Bypass graft to the midpopliteal artery with a combined anterior and posterior approach

PURPOSE: The medial supragenicular and infragenicular approaches to the popliteal artery were introduced almost 50 years ago and replaced the posterior approach to the popliteal artery for distal graft implantation. We review a contemporary series of bypass grafts to the midpopliteal artery by use of a combined anterior and posterior approach to evaluate its potential clinical benefits. TECHNIQUE: After the proximal graft anastomosis is constructed, an incision is made in the popliteal fossa to access the midpopliteal artery, the graft is passed into that incision, and all but the popliteal incision is closed. The patient is turned, the midpopliteal artery dissection is completed, and the graft is anastomosed distally. METHODS: Fifty-seven bypass grafts, implanted distally on the midpopliteal artery by this technique over a 13-year period, chosen in preference to an infragenicular bypass graft in selected patients when a supragenicular bypass was not feasible, were assessed in terms of indications for surgery, conduit type, complications, length of postoperative hospitalization, and graft patency. RESULTS: Bypass grafting originated from the axillary artery in two cases, the common iliac artery in one case, and the femoral artery in 54 cases. The procedure was performed in five patients with a popliteal trifurcation anomaly, nine patients with a blind popliteal segment, 20 patients with limited length of autologous vein, and five patients with an above-knee graft infection requiring an alternate path for revascularization. Autologous vein was used in 35 and polytetrafluoroethylene (PTFE) in 19 bypass grafts. Three other patients had a composite sequential femoral-popliteal-tibial bypass graft, with PTFE and autologous vein. Postoperative (30 day) complications include one death (composite sequential), one stroke (PTFE), and one graft thrombosis (saphenous vein). The mean postoperative hospitalization for the last 31 patients was 4.2 +/- 3.7 days. In the autologous vein group, the 1-year primary patency rate was 87%, and the primary assisted patency rate was 94%. In the PTFE group, the 1-year primary patency rate was 72%. Two composite sequential grafts remained patent at 1 year. CONCLUSIONS: Bypass grafting to the midpopliteal artery with a combined anterior and posterior approach offers a safe and effective option to below-knee bypass grafting when an above-knee bypass grafting is not feasible. Compared with the medial infragenicular incision, the posterior incision results in reduced morbidity rates, rapid mobilization, and early hospital discharge.     

Long-term evaluation of composite sequential bypass for limb-threatening ischemia.

When sufficient vein for a completely autogenous femorotibial artery bypass is not available, composite sequential grafting by using vein combined with polytetrafluoroethylene material is a surgical option. This study reviews what is currently the largest collection of these grafts and focuses on technical aspects and long-term patency characteristics. During a 7-year period 67 composite sequential bypasses were used to manage rest pain (38), ulcer (18), or gangrene (11) in 62 patients (mean age, 66 years). Fifty-two percent were men, and 51% had diabetes. This method was used as a primary reconstruction in 30, a second bypass in 16, and in 21 it was used after multiple other failed bypasses. Femoral to above-knee popliteal (44) and below-knee popliteal (23) 6 mm polytetrafluoroethylene grafts were placed. Then extensions of greater saphenous (57) or lesser saphenous (10) vein were anastomosed to the anterior tibial (19), posterior tibial (26), or peroneal (22) arteries. Fifty-three percent were maintained on long-term warfarin (Coumadin) anticoagulation, and 33% were maintained on aspirin. No deaths occurred in the perioperative period. Bypass patency was ascertained by a Doppler pressure and waveform analysis, with mean follow-up of patency or to the time of graft failure of 33 months (1 to 91 months). Three-year patient survival was 72%. Cumulative life-table primary patency of 72% (1-year), 64% (2-year), and 48% (3-year) was calculated. Two grafts are functioning 7 years after placement. Limb salvage was 84% at 2 years and 70% at 4 years. At the time of failure, five grafts retained a patent venous bypass segment, which allowed prompt reconstruction of the proximal portion. In a comparison of grafts with early failure and those with long-term patency, the SVS/ISCVS runoff score, vein diameter, tibial artery diameter, and coagulation status were similar. However, patients with the popliteal anastomosis above the knee had 2-year patency of 72% compared with 46% for those with below-knee anastomoses. This technique, when possible, appears preferable to an all prosthetic tibial bypass.     

