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Tipps und Tricks zur erfolgreichen kruropedalen Bypasschirurgie

Useful tips and tricks for successful crural and pedal bypass surgery

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Zusammenfassung

Die Strategie für eine erfolgreiche distale Bypassanlage sollte bereits im Rahmen des ersten Patientenkontaktes nach Einschätzung des allgemeinen operativen Risikos festgelegt werden. Vorrausetzung ist eine adäquate Bildgebung, die eine sichere Beurteilung des arteriellen Zu- und Abstroms sowie die Planung der Anastomosenlokalisation erlaubt. Grundsätzlich sollte bei allen peripheren Bypassoperationen nach Möglichkeit immer eine voll autologe Rekonstruktion angestrebt werden, bevor Prothesenmaterial zum Einsatz kommt. Eine intakte ipsi- oder kontralaterale V. saphena magna ist zwar das ideale Graft, steht aber nicht immer in der notwendigen Länge und Qualität zur Verfügung. Die Armvenen und die V. saphena parva sollten daher regelhaft in die Planung eines voll autogen Bypasses einbezogen werden. Dazu muss die Technik der Veno-Venostomie zur Herstellung eines autologen Venengrafts aus Teilstücken sicher beherrscht werden. Lokalisation und Konfiguration der proximalen Anastomose orientieren sich an der individuellen Anatomie, wobei die Möglichkeit des Bypassursprungs an der A. profunda femoris bedacht werden sollte. Die periphere Anastomose sollte am besterhaltenen Gefäß mit möglichst direktem Ausstrom zum Fuß erfolgen. Eine vorsichtige subtile Operationstechnik mit sparsamer Exposition der kruralen und pedalen Gefäße mit Vermeidung einer Klemmung ist entscheidend. Die Anastomosierung von stark verkalkten Gefäßen kann durch eine einfache Form der Blutleere entscheidend erleichtert werden. Prothesenmaterial sollte in der kruralen und pedalen Bypasschirurgie nur dann zur Anwendung kommen, wenn autologe Vene nicht in der notwendigen Länge zur Verfügung steht. In diesem Fall ist die Anlage der distalen Anastomose mit einem autologen Venencuff oder einem Patch zu bevorzugen. Im Einzelfall kann eine sequenzielle Composite-Technik mit autologer Vene erwogen werden. Prothesengrafts sollten nach Möglichkeit subfazial positioniert werden. Autologe Venengrafts können auch sehr gut subkutan verlegt werden. Jede krurale oder pedale Bypassrekonstruktion sollte als individualisierte Konstruktion angesehen werden.

Abstract

The strategy for successful placement of a distal bypass should already be defined during the first patient contact after estimation of the general operative risk. A prerequisite is an adequate imaging that enables a reliable assessment of the arterial inflow to the leg and the planning of the site of the anastomosis. A completely autologous reconstruction should fundamentally always be the primary goal of all peripheral bypass operations, before the prosthetic material is used. An intact ipsilateral or contralateral greater saphenous vein is considered to be the ideal graft but is not always available in the necessary length and quality. For this reason, arm veins and lesser saphenous vein should always be included in the planning of a completely autologous bypass. Mastering the technique of venous end-to-end anastomosis is essential to enable the construction of autologous spliced vein grafts. The localization and configuration of the proximal anastomosis are selected according to the individual anatomy. The possibility to use the profunda femoris artery for the origin of the bypass should always be borne in mind. For the distal anastomosis, the best-preserved distal vessel with a direct outflow to the foot should be chosen whenever possible. A careful and subtle surgical technique with limited exposure of the crural and pedal vessels and avoidance of clamping is crucial. A simple tourniquet technique can enable an anastomosis of severely calcified vessels in a bloodless field. Prosthetic material should only be used for crural and pedal bypass surgery if autologous veins in the necessary length are unavailable. In this case, the creation of the distal anastomosis with an autologous vein cuff or patch should be preferred. In selected cases a sequential composite bypass graft with autologous veins can be a good solution. Prosthetic grafts should be preferentially placed in a subfascial position. Autologous vein grafts can also be placed in the subcutaneous tissue. Each crural or pedal bypass reconstruction should be regarded as an individualized construction.

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  1. Klinik und Poliklinik für Herz- und Gefäßchirurgie, Universitätsmedizin der Johannes Gutenberg-Universität, Langenbeckstr. 1, 55131, Mainz, Deutschland

    Achim Neufang

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Vorschlag zur systematischen Auswahl des Bypassgraftmaterials in der Planung eines kruralen oder pedalen Bypasses.

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Neufang, A. Tipps und Tricks zur erfolgreichen kruropedalen Bypasschirurgie. Gefässchirurgie 28, 175–188 (2023). https://doi.org/10.1007/s00772-023-00977-7

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