Comparison of axillounifemoral and axillobifemoral bypass operations

Routine use of axillobifemoral (ABF) bypass has been advocated because this operation is thought to achieve better patency than the axillounifemoral (AUF) procedure. In 5 years we performed 34 AUF and 22 ABF bypass operations for limb salvage in high-risk patients using 6 mm polytetrafluoroethylene grafts. Five-year cumulative life table patency rates for AUF bypasses were 71% with reoperation (secondary patency) and 44% without reoperation (primary patency). These values were not significantly different (p greater than 0.5) from those for ABF bypasses (77% and 50%, respectively). Five-year limb salvage results (AUF 73%; ABF 89%) were also not significantly different (p greater than 0.1). Correlation of arterial outflow characteristics with graft patency revealed that 78% of the patients who never had graft occlusion had occluded superficial femoral arteries (SFA) demonstrated at the first operation, while 79% of the patients who experienced graft closure had comparable SFA occlusions. Our aggressive approach to graft thrombosis included angiographic study of the inflow arterial system. This revealed that 16% of the failed grafts were associated with hemodynamically significant stenosis of the donor subclavian artery. Our results indicate that AUF bypass is the procedure of choice for unilateral limb ischemia in high-risk patients who require an axillary source and that patency of the SFA does not affect outcome. These results also emphasize the need to obtain angiographic evaluation of the inflow system.     

Sixteen-slice multidetector computed tomography for graft patency evaluation after coronary artery bypass surgery

OBJECTIVE: To investigate the ability of 16-slice multidetector computed tomography (MDCT) to assess coronary artery bypass graft patency and to detect bypass stenosis by comparison with coronary angiography. METHODS: Thirty patients underwent both conventional coronary bypass angiography and retrospective ECG gated 16-slice multidetector computed tomography after surgery using 0.4 seconds rotation time and 1.25 mm slice thickness. RESULTS: Among a total of 107 bypass grafts, 101 grafts (94.4%) were evaluable by MDCT. Thirteen patients were taking oral beta blockers. Mean heart rate was 73.6 (52-105). Of the 40 internal mammary arteries and two radial arteries examined, only one was occluded by coronary bypass angiography and MDCT, resulting in a sensitivity of 100% and a specificity of 100%. MDCT correctly diagnosed all patent venous grafts and missed two of the 14 venous grafts shown occluded by conventional angiography resulting in a sensitivity of 85.7% and specificity of 100%. When occluded grafts were excluded, MDCT did not detect two out of two anastomotic arterial graft stenosis >50% and resulted in one false positive result for a sensitivity and specificity of 0% and 97.4%, respectively. MDCT correctly diagnosed one out of three venous stenosis >50% and falsely diagnosed one venous graft stenosis >50% yielding a 33.3% and 97.6% sensitivity and specificity, respectively. CONCLUSION: Sixteen-slice MDCT allows for noninvasive evaluation of coronary bypass grafts patency with high diagnostic accuracy. Assessment of distal anastomotic stenosis was deficient, particularly for arterial grafts, still limited by low resolution or artifacts. Improved accuracy may be obtained by more aggressive heart rate reduction.     

Comparison of superficial femoral vein and saphenous vein as conduits for mesenteric arterial bypass

PURPOSE: Gangrenous bowel, intraabdominal sepsis, and previous failed mesenteric bypass are indications for use of an autogenous conduit for mesenteric arterial reconstruction. Saphenous vein (SV) is often used as the autogenous conduit of choice, but it may be prone to graft stenosis or occlusion. Recent experience with superficial femoral vein (SFV) suggests that it is an excellent alternative conduit for major arterial reconstruction. The purpose of this study was to compare the outcomes of SV and SFV for mesenteric arterial bypass. METHODS: During a 7-year period, 26 patients underwent 43 mesenteric arterial bypass procedures with autogenous conduit. SV was used for 23 bypasses (53%), and SFV was used for 20 bypasses (47%). Indications for revascularization included chronic mesenteric ischemia (n = 15; 58%), acute mesenteric ischemia (n = 9; 35%), and mycotic aneurysm of the paravisceral aorta (n = 2; 7%). Three patients (11%) underwent revascularization with SV grafts and two patients (8%) with SFV grafts after previous failed mesenteric bypass. RESULTS: The 30-day mortality rate was 15%. Three deaths occurred after SV bypass for acute mesenteric ischemia, and one death occurred after a SFV bypass for a ruptured paravisceral mycotic aneurysm. Twenty-two surviving patients were followed for a mean of 31 +/- 6 months. Three of 11 patients (27%) who survived after SV bypass had recurrent mesenteric ischemia develop (acute, n = 1; chronic, n = 2) from graft thrombosis at a mean interval of 32 +/- 22 months after surgery. No patient had recurrent symptoms develop after SFV bypass. One of the three patients with SV graft failure died of acute mesenteric ischemia, and the other two patients underwent successful bypass with SFV. Symptomatic graft failure was significantly more likely to occur in patients receiving SV grafts compared with SFV grafts (P <.05). CONCLUSION: SFV yields acceptable clinical outcomes for mesenteric arterial bypass compared with SV. SFV is a viable alternative to SV when autogenous conduit is indicated for mesenteric arterial reconstruction.     

