Peripheral bypass re-operation: detection of thrombus in graft and flow in side branches

Case

Patient medical history: Patient with PAD and Fontaine stage IV on the right side. See image 1.

Initial surgery: Fem-pop bypass. The surgery went uneventfully and the TTFM showed 41 ml/min with a PI of 2,9 after ligation of all residual saphenous vein side branches that were visible on angio, as seen in image 2.

Re-operation

On post-op day 8, the patient experienced pain in the foot. Percutaneous ultrasound showed a distal occlusion of the bypass as well as flow in the vein side branch (fistula) as seen in image 3. The patient was readmitted for surgery and during the procedure, HFUS revealed a large open side branch and a thrombus in the vein graft, as seen in image 4.

TTFM was first measured at M1 proximally to the open side branch before the thrombectomy in the SVG graft as seen in image 5. After the thrombectomy, TTFM was measured at M2 distally to the closed side branch and showed reduced flow which revealed that there was a side branch A.
Then, as shown in image 6, after ligating side branch A, TTFM was measured at M3 close to the distal anastomosis and showed reduced flow as well which suggested a second side branch B. After ligating the second side branch B, TTFM was measured at M4. The high PI may be due to high resistance in the tibial trunk, hence, angioplasty of the tibial trunk was performed simultaneously. A final TTFM was performed with an acceptable flow and PI

Reference

Reference: Case Example by Dr. Alexander Meyer, Department of general and vascular Surgery, Johanniter Krankenhaus Rheinhausen

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