16 years old history of a venous

femoral-distal popliteal bypass:

late complication and solution
A.Furdui, G. Taranu, M.Ionac

Timis County Clinical Emergency Hospital – Vascular Surgery

 Case report
• 59 years old male
• pulsating pseudotumor on the left distal thigh
• onset: one week before presentation,
rapid growth

Clinical: Left lower limb: femoral pulse

distal pulse present
ABI: 1.04
History
• 2005: Saphenectomy of the
right great saphenous vein

• 2006: Venous graft (GSV)

femoral-popliteal (below the
knee) bypass on the left
lower limb
Comorbidities and Medication

ACENOCUMAROLUM 4mg (daily)

• GR I Hypertension
ASPIRIN 75 mg
• Mitral regurgitation
• Tricuspid regurgitation ROSUVASTATINUM 20 mg

• Dyslipidemia TRIMETAZIDINUM 35 mg

NEBIVOLOLUM 5 mg
Investigations
Dupplex 7-8 cm pseudoaneurysm
swirling flow

CT angiography

• Femoral – distal popliteal bypass – functional

• Above the knee, vein graft pseudoaneurysm

confirmed by computed tomography
angiography
Procedure
Interposition of a
tube graft
manufacturated
from bovine
pericardial patch

ALTERNATIVE TREATMENT OPTIONS:

• Autologus vein from upper limb
• Autologus small saphenous vein
• PTFE sintetic graft
Procedure
Procedure
 Procedure

BOVINE PERICARDIUM HANDMADE

TUBULAR GRAFT

END-TO-END PROXIMAL AND DISTAL

ANASTOMOSIS
In hospital evaluation
 Post-operative
TECHNICAL SUCCES

DISTAL PULSES PRESENT

RECOMMENDATION TREATMENT

• Physical exercise: walking daily minimum 3 km (30 min/day) RIVAROXABANUM 2,5 mg (1 – 0 – 1)

ASPIRIN 75 mg (0 – 1 – 0)
• Recovery – physiotherapy ROSUVASTATINUM 40 mg (0 – 0 – 1)
• Maintaining a normal body mass index (≤ 25 kg/m2) TRIMETAZIDINUM 35 mg (1 – 0 – 1)
• Low-sodium, hypolipidic diet NEBIVOLOLUM 5 mg (1 – 0 – 0)

VOYAGER PAD
•Randomized trial, multicenter, 6564 subjects
•Patients with PAD who underwent lower extremity
revascularization:rivaroxaban 2x2.5 mg/day + aspirin VS
aspirin

-significantly lower incidence of acute limb ischemia,

major amputation for vascular causes, MI, ischemic
stroke or death from CV causes.
Follow up – 4 weeks

SURGICAL WOUND HEALD

DISTAL PULSES PRESENT

SYMPTOMATOLOGY REMITTED
Follow up – 6 months
TUBULAR PERICARDIUM GRAFT PARIETAL THROMBUS ~40% flux limitation
DUPPLEX WAVEFORM IN THE DUPPLEX WAVEFORM IN THE VEIN GRAFT
PERICARDIUM GRAFT
Discussions
• arterialized autologous veins are at risk of degenerative changes because of histological differences
between veins and arteries.
• the cause of true aneurysmal degeneration of these grafts is still unknown.
• the mean time from graft implantation to clinical manifestation of the aneurysm is 7 years.
• the management of venous graft aneurysms should be subjected to the same criteria as other
aneurysms
• the first choice in detecting vein graft aneurysms is Duplex ultrasonography
• the type of surgical intervention depends on the cause, type and extension of aneurysmal dilatation
Conclusions
• Doppler ultrasound guided surveillance of GSV grafts should be mandatory and
long time from vein graft creation to onset of aneurysms makes long-term graft
surveillance even more imperative.
• aneurysmal degeneration of lower extremity vein conduits implanted for vascular
reconstruction has been rarely reported.

• they can lead to graft thrombosis, distal embolization, acute rupture, or skin
ulceration.