Off-Pump Coronary Artery Bypass Grafts Assessment by Multislice Computed Tomography

Abstract Background: Selective coronary angiography is the standard but invasive procedure for postoperative assessment of coronary artery bypass graft patency. The aim of this prospective study is to evaluate the multislice computed tomography (CT) as a means of postoperative patency assessment and anastomotic site control of arterial and venous coronary bypass grafts performed with off-pump coronary artery bypass techniques. Methods: Over a 6-month period, 20 patients underwent isolated coronary artery bypass (beating heart technique) and benefited, 7 days later, from a patency and anastomotic site control by multidetector angio multislice CT with cardiac gating. Results: Whole internal thoracic artery bypasses and venous grafts were visualized perfectly on their entire length, including the anastomotic site, and 3-dimensional reconstruction was possible. The relationship between cardiac cavities and the bypasses were well visualized, allowing quantification of bypass stenosis ensured by software analysis. Conclusions: Postoperative control of coronary bypasses is possible by multislice CT with a very satisfactory resolution, thus making it possible to check the patency of coronary bypasses and the quality of anastomosis with a noninvasive method. Three-dimensional reconstructions are very useful in the event of redo surgery.     

Multi-detector computed tomography in coronary artery bypass graft assessment: a meta-analysis

Multi-detector computed tomography (MDCT) has become an alternative to coronary angiography in diagnosis of graft occlusion and stenosis after coronary artery bypass. A literature search was performed for studies comparing angiography to 8-slice, 16-slice, and 64-slice MDCT in the assessment of coronary grafts. In assessing occlusion, 14 studies produced pooled sensitivity of 97.6%, specificity of 98.5%, diagnostic odds ratio of 934.2, area under the curve of 0.996, and Q* of 0.977. Ninety-six percent of all grafts were visualized for occlusion assessment. Beta blockers, symptomatic status, and postoperative period did not significantly affect diagnostic performance. Stenosis assessment produced sensitivity of 88.7% and specificity of 97.4%. Eighty-eight percent of patent grafts could be assessed for stenosis. The diagnostic accuracy of MDCT approaches angiography for diagnosing graft occlusion and stenosis in patients with venous and arterial coronary bypass grafts. Our findings show that cardiac surgeons will need to interpret MDCT images of both native and grafted vessels soon in preparation for primary or re-do coronary bypass grafting procedures.     

Pedal branch artery bypass: a viable limb salvage option

PURPOSE: We reviewed our experience with pedal branch artery (PBA) bypass to confirm the role of these target arteries for limb salvage and to identify patient and technical factors that may be associated with graft patency and limb salvage. METHODS: In this retrospective study we analyzed 24 vein grafts to PBAs performed from 1988 to 1998 for limb salvage in 23 patients who had no suitable tibial, peroneal, or dorsal pedal target arteries. These PBA grafts were compared with 133 perimalleolar posterior tibial, defined at or below the ankle, or dorsalis pedis bypass grafts performed contemporaneously; the Kaplan-Meier life table was used in the analysis of graft patency and limb salvage. Life table analyses and logistic regression analysis of prognostic patient variables were also performed. RESULTS: The PBA bypass represented 3% of infrainguinal revascularizations for chronic critical limb ischemia at our institution over the study period. Patients who received PBA bypasses were more likely to be male (92% vs. 69%, P =.02) with lower incidences of overt coronary artery disease (33% vs. 50%, P =.12) and stroke (0% vs 15%, P =.04), and a higher incidence of end-stage renal disease (21% vs 8%, P =.06) than those undergoing perimalleolar bypass. Seventeen percent of PBA bypasses were performed with the anterior lateral malleolar artery, a vessel not previously described as a common bypass target. Two-year primary patency and limb salvage for PBA versus perimalleolar bypass was 70% versus 80% (P =.16) and 78% versus 91% (P = .28), respectively. Patency and limb salvage rates were no different in bypasses with above-knee or below-knee inflow arteries. CONCLUSION: An autogenous vein bypass to the PBA, though rarely required, provides acceptable primary patency and limb salvage when compared with perimalleolar tibial artery bypass when no suitable, more proximal target arteries are available. The PBA bypass should be considered before major amputation is undertaken.     

