Polytetrafluoroethylene grafts as the first-choice arterial substitute in femoropopliteal revascularization

We studied a series of femoropopliteal bypass operations in which polytetrafluoroethylene (PTFE) grafts were used as the first choice, regardless of the availability of saphenous vein. From Jan 1, 1979 to Dec 31, 1982, 63 PTFE femoropopliteal bypass grafts were placed in 55 patients without exploration of the saphenous vein. Forty-three grafts were placed for limb salvage, and 20 grafts were placed for disabling claudication. Patients were followed up for nine to 53 months (average, 23 months). The operative mortality was 1.8%. There were no infections. The overall patency at 30 months was 76.1%. The 30 months' cumulative patency rate for patients with claudication was 89.3%, and there were no amputations. The cumulative 30-month patency for limb salvage was 70.1%, and there was a limb salvage rate of 81.2%. Because the 30-month results were comparable with reported series using autogenous saphenous vein, we concluded that PTFE conduits may be considered the first-choice arterial substitute for femoropopliteal reconstruction. Until longer follow-ups are available, reversed autogenous saphenous vein should probably be the graft of first choice in younger patients (less than 60 years of age) without coronary artery disease who are undergoing femoropopliteal revascularizations.     

Prospective randomized study on bilateral above-knee femoropopliteal revascularization: Polytetrafluoroethylene graft versus reversed saphenous vein

OBJECTIVE: Some controversy exists as to whether polytetrafluoroethylene (PTFE) is equivalent to reversed saphenous vein (SV) as bypass graft material for above-knee femoropopliteal revascularization. We compared the 5-year patency rate with reversed SV and PTFE grafts in patients with claudication who underwent bilateral above-knee femoropopliteal revascularization. METHODS: Between January 1994 and December 1997, 51 patients (102 limbs) with bilateral disabling claudication due to superficial femoral artery occlusion underwent above-knee femoropopliteal bypass grafting, with SV in one limb and PTFE graft in the other limb. Patients were randomly selected for sequential surgical treatment with either SV-PTFE or PTFE-SV. Kaplan-Meier analysis was used to estimate patency rate, and various factors were analyzed to ascertain any association with revascularization failure. RESULTS: There was no perioperative (30 day) limb loss or death, but five late deaths (late survival rate, 90%). Mean follow-up was 59 months. In the SV group, three bypass grafts failed, requiring repeat operation in only one patient. In the PTFE group, eight bypass grafts failed, leading to five repeat operations. There was no statistically significant difference in primary "assisted" patency rate for the two grafts: 100%, 98%, and 94% for SV grafts, and 96%, 84%, and 84% for PTFE grafts (P =.09), after 1, 3, and 5 years, respectively. CONCLUSIONS: The overall results of this randomized study show that SV and PTFE grafts have a statistically comparable patency rate when used above the knee in patients with claudication. Use of SV, however, leads to fewer occlusions and repeat operations.     

Seven-year follow-up of expanded polytetrafluoroethylene (PTFE) femoropopliteal bypass grafts.

Expanded polytetrafluoroethylene (PTFE) grafts have proven to be an acceptable short-term alternative for femoropopliteal reconstruction in those patients without suitable autologous saphenous vein. One hundred and twenty-seven femoropopliteal arterial bypass operations utilizing PTFE grafts were performed in 105 patients. Seven-year follow-up is now available for 20 grafts, 6-year follow-up for 47 grafts, and 5-year follow-up for 62 grafts. Graft occlusion was determined by angiography, Doppler assessment, loss of previously palpable pulses, or return of symptoms. Thirty nonocclusive graft losses were due to death, infection, aneurysm, amputation, or proximal occlusive disease. Overall cumulative patency rate, according to occlusive criteria alone and calculated by the life-table method, was 74% at 6 months, 63% at 1 year, 48% at 3 years, 40% at 5 years, and 35% at 7 years. Excluding early bypass failures (less than 1 year patency), 75% of grafts were patent at 3 years, 63% at 5 years, and 55% patent 7 years following operation. Diabetes mellitus was associated with a significantly lower patency rate. Patency rates were not adversely affected by graft diameter, distal popliteal anastomotic site, number of patent runoff vessels, preoperative symptoms, or prior arterial reconstruction. In patients without suitable autologous saphenous vein, the PTFE graft has proven to be a durable and dependable long-term alternative for femoropopliteal reconstruction.     

