Femoral-distal bypass with in situ greater saphenous vein. Long-term results using the Mills valvulotome.

During a 7-year period, 440 consecutive in situ saphenous vein grafts originating in the groin were performed in 371 patients, exposing the entire vein for valvulotomy with a modified Mills valvulotome. critical ischemia was the indication for bypass in 68%, and the distal anastomosis was to an infrapopliteal artery in 46%. Thirty-day operative mortality was 2.0%. Postoperative surveillance identified 18 stenotic grafts (4.1%), which were revised while still patent (primary revised patency); 36 grafts (8.2%) underwent revision after graft occlusion (secondary patency). Five-year life-table analysis showed overall primary revised patency of 78%, secondary patency of 83%, limb salvage of 88%, and patient survival of 66%. Femoroperoneal and inframalleolar bypasses fared well. The presence of diabetes did not diminish late graft patency. In contrast to reversed vein grafts, long infrapopliteal in situ grafts had long-term secondary patency similar to shorter femoropopliteal bypass grafts (p greater than 0.05). These results, coupled with the versatility and simplicity of the technique as used in the present series, suggest that in situ vein grafting is the procedure of choice for long infrapopliteal bypass.     

A comparison of in situ and reversed saphenous vein grafts for infrainguinal reconstruction

Despite the recent popularity of the in situ saphenous vein graft for infrainguinal arterial reconstruction, considerable doubt exists as to whether this approach offers any real advantage over conventional reversed vein grafts. Therefore we have reviewed our experience with 675 infrainguinal vein grafts undertaken during the past 10 years. There have been no substantial modifications in the technique used for 535 reversed vein grafts over the 10-year period. During the past 3 years, 140 in situ vein grafts have been carried out with the Leather valvulotome used to incise the venous valves. Life-table analysis of 449 femoropopliteal reversed saphenous vein grafts demonstrated 1- and 3-year cumulative patency rates of 81% and 73%, respectively, and a 5-year patency rate of 63%. Seventy-five femoropopliteal in situ bypasses demonstrated a patency rate of 85% at both 1- and 3-year intervals. Cumulative patency rates for 86 femoroinfrapopliteal reversed saphenous vein grafts were 64% and 62% at 1 and 3 years, respectively. Comparable patency rates for 65 infrapopliteal in situ saphenous vein grafts remained stable at 87% for 3 years. Fifteen of the in situ bypasses were anastomosed to vessels at the ankle or foot level, whereas none of the reversed bypasses was carried that far distally. This experience with both in situ and reversed techniques on one service by the same surgeons demonstrates a clear superiority of the in situ saphenous vein graft for infrapopliteal reconstruction at the 3-year interval.     

In situ versus reversed femoropopliteal vein grafts: long-term follow-up of a prospective, randomized trial.

In a prospective, randomized trial, 226 patients undergoing femoropopliteal bypass for lower limb ischaemia were allocated to reversed (123 patients) or in situ (103) techniques. The groups were comparable for age, sex, incidence of diabetes, and indications for surgery. Eleven veins were rejected at operation, nine in the reversed group and two in the in situ group, leaving 114 reversed and 101 in situ grafts for study. Cumulative patency rates were not significantly different between reversed and in situ grafts at any time up to 6 years after operation, with primary patency rates at 1, 3 and 5 years of 84.8, 69.5 and 62.4 per cent for reversed grafts and 79.9, 71.2 and 63.5 per cent for in situ grafts. Small vein grafts (< 4 mm in diameter) were associated with patency rates at 1, 3 and 5 years of 63.5, 46.7 and 36.0 per cent compared with 93.9, 82.5 and 75.9 per cent for vein grafts > or = 4 mm in diameter (P < 0.002, log rank test). The patency rates of small veins employed in situ and reversed were similar. The in situ technique confers neither short- nor long-term advantage over reversed vein grafting for femoropopliteal bypass.     

