股浅动脉闭塞122例治疗体会

目的总结股浅动脉支架与股-腘动脉人工血管旁路移植术治疗股浅动脉闭塞病变的效果。方法选取我院2008年1月至2011年4月期间接受经皮腔内血管成形术+支架置入术(简称"PTA/S术组")或股-腘动脉人工血管旁路移植术(简称"动脉旁路移植术组")治疗股浅动脉闭塞病变的122例患者(136条患肢)作为研究对象。记录患者的年龄、住院时间、术前合并症、术后并发症、TASCⅡ分级、远端流出道情况、一期通畅率、有无截肢、死亡等。结果 1 PTA/S术组有64例74条患肢,动脉旁路移植术组有58例62条患肢,PTA/S术组患者的年龄大于动脉旁路移植术组(P0.05);PTA/S术组TASCⅡA、B级病变肢体所占比例较动脉旁路移植术组高(P0.05),TASCⅡC、D级病变肢体所占比例较动脉旁路移植术组低(P0.05);PTA/S术组拥有1条和3条远端流出道血管的患肢数目分别较动脉旁路移植术组多(P0.05);2组患者拥有2条远端流出道血管的患肢数目、术前合并糖尿病、合病高血压、合病糖尿病及高血压以及术前吸烟史病例数比较差异均无统计学意义(P0.05)。2 2组患者均无围手术期死亡患者;PTA/S术组的住院时间短于动脉旁路移植术组〔(7.2±1.2)d和(14.1±1.4)d,P0.05〕;而术后3年死亡率PTA/S术组高于动脉旁路移植术组(4.7%比1.7%,P0.05);切口感染率PTA/S术组低于动脉旁路移植术组(0比3.2%,P0.05);2组患者截肢率比较差异无统计学意义(P0.05);2组患者术后6、12及24个月一期通畅率比较差异无统计学意义(P0.05),36个月一期通畅率动脉旁路移植术组明显高于PTA/S术组(50.0%比40.5%,P0.05)。结论对于股浅动脉闭塞采用股-腘动脉人工血管旁路移植术能够获得较高的远期通畅率,但住院时间较长,个别患者会发生切口感染。股浅动脉球囊扩张成形+支架置入术手术创伤小,患者恢复快,住院时间短,对于年龄大,身体状况较差不能耐受股-腘动脉人工血管旁路移植术的患者有重要意义,但其远期通畅率有待进一步提高。     

多普勒血流检查评价下肢动脉旁路术流出道的价值

目的 探讨多普勒血流检查中节段性压力比值对评估下肢动脉硬化闭塞症患者远端动脉流出道的应用价值,以对人工血管旁路术适应证的选择提供参考.方法 回顾性分析北京安贞医院血管外科1998--2005年收治的166例下肢动脉硬化闭塞症行人工血管旁路术患者的资料,分析流出道节段性压力比值差值等与人工血管通畅率相关的因素,比较人工血管通畅组与阻塞组术前流出道节段性压力比值差值的差异.结果 流出道的节段性压力比值差值是影响人工血管术后通畅率危险程度最高的相关因素之一.人工血管通畅组与阻塞组流出道节段性压力比值差值分别为0.12±0.09和0.24±0.14,两组间比较,差异有统计学意义(P=0.001).人工血管通畅组流出道的节段性压力比值差值的95%可信区间为(0,0.27).结论 多普勒血流检查是一种量化的检查方法,节段性压力比值差值的区间范围可以作为临床上评价流出道及预测手术通畅率的参考.     

术中髂动脉支架结合股动脉旁路术治疗多节段动脉硬化闭塞症

目的 探讨术中髂动脉腔内成形及支架植入结合股-Guo动脉旁路术治疗多节段动脉硬化闭塞症的初步临床经验。方法 采用术中同时行髂动脉腔内成形和支架植入结合股-Guo动脉旁路术治疗多节段动脉硬化闭塞症10例（12条肢体）。结果 术中11条髂动脉行腔内成形和支架植入均获成功,9条肢体行股-Guo动脉人工血管旁路术,3条肢体行股-股-Guo动脉人工血管旁路系列转流术;1条肢体股-Guo动脉旁路术失败,本组患者无重要脏器并发症和手术死亡。平均随访时间6个月（1-12个月,髂动脉腔内支架通畅率100%;3条股-股动脉耻骨上人工血管转流均通畅;而股-Guo动脉人工血管通畅率83.3%;截肢率8.3%。结论 术中髂动脉腔内支架结合股-Guo动脉旁路术是治疗多节段动脉硬化闭塞症的安全、有效方法。     