Heparin-bonded Dacron or polytetrafluoroethylene for femoropopliteal bypass grafting: a multicenter trial

BACKGROUND: Dacron (polyester fiber) was largely abandoned for femoropopliteal bypass grafts 30 years ago because saphenous vein achieved better patencies. However, in patients taking aspirin, patency in above-knee femoropopliteal bypass grafts has recently been shown to be equivalent to that with saphenous vein. We compared heparin-bonded Dacron (HBD) and polytetrafluoroethylene (PTFE) in a randomized multicenter trial including below-knee popliteal or tibioperoneal trunk bypass graft where the long saphenous vein was absent or inadequate. METHODS: Over 28 months, 209 patients undergoing femoropopliteal bypass grafts (180 above-knee, 29 below-knee) were randomized to HBD (n = 106) or PTFE (n = 103). Each patient was given aspirin (300 mg/d) before surgery, and this continued unless the patient had intolerance to the aspirin. RESULTS: The mean follow-up was 42 months (range, 28-55). Fifteen (7.1%) patients died with patent grafts, and three (1.4%) infected grafts were removed. Patency (measured with Kaplan-Meier survival analysis) at 1, 2, and 3 years for HBD was 70%, 63%, and 55% compared with 56%, 46%, and 42%, respectively, for PTFE (P =.044). A total of 67 secondary interventions were performed on 48 thrombosed grafts; long-term patency was achieved in only three. Risk factors for arterial disease did not significantly influence patency. Amputations have been performed in 23 patients, six after HBD and 17 after PTFE bypass grafts (P =.015). CONCLUSIONS: HBD achieved better patency than PTFE, which carried a high risk of subsequent amputation.     

Is the preferential use of polytetrafluoroethylene grafts for femoropopliteal bypass justified?

The objective of this review is to analyze the long-term results of femoropopliteal bypass done preferentially with polytetrafluoroethylene (PTFE) grafts in patients who presumably had saphenous vein available. The results are analyzed according to preoperative variables in an attempt to determine those instances in which PTFE grafts may be preferred for the first reconstruction and to identify those patients who benefited from vein preservation. From 1979 to 1985, 146 femoropopliteal bypass operations were performed in 120 patients with 6 mm PTFE grafts used preferentially. The results with follow-up at 5 years are analyzed by actuarial methods. The patency rate at hospital discharge was 100%. The overall primary patency rate at 5 years was 57%. Reconstructions above the knee (101) and below the knee (45) had significantly different 5-year patency rates (63% vs 44%, p less than 0.03). Sixty-two reconstructions done to alleviate disabling claudication had a 5-year primary patency rate of 69% and no amputations. Eighty-one reconstructions were done to treat critical ischemia with a 5-year patency rate of 49% and a 5-year foot salvage rate of 73%. When secondary operations were required to treat graft failures, the 4-year cumulative patency rate of the secondary reconstruction was 18% when performed with a prosthetic graft, in contrast to 70% when performed with the spared saphenous vein. We conclude that femoropopliteal reconstruction with PTFE grafts is a reasonable alternative for older patients with disabling claudication. Patients with critical ischemia will likely benefit from preservation of the vein with initial femoropopliteal reconstruction done with PTFE. Staged infrainguinal revascularization for foot salvage may improve present results. In this regard the sequence PTFE-then-vein carries a higher predicted patency rate than the sequence vein-then-PTFE.     