Staged infrainguinal revascularization: initial prosthetic above-knee bypass followed by a distal vein bypass for recurrent ischemia. A valid concept for extending limb salvage?

Optimal infrainguinal revascularization should provide limb salvage for the longest duration of time. It is not known whether limb salvage is longer with an initial below-knee popliteal or tibial in situ saphenous vein graft or with staged bypasses; that is, an initial above-knee popliteal prosthetic bypass if feasible, followed by a more distal vein graft should the above-knee prosthetic graft fail. A retrospective review of 197 lower extremity vascular reconstructions performed since 1976 utilizing polytetrafluoroethylene (PTFE), umbilical vein, or in situ saphenous vein was completed. The data were analyzed for differences in limb salvage and prevention of limb threatening ischemia among three subgroups: above-knee prosthetic bypass, below-knee or tibial in situ saphenous vein bypass, and staged reconstructions (above-knee prosthetic bypass with subsequent in situ bypass). The groups were similar with respect to severity of limb threatening ischemia as indicated by mean preoperative ankle-brachial indices. Cumulative secondary limb salvage at 36 months was 73 percent for prosthetic grafts in the above-knee position, 78 percent for in situ saphenous vein grafts in the below-knee or tibial position, and 87 percent for staged reconstruction with an initial prosthetic graft to the above-knee position followed by a distal in situ vein bypass when the prosthetic graft fails.     

Distal venous patch improves results in PFTE bypasses to tibial arteries

In recent years, the management of limb-threatening ischemia has involved the use of distal bypasses to vessels beyond the popliteal trifurcation. Excellent patency rates and limb salvage data are achieved through the use of autologous long saphenous vein. However, an increasing number of patients in need of tibial bypass do not have adequate saphenous vein due to previous procedures, thrombophlebitis, or inadequate vein. In such cases alternative conduits have been proposed including lesser saphenous vein, arm vein, composite veins, composite vein with polytetrafluoroethylene (PTFE), and PTFE with or without a distal arteriovenous fistula. Unfortunately these alternative conduits have not resulted in equivalent results when used for distal bypass to tibial arteries. Several authors have reported upon the use of venous tissue at the distal anastomosis in the form of cuffs, collars, and boots to improve the results of prosthetic grafts in this challenging patient population. These techniques have been proposed as an option for revascularization in patients without adequate saphenous vein in an attempt to obtain limb salvage. The purpose of this review is to examine some of those techniques and focus on distal vein patch configuration with its perceived advantages and drawbacks.     

Distal Venous Patch improves results in PFTE bypasses to Tibial arteries

In recent years, the management of limb-threatening ischemia has involved the use of distal bypasses to vessels beyond the popliteal trifurcation. Excellent patency rates and limb salvage data are achieved through the use of autologous long saphenous vein. However, an increasing number of patients in need of tibial bypass do not have adequate saphenous vein due to previous procedures, thrombophlebitis, or inadequate vein. In such cases alternative conduits have been proposed including lesser saphenous vein, arm vein, composite veins, composite vein with poly-tetrafluoroethylene (PTFE), and PTFE with or without a distal arteriovenous fistula. Unfortunately these alternative conduits have not resulted in equivalent results when used for distal bypass to tibial arteries. Several authors have reported upon the use of venous tissue at the distal anastomosis in the form of cuffs, collars, and boots to improve the results of prosthetic grafts in this challenging patient population. These techniques have been proposed as an option for revascu-larization in patients without adequate saphenous vein in an attempt to obtain limb salvage. The purpose of this review is to examine some of those techniques and focus on distal vein patch configuration with its perceived advantages and drawbacks.     