External polytetrafluoroethylene reinforcement of varicose autologous vein grafts in peripheral bypass surgery produces durable bypass function

Objective

Use of autologous veins as peripheral bypass graft may become critical in the presence of significant varicose degeneration of the harvested vein. External support of such dilated veins with standard polytetrafluoroethylene (PTFE) prostheses was recommended as an option to use these veins for peripheral bypass. A single-center experience with this technique regarding long-term graft function, secondary reinterventions, and potential graft degeneration is presented.

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.     

Femoral-tibial bypass for calcific arterial disease

Overt calcification of the recipient artery and outflow bed has been regarded as a poor prognostic factor for femoral-distal arterial bypass patency and subsequent wound healing. In order to determine the short- and long-term limb salvage and graft patency rates achieved in these patients, the records of 35 patients undergoing 38 attempted femoral-tibial bypasses to a calcified recipient artery were reviewed. Two patients were unreconstructable at the time of surgery. Thirty-one of the 36 operations (86 percent) were performed using in situ saphenous vein bypass techniques, 3 were performed with polytetrafluoroethylene (PTFE), 1 with a composite sequential, and 1 with a composite vein graft. Immediate limb salvage was achieved in 31 of 36 limbs (86 percent). Five early below-knee amputations (14 percent) were required, two due to graft thromboses and three due to progressive foot necrosis despite patent grafts. One patient (3 percent) died secondary to sepsis. Three-year primary graft patency and limb salvage rates did not differ significantly from bypasses to noncalcified vessels. Femoral-distal bypass in the presence of overt calcific arterial disease may be successfully accomplished and offers an excellent prognosis for long-term graft patency and limb salvage.     

64排CT对冠状动脉旁路移植术后桥血管病变的诊断研究

目的 评价64排螺旋CT血管造影(MSCTA)对冠状动脉旁路移植术(CABG)术后桥血管病变诊断的准确性.方法 2005年7月至2007年4月,共228例患者于CABG术后复查64-MSCTA,其中31例患者(82支桥血管)因有心绞痛或CT结果提示桥血管损害,进一步行冠状动脉造影(CAG).结果 所有桥血管均获得评价.64-MSCTA共发现13支桥血管闭塞,均得到CAG证实.CAG发现15支桥血管严重狭窄,64-MSCTA发现14处,漏诊1处,误诊1处.64-MSCTA诊断冠状动脉桥狭窄的灵敏度、特异度、阳性预测值、阴性预测值和与CAG符合率分别为93.3%、98.1%、93.3%、98.1%和97.1%;诊断桥血管病变的灵敏度、特异度、阳性预测值、阴性预测值和与CAG符合率分别为96.4%、98.1%、96.4%、98.1%和97.6%.结论 64-MSCTA可以准确评价术后桥血管通畅情况.     

A twelve-year experience with the popliteal-to-distal artery bypass: the significance and management of proximal disease.