Aortofemoral bypass and the role of concomitant femorodistal reconstruction

A consecutive series of 200 patients having aortofemoral bypass grafts were studied in order to determine the effect of femoropopliteal occlusive disease on the results and the role of concomitant femorodistal bypass. Bifurcated aortic grafts were used in 177 patients and unilateral aortofemoral grafts in 23 giving 377 limbs for study. Of the 377 limbs, 184 (49 per cent) had minimal femoropopliteal disease (Group 1), 24 (6.4 per cent) had a femoropopliteal stenosis (Group 2) and 169 (44.6 per cent) had complete femoropopliteal occlusion (Group 3). In Group 3 aortofemoral bypass was carried out alone in 106 cases (Group 3a): in the other 63 cases femorodistal bypass was carried out at the same time as aortoiliac reconstruction (Group 3b). The cumulative patency at 5 years for all aortofemoral grafts together was 91 per cent. However, that for grafts in Group 3a was only 65 per cent compared with 98 per cent for Groups 1 and 3b and 94 per cent for Group 2. The cumulative patency rate for grafts in Group 3a was significantly lower than for all other groups (P less than 0.001). The operative mortality for those patients who had concomitant aortofemoral and femorodistal grafts (Group 3b) did not differ significantly from that of any of the other groups (P greater than 0.1). Of the cases in Group 3a, 21 (26 per cent) required femoropopliteal reconstruction at a later date. The results indicate that in the presence of combined aortoiliac and femoropopliteal occlusive disease concomitant reconstruction of both arterial segments yields significantly better results than aortoiliac bypass alone.     

Distal in situ saphenous vein grafts for limb salvage. Increased operative blood flow and postoperative patency

Early failure remains a major obstacle to successful distal bypass surgery using vein grafts for limb salvage. Thirty distal bypass graft procedures were performed for limb salvage using the in situ technique. Grafts were anastomosed to the distal popliteal artery in 13 patients and to the infrapopliteal artery in 17 patients. Sixteen patients had inadequate saphenous veins for reversed vein grafts. The mean blood flow measured through these grafts (n = 20) was 164 +/- 22 ml/min and increased to 278 +/- 31 ml/min after administration of 30 mg of papaverine. All grafts were patent at the time of hospital discharge and patients were followed for 1 to 28 months. Life table analysis of the 30 procedures shows a patency of 100 percent at 18 months follow-up. One graft subsequently failed at 22 months. Long-term limb salvage was achieved in 100 percent of the patients in this series. The excellent blood flow through these grafts suggests that the in situ vein graft technique may be more favorable for arterial reconstruction than the reversed vein graft technique. Our preliminary data confirm the observations of Leather et al [3,4], that the rates of vein utilization and graft patency are higher with the in situ technique.     

Prospective randomized multicenter comparison of in situ and reversed vein infrapopliteal bypasses

We have performed a prospective, randomized, multicenter study to compare in situ and reversed vein grafts for long limb salvage bypasses from the proximal thigh to an infrapopliteal artery. Three hundred eighty-four patients required an infrapopliteal bypass for critical lower extremity ischemia. Of these, 259 were excluded because a short vein bypass was performed or because the vein was considered inadequate. The remaining 125 patients had a randomized vein bypass, 63 reversed, 62 in situ. The two groups were similar with regard to risk factors, indications, graft dimensions, and outflow. Secondary patency at 30 months was similar for both techniques: reversed 67% +/- 9% (+/- SE); in situ 69% +/- 8%. For veins less than or equal to 3.0 mm in minimum distended diameter 24-month patency rates were 61% +/- 22% for 12 in situ veins and 37% +/- 29% for 10 reversed veins (p greater than 0.05). Angiographic evaluation of failing grafts revealed lesions similar in type and frequency in both types of grafts. These included focal (in situ, n = 4; reversed, n = 7) and diffuse vein hyperplasia (in situ, n = 2; reversed, n = 1), and inflow and outflow stenoses (in situ, n = 4; reversed, n = 3). The incidence of wound complications and the mortality rate were similar for the two groups. These data show no significant difference in overall patency rates for the two types of vein grafts at 2 1/2 years.(ABSTRACT TRUNCATED AT 250 WORDS)     

Prospectively randomized clinical trial to compare in situ and reversed saphenous vein grafts for femoropopliteal bypass

Two hundred and fifteen femoropopliteal bypass procedures using autologous saphenous vein grafts were randomly allocated to either the reversed or in situ technique. Eleven veins (5 per cent) were rejected at operation on the basis of their small size, nine in the reversed group and two in the in situ group, and there were two (2 per cent) perioperative deaths in each group, leaving 102 reversed and 98 in situ grafts for further study. The cumulative patency at 3 years of the reversed grafts was 77 per cent and that of the in situ grafts was 68 per cent (n.s.). The patency of all grafts was affected adversely by small veins (P less than 0.005), long grafts (P less than 0.05), low volume of blood flow in the grafts (P less than 0.001) and poor run-off (P less than 0.05). These factors influenced the outcome of the in situ and reversed operations to a similar degree and there was no statistically significant difference between them within any subgroup. The mean compliance of the in situ grafts measured 3 months or more after operation with an ultrasonic echo-tracking system was 0.024 +/- 0.01 per cent/mmHg (+/- s.d.) compared with 0.017 +/- 0.01 per cent/mmHg for the reversed grafts (t = 2.43, P less than 0.02). The incidence of fibrous stricture formation as shown by intravenous digital subtraction angiography was 29 per cent in both the reversed and the in situ grafts. The results of the study to date indicate that reversed and in situ vein grafts are equally effective for femoropopliteal bypass.     

