Innovative Technique for Below the Knee Arterial Revascularisation Using Porcine Self Made Stapled Pericardial Tube Grafts

Abstract

Introduction When no autologous vein is available for distal bypass in the setting of chronic limb threatening ischaemia (CLTI), new alternatives are required to solve the problems of availability, patency, and resistance to infection. An innovative technique of below the knee bypass for CLTI using a porcine self made stapled pericardial tube graft is reported. Report An 84 year old man, admitted with right CLTI with foot infection due to long occlusion of the femoropopliteal segment, required urgent revascularisation. In the absence of autologous vein and cryopreserved vessels, a 4 mm self made stapled porcine pericardial tube graft 56 cm long was created from two 14 × 8 cm patches, to perform a femorotibioperoneal trunk bypass. On day 10, bypass thrombectomy and balloon angioplasty of the distal anastomosis were needed to treat early occlusion. Oral anticoagulation was then started. Right toe pressure increased from 0 to 70 mmHg, and no infection was reported. Complete wound healing was achieved. At six months, the bypass was still patent. Discussion The use of porcine self made stapled pericardial tube grafts could offer new options for revascularisation in CLTI. Larger cohort studies with longer follow up are needed to confirm this successful preliminary experience.

Early and Mid-Term Results of Native and Abdominal Aortic Graft Infection Treatment via Surgeon-Constructed Porcine Pericardial Aortic Tubes

“…The death occurred on the 21st postoperative day due to severe septicemia and multiorgan failure. The early postoperative course was uneventful in the remaining cases, and patients were discharged home after a median of 12 days (6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22).…”

“…5,6 It has been used successfully in various vascular beds. [7][8][9][10] It is widely used as the leaflet material in Transcatheter Aortic Valve Implantation (TAVI) valves. 8 However, evidence of its use in arterial infection is scarce.…”

The Central Role of Vascular Surgeons in Innovation

“…presented the case of a patient with critical limb threatening ischaemia in which they used a homemade stapled pericardial tube graft with off the shelf porcine patches implanted as a femoro-tibioperoneal trunk bypass, in the absence of suitable or available material. 1 Even if the technique has already been described by the same team to create a shorter conduit, in this report the authors proposed to push forward the challenge with a longer conduit. 2 However, some points need to be discussed.…”

“… 3 In their report, the authors advocate the advantages of rapid and easy construction of tubularised grafts using vascular staplers, rather than a running suture. 1 However, metallic staples can be considered as foreign material that should be avoided in the setting of infection. 3 , 4 Even if it would take longer to perform a running suture, and even if the suture must be cut when the created graft is too long, a running suture should be favoured over stapling.…”

“…In fact, the authors reported that additional stitches in some parts of the staple lines were necessary owing to oozing. 1 Accordingly, biomechanical properties such as resistance, durability, and the compliance of such homemade stapled pericardial tube grafts need to be investigated to know how the stapling line behaves compared with a running suture before promoting large scale use of these grafts.…”