周围血管疾病：膝下动脉硬化闭塞的血管腔内治疗

下肢动脉硬化闭塞多发生在髂、股及胭动脉，但随着糖尿病的发病率逐步增高，动脉硬化闭塞合并糖尿病的患者中发生膝下动脉狭窄及闭塞的患者亦逐步增多。对于膝上动脉硬化闭塞的患者，如果合并膝下动脉狭窄及闭塞，由于远端流出道不通畅，因此即使行膝上动脉的重建手术，其近、远期效果及通畅率仍不理想。膝下动脉内径细，如果行血管旁路手术，其吻合难度较大，即使利用隐静脉作为移植物，其远期通畅率仍不理想。因此许多医师对于膝下动脉闭塞的患者往往采取药物治疗的方式。     

微创技术结合外科手术治疗重症下肢缺血

目的 探讨术中血管微创治疗技术结合外科手术治疗重症下肢缺血的初步临床经验。方法 1999年7月至2000年10月,采用术中同时行髂动脉腔内微创治疗技术(球囊扩张和支架植入)结合肢体远端动脉重建术治疗广泛多节段动脉硬化闭塞症15例(20条肢体)。结果 术中17条髂动脉微创介入治疗均获成功,11条肢体同时行股-腘动脉人工血管旁路术,3条肢体行股-股-腘动脉人工血管旁路系列转流术,5条肢体行股深动脉成形术。其中有1条肢体股-腘动脉旁路术失败。本组患者无重要脏器并发症和手术死亡。平均随访时间8个月(1-16个月),髂动脉腔内支架通畅率100％,3条股-股动脉耻骨上人工血管转流均通畅,而股-腘动脉人工血管通畅率78．6％,截肢率10．0％。结论 术中髂动脉腔内微创介入治疗技术同时结合远端动脉重建术是治疗广泛多节段动脉硬化闭塞症的害全右特肯沸．     

股深动脉重建下肢组织血供的临床研究

采用股深动脉作为流出道和流入道施行旁路转流术治疗下肢动脉硬化闭塞症２２例，共３１条患肢。２２例已随访６～５０个月，平均２４．５个月。疗效良好者１９例；１例症状好转；１例保留足跟的截足者，仅保持户内活动，但生活自理；另１例术后６个月，因严重感染作膝下截肢术。作者认为，当髂股或股浅动脉广泛闭塞时，股深动脉作为流入道和流出道，为重建下肢血液循环起到了重要的作用。术前控制糖尿病并通过动脉造影了解股深动脉的通畅情况，是取得满意疗效的重要条件。     

膝下动脉硬化闭塞的血管腔内治疗

下肢动脉硬化闭塞多发生在髂、股及动脉,但随着糖尿病的发病率逐步增高,动脉硬化闭塞合并糖尿病的患者中发生膝下动脉狭窄及闭塞的患者亦逐步增多。对于膝上动脉硬化闭塞的患者,如果合并膝下动脉狭窄及闭塞,由于远端流出道不通畅,因此即使行膝上动脉的重建手术,其近、远期效果及通畅率仍不理想。膝下动脉内径细,如果行血管旁路手术,其吻合难度较大,即使利用隐静脉作为移植物,其远期通畅率仍不理想,因此许多医师对于膝下动脉闭塞的患者往往采取药物治疗的方式。随着血管腔内技术和材料的不断进步,通过血管腔内的方法治疗髂、股动脉的狭窄和…     

下肢动脉旁路移植术后再狭窄与闭塞的处理

自1948年Kunlin和Lerlche用自体静脉行旁路移植术获得成功、1965年Connlg开展原位大隐静脉旁路术及上世纪70年代William Gore的膨体聚四氟乙烯（ePTFE）人工血管广泛使用以来,动脉旁路移植术已成为目前治疗肢体缺血性疾病的主要手术方封”。然而无论是白体静脉还是人工血管,随着术后时间的延长,移植血管的通畅率逐年降低,而最易发生狭窄与闭塞的是下肢动脉旁路移植术,尤以移植至膝下者多见,使病人再次出现更为严重的肢体缺血的临床症状。     