Patency of femoropopliteal and femorotibial grafts after outflow revascularization (jump grafts) to bypass distal disease

Repair of failing femorodistal bypass grafts with secondary distal "jump" grafts was performed 34 times in 33 patients. Indication for operation was limb salvage for all distal jump grafts and for 85% of the initial femorodistal bypass grafts. Autogenous vein bypass grafts were used in 28 of 33 initial femorodistal grafts (85%) and in 29 of 34 secondary jump grafts (85%). Sixteen of the 33 initial grafts in jeopardy extended to the infrapopliteal level (48%) and 19 of the jump grafts terminated in foot or ankle arteries (56%). The 12 jump grafts performed in the first 2 months of the initial graft were associated with high rates (9%) of graft thrombosis and amputation. Early loss of viability of initial grafts probably resulted from technical and judgment errors or underestimation of distal disease. Progression of distal disease produced late failure after 1 year of implantation of the initial grafts. The 1-year patency rate of the initial femorodistal grafts was 63% but only 32% of these grafted limbs were viable and were not at risk of amputation. Distal jump grafts produced a 49% improvement in limb viability (to an 81% limb salvage rate) and an 11% increase in the initial graft patency rate (to 74%) at 1 year.     

Durability of the in situ saphenous vein arterial bypass: a comparison of primary and secondary patency

The use of the saphenous vein in situ is associated with unique problems that decrease primary graft patency (patency uninterrupted by revision). During the past 5 years, we have performed 192 in situ saphenous vein bypasses in 182 patients, including 61 to the popliteal artery, 128 to infrapopliteal arteries, and three to isolated popliteal artery segments. The operative indications were critical limb ischemia in 178 cases (93%), popliteal aneurysm in eight cases (4%), and disabling claudication in six cases (3%). A progressive decline in primary patency occurred after operation. The primary patency rate at 36 months was only 48% for femoropopliteal bypasses and was 58% for femorotibial bypasses. In contrast, the secondary patency rate (patency maintained by thrombectomy, thrombolysis, or revision) at 36 months was 89% and 80% for femoropopliteal and femorotibial bypasses, respectively. The improved secondary patency was due to postoperative surveillance of graft hemodynamics and the success of graft revision. Problems unique to the in situ technique (incomplete valve incision, residual arteriovenous fistula, graft torsion and entrapment) accounted for 58% of early (less than 30 days) graft revisions and 52% of late revisions. The use of Doppler spectral analysis at operation and duplex scanning after operation can locate unsuspected technical errors and identify grafts with low flow at increased risk for failure. The primary patency of the in situ bypass mandates objective assessment of valve incision sites at operation and a protocol of postoperative surveillance to identify grafts that require revision. Early surgical intervention of hemodynamically abnormal but patent in situ bypasses is rewarded by excellent secondary patency.     

Peripheral resistance measurement in the assessment of severe peripheral vascular disease

Thirty-seven patients undergoing femoropopliteal, fifteen undergoing femorodistal reconstruction and seven below knee amputees were subjected to prospective measurement of peripheral resistance. Resistance was significantly higher in the amputation and femorodistal groups than in the femoropopliteal group (P less than 0.03 and P less than 0.005 at 76 ml/min). In the femoropopliteal group patients with three vessel runoff had a significantly lower resistance than those with two or single vessel runoff (P less than 0.01). In the femoropopliteal group resistance of patent grafts at four months was significantly less than thrombosed grafts (P less than 0.006). Patients with a resistance less than 1200 mPRU had a significantly better patency than those in whom the resistance was greater than 1200 mPRU (P less than 0.05). Taking all the failed grafts there was a significant correlation between graft patency and resistance (P less than 0.003). Resistance measurement has been shown to correlate with the severity of the disease, with runoff defined radiographically and with graft patency. In a simplified form it may prove a useful adjunct to other methods of assessment in patients with distal disease.     

The myth of the in situ graft: superiority in infrainguinal bypass surgery?