Early results for below-knee bypasses using Distaflo

In patients who require lower extremity revascularization, prosthetic graft is a reasonable alternative in the absence of a suitable autologous vein conduit. However, prosthetic bypass grafts have limited patency, especially for infrageniculate reconstruction. Polytetrafluoroethylene grafts were geometrically modified at the distal end to increase their patency. The authors reviewed their experience with the Distaflo graft in patients who required lower extremity below-knee popliteal and tibial bypasses when no suitable autologous vein conduit was available. Chart review was conducted of the 57 patients who underwent 60 lower extremity bypasses over a 3-year period between June 2003 and April 2006. Twenty-four revascularizations were constructed to the tibial outflow sites, whereas the remaining grafts were placed to the below-knee (28) and above-knee (8) popliteal artery, respectively. Study endpoints were primary, assisted primary, secondary patency, and limb salvage at the time of follow-up. Distaflo bypass was performed at the infrageniculate level in 86.7% of cases (28 below-knee popliteal, 24 tibial). Mean follow-up time was 12 months (range, 0.5-37.5 months). At 1 year, primary, assisted primary, and secondary patencies and limb salvage rates for below-knee popliteal bypasses were 83.5%, 89.5%, 94.7%, and 94.4%, respectively. Primary, assisted primary, and secondary patencies and limb salvage rates for tibial bypasses were 44.4%, 44.4%, 63.2%, and 74.9%, respectively. Distaflo precuffed graft is a good alternative conduit for below-knee popliteal and tibial lower extremity reconstructions in the absence of an autologous vein and appears to have promising early patency and limb salvage rates even when used for tibial bypasses.     

Early experience utilizing the in situ saphenous vein technique in 54 patients

We have compared our early and late experience utilizing in situ saphenous vein bypass graft for lower extremity arterial occlusive disease in 54 patients who underwent in situ femoral to popliteal and distal bypass grafts between July of 1983 and February 1985. There were 3 femoral to above-knee popliteal bypasses, 27 femoral to below-knee popliteal bypass grafts, 12 femoral to anterior tibial dorsalis pedis bypass grafts, 10 femoral to posterior tibial bypass grafts and 2 femoral to peroneal in situ bypass grafts. The operative indications were progressive disabling claudication in 8 (15%) and limb salvage in 46 (85%). Eighty-nine percent of the limb salvage patients had 0-1 vessel runoff by arteriogram. Cumulative life table patency of the 54 in situ bypass grafts was 79% at 20 months. One hundred percent of the patients who were operated on for disabling claudication had patent grafts at 20 months. Seventy-eight percent of the limb salvage patients had patent grafts. Fourteen of the limb salvage patients required amputation and of these 14, 10 had patent grafts at the time of amputation. There were 8 deaths in the series. Our results demonstrate that a definite learning curve exists with this technique, however, once established, long-term patency and improved limb salvage statistics can be obtained.     

Lower extremity revascularization with in situ saphenous vein for critical ischemia

Over a 3 1/2 year period, 55 limbs were revascularized with in situ saphenous vein bypass grafts in 49 patients. Ninety-five percent of grafts were constructed in patients with critical ischemia for limb salvage, and 5 percent were constructed for debilitating claudication. The proximal anastomosis was performed in the groin in all patients. The distal graft was taken to the popliteal artery in 45 percent and to a tibial or isolated popliteal segment in 55 percent, with 55 percent of the grafts having single-vessel runoff. The perioperative mortality rate was 7 percent. The primary immediate patency rate was 91 percent and the secondary immediate patency rate was 98 percent at 1 month. The cumulative patency rate at 42 months was 85.4 percent overall, 86.6 percent for the tibial grafts, and 84 percent for the popliteal grafts. The cumulative limb salvage rate was 100 percent for the popliteal grafts, 90 percent for the tibial grafts, and 94.5 percent overall. All of the patients were followed and 3 required secondary revision. In situ vein bypass is a technically demanding procedure that can be performed successfully in high-risk patients with limbs with minimal runoff and can yield very high long-term patency and limb salvage rates in a community hospital setting.     

