Infected dialysis graft- local excision with bypass

This is how we deal with a recurrent dialysis ePTFE infection. The infection is localized at the bending area of the forearm loop graft. The graft was patent with good flow. However, there was repeated graft infection despite of debridement procedures.

Usually we have to deal with this kind of situation aggressively. That is to say, we have to remove all the infected segment of ePTFE graft. In this case, the infected segment (which was located just at the bending portion of the loop) had to be removed. According to the principle of surgery, we did the bypass surgery prior to the removal of infected portion to maintain the flow. We did bypass from the arterial limb to the venous limb, and we have tunneled the new graft through the healthy area to avoid contamination. After the flow of dialysis access was established, we then extracted the infected segment through the previously infected open wound (where the exposed graft lied). The dirty wound had been put on wet dressing.

And the patient can be put on dialysis via the original access without problem since the puncture area was non-touched.

less invasive revascularization

This is a case I have completed today.
A 80 y.o. gentleman ,who suffered from intermittent claudication for a long time. A total occlusion over his left thigh artery was diagnosed. From the angiography above, you can see there is a block on the artery which makes the distal artery lack of blood flow. Since the smptoms getting worse day by day, he was suggested to have a "revascularization".
In the old days, we surgeons tend to do "open bypass" which means insertion of a artifical tube into the leg to drain the blood from healthy arteries to distal artery. Usually the bypass surgery needs to cut multiple wounds on the leg and to make tunnels in the leg to insert the artifical artery. Sure the procedure is a painfula and lengthy procedure with relatively painful recovery course.
Nowadays we adopt the so call "endovascular revascularization". Like in this case, we have just stick a tiny hole on the thigh (without even using a blade!) and insert some king of balloon catheter into the artery. We have found the blockage under X ray and open the blockage by balloon. No cutting or sutures on the artery needed. No painful tunneling in the flesh needed. The recovery course will be very easy to the patient and he will be able to walk a couple of hours later.

Thanks to the endovascualr technique, we can render more effective treatments to patients with artery diseases in a less invasive fashion.

popliteal total occlusion: bypass with Distaflo!

History
A patient of chronic ischemic leg presented with right side gangrene toes. Image study showed right side popliteal artery total occlusion. Revascularization was thus indicated.
Op finding
The right side above knoww popliteal artery was explored to be severe calcified and severe diseased. Endarterectomy was done. The below knee popliteal artery was then explored.
Operation Strategy
PTA alone was note considered because of longer patency was expected. Due to the location of the total occlusion(just behind the knee joing), PTA with stentgrafting was not considered. A Distaflo (cuffed ePTFE graft was implanted as a bypass graft. You can see the cuff of the graft was nicely seated on the target vessel.

case: FP bypass using Distaflo graft

Today, a patient of PAOD (peripheral artery occlusive disease) who was discharged from the hospital some 10 days ago came back to the clinic for his posoperative check. Here is his postoperative images.
History
He was a victim of right femoral artery total occlusion presented with severe intermittent claudiction. a right side femoro-popliteal bypass had been performed in some other hospital around half a year ago. unfortunately, the graft failed almost immediately after the procedure and the symptom had never been treated. (Here you can see the previous inserted graft, which is occluded already) He thus then came to my institution for further help.
Operative finding
severe atheromatous change of CFA, right side was noted during the procedure. I have used a ePTFE graft which has a cuffed design (Distaflo, BARD) for the bypass graft. the target vessel was the below knee popliteal artery. The postoperative image showed here a patent graft with beautiful distal anastomosis. The cuffed shape of the arterial anastomosis had been showed clearly and beautifully. The flared cuff design of the graft, compare to the regular graft, can enhance the artery blood flow and decrease the possible turbulance blood flow over the anastomosis thus in turn decrease the future intimal hyperplasia on the vessel wall. Theoretically, it can prolong the distal bypass graft patency.

The patient had been rather well after the surgery. No more claudication was complained.
I sure hope that the cuffed design of the graft can minimize the possible stenosis in the future!