OBJECTIVES: to compare the clinical outcome of in situ and reversed bypass grafting. DESIGN: multicentre, prospective, non-randomised study. PATIENTS AND METHODS: five-hundred patients with an in situ graft and 955 patients with a reversed graft were compared regarding graft occlusion, the need for graft revision, and limb salvage. RESULTS: two-year assisted primary patency of femoropopliteal bypass procedures was 82% for in situ and 82% for reversed grafts. The corresponding hazard ratio (HR) for occlusion was 1.27 (95% CI 0. 91-1.77). The 2-year assisted primary patency of femorocrural bypass procedures was 69% for in situ vs. 70% for reversed grafts. The corresponding HR was 1.13 (95% CI 0.73-1.75). Adjustment for relevant baseline variables did not change the results. More reinterventions were needed to maintain integrity and patency of the in situ graft especially in crural bypasses. No differences in limb salvage rates were seen. CONCLUSIONS: reversed and in situ vein grafts have similar patency and limb salvage rates for both femoropopliteal and femorocrural bypass procedures. The in situ graft needs more secondary interventions.     

Quantitative assessment of outflow resistance in lower extremity arterial reconstructions

Graft patency is thought to correlate with resistance in the runoff bed or outflow resistance. However, accurate measurement of this parameter has been difficult. A simple and reproducible method for direct measurement of outflow resistance following completion of the distal anastomosis of a bypass graft has been developed. This method employs injection of a fixed amount of normal saline through the proximal end of the graft and measurement of the resulting integrated pressure increment by an analog computer. Division of this pressure integral by the volume injected is a measure of the outflow resistance expressed in resistance units (mm Hg/ml/min). The median outflow resistance in 31 femoropopliteal bypasses was 0.29 units with a range of 0.08-1.38 units. The median outflow resistance in 33 femorodistal bypasses was 0.7 units with a range of 0.18-2.34 units. All bypasses with an outflow resistance of 1.1 units or less remained patent for 3 months. There were 51 grafts in this group (30 femoropopliteal; 21 femorodistal) and their outflow resistance ranged from 0.08 to 1.1 units. All bypasses with an outflow resistance of 1.2 units or higher thrombosed within the first postoperative month. There were 13 grafts in this group (1 femoropopliteal; 12 femorodistal) and their outflow resistance ranged from 1.2 to 2.38 units. Eight of the 13 grafts that failed originally were subjected to thrombectomy, which was uniformly unsuccessful. Although this method does not yet allow bypass surgery to be denied to any patient, it does define a group of patients in whom thrombectomy will not be effective and should not be attempted.(ABSTRACT TRUNCATED AT 250 WORDS)     

Present status of reversed vein bypass grafting: five-year results of a modern series

From January 1980 through December 1988, 564 limbs in 434 patients were treated for infrainguinal arterial ischemia. Of these, 516 limbs in 387 patients underwent reversed vein bypass grafting. The remainder were treated by primary amputation (11 limbs, 1.9%) or by prosthetic bypass (37 limbs, 6.4%). The indications for operation were limb salvage in 80% of limbs and claudication in 20%. Adequate ipsilateral greater saphenous vein was available for 285 (55%) grafts, with reversed vein bypass achieved in the other 231 operations by use of distal graft origins (151 grafts), use of alternate vein sources (120 grafts), and splicing of venous segments (81 grafts). Seventy-six grafts (15%) were to the above-knee popliteal artery, 199 grafts (37%) were to the below-knee popliteal artery, and 241 grafts (47%) were to infrapopliteal arteries, 26 of which (11%) were to inframalleolar arteries. The primary and secondary patencies for all grafts at 5 years were 75% and 81%, respectively. Grafts to infrapopliteal arteries had significantly worse primary patency (69%) at 5 years than did grafts to the popliteal artery (77%, above knee; 80%, below knee) and grafts formed of adequate ipsilateral greater saphenous vein had significantly better primary patency (80%) than did grafts performed when this conduit was not available (68%). Secondary patency of all graft categories ranged from 76% to 85%, and there were no significant differences regardless of site of distal anastomosis, source of venous conduit, or site of graft origins. We prefer the use of reversed vein bypass grafting for lower extremity revascularization both because of the excellent patency results and because the technique can be applied to the larger number of patients in our practice who lack intact ipsilateral greater saphenous vein, in contrast to in situ vein bypass procedures.     

