Jornal Vascular Brasileiro
https://www.jvascbras.org/article/doi/10.1590/1677-5449.210042
Jornal Vascular Brasileiro
Therapeutic Challenge

Fístula arteriovenosa como tratamento adjunto na revascularização arterial do membro em risco

Arteriovenous fistula as adjuvant treatment in arterial revascularization of an at-risk limb

Júlio César Gomes Giusti; Sabrina Payne Tartarotti; Fabio Henrique Rossi; João Paulo Neves Beraldo; Francisco Cardoso Brochado Neto

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Resumo

Resumo: A oclusão arterial aguda do membro inferior continua sendo um grande desafio para o cirurgião vascular. A abordagem cirúrgica depende principalmente da gravidade da lesão tecidual e da duração dos sintomas. Diversas técnicas estão disponíveis no arsenal terapêutico atual; porém, independentemente da técnica escolhida, fatores pós-operatórios, como o escoamento arterial limitado e o baixo fluxo nos substitutos arteriais, podem contribuir negativamente no resultado da revascularização. Descrevemos um caso de oclusão arterial aguda de membro inferior, no pós-operatório de uma derivação femorotibial, que se encontrava ocluída devido a limitação de escoamento e a alta resistência vascular periférica. Foi submetido a nova revascularização femorotibial, associada à confecção de uma fístula arteriovenosa, seguido de amputação de antepé e enxerto parcial de pele. O investimento enérgico no membro em risco possibilita reduzir os desfechos desfavoráveis, como amputação e óbito, e acelera a recuperação dos tecidos acometidos pela isquemia aguda.

Palavras-chave

enxerto vascular, fístula arteriovenosa, doença arterial periférica, transplante de pele

Abstract

Acute arterial occlusion remains a major challenge for the vascular surgeon. The therapeutic approach depends mostly upon the severity of the tissue injury and the duration of symptoms. Several techniques are available in the current therapeutic arsenal, however, regardless of the technique chosen, postoperative factors frequently observed, such as poor outflow status, or even low graft flow, can contribute negatively to the outcome of revascularization. We describe a case of acute limb ischemia, in the postoperative period of a femoral-tibial bypass, which was occluded due to outflow limitation and high peripheral vascular resistance. The patient underwent a second tibial revascularization combined with construction of an arteriovenous fistula, followed by forefoot amputation and partial skin graft. An energetic approach to the at-risk limb makes it possible to reduce unfavorable outcomes, such as amputation and death, and accelerates recovery of tissues affected by acute ischemia.

Keywords

vascular graft; arteriovenous fistula; peripheral arterial disease; skin transplantation.

References

1 Veenstra EB, van der Laan MJ, Zeebregts CJ, de Heide EJ, Kater M, Bokkers RPH. A systematic review and meta-analysis of endovascular and surgical revascularization techniques in acute limb ischemia. J Vasc Surg. 2020;71(2):654-668.e3. http://dx.doi.org/10.1016/j.jvs.2019.05.031. PMid:31353270.

2 Creager MA, Kaufman JA, Conte MS. Clinical practice. Acute limb ischemia. N Engl J Med. 2012;366(23):2198-206. http://dx.doi.org/10.1056/NEJMcp1006054. PMid:22670905.

3 Smeds MR, Sandhu HK, Leake SS, Miller CC, Charlton-Ouw KM. Patterns in the Management of Acute Limb Ischemia: a VESS Survey. Ann Vasc Surg. 2017;38:164-71. http://dx.doi.org/10.1016/j.avsg.2016.09.007. PMid:27793619.

4 Marqués de Marino P, Martínez López I, Revuelta Suero S, et al. Results of infrainguinal bypass in acute Limb Ischaemia. Eur J Vasc Endovasc Surg. 2016;51(6):824-30. http://dx.doi.org/10.1016/j.ejvs.2016.03.023. PMid:27133389.

5 Laurila K, Luther M, Roth WD, et al. Adjuvant arteriovenous fistula as means of rescue for infrapopliteal venous bypass with poor runoff. J Vasc Surg. 2006;44(5):985-91. http://dx.doi.org/ 10.1016/j.jvs.2006.06.037.

