title: Very distal vein bypass in patients with thromboangiitis obliterans.
abstract: BACKGROUND
  Surgical revascularization for chronic critical limb ischaemia in patients with thromboangiitis obliterans (TAO) still remains controversial. Generally, besides cessation of smoking, conservative treatment supported by intravenous administration of vasoactive agents is regarded as the treatment of choice, in combination with local wound therapy or minor amputation.
  
  
  METHODS
  In four male patients (42-47 years) surgical revascularization was chosen as therapy for established gangrene or non-healing ulceration after unsuccessful conservative treatment and cessation of smoking. Angiography was able to identify a suitable distal arterial segment for the bypass which was revascularized by means of an autologous vein graft. Grafts were followed with repetitive duplex ultrasound. Revision of the bypass graft was initiated if indicated by pathological duplex findings.
  
  
  RESULTS
  In all cases a bypass could be constructed with either the ipsilateral greater saphenous vein or arm veins. A distal origin configuration was possible in three cases with popliteo-pedal or cruro-pedal bypasses. In the fourth case the distal superficial femoral artery was used for inflow. Two early graft thromboses underwent successful revision. During follow-up, duplex ultrasound identified graft stenoses in three bypasses which were successfully treated with endovascular techniques. All grafts are patent with complete resolution of ischaemic symptoms after 46, 42, 32, and 29 months. The patients remained non-smokers and returned to a professional life.
  
  
  CONCLUSIONS
  Surgical therapy with distal vein bypass for persistent ischaemic symptoms after definitive cessation of smoking seems feasible in selected cases with TAO and a suitable distal artery. Close follow-ups of the patients with duplex ultrasound are necessary to identify developing vein graft stenoses. Angioplasty seems to be an important part of the long-term therapeutic concept.
authors.affiliation: 1 Helios Dr. Horst Schmidt Klinik, Department of Vascular Medicine, Wiesbaden, Germany.
authors.forename: Achim
authors.initials: A
authors.lastname: Neufang
authors.affiliation: 1 Helios Dr. Horst Schmidt Klinik, Department of Vascular Medicine, Wiesbaden, Germany.
authors.forename: Carolina
authors.initials: C
authors.lastname: Vargas-Gomez
authors.affiliation: 1 Helios Dr. Horst Schmidt Klinik, Department of Vascular Medicine, Wiesbaden, Germany.
authors.forename: Patrick
authors.initials: P
authors.lastname: Ewald
authors.affiliation: 1 Helios Dr. Horst Schmidt Klinik, Department of Vascular Medicine, Wiesbaden, Germany.
authors.forename: Nicolaos
authors.initials: N
authors.lastname: Vitolianos
authors.affiliation: 1 Helios Dr. Horst Schmidt Klinik, Department of Vascular Medicine, Wiesbaden, Germany.
authors.forename: Tolga
authors.initials: T
authors.lastname: Coskun
authors.affiliation: 2 Helios Dr. Horst Schmidt Klinik, Department of Radiology, Wiesbaden, Germany.
authors.forename: Nael
authors.initials: N
authors.lastname: Abu-Salim
authors.affiliation: 3 Westpfalzklinikum II Kusel, Department of Angiology, Kusel, Germany.
authors.forename: Rainer
authors.initials: R
authors.lastname: Schmiedel
authors.affiliation: 3 Westpfalzklinikum II Kusel, Department of Angiology, Kusel, Germany.
authors.forename: Peter
authors.initials: P
authors.lastname: von Flotow
authors.affiliation: 1 Helios Dr. Horst Schmidt Klinik, Department of Vascular Medicine, Wiesbaden, Germany.
authors.forename: Savvas
authors.initials: S
authors.lastname: Savvidis
mesh_terms: D000328:Adult; D001132:Arm / Q000098:blood supply*; D016208:Databases, Factual; D057510:Endovascular Procedures; D006083:Graft Occlusion, Vascular / Q000000981:diagnostic imaging / Q000209:etiology / Q000503:physiopathology / Q000628:therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D010690:Phlebography; D012189:Retrospective Studies; D012307:Risk Factors; D012501:Saphenous Vein / Q000637:transplantation*; D012907:Smoking / Q000009:adverse effects; D016540:Smoking Cessation; D000074606:Smoking Prevention; D013919:Thromboangiitis Obliterans / Q000000981:diagnostic imaging / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D013997:Time Factors; D014182:Transplantation, Autologous; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex; D058017:Vascular Grafting / Q000009:adverse effects / Q000379:methods*; D014654:Vascular Patency; D020246:Venous Thrombosis / Q000000981:diagnostic imaging / Q000209:etiology / Q000503:physiopathology / Q000628:therapy
keywords: Thromboangiitis obliterans; bypass; human; limb salvage; vascular patency