We describe here an innovative technique of Percutaneous Arterial Bypass (PAP), which eliminates the need for a surgical approach, but also for arterial clamping, and for vascular sutures, with the perspective of avoiding the inherent complications. We report our initial experience at the level of the lower limb, the upper limb, and the abdominal aorta.

The general principle consists in puncturing, under ultrasound guidance, the target vessel on each side of the arterial occlusion, with the placement of introducers in opposite direction, then to puncture the vessel at a distance to introduce a guidewire. This will have to take the proximal sheath to get out of the vessel above the occluded segment, run along it, and re-enter into the arterial lumen below the occluded segment through the distal sheath. A long sheath is then pushed among this guide from the first puncture point, and down to the downstream part of the vessel, allowing the deployment of covered stents, such as Viabahn, for the realization of a bypass (extra- vascular). Thus, the punctures replace the surgical approaches, as well as the classic stitches anastomosis, and are carried out in circulating flow.

This technique has allowed us to perform, since January 2018, 41 femoral-popliteal bypasses, 2 saphenous bypasses, one subclavian-humeral bypass, and four aorto-femoral bypasses - requiring for the latter a minimally invasive retroperitoneal access. In all the cases, technical success was noted. For the 48 patients the outcome, despite the heterogenicity of the pathologies, has showed encouraging results. 30 days follow-up showed one coronary related death, one early thrombosis successfully treated by thrombolysis, 3 mild hematoma without necessity of surgical evacuation . The mid-term patency has shown to be similar on that of conventional surgical bypass grafts.

The Trans-Cathéter Bypass technique allows to perform percutaneous arterial bypasses, under defined circumstances, without clamping, without suturing, and without opening. Further evaluation is still necessary to confirm the potential benefits.