Infragenicular Bypass Graft for Limb Salvage Using Polytetrafluoroethylene and Distal Vein Cuff as the First Alternative in Patients Without Ipsilateral Greater Saphenous Vein

The objectives of this study were to evaluate the results of polytetrafluoroethylene infragenicular bypass grafts with a distal interposition vein cuff in patients with critical limb ischemia in the absence of ipsilateral greater saphenous vein. From January 1997 to June 2002, 58 consecutive below-knee bypass grafts with PTFE and distal interposition vein cuff were performed in 57 patients with a median age of 70.8 years. The distal anastomosis was located at the infragenicular popliteal artery in 18 cases and at tibial vessels in 40. Primary patency, secondary patency, and limb salvage were analyzed using the Kaplan-Meier method. During a median follow-up of 14.4 months (range, 1-50) 26 cases of graft occlusion and 19 major amputations were registered. The primary and secondary patency rates at 12, 24, and 36 months were 57%, 54%, and 47% and 61%, 58%, and 50%, respectively. Limb salvage rates reached 69%, 69%, and 59% at 12, 24, and 36 months. When below-knee revasculanzation is required in patients with limb-threatening ischemia, in the absence ipsilateral greater saphenous vein, PTFE grafts with a distal vein cuff are a reasonable substitute with acceptable long-term patency and limb salvage rates.     

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.     

复合血管序贯式旁路移植术治疗慢性肢体缺血的临床分析

目的:探讨复合血管序贯式下肢动脉旁路术治疗慢性下肢缺血的效果。方法:回顾性分析3年内采用复合式血管序贯式动脉血管重建的25例慢性下肢缺血患者的临床资料。复合血管由聚四氟乙烯（PTFE）人工血管及自体静脉组合而成。PTFE近心端与股总动脉吻合，远端与孤立腘动脉吻合；自体静脉从PTFE血管远端发出并与小腿的胫或腓动脉吻合。结果:自体静脉远端吻合口止于胫前动脉5例，胫后动脉8例，腓动脉12例。术后1，2，3年累积通畅率分别为78%， 72%， 61%。二期累积通畅率分别为83%，77%，68%。救肢率分别为83%，83%，73%。结论:复合血管序贯旁路术治疗慢性肢体缺血远期通畅率较高，具有较好的救肢效果，是解决自体静脉不足的合理选择。     

Below-knee bypass for limb salvage. Comparison of autogenous saphenous vein, polytetrafluoroethylene, and composite dacron-autogenous vein grafts

Autogenous saphenous vein was used preferentially for 92 below-knee bypass procedures (44 femoral-distal popliteal and 48 femoral-distal tibial or peroneal) performed for limb salvage in 87 adult male patients during a 30-month period of study. When a saphenous vein was unavailable or of unsuitable length or diameter, we randomly used expanded polytetrafluoroethylene (PTFE) and composite Dacron-autogenous vein (DV) grafts. With good run-off, all grafts have remained patent. However, with poor run-off, cumulative patency by the life table method decreased to 54% for autogenous saphenous vein and 45% for PTFE, which was not significantly different. All composite DV grafts used with poor run-off became occluded within the first ten months of the study. We continue to recommend use of autogenous saphenous vein for revascularization of the ischemic lower extremity. When a suitable saphenous vein is unavailable, PTFE is a satisfactory alternative graft that is superior to composite DV grafts.     

Femoro-distal bypass for critical ischemia: is the use of prosthetic grafts justified?

The results of 240 femoro-distal bypass operations for critical ischemia have been reviewed. Autologous saphenous vein was the graft material in 112 cases (46.7%) and prosthetic grafts were used in the other 128 cases (53.3%). A distal arteriovenous shunt (AVS) was employed as an adjunct to 72 grafts (30%). The cumulative patency rate at 4 years was 53% for all of the grafts together and the cumulative limb salvage rate was 70%. When autologous saphenous vein was available the actual patency rate at one year after operation was 70% for popliteal grafts and 53% for tibial grafts. In the case of prosthetic grafts the equivalent patency rates were 51% and 35%. In view of the poor success rate of prosthetic grafts anastomosed to distal tibial vessels these procedures are of doubtful value in routine clinical practice.     

