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.     

Intraoperative superficial femoral artery balloon angioplasty and popliteal to distal bypass graft: an option for combined open and endovascular treatment of diabetic gangrene

PURPOSE: The purpose of this study was to evaluate the results of combining intraoperative balloon angioplasty (IBA) of the superficial femoral artery (SFA) with distal bypass graft originating from the popliteal artery as a method of lower extremity revascularization in diabetic patients with gangrene. METHODS: Among 380 infrainguinal bypass grafts performed over a 6-year period, there were 110 reversed saphenous vein bypass grafts to the tibial or pedal arteries to treat diabetic patients with gangrene. Diffuse infrainguinal disease was treated with femoral-distal bypass graft (long; n = 46). Popliteal-distal bypass graft was performed when the inflow femoral artery was not significantly diseased (short; n = 52). Focal SFA stenosis and severe infrageniculate disease were treated with combined IBA of the SFA and distal bypass graft originating from the popliteal artery (combined; n = 12). Follow-up was performed with duplex scan surveillance of both the bypass graft and IBA sites. Treatment groups were compared with life-table analysis. RESULTS: There were no perioperative graft failures or amputations. The perioperative mortality rate was 1% (1 of 110). The 2-year primary patency rates were similar in the three groups: 72% in the long bypass graft group, 82% in the short bypass graft group, and 76% in the combined group (P =.8, log-rank test). SFA IBA sites developed recurrent stenosis in two patients, at 7 and 48 months; both were detected with surveillance and treated with percutaneous transluminal balloon angioplasty. The overall 5-year rate of primary patency was 63%, secondary patency was 78%, limb salvage was 81%, and survival was 35%. There were no significant differences among the three treatment groups with respect to these outcomes. CONCLUSION: Results with the combined procedure were similar to those achieved with either femoral-distal bypass graft or popliteal-distal bypass graft without SFA IBA. These data suggest that IBA of the inflow SFA may be combined with popliteal to distal bypass graft and that this technique is a reasonable alternative to longer, femoral-origin bypass graft in selected diabetic patients with gangrene.     

Late failure of reversed vein bypass grafts.

Late failure of reversed vein bypass grafts is preceded by the appearance of stenotic lesions, which progress to total occlusion. These lesions appear either as intrinsic graft lesions or as new arteriosclerotic lesions in contiguous arteries. The present study summarizes the University of Pennsylvania experience with these lesions in 521 vein grafts inserted from 1979 to 1985. The grafts were grouped according to the site of the distal anastomosis; 231 above-knee popliteal (FP AK), 171 below-knee popliteal (FP BK), and 119 tibial (FT). The overall incidence of stenotic lesions was essentially identical with the three grafts (21%), but the relative incidence of intrinsic graft to arterial lesions was higher with the more distal grafts. The most common graft lesions developed adjacent to the proximal anastomosis, which is the narrowest part of a reversed vein graft. The popliteal artery was the most common site of outflow stenosis. There was negligible incidence of tibial lesions. The most common inflow arterial lesion was located in the common femoral and iliac arteries. The superficial femoral artery (SFA) was a rare site of inflow stenosis, even though it was at risk because 96 grafts originated from the SFA or popliteal artery. Sixty-seven per cent of the graft and 52% of the arterial lesions were treated successfully by percutaneous transluminal angioplasty; the rest had minor surgical revisions. This resulted in a 19%, 10%, and 9% improvement in 5-year patency for the FT, FP BK, and FP AK bypasses. These results justify an aggressive policy of graft surveillance to identify and treat stenotic graft lesions before graft occlusion.     

Popliteal-to-distal bypass grafts for critical leg ischaemia

BACKGROUND: To assess the value of revascularization to crural and pedal arteries using the popliteal artery as inflow source. METHODS: Experimental design: Retrospective study with a mean follow-up period of 15.2 months (range, 0-46). Setting: Academic referral center. Patients: 62 patients with critical leg ischaemia and popliteal artery suitable as inflow source for infrapopliteal arterial revascularisation. Interventions: 66 popliteal-to-distal bypass procedures, of which 18 popliteal-crural bypass grafts and 48 popliteal-pedal bypass grafts. Main outcome measures: Bypass graft patency, leg salvage, survival and success defined as patients alive with leg. RESULTS: At 1-month, 1-year, and 2-year follow-up, the primary patency rates were 87%, 58%, and 55%, secondary patency rates were 95%, 70%, and 67%, leg salvage rates were 97%, 88%, and 88%, while 88%, 70%, and 66% of patients were alive with legs at the same intervals. At 2-year follow-up the survival rate was 72%. Above-knee popliteal-to-distal bypasses achieved better primary patency (p=0.02) and corrected primary patency rates (p=0.01) than below-knee popliteal-to-distal bypasses. Diabetes and uraemia affected the survival and patients alive with leg rates. CONCLUSIONS: Popliteal-to-distal bypass surgery is worthwhile for the management of severe, isolated infrapopliteal atherosclerotic disease. Diabetic and uraemic patients are at high risk for both leg and life loss after revascularisation. Grafts originating from the above-knee popliteal artery may achieve better patency rates than those originating from the below-knee popliteal artery.     

