The use of arm vein conduits during infrageniculate arterial bypass.

To further examine the use of arm vein for bypass to the popliteal or infrapopliteal arteries, we retrospectively reviewed 43 patients undergoing infrageniculate arterial bypass by use of an arm vein as a conduit. Nine grafts were done to the below-knee popliteal artery and 34 to the infrapopliteal arteries. Six grafts were done by use of a single segment of an arm vein, whereas 37 grafts were composites of either multiple segments of arm vein (n = 19) or segments of saphenous and arm vein (n = 18). Mean follow-up time was 15 1/2 months. Initial (30-day) graft patency and limb salvage were 95%. Primary graft patency by life-table analysis was 67% at 1 year and 49% at 3 years. Follow-up examination detected graft stenosis before occlusion in six patients (all of whom were given anticoagulant medication) and three failing grafts were salvaged. This increased overall 3-year secondary graft patency to 64% and 3-year secondary patency for infrapopliteal bypasses to 66%. Eleven of 12 graft occlusions resulted in major amputations (eight were above the knee, and three were below the knee) so that limb salvage paralleled secondary graft patency (63% at 3 years). Thus arm veins provide an excellent alternative venous conduit for infrageniculate arterial bypass, even when composite venous grafts must be used.     

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.     

Redo bypass surgery to the infrapopliteal arteries for critical leg ischaemia.

OBJECTIVES: to evaluate the results of redo bypass surgery to the infrapopliteal artery and the value of adjuvant arteriovenous fistula (AVF) in this setting. DESIGN: retrospective study. MATERIALS: fifty-one redo reconstructions to the infrapopliteal arteries were done for critical leg ischaemia in 45 patients who have had primary infrainguinal reconstructions to the popliteal artery in 20 cases (39%), the crural arteries in 18 (35%), and the pedal arteries in 13 (25%). METHODS: a PTFE prosthesis was used in 21 cases (41%). A Miller cuff was used in 16 prosthetic grafts. Adjuvant AVF was added to three autogenous vein and 12 prosthetic grafts. RESULTS: at 2 years, the primary patency rate was 42%, the secondary patency was 43%, the limb salvage was 67%, the survival was 77%, and 53% of patients were alive with salvaged leg. The primary patency rate with a vein graft was 44% at 1 year, with prosthesis plus AVF 67%, but with prosthesis without AVF only 19%. Secondary patency rates were similar. Prosthetic graft with AVF and those without AVF achieved a 1-year leg salvage rate of 100% and 51%, respectively (p =0.01). Patients with adjuvant AVF had a worse 2-year survival rate that those without AVF (31% vs 89%) (p =0.007; RR: 8.87, CI 95%: 1.62-48.42). CONCLUSIONS: redo bypass surgery using autogenous vein graft may achieve satisfactory long-term results. The use of adjuvant AVF may improve patency of redo infrapopliteal prosthetic bypass grafts.     

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.     

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)     

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.     

PTFE-vein composite grafts for critical limb ischaemia: a valuable alternative to all-autogenous infrageniculate reconstructions.

OBJECTIVES: to analyse the long-term results of primary composite bypass grafts comparing them to PTFE and vein grafts. DESIGN: a retrospective observational study. MATERIALS AND METHODS: between 1980 and 1996, 568 primary infrageniculate bypass procedures were performed; a saphenous-vein graft was used in 428 procedures, a PTFE graft in 44 and a composite PTFE-saphenous-vein graft in 96. Thirty-six composite grafts were below the knee and the remaining 60 extended more distally. Twenty-one bypass grafts from the latter group were sequential. Mean follow-up was 45.6 months. Five-year primary and secondary patency and limb salvage rates were compared by life-table analysis. RESULTS: cumulative 5-year primary patency for composite grafts was 58% and for saphenous-vein grafts 74%, while secondary patency rate was 75% and 82%, respectively (p <0.05). The 5-year limb salvage rate was 80% for composite grafts and 88% for saphenous-vein grafts (p >0.05). The primary and secondary patency and limb salvage rate for PTFE grafts was 24%, 31% and 40%, respectively. CONCLUSION: Composite grafts of PTFE and saphenous vein are significantly superior to PTFE graft alone and should be used in patients who lack sufficient length of saphenous vein.     