6 Aherne T, Kheirelseid E, O’Neill D, et al. The use of arteriovenous fistulae as an adjunct to peripheral arterial bypass: a systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2016;51(5):707-17. http://dx.doi.org/10.1016/j.ejvs.2016.01.014. PMid:27067191.

7 Hamsho A, Nott D, Harris PL. Prospective randomised trial of distal arteriovenous fistula as an adjunct to femoro-infrapopliteal PTFE bypass. Eur J Vasc Endovasc Surg. 1999;17(3):197-201. http://dx.doi.org/10.1053/ejvs.1998.0671. PMid:10092890.

8 Ascer E, Gennaro M, Pollina RM, et al. Complementary distal arteriovenous fistula and deep vein interposition: a five-year experience with a new technique to improve infrapopliteal prosthetic bypass patency. J Vasc Surg. 1996;24(1):134-43. http://dx.doi.org/10.1016/S0741-5214(96)70154-4. PMid:8691516.

9 Moawad J, Gagne P. Adjuncts to improve patency of infrainguinal prosthetic bypass grafts. Vasc Endovascular Surg. 2003;37(6):381-6. http://dx.doi.org/10.1177/153857440303700601. PMid:14671692.

10 Baril DT, Patel VI, Judelson DR, et al. Outcomes of lower extremity bypass performed for acute limb ischemia. J Vasc Surg. 2013;58(4):949-56. http://dx.doi.org/10.1016/j.jvs.2013.04.036. PMid:23714364.

11 Sauvage LR, Walker MW, Berger K, et al. Current arterial prostheses. Experimental evaluation by implantation in the carotid and circumflex coronary artery of the dog. Arch Surg. 1979;114(6):687-91. http://dx.doi.org/10.1001/archsurg.1979.01370300041005.

12 Giusti JCG, Fernandes JR, Soares SP, et al. Alternative iliofemoral revascularization in extensive aortoiliac occlusive disease. J Vasc Bras. 2019;18:e20180083. http://dx.doi.org/10.1590/1677-5449.180083. PMid:31360150.

13 Gomes Giusti JC, Neves Beraldo JP, Rossi FH, et al. The descending genicular artery as a recipient vessel in chronic limb-threatening ischemia - a case report and literature review. Ann Vasc Surg. 2020;69:450.e23-8. http://dx.doi.org/10.1016/j.avsg.2020.06.008. PMid:32561240.

14 Biancari F, Railo M, Lundin J, et al. Redo bypass surgery to the infrapopliteal arteries for critical leg ischaemia. Eur J Vasc Endovasc Surg. 2001;21(2):137-42. http://dx.doi.org/10.1053/ejvs.2000.1290. PMid:11237786.

15 Ambler GK, Twine CP. Graft type for femoro-popliteal bypass surgery. Cochrane Database Syst Rev. 2018;2(2):CD001487. PMid:29429146.

16 Naz I, Walters ET, Janhofer DE, et al. Outcomes of split-thickness skin grafting for foot and ankle wounds in patients with peripheral arterial disease. Wounds. 2019;31(11):272-8. PMid:31730509.

17 Chang DW, Sanchez LA, Veith FJ, Wain RA, Okhi T, Suggs WD. Can a tissue-engineered skin graft improve healing of lower extremity foot wounds after revascularization? Ann Vasc Surg. 2000;14(1):44-9. http://dx.doi.org/10.1007/s100169910008. PMid:10629263.

18 Aust MC, Spies M, Guggenheim M, et al. Lower limb revascularisation preceding surgical wound coverage - an interdisciplinary algorithm for chronic wound closure. J Plast Reconstr Aesthet Surg. 2008;61(8):925-33. http://dx.doi.org/10.1016/j.bjps.2007.09.060. PMid:18407817.

19 Barshes NR, Bechara CF, Pisimisis G, Kougias P. Preliminary experiences with early primary closure of foot wounds after lower extremity revascularization. Ann Vasc Surg. 2014;28(1):48-52. http://dx.doi.org/10.1016/j.avsg.2013.06.012. PMid:24189006.
 


Submitted date:
04/15/2021

Accepted date:
07/30/2021

61608c2aa95395187b046ba5 jvb Articles

J Vasc Bras

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