In situ femoropopliteal and infrapopliteal bypass. Two-year experience

We describe 83 in situ femoropopliteal and infrapopliteal artery bypass grafts. The in situ technique involved the valve incision method using scissors, the valvulotome (Leather), and a modified valve cutter (Hall). Arteriovenous fistulae were detected intraoperatively by angiography and/or the Doppler method and ligated. The operative indications were rest pain, ulcer, and gangrene in 88% of cases, and claudication in 7.2%. The mean preoperative ankle pressure was 61.3 mm Hg and the ankle-brachial index was 0.43. The mean postoperative ankle pressure was 125.3 mm Hg and the ankle-brachial index was 0.97. The vein utilization rate was 96%. One-year patency for popliteal anastomoses was 85.7%, for peroneal anastomoses it was 100%, and for infrapopliteal anastomoses it was 89.6%. The data suggest that the practicing vascular surgeon can adopt the in situ technique and can expect high graft patency rates even in limb salvage situations with poor distal outflow.     

Balloon angioplasty as a treatment of failing infrainguinal autologous vein bypass grafts

PURPOSE: The purpose of this study was to evaluate the role of balloon angioplasty in the treatment of failing infrainguinal vein bypass (IVB) grafts. METHODS: A retrospective chart review of patients undergoing revision of a failing IVB graft by vascular surgeons at a tertiary care center from 1990 to 2001 was performed. Failing bypass grafts were identified by routine duplex scan surveillance and physical examination. The criteria for endovascular intervention varied on the basis of surgeon preferences and time period; factors considered when choosing balloon angioplasty included significant comorbidities that precluded operative intervention, the lack of adequate conduit for surgical revision, or poor accessibility of the stenotic lesion. Data recorded included demographic patient data, type of IVB graft, patency status, further procedures performed, and all complications and mortalities. Cumulative primary and assisted patency rates were calculated by using Kaplan-Meier life-table analysis. RESULTS: A total of 45 balloon angioplasties were performed in 36 patients. There were 36 angioplasties of vein bypass grafts, and additional balloon angioplasties were performed on nine of these patients. Locations of IVB grafts included femoropopliteal (13 patients), femorodistal (13), and popliteal to distal (10). Initial success was achieved in 33 of 36 vein bypass grafts (91.7%). In these bypass grafts, the stenotic lesions were identified and treated at the proximal anastomosis (3 patients), mid-bypass graft (6 patients), and distal anastomosis (27 patients). Autogenous vein was used for all bypass grafts. Cumulative vein bypass graft (life-table analysis) primary patency rates (those free of occlusion or bypass graft threatening stenosis) were 74.2% at 6 months, 62.7% at 12 months, and 58.2% at 24 months. Repeat interventions included surgical thrombectomy with vein patch angioplasty or bypass graft revision, as well as repeat balloon angioplasty with or without thrombolysis. Cumulative assisted vein bypass graft patency rates (those free of occlusion or bypass graft threatening stenosis) were 87.0%, 83.2%, and 78.9% at 6, 12, and 24 months, respectively. Two patients (4%) developed thigh hematomas; no other procedure-related complications were noted, and there were no deaths in the perioperative period. CONCLUSION: Balloon angioplasty of failing infrainguinal vein bypass grafts can be successfully performed with a low rate of complications. Acceptable short-term patency can be achieved. This procedure should be considered as an initial option in failing IVB grafts.     

Percutaneous transluminal angioplasty versus surgery for limb-threatening ischemia

This retrospective study compared the results of percutaneous transluminal angioplasty (PTA) with those of infrainguinal bypass procedures in patients with critical arterial ischemia to determine which procedure had superior patency, limb salvage, and durability. The records of 54 patients who underwent 54 PTAs and 56 patients who underwent 63 infrainguinal bypasses (29 femoropopliteal and 34 femorodistal) from 1981 to 1987 were reviewed. In each patient PTA or bypass was the initial vascular procedure. Patients in both groups were comparable with respect to age, sex, and the presence of diabetes, hypertension, obesity, hypercholesterolemia, and smoking. Mean follow-up was 40 months (4 to 88 months) for the PTA group and 28 months (6 to 78 months) for the surgery group. Thirty-nine of the 54 patients (72%) were initially improved after PTA, whereas 15 patients (28%) showed no improvement. During follow-up, 20 initially successful PTAs reoccluded. Thirty-two of 54 patients (59%) underwent subsequent procedures, which included repeat PTA (10) and distal bypass (14). Patency determined by noninvasive Doppler studies was 18% at 2 years. Limb salvage, which included such secondary procedures, was 78%. Two-year patency for femoropopliteal bypasses was 68% with a limb salvage of 90%. Femorodistal bypasses had a 2-year patency of 47% and a limb salvage of 74%. No perioperative deaths occurred. Twenty-one of the 63 patients (33%) had subsequent procedures, which included thrombectomy (5) and bypass revision (9). In patients treated for limb-threatening ischemia the 2-year patency after femoropopliteal bypass (68%) or femorodistal bypass (47%) is significantly better than that from PTA (18%, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