Observations on the use of thrombolytic agents for thrombotic occlusion of infrainguinal vein grafts

Vein graft failure remains a major challenge for the vascular surgeon. Thrombolysis of occluded vein grafts has shown promising short-term results in restoring vein graft patency, however, the long-term results are not established. This study examines the long-term patency and limb salvage after successful thrombolysis and revision of 22 thrombosed vein grafts in 21 patients. There were 17 men and four women with an average age of 60 years (38 to 77 years). Failed vein grafts had an average primary patency of 19 months (1 to 84 months) and included eight in situ grafts and 14 non-in situ grafts. Twelve grafts were to the popliteal level, whereas 10 were infrapopliteal. Thrombolytic agents used included urokinase (15), tissue plasminogen activator (5), and streptokinase (2). After successful thrombolysis, 19 grafts underwent 26 additional procedures including percutaneous transluminal angioplasty (9), vein patch angioplasty (4), vein interposition or jump extension graft (9), or other procedures (4). Three patients had no additional procedure, but one was placed on sodium warfarin (Coumadin). After successful initial vein graft salvage, life-table analysis revealed a 36.6% +/- 11.9% patency at 1 year and a 22.9% +/- 11.6% patency at 3 years. After secondary failure six patients had further interventions contributing to an improved limb salvage of 66.9% +/- 11.6% at 1 year and 60.3% +/- 19.0% at 3 years. The results suggest that thrombosed vein grafts initially salvaged with thrombolysis and revision do not have a favorable long-term patency, and that a premium must be placed on the detection of the failing vein graft before thrombosis.     

Infrapopliteal composite bypass with autologous vein and second generation glutaraldehyde stabilized human umbilical vein (HUV) for critical lower limb ischaemia.

OBJECTIVE: To audit a single center consecutive series of infrapopliteal composite bypasses with second generation glutaraldehyde stabilized human umbilical vein. DESIGN: Retrospective study. PATIENTS: From January 1996 to July 2006 89 femoro-distal bypasses were constructed in 85 patients with HUV and residual vein segments as composite grafts in the absence of sufficient length of autologous vein. METHODS: All patients with infrainguinal bypass operations were registered prospectively. Bypasses to infrapopliteal arteries performed with HUV-composite grafts were reviewed for graft patency, limb salvage, patient survival and possible biodegeneration of the HUV. RESULTS: Early graft thrombosis was noted in 21.3%, necessitating revision surgery. Primary, primary assisted and secondary patency rates were 35%, 40% and 42% respectively, with a limb salvage rate of 87% after 5 years. Graft infection occurred in 7 limbs. Aneurysmal HUV graft degeneration was not detected by duplex scanning. CONCLUSION: HUV-composite bypasses provide acceptable patency and favorable limb salvage rates. Patency was similar to previous series using PTFE-composite bypasses but was significantly inferior to vein bypass. Possible biodegradation of the HUV grafts seems to be of minor clinical relevance.     

Meta-analysis of alternate autologous vein bypass grafts to infrapopliteal arteries

BACKGROUND: Several studies have described acceptable results for infrapopliteal bypass surgery that uses an autogenous vein other than the greater saphenous vein but is still no reliable prediction of outcomes. The objective of this study was to use meta-analysis to assess the long-term outcomes after infrapopliteal bypass grafting done with alternate autologous veins. METHODS: Studies published from 1982 through 2004 were identified from electronic databases and pertinent original articles. Thirty-two series were selected, all of which had used survival analysis and had reported a 1-year graft patency rate, with at least 15 bypasses. An interval success rate was calculated for each month in each series of grafts by using data from life tables, survival curves, and texts. Monthly success rates were combined across series to obtain a pooled estimate of success for each month. Pooled survival curves were then constructed for graft patency and foot preservation. RESULTS: The 5-year pooled estimates were 46.9% (95% confidence interval [CI] = 35.5%-58.3%) for primary patency, 66.5% (95% CI = 54.9%-78.2%) for secondary patency, and 76.4% (95% CI = 68.0%-84.8%) for foot preservation. These results were far superior to those reported for nonautologous grafts. Intensive duplex surveillance had a favorable impact on graft patency and foot preservation. No publication bias was detected. CONCLUSIONS: When the greater saphenous vein is unavailable, alternate autologous veins are preferable to other graft materials in bypass surgery to infrapopliteal arteries.     

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.     

In situ saphenous vein for lower extremity revascularization.