下肢动脉人工血管旁路术后再闭塞的治疗经验

目的总结治疗下肢动脉人工血管旁路术后再闭塞的治疗经验,探索合理的治疗策略。方法回顾性总结19例下肢动脉人工血管旁路术后再闭塞的病例,分析再闭塞的原因,并根据原因选择再次手术的方式。其中4例行人工血管取栓术,5例行人工血管取栓＋远端吻合口成形术,3例行人工血管取栓＋股深动脉扩大成形术,2例行新的人工血管旁路术,1例行髂外动脉内膜剥脱术,2例行骨髓干细胞移植,2例由于肢体广泛坏死,行1期截肢术。在术后进行规律的随访以明确手术的效果。结果19例患者术后1年中定期随访。除2例截肢外,14例围手术期获得了1期成功,成功率82．4％,3例（17．6％）手术失败,术后1年内死亡2例,病死率10．5％。术后1年随访时,人工血管通畅6例,血管通畅率35．3％,保肢率76．4％（13例）。结论人工血管旁路术后再闭塞的治疗比较棘手,术前有效地评估闭塞原因、选择正确的手术方式和良好的随访计划是保持患者肢体功能和生存质量的重要因素。     

动脉旁路手术治疗慢性下肢缺血的中远期结果

目的 探讨慢性下肢缺血的动脉旁路治疗的中远期效果.方法 回顾性分析2002年1月至2007年4月212例经动脉旁路治疗的慢性下肢缺血患者的临床资料.治疗方式包括股.膝上腘动脉旁路111例,股-膝下胭动脉旁路59例,主-髂动脉旁路25例,股股转流17例.结果 术后186例(87.7%)获随访6～68个月(中位随访期18个月),股-膝上胭动脉旁路术与股-膝下胭动脉旁路术1年初次通畅率分别为69.7%、53.5%,二次累计通畅率为81.6%、60.5%,两者差异无统计学意义(P＞0.05);其3年通畅率分别为56.3%和23.8%,两者差异有统计学意义(P＜0.05);腹主-髂股旁路与股一膝上胭动脉旁路及股股转流术近远期通畅率差异均无统计学意义(P＞0.05).随访期内52例患者行二次手术,23例行膝上或膝下截肢,保肢率为89.2%.围手术期死亡10例(4.7%),随访死亡20例,多数死于心脑血管原发疾病;人工血管感染6例.结论 根据患者病情选用适当的旁路手术方式,可取得满意的效果.股-膝上腘动脉旁路中、远期通畅率高于股-膝下胭动脉旁路,两者近期通畅率无差异.     

Femoro-popliteal and femoro-distal bypass: a comparison between in situ and reversed technique

The present report compares the in situ technique with that using the reversed vein for femoropopliteal bypass. In 1986 the in situ technique was introduced at our clinic as the preferred method for femoropopliteal bypass with the lower anastomosis below the knee or femorodistal bypass. Forty patients operated with the in situ technique were compared with an equal number of patients operated with the reversed technique 1983-1985. The two groups were comparable regarding concomitant cardiovascular and pulmonary disease, preoperative ankle-brachial index and level of distal anastomosis. Patency after 6 months was significantly higher (84%) for the in situ grafts compared to reversed veins (49%). The difference was mainly caused by a significantly higher patency for in situ grafts anastomosed to infrapopliteal arteries. Despite better patency rates in the in situ group limb salvage at 6 months was the same in both groups. Operating time was also similar in both groups. It is concluded that the in situ technique is superior to the reversed technique, at least in infrapopliteal reconstructions. The superior patency rate and the technical advantages without apparent disadvantages are the basis for the recommendation to use the in situ technique for femoropopliteal and femorodistal bypass.     

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.     