The value of the popliteal-to-distal artery bypass in limb salvage is well documented. However, the influence of progression of disease in the superficial femoral artery or proximal popliteal artery, and the role of percutaneous transluminal angioplasty of these vessels before bypass have not been adequately assessed. To evaluate these and other factors, we reviewed our experience with 153 nonsequential popliteal-to-distal artery bypasses performed over a 12-year period. Limb salvage was the indication for all procedures, and 87% of the patients were diabetic. The 5-year primary and secondary graft patency rates were 55% and 60%, respectively, and the limb salvage rate was 73%. Preoperative arteriograms were evaluated for stenosis in the superficial femoral artery or popliteal artery proximal to the graft. Fifty-six grafts with a proximal stenosis 20% or less were identified and had primary graft patency of 77% at 2 years, similar to the 70% patency for the 20 grafts placed distal to a 21% to 35% stenosis. The 18 grafts placed distal to a stenosis greater than 35% had 53% 2-year primary graft patency (p = 0.25). Percutaneous transluminal angioplasty of a superficial femoral artery or popliteal artery stenosis (24% to 85% luminal narrowing) in 19 limbs resulted in 68% 2-year graft patency, not significantly lower than grafts with 35% or less proximal stenosis (75%, p = 0.25). Other factors associated with significant decreases in graft patency included a vein graft diameter less than 3.0 mm, a dorsalis pedis outflow site, and poor quality outflow. Thus the popliteal-to-distal bypass is a durable procedure.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparative analysis of autogenous infrainguinal bypass grafts in African Americans and Caucasians: the association of race with graft function and limb salvage

OBJECTIVE: African Americans (AAs) are at risk for developing diabetes mellitus and atherosclerosis. Whether race influences the results of infrainguinal arterial reconstruction is unclear. The purpose of this study was to compare the results of autogenous infrainguinal bypasses in AAs and Caucasians to determine the association of race with graft function and limb salvage. METHODS: This was a retrospective, comparative cohort study of AA and Caucasian patients who had undergone autogenous infrainguinal bypass surgery. Only single-limb bypasses in each patient cohort were considered in this analysis. In patients who had undergone bilateral lower limb bypasses, the first limb bypass was chosen as the index bypass procedure. RESULTS: From January 1985 to December 2003, 1459 autogenous infrainguinal bypasses were performed in 1459 patients for lower limb ischemia. Within this group, 89 AA patients/vein grafts formed the study cohort. The control group comprised 1370 Caucasian patients/vein grafts. Compared with the Caucasian cohort, AA patients were significantly younger (median age, 65 vs 70 years, respectively; P = .001) and predominantly female (57% vs 41%, respectively; P = .002). AA patients also had a higher prevalence of diabetes mellitus, hypertension, cerebrovascular disease, congestive heart failure, and dialysis-dependent renal failure. More AA than Caucasian patients presented with gangrene (34% vs 16%, respectively; P = .001), and more underwent bypass surgery for limb salvage indications (91% vs 81%, respectively; P = .01). The venous conduit used was predominantly the greater saphenous vein (AA, 83%; Caucasian, 85%), and the site of distal anastomosis was at the tibial/pedal level in 67% of AA and 61% of Caucasian patients. Overall morbidity (AA, 28%; Caucasian, 23%) and 30-day mortality (AA, 3%; Caucasian, 3%) were similar. Thirty-day graft failure was significantly greater in AAs than Caucasians (12% vs 5%, respectively; P = .003). The overall 5-year primary graft patency (+/-SE) was significantly worse in AA patients (AA, 52% +/- 6%; Caucasian, 67% +/- 2%; P = .009). The 5-year limb salvage rate (+/-SE) was also significantly worse in AA patients (AA, 81% +/- 5%; Caucasian, 90% +/- 1%; P = .04). With the Cox proportional hazard model, significant risk factors associated with primary graft failure were AA race, age younger than 65 years, female sex, secondary reconstructions, tibial bypasses, and critical limb ischemia. Significant risk factors associated with limb loss were age younger than 65 years, female sex, absence of coronary disease, presence of critical limb ischemia, and secondary reconstructions. CONCLUSIONS: Autogenous infrainguinal bypass surgery in AAs is associated with poorer primary graft patency and limb salvage rates compared with those of Caucasians. This may partially account for the higher rate of limb loss in AA patients with peripheral arterial occlusive disease.     

Lower extremity revascularization via the lateral plantar artery

Lower extremity bypass grafts to the tibial and crural arteries are commonly employed to treat patients with atherosclerotic limb-threatening ischemia. Although occasional series have mentioned bypasses to a plantar artery, few of these specifically examine the results of arterial reconstructions using these vessels. Six patients underwent femoral to lateral plantar artery (LPA) bypass within a 19-month period for gangrene of the forefoot. There was one early graft failure and in the five completely autogenous reconstructions, graft patency and limb salvage had been achieved during a follow-up ranging from three to 22 months. The LPA is an acceptable site for anastomosis of lower extremity bypass grafts and the early results presented herein support its more liberal use when proximal sites are unavailable.     