BACKGROUND. During a 6-year period, 349 in situ saphenous vein bypass grafts were performed for limb salvage by three surgeons. METHODS. Outflow anastomoses were constructed to the infrageniculate popliteal (25%), posterior tibial (20%), peroneal (20%), anterior tibial (19%), and dorsal pedal arteries (7%). Mean patient age was 70 1/2 years. RESULTS. The 30-day mortality rate was 3.2%, and 19% died during the ensuing 68-month interval. At 1, 24, and 60 months primary graft patency was 89%, 77%, and 74%, secondary graft patency was 91%, 80%, and 78%, and cumulative limb survival was 94%, 88%, and 84%, respectively. Cumulative patency rates at 60 months depending on outflow site were as follows: popliteal (85%), anterior tibial (80%), posterior tibial (70%), dorsal pedal (68%), and peroneal (60%). Patency at the peroneal position was significantly inferior to that of other infrapopliteal sites combined (p less than 0.05). Cumulative limb survival at 60 months, according to outflow site, was as follows: popliteal (95%), anterior tibial (85%), posterior tibial (78%), dorsal pedal (73%), and peroneal (67%). There was no significant difference in limb salvage among infrapopliteal outflow sites. However, patency rates and limb salvage were significantly better for the popliteal outflow site than the infrapopliteal outflow sites (p less than 0.01). CONCLUSIONS. (1) A 5-year graft patency rate of 78% and a limb salvage rate of 84% are achievable, (2) peroneal bypass is associated with a lower rate for graft patency but not limb salvage, and (3) popliteal bypass has the best graft patency and limb salvage rates.     

Natural history of infrainguinal vein graft stenosis relative to bypass grafting technique

Purpose: To determine whether the incidence of vein graft stenosis is related to bypass grafting technique and thus modification of postoperative surveillance protocols may be required.Methods: From 1991 to 1996, 338 infrainguinal vein bypasses constructed using in situ (n = 131), reversed (n = 120), nonreversed translocated (n = 48), or spliced/upper extremity vein (n = 39) grafting techniques were evaluated by intraoperative duplex scanning to optimize bypass construction and serially thereafter to detect developing vein graft stenoses. Bypass procedures were performed in 322 patients for critical limb ischemia (83%), claudication (13%), or popliteal aneurysm (4%). Using life-table analysis, graft patency and revision/failure rates were compared relative to grafting technique, need for operative revision, and intraoperative duplex scan results.Results: Three-year primary and secondary graft patency rates were higher (p < 0.001) for in situ bypass grafts (85%/97%) compared with reversed (57%/83%), nonreversed translocated (62%/78%), or alternative (51%/76%) vein bypass grafts. During a mean follow-up interval of 19 months, the incidence of graft revision was higher for reversed saphenous (23%) and alternative (28%) vein bypass grafts compared with in situ (10%) or nonreversed (16%) saphenous vein bypass grafts. Despite a normal intraoperative graft duplex scan, the revision/failure rate of reversed vein grafts was 2.5 times greater than in situ/nonreversed translocated vein conduits (primary patency rate at 3 years, 60% vs 87%, p = 0.009). Bypass grafts modified at operation on the basis of duplex scanning were two times more likely to require postoperative revision than grafts with normal intraoperative scans.Conclusions: The incidence of postoperative graft stenosis and need for revision varies with bypass grafting technique. Reversed vein bypasses and grafts modified at operation may be more prone than in situ vein bypass grafts to develop stenosis and thus require intensive surveillance. Infrainguinal vein graft failure and the need for revision may be reduced by the adoption of bypass grafting techniques that include valve lysis and intraoperative duplex scan assessment. (J Vasc Surg 1997;25:211-25.)     

Preoperative angiographic score and intraoperative flow as predictors of the mid-term patency of infrapopliteal bypass grafts.

OBJECTIVES: preoperative angiographic characteristics of the outflow tract have emerged as a predictive factor for the outcome of infrapopliteal reconstructions. Direct flow measurement can be routinely performed intraoperatively, but little is known regarding its impact on graft outcome. The present study was undertaken to compare the value of these parameters in predicting the mid-term patency of infrapopliteal bypass grafts. DESIGN: retrospective clinical study. PATIENTS: 172 infrapopliteal reconstructions using autogenous vein were performed, of which 92 had a crural and 80 a pedal recipient artery. METHODS: the preoperative angiogram was scored according to the SVS/ISCVS Ad Hoc Committee. At the end of the operation flow was measured with a transit-time flowmeter. Follow-up consisted of pressure measurements and duplex scanning. RESULTS: the runoff score had no impact on femorocrural graft patency. For pedal grafts there was a tendency for inferior outcome with high runoff score, as the 1-year assisted primary patency for grafts with a completely occluded pedal arch was 11% compared with 52% for grafts with lower scores (p=0.056). Both intraoperative volume graft flow and maximum flow capacity had a highly significant influence on the outcome on crural reconstructions on univariate analysis. For pedal reconstructions only a a severely reduced maximum flow capacity after injection of papaverin was associated with an adverse outcome. Multivariate analysis revealed that maximum flow capacity was an independent significant factor affecting patency of femoroinfrapopliteal grafts (relative risk=0.53 per 30 ml/min increase, p<0.001). The runoff score was also a weak independent predictor of 1-year assisted primary patency in these grafts (relative risk=1.9 for a score >4 in crural and a score >5.5 in pedal grafts, p=0.036). CONCLUSIONS: a completely occluded pedal arch in preoperative angiography was associated with poor infrapopliteal bypass outcome. Graft flow and maximal flow capacity are good predictors of the 1-year graft patency of femorocrural bypasses.     

