Gradman W S, Cohen W, Laub J, Haji-Aghaii M
Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
J Vasc Surg. 2001 Apr;33(4):888-94. doi: 10.1067/mva.2001.111745.
The medial supragenicular and infragenicular approaches to the popliteal artery were introduced almost 50 years ago and replaced the posterior approach to the popliteal artery for distal graft implantation. We review a contemporary series of bypass grafts to the midpopliteal artery by use of a combined anterior and posterior approach to evaluate its potential clinical benefits.
After the proximal graft anastomosis is constructed, an incision is made in the popliteal fossa to access the midpopliteal artery, the graft is passed into that incision, and all but the popliteal incision is closed. The patient is turned, the midpopliteal artery dissection is completed, and the graft is anastomosed distally.
Fifty-seven bypass grafts, implanted distally on the midpopliteal artery by this technique over a 13-year period, chosen in preference to an infragenicular bypass graft in selected patients when a supragenicular bypass was not feasible, were assessed in terms of indications for surgery, conduit type, complications, length of postoperative hospitalization, and graft patency.
Bypass grafting originated from the axillary artery in two cases, the common iliac artery in one case, and the femoral artery in 54 cases. The procedure was performed in five patients with a popliteal trifurcation anomaly, nine patients with a blind popliteal segment, 20 patients with limited length of autologous vein, and five patients with an above-knee graft infection requiring an alternate path for revascularization. Autologous vein was used in 35 and polytetrafluoroethylene (PTFE) in 19 bypass grafts. Three other patients had a composite sequential femoral-popliteal-tibial bypass graft, with PTFE and autologous vein. Postoperative (30 day) complications include one death (composite sequential), one stroke (PTFE), and one graft thrombosis (saphenous vein). The mean postoperative hospitalization for the last 31 patients was 4.2 +/- 3.7 days. In the autologous vein group, the 1-year primary patency rate was 87%, and the primary assisted patency rate was 94%. In the PTFE group, the 1-year primary patency rate was 72%. Two composite sequential grafts remained patent at 1 year.
Bypass grafting to the midpopliteal artery with a combined anterior and posterior approach offers a safe and effective option to below-knee bypass grafting when an above-knee bypass grafting is not feasible. Compared with the medial infragenicular incision, the posterior incision results in reduced morbidity rates, rapid mobilization, and early hospital discharge.
腘动脉膝上内侧和膝下入路在近50年前就已被引入，取代了腘动脉后入路用于远端移植物植入。我们回顾了一组当代采用前后联合入路至腘动脉中段的旁路移植术，以评估其潜在的临床益处。
在完成近端移植物吻合后，在腘窝做切口以显露腘动脉中段，将移植物放入该切口，除腘窝切口外的其他切口均关闭。患者翻身，完成腘动脉中段的解剖，然后将移植物进行远端吻合。
在13年期间，采用该技术在腘动脉中段远端植入了57例旁路移植物，在选择患者时，当膝上旁路不可行时，优先于膝下旁路移植物，评估了手术指征、管道类型、并发症、术后住院时间和移植物通畅情况。
旁路移植术起源于腋动脉2例，髂总动脉1例，股动脉54例。该手术在5例腘动脉三叉异常患者、9例腘动脉盲段患者、20例自体静脉长度有限的患者以及5例膝上移植物感染需要另一条血管重建路径的患者中进行。35例旁路移植物使用自体静脉，19例使用聚四氟乙烯（PTFE）。另外3例患者进行了股 - 腘 - 胫复合序贯旁路移植术，使用了PTFE和自体静脉。术后（30天）并发症包括1例死亡（复合序贯）、1例中风（PTFE）和1例移植物血栓形成（大隐静脉）。最后31例患者的平均术后住院时间为4.2±3.7天。在自体静脉组中，1年的原发性通畅率为87%，原发性辅助通畅率为94%。在PTFE组中，1年的原发性通畅率为72%。2例复合序贯移植物在1年时仍保持通畅。
当膝上旁路移植不可行时，采用前后联合入路至腘动脉中段的旁路移植术为膝下旁路移植提供了一种安全有效的选择。与膝下内侧切口相比，后入路切口导致发病率降低、活动恢复快且早期出院。