Pedal branch arterial bypass for limb salvage

In patients with critical lower extremity ischemia and occlusion of the distal tibial and pedal arteries bypasses to pedal artery branches may offer the only alternative to primary amputation. The results of 22 pedal branch arterial bypasses are reported, and a review of the literature is offered. The charts of 22 patients undergoing pedal branch arterial bypass during a 12-year period were retrospectively reviewed. The results of six additional reports of this technique were also evaluated. In the present series the cumulative primary graft patency rate was 72 per cent after 2 years. The cumulative limb salvage rate during this interval was 82 per cent. Similar graft patency and limb salvage rates were obtained with the approximately 200 other bypasses of this nature as reported in six other series. Pedal branch arterial bypass offers limb salvage results that are comparable to perimalleolar and pedal artery bypasses. In patients with critical limb ischemia and occlusion of distal tibial and pedal arteries, pedal artery branches should be sought as potential outflow sites. Bypasses to these arteries result in good long-term limb salvage, improved survival, and good functional ability for amputation. Pedal artery branch bypasses are a superior alternative to primary amputation.     

Detection of coronary artery bypass graft patency by contrast enhanced magnetic resonance angiography.

OBJECTIVE: The subject and purpose of the prospective study was to delineate coronary artery bypass graft (CABG) course and to determine patency of aortocoronary venous bypass grafts (ACVB) compared with internal mammary artery bypass grafts (IMA) in the early postoperative follow-up, by contrast enhanced magnetic resonance angiography (MRA). For control, patients were examined with X-ray angiography and spiral-computed tomography (CT). METHODS: Eighty-five patients (74 male/11 female) with a mean age of 63.7 years underwent MRA examination, applying contrast enhanced gradient-echo sequence after an average distance of 7 days from CABG surgery. A 1.5 Tesla magnetom vision (Siemens, Erlangen, Germany) with phased array coil technology was used. Overall, 247 bypass grafts (160 ACVB/87 IMA) were studied with a 3D (three dimensional) ultrashort TE gradient-echo sequence (TR/TE/a:5 ms/2 ms/40 degrees) with 512*512 matrix and 500 mm FoV in single breath-hold technique after Gd-DTPA bolus injection. CABGs were judged in three different parts, including the course of CABG and both anastomoses. CABGs were controlled by angiography and spiral-CT to examine sensitivity, specificity and efficiency of MRA examination. Additional measurement of bypass graft flow velocity of arterial and venous grafts was performed with 2D phase contrast technique in breath-hold technique with ECG triggering. RESULTS: One hundred and thirty-nine of 160 (86.9%) ACVB grafts and 83 of 87 (95.4%) IMA grafts could be visualized. Suspected occlusions of 10 CABGs were confirmed in 80% with a second modality. Five CABGs were false positive in MRA. MRA proved a high specificity (93.8%), sensitivity (89.9%) and efficiency (1.73), especially in detection of IMA to LAD and ACVB to LAD and RCA (Table 1). 3D maximum intensity projection (MIP) reconstruction was helpful in delineating CABG course and in several cases in detecting stenosis of coronary arteries. Results of flow velocity showed a significant higher mean systolic velocity in arterial bypasses than in venous grafts with a higher maximum velocity in systole than in diastole in both grafts. Bypass stenosis in distal anastomosis could not be verified with MRA and flow method. CONCLUSION: Contrast enhanced 3D ultrashort TE gradient-echo magnetic resonance angiography has the potential for being a reliable method for CABG visualization and CABG patency determination in the early postoperative period. MR flow measurement was not qualified for detection of a bypass stenosis.     