流出道对于股-腘人工血管旁路术后重度狭窄闭塞的影响

目的探讨流出道对于人工血管旁路术后重度狭窄闭塞的影响。方法回顾性分析2007年3月～2009年3月收治的115例外周动脉硬化性闭塞症患者的临床资料。根据术前流出道情况分为两组:膝下仅1条流出道通畅者为一组;膝下1条以上流出道通畅者为另一组。观察两组患者术后2、6、12、24个月人工血管的通畅情况。结果随访24个月,膝下仅1条流出道通畅组与膝下1条以上流出道通畅组患者的人工血管原发通畅率比较,差异有统计学意义(45.5%vs63%,P<0.05)。结论流出道对股腘动脉(膝上)人工血管旁路术长期通畅率有所影响,近期通畅率影响不大。     

Angiographic criteria for prediction of early graft failure of secondary infrainguinal bypass surgery

Complete intraoperative postreconstruction angiograms were obtained during 93 reoperations after failed femoropopliteal and femorodistal bypass grafts to evaluate the predictive value of a new method of angiographic runoff assessment. Good runoff was defined as patency of two or three lower leg arteries to the foot, or one patent vessel continuous with an intact anterior or posterior foot arch in femoropopliteal and proximal femorodistal bypasses, and integrity of both arches in low femorodistal bypasses. All other outflow patterns were considered poor. The cumulative 1-year patency rate was 61% with a 79% limb salvage rate after reoperations performed in limbs with good runoff. In reoperations with poor runoff, the patency rate was only 5% with a 22% limb salvage rate. In reoperations with good runoff, and 85% patency rate of vein grafts compared to 43% of prosthetic grafts clearly demonstrated the importance of graft material on early outcome. The improved prediction of early outcome with this new method of angiographic runoff evaluation might allow more rational management of patients with failed infrainguinal grafts.     

Runoff resistance and early graft failure in infrainguinal bypass surgery

Recent reports suggest that intraoperatively measured runoff resistance can identify patients destined for early graft failure. We measured runoff resistance in 80 consecutive patients who had undergone infrainguinal bypass surgery, and periodically assessed graft patency. There were 57 femoropopliteal bypass grafts and 23 infrapopliteal bypasses. After 3, 6, or 12 months, there was no significant difference in mean resistance between those grafts remaining patent and those that failed. Moreover, among patients with very high resistance (greater than 1.2 mm Hg/mL/min), 12 bypass grafts remained patent for more than one year. These results demonstrate that even patients with relatively high runoff resistance can undergo successful bypass grafting. Consequently, patients with measured or angiographic evidence of poor runoff should not be denied vascular reconstruction on this basis alone. We believe that graft failure is a multifactorial process in which the nature of the graft material, location of the distal anastomosis, runoff resistance, and a number of other factors are likely to play a role.     

Comparison of initial limb salvage in 98 consecutive patients with either reversed autogenous or in situ vein bypass graft procedures

A retrospective review of 98 consecutive patients undergoing femoropopliteal or distal bypass procedures was conducted to determine whether in situ bypass grafting offers statistically significant initial limb salvage over reversed autogenous techniques. Over a 40 month period, 98 consecutive patients received either in situ or reversed autogenous vein grafts to effect limb salvage. The groups were similar in incidences of diabetes and previous myocardial infarctions, as well as in site of distal anastomosis (beneath the tibial peroneal trunk in more than 80 percent). The in situ vein graft group had an overall limb salvage rate of 92 percent with an 88 percent cumulative patency rate at 4 to 18 month follow-up, whereas the reversed autogenous vein graft group had a limb salvage rate of 86 percent with a 79 percent cumulative patency rate at up to 18 months. Results after 30 days showed 47 patients had improvement and 3 patients (6 percent) had died in the in situ vein graft group. In the reversed autogenous vein graft group, 44 patients improved, 4 did not improve and required amputations, and 2 (1 percent) died. Our study supports the use of in situ vein bypass grafting for limb salvage.