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13. Adjunctive Techniques: Distal Anastomosis of an Infrainguinal Prosthetic Bypass
Vein Patches and Cuffs
Neointimal hyperplasia is a leading cause of bypass failure in the intermediate postoperative period (2–24 months). In prosthetic bypasses, neointimal hyperplasia is most likely to develop at the level of the distal anastomosis. Several techniques have been developed in an attempt to improve the patency of infrainguinal prosthetic bypasses [1, 2, 5, 6, 7, 8, 9, 10]. These techniques involve incorporating a segment of vein between the prosthetic bypass and the recipient artery. The theory behind these techniques is that the interposition of the vein segment may ameliorate the future development of neointimal hyperplasia at the level of the distal anastomosis. In addition, incorporating the vein segment could facilitate the construction of the distal anastomosis and improve bypass patency in the immediate postoperative period. Although these techniques were often used, there are very few prospective randomized trials to date that show their efficacy [1, 2, 3]. Furthermore, there are no prospective randomized trials that compare these various techniques in an attempt to identify which technique is best. With the advancement of endovascular technology and the availability of aggressive infrainguinal and infrapopliteal revascularization options, including retrograde pedal and popliteal access, tibial prosthetic bypasses are rarely performed nowadays. Nevertheless, when used as a last resort prior to an amputation, adjunctive techniques may be useful.
Linton Patch
In one technique (section “Linton Patch”), a vein patch angioplasty is initially performed at the site selected for the distal anastomosis. An incision is created in the patch and used as the new site for constructing the anastomosis. The graft is then sutured to the vein patch. This technique is often referred to as the “Linton patch” technique [1, 3, 4]. It is relatively simple to perform and can facilitate the construction of the anastomosis, especially in a heavily calcified vessel.
Miller Cuff
Another technique involves suturing a segment of vein to the arteriotomy at the site selected for the distal anastomosis as a collar or a cuff. The graft is then sutured to the vein cuff. This technique originally described by Siegman is usually referred to as the “Miller cuff technique” [5, 7]. Several modifications of this technique have been described. The simplest method to perform is illustrated in section “Miller Cuff.” St. Mary’s boot, another modification of the Miller cuff, is also described in section “Miller Cuff” [5].
Taylor Patch
Another technique involves constructing the distal anastomosis directly between the graft and the artery. An incision is then created in the graft at the level of the distal anastomosis and extended through the apex for 1–2 cm into the outflow artery. A vein patch angioplasty of the incision is then performed. This method is referred to as the “Taylor patch” (section “Taylor Patch”) [9]. This technique can be technically demanding and requires mobilization of a long segment of artery in order to construct the anastomosis.
Vein Patches and Cuffs
Linton Patch
Create an arteriotomy measuring 1.5–2.0 cm. Suture a vein patch to the arteriotomy as shown in Chap. 8.
Perform an incision in the center of the patch.
Transect the prosthetic graft in a beveled manner to match the incision in the vein patch.
Start one suture at the heel the graft (outside-inside), and then through the intimal part of the vein patch. place a similar suture at the apex.
Vein Patches and Cuffs
Linton Patch
Tie both sutures.
Start suturing with the heel suture. Introduce the needle outside-inside in the graft and inside-outside in the vein patch. Do the same with the apical suture.
Tie the sutures.
Flip the graft and replicate the suturing process on this side.
Vein Patches and Cuffs
Miller Cuff
Create an arteriotomy measuring 1.5–2.0 cm. Harvest a 4-cm segment of vein and slit the vein to create a patch.
The suture is first started in the center of the vein patch. The needle is introduced from the adventitial side of the vein.
The needle is then introduced from the intimal side of the artery in the middle of the arteriotomy.
Tie the suture and start suturing by introducing the needle outside-inside in the vein patch and inside-outside in the artery.
Vein Patches and Cuffs
Miller Cuff
Place several sutures until the apex is reached. Fold the vein cuff and place an apical bite in the vein.
Introduce the needle through the apex of artery. Continue suturing until you reach one end of the patch.
Vein Patches and Cuffs
Miller Cuff
Vein Patches and Cuffs
Miller Cuff
Flip the patch.
Again, introduce the needle from the adventitial side of the vein patch and then from the intimal side of the artery.
Vein Patches and Cuffs
Miller Cuff
Continue suturing until the heel of the arteriotomy is reached.
Fold the vein.
Vein Patches and Cuffs
Miller Cuff
Place the heel sutures. (Again, outside-inside in the vein, inside-outside in the artery.) Continue suturing until both ends of the vein patch meet. Tie the sutures and cut one end.
Tie the sutures and cut one end. Start another suture at the apex to join the edges of the vein patch. Continue suturing toward the arterial suture line. Tie the sutures together.
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