Evaluation of extracranial-intracranial bypass using quantitative magnetic resonance angiography

OBJECT: To date, angiography has been the primary modality for assessing graft patency following extracranial-intracranial bypass. The utility of a noninvasive and quantitative method of assessing bypass function postoperatively was evaluated using quantitative magnetic resonance (MR) angiography. METHODS: One hundred one cases of bypass surgery performed over a 5.5-year period at a single institution were reviewed. In 62 cases, both angiographic and quantitative MR angiographic data were available. Intraoperative flow measurements were available in 13 cases in which quantitative MR angiography was performed during the early postoperative period (within 48 hours after surgery). There was excellent correlation between quantitative MR angiographic flow and angiographic findings over the mean 10 months of imaging follow up. Occluded bypasses were consistently absent on quantitative MR angiograms (four cases). The flow rates were significantly lower in those bypasses that became stenotic or reduced in diameter as demonstrated by follow-up angiography (nine cases) than in those bypasses that remained fully patent (mean +/- standard error of the mean, 37 +/- 13 ml/minute compared with 105 +/- 7 ml/minute, p = 0.001). Flows were appreciably lower in poorly functioning bypasses for both vein and in situ arterial grafts. All angiographically poor bypasses (nine cases) were identifiable by absolute flows of less than 20 ml/minute or a reduction in flow greater than 30% within 3 months. Good correlation was seen between intraoperative flow measurements and early postoperative quantitative MR angiographic flow measurements (13 cases, Pearson correlation coefficient = 0.70, p = 0.02). CONCLUSIONS: Bypass grafts can be assessed in a noninvasive fashion by using quantitative MR angiography. This imaging modality provides not only information regarding patency as shown by conventional angiography, but also a quantitative assessment of bypass function. In this study, a low or rapidly decreasing flow was indicative of a shrunken or stenotic graft. Quantitative MR angiography may provide an alternative to standard angiography for serial follow up of bypass grafts.     

Reoperation for polytetrafluoroethylene bypass failure: The importance of distal outflow site and operative technique in determining outcome

Of 724 bypasses with polytetrafluoroethylene grafts performed for critical ischemia during a 6-year period, 165 (23%) failed and necessitated reoperation for continued limb salvage. Forty-three failures occurred in 199 femoral-above-knee-popliteal bypasses (F-AKP), 33 failures in 177 femoral-below-knee-popliteal bypasses (F-BKP), 52 failures in 182 femorodistal bypasses (F-D), 28 failures in 85 axillofemoral bypasses (Ax-F), and nine failures in 81 femorofemoral bypasses (F-F). Our reoperative approach consisted of dissection of the distal anastomosis, longitudinal incision in the hood of the graft directly over the anastomosis, and proximal graft thrombectomy. Intimal hyperplasia was treated by patch angioplasty, proximal or distal progression of atherosclerosis was treated by a graft extension, and thrombectomy alone was performed when no cause of graft failure was identified. More recently, a totally new bypass was constructed in 27 cases of F-BKP or F-D failures. Reoperations featuring graft salvage for failed extra-anatomic and F-AKP bypasses yielded 3-year patency rates from the time of first reoperation of 71% and 52%, respectively, whereas for F-BKP and F-D reoperations, 3-year patency rates were 13% and 15%, respectively, at 3 years. However, totally new grafts to a different outflow artery in these settings had 3-year patency rates of 48% and 39%. These data support the aggressive use of reoperation with graft salvage when F-AKP or extra-anatomic graft failure reproduces critical ischemia. Conversely, a new bypass to a virginal outflow site, preferably with autologous vein, should be performed when a polytetrafluoroethylene F-BKP or F-D bypass fails. (J VASC SURG 1987;5:298-310.)     

Long-term results of infragenicular bypasses with autogenous vein originating from the distal superficial femoral and popliteal arteries

Forty-nine bypasses originating from the distal superficial femoral artery or popliteal artery in 46 patients were reviewed to examine late patency, limb salvage, and factors leading to graft failure. Operations were performed because of tissue loss in 86%, rest pain in 12%, and limiting claudication in 2% of limbs. Proximal anastomosis was from the distal superficial femoral artery in 12% and the popliteal artery in 88%. Distal anastomosis was to the below-knee popliteal artery or proximal tibial vessels in 20% and the distal tibial vessels in 80%. Life-table analysis showed a primary patency rate of 83%, 62%, and 41%, at 1, 3, and 5 years, respectively. The rate of limb salvage at 6 years for all grafts was 69%. Cox proportional hazards analysis determined that stenosis of 20% or greater in the proximal superficial femoral artery before bypass was a significant risk factor for graft failure (p = 0.02) despite the presence of normal intra-arterial pressure at the site of the proximal anastomosis at the time of bypass. Long-term survival in these patients was low, with a 6-year survival rate of only 24%. Infragenicular bypasses originating from the distal superficial femoral artery or the popliteal artery can be performed with patency and limb salvage rates comparable to bypasses originating from the common femoral artery. These bypasses are more likely to fail when performed in the presence of a stenosis 20% or greater in the superficial femoral or popliteal artery proximal to the graft origin.     