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.     

56例腘动脉以下肢体动脉缺血的血管重建术分析

目的总结腘动脉水平动脉闭塞血运重建术治疗的临床疗效。方法对2001年7月至2005年8月56例累及腘动脉及腘动脉以下三分支病变重建肢体血运进行回顾性分析。根据病变阻塞平面不同,采用不同的血管架桥,对多平面、多节段动脉闭塞采用聚四氟乙烯人工血管和自体静脉桥复合序贯架桥血运重建。结果术后平均随访17个月,移植血管一期通畅率67．3％,二期通畅率78．8％。结论复合序贯搭桥术治疗累及股浅-腘动脉水平以下多节段（平面）动脉闭塞症是一种较实用的方法,可有效解决自体血管不足和单纯使用人工血管腘动脉以下血管重建通畅率差的问题。     

Infrapopliteal bypass for severe ischemia: comparison of autogenous vein, composite, and prosthetic grafts

Results of 253 consecutive bypass grafts to infrapopliteal arteries were reviewed. Most (92%) were placed for rest pain (103) or tissue loss (130). Autogenous veins were used in 175 (69%) cases, composite vein-prosthetic grafts were used in 45 (18%), and prosthetic grafts alone were used in 33 (13%). Follow-up ranged from 0 to 101 months (mean, 19 months); 37 grafts (15%) were lost to follow-up. The operative mortality rate was 4%, and 5-year patient survival rate was 44%. Limb salvage was 82% at 5 years. The 5-year patency of vein grafts (63%) exceeded that of both composite (28%) and prosthetic (7%) grafts (p = 0.005 and p = 0.00007, respectively); but the patency of composite and prosthetic grafts did not differ significantly (p = 0.29). The patency of reversed vein (59%) and in situ vein grafts (74%) was not significantly different at 5 years (p = 0.34). Patency was also not affected by the site of the proximal or distal anastomoses or diabetes. The major determinant of long-term patency in infrapopliteal reconstructions continues to be graft material. Composite grafts offered no clear advantage over prosthetic grafts, and both should be used only when there is no other alternative to amputation.     

Distal polytetrafluoroethylene bypasses in patients older than 75 years

HYPOTHESIS: Polytetrafluoroethylene (PTFE) alone is justified for infrapopliteal arterial grafting in elderly patients with critical ischemia of the lower limbs who lack a suitable, autogenous saphenous vein. DESIGN: A consecutive sample clinical study with a mean follow-up of 16 months. SETTING: The surgical department of an academic tertiary care center and an affiliated secondary care center. PATIENTS: Thirty-one patients older than 75 years with critical ischemia of the lower limbs received 34 PTFE bypass grafts to the infrapopliteal arteries: 12 patients to the anterior tibial, 8 to the peroneal, 8 to the posterior tibial, and 2 to the dorsalis pedis artery. MAIN OUTCOME MEASURES: Cumulative survival, primary graft patency, and limb salvage rates expressed by standard life-table analysis. RESULTS: Operative mortality rate was 3%. Cumulative survival rate was 80% at 2 years (SE, 9.2%) and 43% at 3 years (SE, 11.4%). Cumulative primary patency rate was 67% at 2 years (SE 9.1%), and 61% at 3 years (SE, 12.7%). Cumulative limb salvage rate was 77% at 2 years (SE, 8.7%) and 70% at 3 years (SE, 12.8%). CONCLUSION: Polytetrafluoroethylene alone is justified as graft material for infrapopliteal bypass grafts in elderly patients with critical ischemia of the lower limbs and without a suitable autogenous saphenous vein.     

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.