Superficial femoral artery as inflow for bypass to the proximal popliteal artery

We have obtained long term follow-up on 58 patients in whom the superficial femoral artery was used as a donor site for bypass to the proximal popliteal artery. The indication for the reconstructive procedure was intermittent claudication 36%, rest pain 34%, and gangrene 26%. All patients had angiographic evidence of a patent proximal superficial femoral artery and many had relative indications for short bypass such as limited saphenous vein availability or compromised medical condition. There was a cumulative patency rate of 79% by life table method for the series with a six year follow-up. We have observed that the superficial femoral artery is a satisfactory inflow site for proximal popliteal bypass grafts in selected patients. The procedure can maximize use of a limited segment of vein with minimal operative time and morbidity. Inflow stenosis can be revised or long bypass procedures can be offered in the event of graft failure.     

Popliteal-to-Distal Bypass Grafts for Limb Salvage

From July 1989 to July 1994, a total of 44 popliteal-to-distal artery bypasses were performed in 36 patients (29 men and seven women, mean age 62 ± 10 years). These procedures accounted for 8.8% of all infrainguinal revascularizations performed during that period. Risk factors included diabetes in 33 patients (92%), smoking in 18 (50%), and coronary artery disease in 15 (42%). Prior to revascularization all patients were at risk of limb loss. Tissue necrosis was present in 31 cases (71%), ulceration in eight cases (18%), and rest pain in five cases (11%). Patency of the femoral and popliteal arteries was confirmed prior to surgery in all cases. Intraoperative percutaneous angioplasty of the superficial femoral artery was performed in three cases. Proximal anastomosis was made to the distal popliteal artery in all cases. A total of 52 distal anastomoses (eight sequential bypasses) were made on the following arteries: posterior tibial artery in 13 cases, anterior tibial artery in eight cases, peroneal artery in six cases, plantar artery in two cases, and dorsalis pedis artery in 21 cases. The greater saphenous vein was used as graft material in 42 cases (95%) and the lesser saphenous vein in two cases (5%). No patient died during hospitalization. Early bypass occlusion occurred in three cases (6.8%) and led to amputation in all cases. Secondary patency and limb salvage rates at 3 years calculated using the actuarial method were 74% and 82% respectively. Bypass thrombosis due to superficial femoral artery deterioration was not observed in any case. The present study indicates that popliteal-to-distal artery bypass is a simple, durable, and low-risk method of lower limb revascularization. Medium-term results are promising and support routine use of popliteal-to-distal artery bypass for limb salvage in patients without significant stenosis of the superficial femoral artery. (Ann Vasc Surg 1997;11:505–509.)     

Incidentally detected stenoses proximal to grafts originating below the common femoral artery: do they affect graft patency or warrant repair in asymptomatic patients?

OBJECTIVE: Stenoses in infrageniculate arteries proximal to a lower extremity vein graft may reduce flow velocity through the bypass graft and are thought to predispose to graft occlusion. Repair of these lesions has been recommended to preserve graft function. This study was undertaken to better define the natural history of grafts below inflow lesions and to evaluate the necessity of repair to preserve graft patency. METHODS: From 1994 through 1999, patients undergoing lower extremity vein grafts by a single surgeon at a university hospital and an affiliated teaching hospital were placed in a prospective protocol for proximal infrageniculate native artery and graft surveillance through use of duplex scanning. The records of those patients with grafts originating distal to the common femoral artery were evaluated; they form the basis for this report. Arteriograms were obtained before bypass grafting, and no patient had a stenosis greater than 50% diameter reduction proximal to the graft origin. Follow-up scans were obtained from the common femoral artery through the graft and outflow artery. The peak systolic velocity and velocity ratio in an infrageniculate native artery proximal to the graft origin were recorded, as were the location and the time interval since the bypass graft. Repair of these proximal lesions was not performed during the course of this study. Revision of the bypass graft or its anastomoses was undertaken according to preestablished duplex scan criteria. RESULTS: During this time, 288 autogenous infrainguinal bypass grafts were performed, of which 159 originated below the common femoral artery; of these, 74 were from the superficial femoral artery, 29 from the profunda femoris artery, 49 from the popliteal artery, and 7 from a tibial artery. The maximum peak systolic velocity proximal to the graft origin was more than 250 in 38 arteries (25%) and more than 300 in 26 arteries (16%). The velocity ratio was 3.0 or more in 32 arteries at the same location as the peak systolic velocity and 3.5 or more in 23 arteries (15%), confirming hemodynamically significant stenoses at these sites. The location of peak systolic velocity was the common femoral artery in 81 patients (51%), the superficial femoral artery in 50 (31%), the popliteal artery in 22 (14%), and a tibial artery in 6 (4%). Follow-up ranged from 8 to 60 months (mean, 35 months). During follow-up, 19 patients died, 18 with patent grafts. Overall, nine grafts occluded. One of the occluded grafts had a velocity ratio greater than 3.0; this may have contributed to graft thrombosis. The other occlusions resulted from an unrepaired graft lesion in 2 patients, graft infection in 2 patients, and graft ligation necessitated by below-knee amputation in 2 patients. No cause for the occlusion could be identified in two of the grafts (neither had evidence of proximal arterial stenosis). Assisted primary patency rates were 95% and 91% at 3 and 5 years, respectively. CONCLUSIONS: For grafts originating distal to the common femoral artery, stenoses proximal to the graft do not affect bypass graft patency and do not require repair to prevent graft occlusion. Surveillance of these lesions may therefore be unnecessary, inasmuch as the repair of proximal lesions should not be undertaken to preserve graft function.     