Vein versus polytetrafluoroethylene in above-knee femoropopliteal bypass grafting: five-year results of a randomized controlled trial

OBJECTIVE: Controversy still exists whether polytetrafluoroethylene is equivalent to vein as bypass graft material for the above-knee femoropopliteal bypass. Therefore, a prospective randomized trial was performed to compare vein with polytetrafluoroethylene for femoropopliteal bypasses with the distal anastomosis above the knee. METHODS: Between January 1993 and December 1996, 151 above-knee femoropopliteal bypasses were performed. The indications for operation were severe claudication in 120 cases, rest pain in 20 cases, and ulceration in 11 cases. After randomization, 75 reversed saphenous venous bypasses and 76 polytetrafluoroethylene bypasses were performed. RESULTS: No perioperative mortality was seen, and 5% of the patients had minor infections of the wound, not resulting in loss of the bypass, the limb, or life. After 5 years, 38% of the patients had died and 7% were lost to follow-up. Only once was the saphenous vein necessary for coronary artery bypass grafting. Primary patency rates after 5 years were 75.6% for venous bypass grafts and 51.9% for polytetrafluoroethylene grafts (P =.035). Secondary patency rates were 79.7% for vein and 57.2% for polytetrafluoroethylene bypasses (P =.036). In the venous group, 14 bypasses failed, leading to five new bypasses. In the polytetrafluoroethylene group, 29 bypasses failed, leading to 16 reinterventions. For these 16 new bypasses, in four cases, the ipsilateral preserved saphenous vein was used. In both groups, one above-knee amputation and one below-knee amputation had to be performed. CONCLUSION: We conclude after 5 years of follow-up of this randomized controlled trial that a bypass with saphenous vein has better patency rates at all intervals and needs fewer reoperations. Saphenous vein should be the graft material of choice for above-knee femoropopliteal bypasses and should not be preserved for reinterventions. Polytetrafluoroethylene is an acceptable alternative if the saphenous vein is not available.     

Prospective study of the long-term permeability of the internal saphenous vein and of polytetrafluoroethylene in the lower femoro-popliteal bypass. Results after 5 years in 100 patients

Autogenous saphenous vein (ASV) (50 patients-group I) was compared to polytetrafluoroethylene (PTFE) (50 patients group II), in 100 below-knee femoropopliteal bypass (FPB) procedures performed for limb salvage during à 5 year-period. PTFE was used as an alternative procedure in the absence of a suitable ASV. Each group made of 50 patients was not significantly different from the other. The mean follow up period for patent graft is now 35 months (12-60 months) and the overall life table cumulative patency at 5 years, is 65% in group I and 18% in group II (P less than 0.05) whereas the limb salvage rate (LSR) is 81% with ASV and 26% PTFE (P less than 0.05). No correlation was demonstrated between patency and run-off. The graft described was used in elderly patients most of whom would have had amputation before the introduction of PTFE. Theses results advocate the use of PTFE only in secondary intention and never to shorter operation time.     

Arterial reconstruction with polytetrafluoroethylene: a preliminary report.

Early results of arterial reconstruction with reinforced expanded polytetrafluoroethylene (PTFE) in the lower extremity have been obtained by reviewing 55 patients undergoing 59 operations - 38 femoropopliteal bypasses and 21 long bypasses distal to the popliteal artery. The one-year accumulated patency rates were 73% for the femoropopliteal bypass group and 50% for the long bypass group. Early results suggest that PTFE is superior to Dacron and is an acceptable substitute for autogenous saphenous vein when the latter is unavailable or of inadequate calibre.     

Axillopopliteal bypass for limb salvage.