Early results of infrainguinal arterial reconstruction with a modified biological conduit

We implanted 112 glutaraldehyde-fixed bovine carotid artery grafts (BioPolyMeric [BPM]) for infrainguinal reconstruction in 107 legs of 98 patients. Indications for surgery were disabling claudication in 28%, rest pain in 33% and tissue loss in 39%. In 32%, BPM bypass followed failed ipsilateral reconstruction. Autologous vein was either absent or inadequate in 60% of cases. BPM was used preferentially over vein in above-knee bypasses. The distal anastomosis was to the above-knee popliteal artery in 40%, to the below-knee popliteal artery in 35%, and to the tibial arteries in 25%. Follow-up was available from one to 25 months, with a mean of nine months. Wound complications developed after 9% of operations, including seven (6%) graft infections. Both patent grafts that became infected were salvaged. Four patients (4%) died within 60 days of surgery due to cardiac complications. Life-table primary and secondary patencies of all grafts were 64% and 65% at one year, and 48% and 62% at two years, respectively. The only factor significantly affecting graft patency was the location of the distal anastomosis (p<.01). Primary patencies at one and two years to the above-knee popliteal artery were 90% and 80%, to the below-knee popliteal artery were 56% and 37%, and to the infrapopliteal arteries were 34% and 26%. Bypass to 16% of extremities resulted in amputation, including 5% that were amputated with patent grafts. No limb loss occurred as a result of operation for claudication. In conclusion, BPM grafts provide early results comparable to saphenous vein above the knee. Future randomization with synthetic grafts is necessary to define the role of BPM grafts below the knee.Presented at the Tenth Annual Meeting of the Southern California Vascular Surgical Society, September 27–29, 1991, Marina Del Rey, California.     

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.     

Long-term Outcome of Femoral Above-knee Popliteal Artery Bypass Using Autologous Saphenous Vein Versus Expanded Polytetrafluoroethylene Grafts

Despite a recent flurry of publications on preferred techniques for femoral above-knee popliteal artery bypass, controversy persists over the use of autologous saphenous vein and expanded polytetrafluoroethylene (ePTFE) grafts. The purpose of this study was to compare our long-term results using these two bypass materials. In a series of 474 infrainguinal bypasses performed between January 1993 and December 1998, we performed a total of 75 femoral above-knee popliteal artery bypass using an autologous saphenous vein graft in 48 cases (64%) and an ePTFE graft in 27 cases (36%). Prosthetic grafts were used by choice in 17 cases and by necessity due to the absence of useable vein in 10 cases. There were 55 men and 18 women with a mean age of 70 years. The indication for bypass was lower extremity arterial occlusive disease at stage II in 17 cases (22.7%), stage III in 9 cases (12%), and stage IV in 36 cases (48%); subacute ischemia in 8 cases (10.7%); and femoropopliteal aneurysm in 5 cases (6.7%). Preoperative arteriography demonstrated three patent leg arteries in 15.5% of cases, two patent leg arteries in 43.5%, and one patent leg artery in 41%. There was no significance difference between the vein graft and ePTFE graft groups with regard to indications and arteriographic findings. No patient died during the immediate postoperative period. The mean duration of follow-up was 25.5 months (range, 3 to 108 months). The primary patency rate at 4 years was 82.2 ± 8% for venous bypass vs. 80.6 ± 11.8% for ePTFE bypass (p = 0.42). The secondary patency rate at 4 years was 84.7 ± 7.4% for vein bypasses and 79.5 ± 12% for ePTFE bypasses (p = 0.26). In our experience, there was no statistically significant difference in long-term outcome of femoral above-knee popliteal artery bypass using autologous vein grafts or prosthetic ePTFE grafts. Presented at the Seventeenth Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 29-31, 2002, Liege, Belgium.     

Late results with Dardik-biograft in peripheral arterial surgery

A total of 117 vascular reconstructions below the inguinal ligament were performed using Dardik's human umbilical vein. The indication for surgery was limb salvage in 91.5%. In 61.5% a previous reconstruction had failed. The distal anastomosis was done with the popliteal artery above the knee in 9 cases, below the knee in 41, and with a tibial or the peroneal artery in 60 cases. The umbilical vein was combined with a prosthesis or the autologous saphenous vein in 20 cases. The cumulative patency rates of all reconstructions were 59.6% after 3, and 46.7% after 6 years. Crural reconstructions had a cumulative patency rate of 52% 3 years after surgery. The main factors influencing patency were the preoperative grade of ischemia, the site of the distal anastomosis and the angiographic run-off. It is concluded that the human umbilical vein is the graft material of choice in long length revascularization whenever the saphenous vein is not available.     