Simultaneous operative repair of multilevel lower extremity occlusive disease

Sixty-two patients (39 men (63%), 23 women (27%), mean age 68 years) with multilevel lower extremity arterial occlusive disease underwent simultaneous inflow and outflow operative arterial repair consisting of aortofemoral bypass in 22 (35%), axillofemoral bypass in 17 (28%), femorofemoral bypass in 15 (24%), iliac endarterectomy in 7 (11%), and unilateral aortoiliac bypass in 1 (2%), combined with 69 outflow procedures (unilateral in 55 patients, 89%), including above-knee femoropopliteal in 12 (17%), below-knee femoropopliteal in 35 (51%), femoroinfrapopliteal in 20 (29%), popliteal tibial in 1 (1%), and femoropedal bypass in 1 (1%). Multiple criteria were used to identify patients with multilevel disease likely to benefit from multilevel procedures. The operations were performed by two operating teams in a median time of 240 minutes. Prosthetic grafts were used for eight (13%) distal bypasses, the remainder were autogenous vein. There was one operative death (1.8%). The mortality rate, morbidity rate, and operative time were not significantly different from a group of patients who underwent concurrent, isolated inflow operations (aortofemoral, axillobifemoral, femorofemoral bypass or iliac endarterectomy). Mean follow-up was 14.9 months (range, 0 to 120). The life-table primary patency for the inflow procedures was 92.6% at 24 months, the outflow was 94.9% at 24 months. Cumulative limb salvage was 90.9% at 48-month follow-up. All patients with claudication were relieved of their symptoms. We conclude that complete correction of multilevel disease can be accomplished with operative time, morbidity rate, and patency equal to that of single level repair. Multilevel procedures provide complete relief of symptoms in a higher percentage of patients than has been reported after single level repair.     

Saphenous vein or PTFE for femoropopliteal bypass. A prospective randomized trial.

To evaluate the patency of PTFE (Gore-tex) as a femoropopliteal bypass, a prospective randomized trial was performed between PTFE and saphenous vein. Forty-nine consecutive patients with intermittent claudication, rest pain, or tissue loss due to an occlusion of the superficial femoral artery entered the study. Randomization between PTFE and saphenous vein was performed at the time of operation after assessment of the quality of the latter. The two groups did not differ significantly regarding stage of peripheral ischemia, outflow tract, or localization of the distal anastomosis. The patency rate 6 weeks after operation was 92% for each group. After a mean follow-up of 54 months, the patency rate for the PTFE group was 37% and 70% for the saphenous vein group (p less than 0.001). In the PTFE group, there were eight major amputations. No amputations were performed in the saphenous vein group. It is concluded from this study that the saphenous vein is by far superior to PTFE as a femoropopliteal bypass.     

Two-year outcome with preferential use of infrainguinal angioplasty for critical ischemia

OBJECTIVE: Infrainguinal angioplasty provides a minimally invasive alternative to bypass surgery in patients with critical ischemia. This study aimed to determine the 2-year patency, limb salvage, and survival rates in patients who underwent infrainguinal angioplasty in a unit where angioplasty is used preferentially whenever possible for critical ischemia. METHODS: A total of 333 consecutive patients who presented with rest pain, tissue loss, or both and who underwent an infrainguinal intervention in the 4-year period between January 1998 and January 2002 were divided into femoropopliteal and femorodistal groups. The TransAtlantic Inter-Society Consensus angiogram scoring system was used to classify the lesions. Angioplasty was the preferred procedure in all patients for whom a stump or portion of a superficial femoral artery was patent. Exclusion criteria included the concomitant or sequential treatment of iliac lesions. Patients were followed up after surgery with ankle-brachial indices and duplex ultrasonography. RESULTS: A total of 180 patients underwent 198 angioplasties. Primary cumulative patency, limb salvage, and survival for femoropopliteal angioplasty (n = 166) at 2 years were 75%, 90%, and 88%, respectively, and 60%, 76%, and 82% for infrapopliteal angioplasty (n = 32). At 30 days, mortality was 2.7%, and the complication rate was 8.3%. There was a restenosis rate (>50%) of 68% and 65% at 2 years for the femoropopliteal and infrapopliteal angioplasty groups, respectively. Seven patients required repeat angioplasty of the same site, 30 underwent subsequent bypass, and 16 of 43 occluded limbs were amputated. A total of 153 comparative control patients underwent 162 bypass procedures during the same period. Primary cumulative patency, limb salvage, and survival for femoropopliteal bypass (n = 80) at 2 years were 69%, 87%, and 76%, respectively, and were 53%, 57%, and 64% for infrapopliteal bypass (n = 82). The 30-day mortality for bypass was 5.2%, the complication rate was 35%, and 31 limbs were amputated. CONCLUSIONS: The results of this study on the intermediate-term outcome of angioplasty suggest that angioplasty, when used preferentially for critical ischemia, in anatomically suitable patients provides very acceptable limb salvage and survival despite a relatively high restenosis rate.     