Forty-one axillopopliteal bypass grafts have been placed in 30 patients for limb salvage in the past 12 years. The mean patient age was 65.6 years; 8 were women; 19 smoked; and six had diabetes. Sixteen grafts were straight axillopopliteal bypass grafts, and 25 were sequential axillopopliteal bypass grafts. Cumulative life-table primary patency rates at 1, 2, and 3 years were 70%, 56%, and 43%, respectively; secondary patency rates were 73%, 57%, and 50%, respectively. Corresponding limb salvage rates were 86%, 69%, and 69%, respectively. Ringed polytetrafluoroethylene (PTFE) graft patency at 3 years was 61% versus 40% for unsupported PTFE grafts (p = 0.35). Ringed PTFE axillofemoral grafts with sequential femoropopliteal saphenous vein grafts had a 3-year patency of 67%. Graft patency was restored in 25% of occluded grafts by thrombectomy and in 80% of occluded grafts by thrombectomy with graft revision (p = 0.21). Cumulative 3-year patient survival was 48%. The 30-day operative mortality rate was 20%; patients operated on for graft infection had a 30-day operative mortality rate of 36%. The data support the use of axillopopliteal bypass for limb salvage when standard revascularization techniques are contraindicated. Long-term patency is enhanced by use of externally supported PTFE and sequential femoropopliteal saphenous vein.     

Saphenous vein versus PTFE for above-knee femoropopliteal bypass. A review of the literature.

The autogenous saphenous vein is considered the best bypass graft material for arterial bypasses below the inguinal ligament. However, a synthetic graft or prosthesis is considered an acceptable alternative, especially when the distal anastomosis is situated above the knee. Some studies even suggest that patency rates for vein and synthetic grafts are comparable, whereas others indicate that a vein graft is superior to a prosthetic graft, even above the knee. To test the hypothesis that both vein grafts and synthetic prostheses are equally beneficial in the above-knee position, we performed a systematic review of available studies comparing the patency of saphenous vein and polytetrafluoroethylene (PTFE) as bypass material. English and German medical literature from 1966 to 2002 was searched using Medline, and 25 articles meeting our inclusion and exclusion criteria were selected. The patency of venous bypasses was superior to that of PTFE bypasses at all time intervals studied. After 2 years, the primary patency rate of venous bypasses was 81% as compared to 67% for PTFE bypasses, and after 5 years it was 69 and 49%, respectively. After 5 years, the secondary patency of PTFE bypasses reached 60%. When only randomized trials were considered, venous bypasses were again superior to PTFE bypasses at all intervals studied. After 2 years, the primary patency rate of venous and PTFE bypasses was 80 and 69%, respectively, and after 5 years it was 74 and 39%, respectively. Since both randomized and retrospective studies comparing venous with PTFE bypasses showed that vein grafts were 'better' than PTFE prostheses, the null hypothesis that there is no difference between the two types of graft material was rejected (p=0.008). We conclude from this systematic review that if a saphenous vein is available, a venous bypass should be chosen at all times, even if patients have an anticipated short life expectancy (<2 years). If the saphenous vein is absent or not suitable for bypass grafting, PTFE is a good alternative as bypass material.     

Polytetrafluoroethylene in above-knee arterial bypass surgery for critical ischemia.

Seventy-one consecutive above-knee polytetrafluoroethylene (PTFE) femoropopliteal arterial bypasses performed between 1981 and 1989 for critical ischemia were followed prospectively to determine graft patency and limb salvage. Cumulative graft patency and limb salvage rates were calculated by life table analysis. Graft patency was 80%, 68%, 55%, 39%, and 39%, and limb salvage 97%, 87%, 84%, 77%, and 77% at 1, 2, 3, 4, and 5 years, respectively. Twenty-nine grafts have occluded with re-emergence of critical ischemia in 14, treated by 5 amputations and 9 reconstructions using autogenous saphenous vein (ASV) in 6 and PTFE in 3. These favorable results are not as good in terms of primary patency as those reported with ASV, but good limb salvage, good early patency, ease of use, and preservation of the saphenous vein for use later have encouraged us toward primary use of PTFE in selected patients. This experience strongly questions the wisdom of an "all autogenous" policy for reconstruction at this level.     

Should polytetrafluoroethylene grafts be used in preference to saphenous vein for femoropopliteal arterial bypass?

