Introduction: In vascular surgery the crossover iliofemoral bypass grafting is a well-known surgical technique. In general surgery the repair of an abdominal defect using a Polypropylene mesh is also a standard procedure. A particular technique is defined by the performance of these 2 separate procedures inside a single operation in which the crossover arterial graft is directed from the retroperitoneal space toward the contra-lateral femoral bifurcation through a Polypropylene mesh which closes the musculoaponeurotic layers of the abdominal wall. We present our experience with the use of this particular surgical technique in patients with critical limb ischemia and with indication for extra-anatomic crossover bypass (high-risk patients with contra-indication for the transperitoneal approach, extensive calcified aortic or iliac wall which contraindicated the direct arterial reconstruction or secondary arterial reconstruction after the occlusion of an aorto- femoral graft).
Methods: In principle, the hernioplasty was performed by using the Lichtenstein tension-free hernia repair technique, followed by the crossover iliofemoral bypass. The main feature of this technique is to pass the vascular graft from the retroperitoneal space above the mesh through a calibrated hole in the mesh RESULTS: The 7 patients with inguinal hernia and l limb-threatening ischemia had favorable evolution, without hernia recurrence, limb-threatening ischemia or any graft complication at 3 years.
Discussion: Using this particular surgical technique we treated 2 surgical diseases using a single intervention for highrisk patients who had both inguinal hernia and contra-lateral critical limb ischemia. Being encouraged by the initial satisfactory results, we extended this technique even for the patients with indication of crossover iliofemoral bypass but without inguinal hernia.
Conclusions: The particular surgical technique of the crossover bypass in which the vascular graft crosses a tension-free Polypropylene mesh from the retroperitoneal space toward the Retzius space represents an efficient and short procedure which treats simultaneously 2 different surgical diseases (inguinal hernia and contra-lateral critical limb ischemia) in high-risk patients. The results were satisfactory: we had no hernia recurrence and the limb-threatening ischemia was successfully treated. The preferred vascular graft for this particular technique is the reversed autogenous vein because its resistance to infections and the vein long-term patency is better than of a vascular prosthesis. When a prosthetic graft is required, we prefer to use the classic technique in which the crossover graft is placed in an under-aponeurosis site, in order to diminish the prosthesis infection risk.
Key words: Abdominal wall, Iliofemoral bypass, Vascular surgery.
Introduzione: Spesso, la malattia vascolare può essere associata ad ernia inguinale richiedendo un trattamento chirurgico in entrambi i casi. Tuttavia, l’innesto incrociato può comportare l’ernia inguinale o femorale. Per risolvere questo problema, vi presentiamo una tecnica chirurgica in cui l’innesto vascolare ileofemorale incrociato attraversa una protesi addominale di riparazione.
Materiale e metodi: Abbiamo eseguito questa tecnica in 18 pazienti ad alto rischio. Sette pazienti avevano comorbilità - ernia inguinale e occlusione dell’arteria iliaca controlaterale) curati contemporaneamente: innesto vascolare incrociato è diretto dallo spazio retroperitoneale mediante la protesi di ernioplastica verso l’arteria femorale contro-laterale. Abbiamo esteso questa tecnica per 11 pazienti senza ernia associata. Innesti vascolari: 10 vene autogene, 8 innesti protesici. Ulteriori indagini sono state completati per tutti i 18 pazienti da un esame clinico. Il periodo mediano di follow-up è stato di 2,5 ani. Abbiamo paragonato questa tecnica con gli interventi incrociati „classici”. che sono state eseguite mediante le tecniche tradizionali. Risultati: non ci sono stati ulteriori recidive di ernia o di ischemia al livello degli arti (nei primi 3 anni), 1 caso di infezione tardiva della protesi e 3 casi di trombosi tardiva della protesi.
Conclusioni: Questa tecnica è stata applicata al trattamento di pazienti ad alto rischio, con 2 malattie, utilizzando un’unico intervento e sembra essere fattibile come procedura incrociata di routine incrociata.