Ascer E, Kirwin J, Mohan C, Gennaro M
Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY 11219.
J Vasc Surg. 1993 Aug;18(2):234-9; discussion 239-41.
It is believed that secondary operations involving the inguinal region are associated with a significant morbidity that includes infection, lymphatic obstruction, lymphorrhea, and neurovascular injury. To prevent these potentially important complications we have avoided a redo groin incision in 38 patients with severely symptomatic disease who had primary (23 cases) or secondary (15 cases) femoropopliteal bypass thrombosis during the past 3 years.
All patients were candidates for prosthetic bypasses because of lack of a suitable vein. Twenty-nine external iliac-to-popliteal bypasses (18 above-knee; 11 below-knee) and nine external iliac-to-infrapopliteal bypasses (five anterior tibial; two posterior tibial; two peroneal) were performed with 6 mm polytetrafluoroethylene ringed grafts in 38 patients. Adjunctive distal arteriovenous fistulas were constructed in all infrapopliteal bypasses. The external iliac artery was exposed via a retroperitoneal approach. The second incision was placed just below the scarred area and deepened to the level of the medial border of the sartorius muscle. A tunnel that connected both incisions was easily created by blunt dissection alongside the anterolateral border of the femoral artery.
Four popliteal bypasses occluded at 4, 6, 10, and 28 months after operation. The remaining 25 grafts are patent (mean 14 months). Three of the infrapopliteal bypasses occluded at 0, 2, and 3 months after operation. The remaining six grafts are patent with follow-up from 4 to 18 months (mean 12 months). Only one patient had a superficial wound infection at the below-knee popliteal incision, which healed with local treatment. All other patients had an uneventful postoperative course.
Thus we believe this approach to be simple, safe, and durable and should be used preferentially to avoid the difficult and hazardous dissection of a previously operated groin.
据信，涉及腹股沟区的二次手术会带来包括感染、淋巴阻塞、淋巴漏和神经血管损伤等显著的发病率。为预防这些潜在的重要并发症，在过去3年中，我们对38例患有严重症状性疾病的患者避免了再次腹股沟切口，这些患者曾发生原发性（23例）或继发性（15例）股腘动脉搭桥血栓形成。
由于缺乏合适的静脉，所有患者均适合进行人工血管搭桥。在38例患者中，使用6毫米带环聚四氟乙烯移植物进行了29例髂外动脉至腘动脉搭桥（18例膝上；11例膝下）和9例髂外动脉至腘动脉以下搭桥（5例胫前动脉；2例胫后动脉；2例腓动脉）。所有腘动脉以下搭桥均构建了辅助性远端动静脉瘘。通过腹膜后途径暴露髂外动脉。第二个切口位于瘢痕区域下方，加深至缝匠肌内侧缘水平。通过在股动脉前外侧缘旁钝性分离，轻松创建连接两个切口的隧道。
4例腘动脉搭桥在术后4、6、10和28个月闭塞。其余25条移植物通畅（平均14个月）。3例腘动脉以下搭桥在术后0、2和3个月闭塞。其余6条移植物通畅，随访4至18个月（平均12个月）。只有1例患者在膝下腘动脉切口处发生浅表伤口感染，经局部治疗愈合。所有其他患者术后过程顺利。
因此，我们认为这种方法简单、安全且持久，应优先使用以避免对先前手术的腹股沟进行困难且危险的解剖。