Some surgeons have advocated using polytetrafluoroethylene (PTFE) as the graft material of choice for femoropopliteal arterial bypass so that the saphenous vein could be preserved for future cardiovascular surgery. We have examined our results to see if this approach could be justified in our patient population. PTFE was used for 101 femoropopliteal reconstructions in 96 patients (56 male and 40 female). Thirty-eight (40%) complained of debilitating claudication and 58 (60%) had limb-threatening ischaemia. There were 83 primary PTFE femoropopliteal reconstructions and 18 repetitive procedures after failure of an earlier ipsilateral bypass. Twenty-nine of the 101 PTFE grafts were anastomosed distally to the popliteal artery above knee and the remaining 72 below knee. At 5 years, the cumulative patency for all grafts was only 11%. The 4 year cumulative patency was better for claudicants (40%) than for those with threatened limb loss (11%) but two of the 38 claudicants required amputation when their grafts failed. Patency rates were not significantly affected by the site of the distal anastomosis or by a previous failed ipsilateral femoropopliteal bypass. Worthwhile limb salvage was achieved only by frequent re-operation. Our results with PTFE are not good enough to use it in preference to an adequate saphenous vein for femoropopliteal bypass.     

Femoropopliteal bypass for claudication: Vein vs. PTFE

The vascular graft of choice for femoropopliteal bypass in patients with intolerable claudication is controversial. We retrospectively reviewed our experience with 239 patients suffering from claudication secondary to superficial femoral artery obstruction. Femoropopliteal reconstruction was performed with saphenous vein to the below-knee popliteal artery in 66 patients (BK-vein). Polytetrafluoroethylene (PTFE) was used in 128 patients as a bypass graft to the above-knee popliteal artery (AK-PTFE) and 45 patients had a PTFE graft to the below-knee popliteal artery (BK-PTFE). All patients were enrolled in a postoperative graft surveillance program with graft revision when appropriate. There was one perioperative death (0.4%). Primary patency at 5 years for AK-PTFE, BK-PTFE, and BK-vein was 58.0%, 55.0%, and 60.3%, respectively, and was not significantly different among the graft groups. Graft revision for failed/failing grafts resulted in 5-year secondary patency rates of 79.2% (AK-PTFE), 73.3% (BK-PTFE), and 74.4% (BK-vein). These secondary patency rates were not statistically different. Eventual conversion to a vein graft in patients initially treated with PTFE maximized patency in the femoropopliteal segment with 5-year patency rates of 84.6% and 93.0% for the AK-PTFE and BK-PTFE graft groups, respectively. Major leg amputation was necessary during the entire course of the study in eight (3.3%) patients. We conclude that long-term patency rates for femoropoliteal bypass in patients with intolerable claudication are similar for PTFE and autologous saphenous vein grafts.Presented at the Twentieth Annual Meeting of the Peripheral Vascular Surgery Society, New Orleans, La., June 10, 1995.     

Heparin-bonded Dacron or polytetrafluorethylene for femoropopliteal bypass: five-year results of a prospective randomized multicenter clinical trial

OBJECTIVE: Dacron was largely abandoned for femoropopliteal bypass 30 years ago, because better patency rates were achieved with saphenous vein. Despite the range of potential prosthetics, polytetrafluoroethylne (PTFE) clearly predominates in current femoropopliteal practice. We compared heparin-bonded Dacron (HBD) with PTFE in a randomized multicenter clinical trial. METHOD: Over 28 months, 209 patients (179 above-knee disease, 30 below-knee disease) were randomized to receive HBD (n = 106) or PTFE (n = 103) grafts. Aspirin, 300 mg/d, was started before surgery, and was continued if tolerated. RESULTS: At follow-up for a minimum of 5 years (mean, 76 months; range, 60-89 months), 37 patients (17.7%) had died with patent grafts and 121 (58%) grafts were occluded. Primary patency rate, measured with Kaplan-Meier survival analysis, was 46% (95% confidence interval [CI], 35%-57%) at year 5 for HBD, compared with 35% for PTFE (CI, 25%-45%; P < .055). Long-term patency was achieved in only 4 of 78 interventions performed in 55 thrombosed grafts. Secondary patency rate for HBD was 47% (CI, 36%-58%), and for PTFE was 36% (CI, 26%-46%). Risk factors for arterial disease did not significantly influence prosthetic patency. Major limb amputation was necessary in 9 patients with HBD grafts and 20 patients with PTFE grafts (P < .025). Two amputations in the HBD group and 8 amputations in the PTFE group were in patients undergoing bypass surgery to treat claudication only. Limb salvage rate was 86% (CI, 77%-95%) and 74% (CI, 64%-84%), respectively. CONCLUSIONS: Significantly better patency rates were achieved with HBD than with PTFE at 3 years (P < .044), but the difference was no longer statistically significant at 5 years (P < .055). The incidence of major limb amputation, however, was significantly greater (P < .025) in the PTFE group compared with the HBD group at both 3 and 5 years of follow-up.     

