Eur J Vasc Endovasc Surg 13, 439-442 (1997)
Residual Arteriovenous Fistulae after "closed" in situ Bypass Grafting:
an Overrated Problem
L. C. van Dijk ~, H. van Urk 2, J. S. Lam6ris ~ and C. H. A. Wittens .3
1Department of Radiology and 2Department of Vascular Surgery of the University Hospital Rotterdam "Dijkzigt" and
3Department of Surgery, St Franciscus Gasthuis, Rotterdam, The Netherlands
Objectives: To prospectively evaluate the incidence and consequences of residual arteriovenous (AV)-fistulae after
"closed" in situ bypass grafting.
Methods: In 34 patients, 35 "closed" in situ bypasses were performed. Postoperative assessment of residual A V-fistulae
and bypass patency was performed with duplex scanning.
Results: Postoperative mortality was 3%. During 35 "closed" in situ bypass procedures 216 side branches were coil
embolised. Postoperatively 39 AV-fistulae were detected (15% of the total number of 216 + 39 =255 side branches). Of
these, 13 (5%) closed spontaneously. Fifteen (6%) remained unchanged and 11 (4%) were treated. In three patients four
asymptomatic residual A V-fistulae were treated. In four patients seven symptomatic A V-fistulae were treated for: decreased
distal bypass flow in one; persistent leg oedema in one; pain and redness of the skin in two. One-year primary patency
was 80% ( S E 8.4%). Residual A V-fistulae were detected in none of six bypass occlusions during follow-up.
Conclusion: Residual A V-fistulae detected following "closed" in situ bypass grafting only need treatment if they are
symptomatic, which is uncommon.
Key words: in situ bypass; Arteriovenous fistulae; Saphenous vein; Endovascular; Coil embolisation.
In situ vein infrainguinal bypass is one of the preferred
techniques for treatment of lower extremity ischaemia.
The standard "open" technique, using ligation of the
side branches via a long skin incision, is associated
with wound complication rates up to 44%. 1'2 To reduce
the number of postoperative wound complications,
"closed" in situ bypass techniques, using peroperative
endovascular coil embolisation of vein side branches,
have been developed. 3'4 A disadvantage of these
"closed" techniques is the high incidence of post-
operative residual arteriovenous (AV)-fistulae. Cikrit
et aI., 5 who used the electronically steerable nitinol
catheter system as first used by Rosenthal et al., 3 re-
ported that 39% of the patients were treated for re-
sidual AV-fistulae after "dosed" in situ bypass grafting.
We have reported that 42% of the patients were treated
for residual AV-fistulae after "closed" in situ bypass
grafting, using a co-axial catheter system in a ran-
domised study comparing the "closed" technique to
the "open" technique. 6 Rosenthal et aI., however, only
* Please address all correspondence to: C. H. A. Wittens, Department
of Surgery, St Franciscus Gasthuis, Kleiweg 500, 3045 PM Rotterdam,
treated 6% residual AV-fistulae after refinement of the
electronically steerable nitinol catheter and increased
operator experience with the "closed" technique. 7
The purpose of this study was to evaluate the in-
cidence and consequences of residual AV-fistulae after
"closed" in situ bypass grafting using a co-axial cath-
eter system for peroperative endovascular coil em-
bolisation of the vein side branches.
Patients and Methods
From June 1992 to March 1996, 35 "closed" in situ
bypasses were performed in 34 patients (23 male, 11
female) in the St Franciscus Gasthuis, Rotterdam. The
mean age was 73 years (range 55-90) and indications
for operation were non-healing ulcers or necrosis in
16, restpain in seven and life-style limiting/disabling
claudication in 11. Fourteen (41%) patients had a smok-
ing history, 17 (50%) had ischaemic heart disease, 17
(50%) had hypertension and six (18%) were diabetic.
Seventeen femorodistal popliteal and 18 femorocrural
bypasses were performed.
The "closed" in situ bypass technique used was
described by Wittens et al. 4 The main characteristics
1078-5884/97/050439 + 04 $12.00/0 © 1997 W.B. Saunders Company Ltd.