Bypass graft complications

So in general, it is not unreasonable to perform percutaneous access on femoral vessels that have a bypass, but access is the key. It sounds like perhaps the access went thru the bypass and then the device would occlude the bypass graft. Patient should also have a duplex of the bypass performed in recent due to the fact the sheath can be occlusive so you do not want to occlude flow for extended periods of time, especially if there are low velocities within the bypass graft. Some key information should be within the angiogram pictures (if surgeon took of access) when performing the balloon angioplasty and the operative dictation of the surgeon when he explored the groin initially.

I think given the temporal relation to the bypass going down, it is likely the procedure was the cause of his bypass occluding. As above, it would be interesting to see what the pictures and full operative dictation reveals.

Several issues with this case: a. The Mynx device like most arterial access closure devices is not indicated for use in the setting of a previous femoral to popliteal bypass (that is a prosthetic bypass, https://cordis.com/apac/products/close/endovascular/mynx-control-vascular-closure-device). That said many surgeons and interventionalist will sue off label for access thus not necessarily a breach in “standard of care” b. The patient underwent an angioplasty of the internal carotid artery after a previous carotid endarterectomy – there is no indication for this type of treatment – this seems like a breach of care to me. c. The patient clearly had an access complication that required intervention as described in the case, again the issue is why did he have the non-indicated angioplasty of his internal carotid artery in the first place. d. The patient subsequently had a groin infection (known complications) that led to his heart value being infected. e. Plavix should be used in these patients, but aspirin is often considered standard of care.

Yes, please see points above. In particular there is no known indication to undertake an angioplasty in the providers outpatient center prior to the definitive re-operative approach to this patient, that is a trans carotid artery revascularization (TCAR).

Answers to posed questions: -Mynx relies on a "plug" of PEG to seal. Whether this was the "best" closure choice is really a matter of debate, as there are no clear "absolutes" in that choice. The real questions to ask are "Why not access above the bypass graft in the common femoral--or via the opposite groin to avoid this risk altogether?" "Was ultrasound used to gain access?" (US is considered SOC). FInally, there are some instances of intravascular presence of the sealant after use, that "may" have contributed to the thrombosis: American Journal of Neuroradiology October 2010, 31 (9) 1737-1740 -The causation for the infection may simply be either break in sterile technique--or poor hygiene after the procedure. Infection is a KNOWN RISK--published at 1-3% in the usual literature. -Clopidogrel (Plavix) is an antiplatelet medication, not a true "blood thinner/anticoagulant". Earlier use of this is also debatable as far as risk for the thrombosis. Other thoughts: The graft, once infected with Pseudomonas, likely needed removal, as this is an aggressive organism that is difficult to clear with topical antibiotic. See Wilson SE. New alternatives in management of the infected vascular prosthesis. Surg Infect (Larchmt) 2001;2(2):171–5

Once infected, despite multiple attempts at debridement, thrombectomy and antibiotic beads with muscle flap coverage, the graft was destined for removal. Alternate conduit with autologous vein from the opposite leg, arm vein, or cadaveric vein, tunneled via alternative "clean" tissue planes from a "clean" source is all that can be done to attempt limb salvage. These are DIFFICULT problems to treat and solve, and much disparate literature has been published attempting to "fix" the problem, with variable resulting success. Bottom line: there is no clear consensus as to how to approach these and anything done here could be supported by some form of literature.