Questionable value of adjuvant arteriovenous fistula in pedal bypass at high risk for early failure

Results of an adjuvant arteriovenous fistula (AVF) in pedal bypass surgery in the presence of poor status of the recipient artery, severely impaired intraoperative runoff, or revision for early failure and flow restitution were analyzed in a retrospective study. From January 1998 to December 2006, 24 adjuvant AVFs were constructed in autologous vein or composite pedal bypasses with low intraoperative bypass flow, poor status of the pedal artery, or during successful early bypass revision to prevent graft failure. All infrainguinal bypass operations were registered in a computerized database and prospectively followed. Pedal bypasses with adjunctive AVF were reviewed for fistula function, graft patency, limb salvage, and patient survival. Primary and secondary bypass patency rates at 1 year were 59% and 77%, respectively, with an AVF patency of 36%. Four legs were amputated despite a patent bypass with patent AVF on three occasions. The corresponding limb salvage rate was 65% at 1 year. Patient survival was 50% at 3 years. Adjuvant AVF constructed in grafts considered at high risk for early failure in pedal vein graft or composite bypass does not seem to prevent future graft failure. In patent bypasses the fistula has a significant tendency for spontaneous occlusion. It may be considered in the use of prosthetic composite pedal grafts in selected cases.     

Bypass to plantar and tarsal arteries: an acceptable approach to limb salvage

OBJECTIVE: This study was undertaken to evaluate our experience with distal arterial bypass to the plantar artery branches and the lateral tarsal artery for ischemic limb salvage. METHODS: This was a retrospective analysis of data prospectively entered into our vascular surgery database from January 1990 to January 2003 for all consecutive patients undergoing bypass grafting to the plantar artery branches or the lateral tarsal artery. Median follow-up was 9 months (range, 1-112 months). Demographic data, indications for surgery, outcomes, and patency were recorded, and statistical analysis was performed to assess significance. RESULTS: Ninety-eight bypass procedures to either the medial plantar artery, lateral plantar artery, or lateral tarsal artery were performed in 90 patients. Eighty-one patients (83%) were men. Mean age was 67.5 +/- 11.6 years. Indications for operation were tissue loss in 93 patients (95%), rest pain in 3 patients (3%), and failing graft in 2 patients (2%). Eighteen patients (18%) had previously undergone vascular reconstruction, and 5 patients (5%) had undergone previous bypass to the dorsalis pedis artery. Seventy-one grafts (72%) had inflow from the popliteal artery, 25 grafts had inflow from a femoral artery or graft (26%), and 2 grafts had inflow from a tibial artery (2%). Conduits used were greater saphenous vein in 67 patients (69%), arm vein in 20 patients (20%), composite vein in 10 patients (10%), and polytetrafluoroethylene conduit in 1 patient (1%). There were 77 bypasses (79%) to plantar artery branches, and 21 bypasses (21%) to the lateral tarsal artery. Thirty-day mortality was 1% (1 of 98 procedures). Early graft failure within 30 days occurred in 11 patients (11%). In the subset of patients with a previous arterial reconstruction, there were 2 early graft failures within 30 days (11%). Both occurred in patients who had undergone previous bypass to the dorsalis pedis artery. Primary patency, secondary patency, limb salvage, and patient survival were 67%, 70%, 75%, and 91%, respectively, at 12 months, and 41%, 50%, 69%, and 63%, respectively, at 5 years, as determined from Kaplan-Meier survival curves. Greater saphenous vein grafts performed better than all other conduits, with a secondary patency rate of 82% versus 47% at 1 year (P = .009). CONCLUSION: Inframalleolar bypass to plantar artery branches and the lateral tarsal artery, even in patients with a previously failed revascularization, can be undertaken with acceptable patency and limb salvage rates. Early graft failure, however, is higher, whereas patency and limb salvage rates are lower, compared with bypass to the dorsalis pedis artery. The use of saphenous vein as a conduit results in the best patency for plantar or lateral tarsal bypass procedures.