Cardiovascular Journal of Africa: Vol 26 No 1 (January/February 2015)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 1, January/February 2015

AFRICA

An alternative method of transperitoneal graft introduction

in aortobifemoral bypass surgery

Yüksel Be

ir, Orhan Gokalp, Hasan Iner, Ihsan Peker, Ufuk Yetkin, Koksal Donmez, Levent Yilik, Ali Gurbuz

Abstract

Introduction:

Intestinal injury and bleeding, which usually

occurs while taking the graft through the transperitoneal

tunnel, is one of the most important complications of

aortobifemoral bypass surgery. In this study, case reports were

examined where, for some reason, the tunneller instrument

could not be used to create the transperitoneal tunnel and the

tunnelling forceps was used. In some of these cases, the grafts

were taken through conventionally and in others an alterna-

tive method was used.

Methods:

Between 2002 and 2013, the records of 81 patients

treated surgically by aortobifemoral bypass for peripheral

arterial disease, were investigated retrospectively. In the

conventional method, after creating a tunnel with tunnelling

forceps, the forceps was re-introduced into the tunnel and the

graft was clasped and brought through the tunnel. In the alter-

native method, a nylon tape was left as a guide in the tunnel

while creating the tunnel, and the forceps was not introduced

again. The graft was taken through the tunnel with the help of

the nylon tape. Patients treated with the conventional method

were included in group 1 (

49) and patients in which the

graft was guided with nylon tape were included in group 2 (

32). The groups were compared peri-operatively.

Results:

There were no significant differences between the

groups in terms of co-morbidity factors. Extubation time,

intensive care length of stay, revision for bleeding, other post-

operative complications, and infection and late-term infection

rates were similar in the two groups (

0.05). Hospital length

of stay and blood usage were significantly higher in group 1

(

0.05). Drainage amounts were higher in group 1 but not

statistically significant.

Conclusion:

Using nylon tape to introduce the graft into the

femoral area during aortobifemoral bypass operations was

found to be more effective than using the tunnelling forceps.

Keywords:

aortobifemoral bypass, tunnel, complication

Submitted 3/12/14, accepted 22/1/15

Cardiovasc J Afr

2015;

: 45–48

www.cvja.co.za

DOI: 10.5830/CVJA-2015-011

Aorto-iliac occlusive (AIO) disease is one of the most common

forms of arteriosclerosis obliterans (ASO).

The gold-standard

treatment of this disease is aortofemoral bypass surgery,

according to the Inter-Society Consensus for the Management

of Peripheral Arterial Disease (TASC II) study.

1-3

Surgeons have performed this procedure for many years with

good long-term results. Vascular damage, bleeding, intestinal

damage, ileus, myocardial infarction and renal failure are

considered short-term complications. Secondary aorto-enteric

fistula, sexual dysfunction, infection, graft thrombosis and

anastomotic pseudo-aneurysm may be considered long-term

complications.

4-6

Among these complications, vascular damage,

intestinal damage and aorto-enteric fistulae usually occur while

introducing the graft into the femoral area.

If the tunneller,whichwas specificallydesigned for aortofemoral

bypass procedures, is not available for some reason, long, blunt-

tipped tunnelling forceps are used instead. A nylon tape is taken

through the tunnel with the tunnelling forceps after the tunnel is

created. Aortic anastomosis is performed after heparinisation.

Connecting the distal ends of the graft to the femoral area

is performed in the conventional method by introducing the

forceps into the tunnel a second time and pulling the graft

through the tunnel. In an alternative method, the nylon tape

that is taken through the tunnel with the tunnelling forceps is

tied to the graft, which is pulled through into the femoral area.

By not introducing the forceps a second time into the tunnel,

complications caused by the forceps may be reduced. The results

of both methods were analysed for postoperative bleeding,

vascular injury and intestinal complications.

Methods

Between May 2002 and November 2013, 81 patients treated by

aortobifemoral bypass (ABFB) via the transperitoneal approach

for ASO were examined retrospectively. Parameters such as

age, gender, pre-operative co-morbid factors, operative and

postoperative data, and postoperative complications and death

during follow up of all patients were recorded. Hospital records

were used for obtaining the data.

Patients treated with the conventional method were included

in group 1 (

49) and patients in whom the graft was introduced

by means of the nylon tape were included in group 2 (

32).

The group results were examined, comparing parameters such

as pre-operative data and postoperative complications. Patients

who previously had undergone abdominal surgery for any reason

and who had had additional non-vascular abdominal surgery

were excluded from the study.

The surgical indications were to relieve ischaemic pain,

heal ischaemic ulcers, prevent limb loss, improve function and

quality of life, and prolong survival, as described in the TASC II

consensus. Digital subtraction angiography was performed on all

patients to indicate the need for surgery.

Ataturk Education and Research Hospital,

zmir Katip

Çelebi University,

zmir, Turkey

Yüksel Be

ir, MD,

yukselbesir@hotmail.com

Orhan Gokalp, MD

Hasan Iner, MD

Ihsan Peker, MD

Ufuk Yetkin, MD

Koksal Donmez, MD

Levent Yilik, MD

Ali Gurbuz, MD