Revascularization of popliteal and below-knee arteries with polytetrafluoroethylene

The expanded polytetrafluoroethylene (PTFE) graft (Gore-tex) is the most frequently used synthetic graft when an alternative to autologous saphenous vein is required. Early results have been encouraging. In the present paper we report on 6 years of results from 153 above-knee (AK) femoropopliteal bypass grafts, 74 below-knee (BK) femoropopliteal bypass grafts, and 54 femorotibial/peroneal bypass grafts. The main indication for the vascular reconstruction was severe ischemia. Preventive antibiotics were given to 95% of the patients. Minimum observation time was 1 year after implantation. There was no operative death. Graft infection was seen in less than 5% of patients. The 6-year cumulative limb salvage rate was 87% for patients with severe ischemia in the AK femoropopliteal bypass group, 59% for those in the BK femoropopliteal bypass group, and 57% for those in the femorotibial/peroneal bypass group. The graft patency rate was 88% at 2 years and 78% at 6 years for the AK femoropopliteal bypass group, for whom the operative indication was disabling claudication, and 81% and 68%, respectively, when the indication for the vascular procedure was severe ischemia. The cumulative graft patency rate was 53% and 43% at 2 and 6 years, respectively, after implantation of BK femoropopliteal bypass grafts and 43% and 39% for femorotibial/peroneal bypass procedures. The expanded PTFE (Gore-tex) graft seems therefore to be a good alternative when an autologous vein is not available, even for reconstructions well below the knee joint.     

Femoropopliteal bypass with either adequate ipsilateral reversed saphenous vein or obligatory polytetrafluoroethylene

The results are presented of a 10-year experience with 312 femoropopliteal bypasses performed in 285 patients using ipsilateral autologous reversed greater saphenous vein when available and adequate and polytetrafluoroethylene (PTFE) when not. The indications for operation were severe claudication in 121 (39%), rest pain in 95 (30%), and minor tissue loss in 96 (31%) limbs. There were 235 (75%) saphenous vein bypasses, of which 157 were above and 78 below the knee, and 77 (25%) PTFE bypasses, 58 above and 19 below the knee. Of these, 232 (79%) saphenous vein and 62 (21%) PTFE bypasses were primary procedures. The 30-day mortality rate was 3% (7/285) and the 30-day amputation rate was 2% (6/312). Overall, 24 (10%) saphenous vein and 30 (39%) PTFE grafts ultimately failed. The cumulative primary patency of all bypasses was 77% ± 4% (mean ± 1 SE) (85% to 69%, 95% confidence interval) at 3 years and 75% ± 4% (86% to 64%) at 5 years. Saphenous vein primary patency was superior to that of PTFE at 3 years, 87% ± 4% (97% to 77%) vs. 54% ± 12% (65% to 41%), (p<0.01), and at 5 years, 81% ± 6% (96% to 67%) vs. 48% ± 16% (63% to 33%) (p<0.01). Above-knee saphenous vein bypass primary patency was slightly better than below-knee patency at 3 years, 89% ± 4% vs. 84% ± 6%, and at 5 years, 83% ± 7% vs. 80% ± 8%. This was superior to above-knee PTFE patency at 3 years, 54% ± 14%, and at 5 years, 34% ± 16% (p<0.01). The overall PTFE failure rate was three to four times that of the saphenous vein rate. These results strongly support the use of autologous greater saphenous vein for all femoropopliteal bypasses when it is available and of good quality. PTFE grafts are valuable secondary conduits when the vein is not available or is inadequate. This series was not randomized since PTFE was used only in patients with inadequate or unavailable ipsilateral greater saphenous veins. When this protocol was followed, the patency rate for greater saphenous vein was excellent and its use is recommended for femoropopliteal bypass when it is available and of good quality.Presented in part at the Fortieth Annual Meeting of the North American Chapter of the International Society for Cardiovascular Surgery, Chicago, Ill., June 9– 10, 1992.     