Late results of two hundred seventeen femoropopliteal bypasses to isolated popliteal artery segments

A 10-year-experience of 217 femoropopliteal bypasses to isolated popliteal artery segments in 207 patients is reported. Thirty-three femoropopliteal bypasses (15%) were performed with reversed saphenous vein and 184 (85%) with polytetrafluoroethylene grafts. Operative indications were gangrene in 121 (56%), nonhealing ulceration in 40 (18%), ischemic rest pain in 51 (24%), and claudication in 5 (2%) cases. The 5-year primary graft patency rate of these bypasses was 59% (reversed saphenous vein, 74%; polytetrafluoroethylene, 55%; p less than 0.05), the secondary 5-year graft patency rate was 61% (reversed saphenous vein, 79%; polytetrafluoroethylene, 56%; p less than 0.05), and the 5-year limb salvage rate was 78% (reversed saphenous vein, 78%; polytetrafluoroethylene, 78%). The 30-day operative mortality rate was 10%, and the 5-year patient survival rate was 38%. Eleven patients (5%) required lower extremity amputation because of progressive gangrene or extensive infection despite a patent bypass to an isolated popliteal artery segment. We conclude that femoropopliteal bypasses to isolated popliteal artery segments (1) have acceptable 5-year graft patency and limb salvage rates; (2) should be performed with reversed saphenous vein grafts when possible; (3) may be performed with polytetrafluoroethylene grafts if necessary, with a resulting limb salvage rate equal to that of reversed saphenous vein grafts; and (4) require sequential extension to an infrapopliteal artery in up to 20% of patients. In addition, the presence of an isolated popliteal artery segment is associated with a high operative mortality rate and limited life expectancy because of coronary artery disease.     

复合血管与倒置大隐静脉旁路移植治疗严重慢性下肢缺血的对比研究

目的比较复合血管序贯式下肢动脉旁路术和倒置自体大隐静脉旁路术治疗严重慢性下肢缺血的效果。方法回顾性分析采用复合式血管(25例)及倒置自体大隐静脉(16例)旁路移植术治疗的41例严重慢性下肢缺血患者的临床资料。复合血管用聚四氟乙烯(PTFE)人工血管及自体静脉组合而成。人工血管近心端与股总动脉吻合,远端与孤立腘动脉吻合;自体静脉从PTFE血管远端发出并与小腿的胫或腓动脉吻合。倒置自体大隐静脉旁路术采用同侧大隐静脉作为血管桥。比较两者血管桥的累积通畅率和保肢率。结果平均随访18.7个月。男29例,女12例。平均年龄(67±10.4)岁。FontaineⅢ级23例,FontaineⅣ级18例。复合血管组中自体静脉远端吻合口止于胫前动脉5例,胫后动脉14例,腓动脉6例;倒置大隐静脉移植组中10例吻合口止于胫后动脉,3例腓动脉,3例胫前动脉。复合血管组踝肱指数术前为0.24±0.14,术后为0.68±0.22(P=0.000)。倒置大隐静脉组平均踝肱指数术前为0.24±0.14,术后为0.68±0.22(P=0.000)。复合血管术后1,2,3年首次通畅率分别为78%,72%,61%;二期通畅率分别为83%,76%,6...     

A flexible approach to infrapopliteal vein grafts in patients with diabetes mellitus

From October 1985 to August 1989, we performed 156 dorsalis pedis artery bypasses in 146 patients, 139 (95%) of whom had diabetes mellitus. A variety of surgical techniques were used to shorten surgery, limit incision length, and optimize size-matching between vein grafts and arteries whenever possible. Arterial inflow was from the common femoral artery in 58 cases, from the distal superficial femoral or popliteal artery in 88 cases, from a tibial artery in three cases, and from a preexisting bypass in seven cases. In situ (75 cases), ex situ reversed- or nonreversed-vein (62), composite vein (nine), and polytetrafluoroethylene (one) bypasses were constructed. Four patients (2.7%) died, and seven grafts (4.5%) failed within 30 days. Actuarial patency and limb salvage 6 to 52 months after surgery were 87.1% and 91.6%, respectively. There were no significant differences in patency between in situ and ex situ vein grafts (93.2% vs 89.7%) or between common femoral artery inflow site and distal superficial femoral/popliteal artery inflow site (89.3% vs 88%).