing a brachial vein bypass, albeit challenging, would provide the best long-term outcomes for our patient.

Conclusion

Infrainguinal bypass remains an effective revascularization technique for patients with occlusive atherosclerotic arterial disease. The brachial vein may be safely used as a viable venous conduit and should therefore be considered as a safe alternative when more commonly used veins are unsuitable or unavailable. More research is needed to determine the potential opportunities and obstacles this alternative might present.