ARTERIAL RECONSTRUCTION WITH POLYTETRAFLUOROETHYLENE: A PRELIMINARY REPORT

Early results ot arterial reconstruction with reintorced expanded polytetrafluoroethylene (PTFE) in the lower extremity have been obtained by reviewing 55 patients undergoing 59 operations – 38 femoropopliteal bypasses and 21 long bypasses distal to the popliteal artery. The one-year accumulated patency rates were 73% tor the femoropopliteal bypass group and 50% for the long bypass group. Early results suggest that PTFE is superior to Dacron and is an acceptable substitute for autogenous saphenous vein when the latter is unavailable or of inadequate calibre.     

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.     

Expanded microporous polytetrafluoroethylene as a vascular substitute: a two year follow-up.

Since 1974, 131 femoropopliteal, distal popliteal, and tibial bypasses have been performed using expanded microporous polytetrafluoroethylene (PTFE). Forty patients were operated on for limb salvage, and 21 had had previous bypass procedures. The overall patency rate was 82%. Early occlusions possibly were related to technical error, but most probably were due to severity of disease and poor runoff. Late occlusions were related to progressive atherosclerosis in the proximal or distal arterial tree. A 75.7% cumulative patency rate was noted at 28 months. In man the PTFE prosthesis demonstrates a smooth intimal lining with fibroblastic ingrowth into the interstices of the graft. These results are considered to be excellent in this high-risk patient population. The patency rates achieved with PTFE are better than those accomplished with alternative conduits and approach the patency rates reported with autogenous saphenous vein. Expanded microporous polytetrafluoroethylene with its high patency, pliability, and tissue incorporation is an excellent arterial substitute. Only with continued use of this material and a more uniform patient selection can more equitable comparisons be made between expanded PTFE and the autogenous vein.     

Seven-year experience with polytetrafluoroethylene as above-knee femoropopliteal bypass graft: Is it worthwhile to preserve the autologous saphenous vein?

A 7-year experience with 90 polytetrafluoroethylene (PTFE) femoropopliteal bypass grafts in the above-knee (AK) position is presented. The 5- and 7-year actuarial patency rate was 58.3%. No statistical difference was found between the patency rate of this series and that of a group of 17 AK and 77 below-knee (BK) femoropopliteal bypass grafts performed during the same period with the autologous saphenous vein (ASV). During the follow-up period (range 6 to 84 months, mean 42 months) a new bypass in a more distal location was required in 20 limbs. The ASV was available in seven of the eight PTFE graft failures and in only one of the 12 ASV failures. The 3-year patency rate of these new groups was 58.3% and 16.7%, respectively (p less than 0.02). Eighteen of the 48 deaths occurring during the follow-up period were related to atherosclerotic heart disease, whereas only one patient underwent coronary artery bypass grafting. Five hundred patients randomly selected from our series of myocardial revascularization procedures were reviewed. In five a femorodistal reconstruction was performed before coronary artery bypass, and in only two (0.4%), the ASV was not available. PTFE use in the AK position may be a reasonable alternative to the ASV to preserve it for additional treatment of more distal occlusive disease. There is no evidence that such a need exists for further treatment of coronary artery disease.