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)     

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.     

Do residual arteriovenous fistulae after in situ saphenous vein bypass grafting influence patency?

PURPOSE: The purpose of this study was to evaluate the influence on patency of residual arteriovenous fistulae (AVF) after in situ saphenous vein bypass grafting. METHODS: Between January 1, 1994, and December 31, 1996, 98 in situ saphenous vein bypass grafting procedures were performed in 94 patients. Patency was evaluated with duplex scanning after operation and at 1, 3, 6, 9, and 12 months. RESULTS: The indications for operation were intermittent claudication in two patients and critical leg ischemia in 92 patients. Two above-knee and 48 below-knee femoropopliteal and 48 femorocrural in situ saphenous vein bypass grafting procedures were performed. The median follow-up period was 9 months (range, 1.5 to 12.5 months). There were no residual AVF in 45 veins (44%; group 1), but 110 residual AVF were found in 53 veins (56%; group 2). In group 2, 36 AVF in 18 veins were surgically or radiologically occluded mainly as a result of a flow velocity decrease distal to the AVF, but the remaining 74 AVF were treated conservatively. The 1-year cumulative primary patency rates were 68% in group 1 and 74% in group 2 (log-rank test, 0.47; degree of freedom = 1; P =.52). The 1-year cumulative assisted primary patency rates were 68% in group 1 and 81% in group 2 (log-rank test, 2.19; degree of freedom = 1; P =. 14). CONCLUSION: Residual AVF after in situ bypass grafting without influence on bypass graft hemodynamics do not compromise patency and thrombose spontaneously.     

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.     

Significance and management of inflow gradients unexpectedly generated after femorofemoral, femoropopliteal, and femoroinfrapopliteal bypass grafting

With multilevel arteriosclerosis, some patients undergoing infrainguinal bypass grafting will develop femoral/brachial pressure gradients only after the bypass is performed. We therefore evaluated arteriographically alternate inflow sites and measured the femoral/brachial pressure gradients before and after placement of 87 femorofemoral and 510 femoropopliteal/infrapopliteal bypasses. No prebypass femoral/brachial pressure gradients were present with and without intraarterial papaverine. However, femoral/branchial pressure gradients greater than or equal to 15 mm Hg were observed after the bypass placement in 16 femorofemoral patients and 43 femoropopliteal/infrapopliteal patients. Gradients averaged 28 +/- 8 (SD) (range, 15 to 50) mm Hg. The post femorofemoral bypass gradients were treated by immediate supplementary inflow extension to the aorta (three patients) or an axillary artery (three patients); by postoperative iliac percutaneous transluminal angioplasty (four patients) or by no treatment (six patients with femoral/brachial pressure gradients of 15 to 35 [23 +/- 5] mm Hg). The 43 postfemoropopliteal/infrapopliteal bypass gradients were treated by immediate supplementary inflow extension to the contralateral femoral artery (15 patients), the aorta (8 patients), or an axillary artery (3 patients); by postoperative iliac percutaneous transluminal angioplasty (5 patients) or by no treatment (12 patients with femoral/brachial pressure gradients of 15 to 30 [21 +/- 4] mm Hg). No thrombosis occurred in the 10 femorofemoral bypasses with postbypass femoral/brachial pressure gradients that were treated. One of the six femorofemoral patients with untreated gradients required a subsequent aortic extension, and one thrombosed after 2 years. Of the 12 untreated patients with femoropopliteal/infrapopliteal bypasses one graft occluded early, and two late failures occurred 12 and 18 months later.(ABSTRACT TRUNCATED AT 250 WORDS)