Early experience with popliteal to infrapopliteal bypass for limb salvage

In an attempt to improve graft patency and limb salvage in patients with isolated tibial vessel and/or popliteal-tibial vessel occlusive disease, bypass grafts from the popliteal or distal superficial femoral artery to infrapopliteal arteries were used in patients requiring bypass for limb salvage. During a 2 1/2-year period, 23 patients with patent axial vessels and hemodynamically normal inflow to the level of the knee underwent such bypasses. Cumulative graft patency and limb salvage rates at 31 months were 84% and 70%, respectively. Five of the six patients who required below-knee amputation did so because of progressive gangrene in the presence of a patent bypass. Short bypasses between the popliteal and infrapopliteal arteries can significantly contribute to limb salvage in patients with tibial vessel occlusive disease and may be particularly useful in patients with saphenous veins too short for longer 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.     

Diagnosis and management of failing lower extremity arterial reconstructions prior to graft occlusion

In 191 instances, infrainguinal graft occlusion was presumed because of a rethreatened foot, diminished pulses and/or decreased ankle pressure. Routine urgent arteriography revealed 38 instances where the graft was patent (22 vein, 16 PTFE). Ten of these grafts were to the femoral artery, 18 to the popliteal artery and 10 were to infrapopliteal arteries. The deterioration despite a patent graft was due to development of inflow stenosis (15), vein graft lesions (13) or distal disease progression (10). All were treated successfully by percutaneous transluminal angioplasty (30) or simple local operative revisions (8). Cumulative life table patency rates 2 years after reintervention were 89% for failing reconstructions to the femoral artery, 94% for those to the popliteal artery and 89% for infrapopliteal procedures. Comparable rates for limb salvage were 90%, 100% and 100%, respectively. These findings underscore the importance of urgent angiography in suspected lower extremity graft failure. Defects may be detected before real graft occlusion occurs and appropriate interventional treatment can provide important additional periods of limb salvage.     

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.     

Superficial femoral artery percutaneous intervention is an effective strategy to optimize inflow for distal origin bypass grafts

BACKGROUND: Iliac angioplasty in preparation for an infrainguinal bypass graft has been shown to be an effective strategy. We undertook this study to determine if superficial femoral artery (SFA) angioplasty offers durable inflow for distal origin grafts originating from the SFA or popliteal artery. METHODS: All distal origin grafts performed at a single institution between 1988 and 2006, 相似文献   

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.     

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.     

Percutaneous transluminal angioplasty of infrarenal arteries in intermittent claudication

Percutaneous transluminal angioplasty was performed on 55 iliac and 31 femoropopliteal arteries in 71 patients with intermittent claudication (23 women, 48 men). The two-year patency rate was 80% after iliac and 41% after femoropopliteal angioplasty. In 17 femoropopliteal cases with lesions greater than or equal to 5 cm the 2-year patency rate was only 32%, but the corresponding figure for shorter lesions was 53%. Complicating haematoma appeared in 10% of the cases and the arterial state deteriorated in one patient. There was no distal embolization. Percutaneous transluminal angioplasty in intermittent claudication is indicated for all cases of occlusion or stenosis of the iliac artery and for occlusion or stenosis shorter than 5 cm of the superficial femoral or the popliteal artery.     

The merit of polytetrafluoroethylene extensions and interposition grafts to salvage failing infrainguinal vein bypasses

Purpose: The purpose of this study was to evaluate the merit of polytetrafluoroethylene (PTFE) extensions and interpositions for the management of failing infrainguinal vein bypass grafts.Methods: The treatment of 133 failing vein grafts in 125 patients over a 10-year period was retrospectively reviewed. Twenty-two graft-threatening lesions were detected in patients who did not have a usable autogenous vein conduit as determined by preoperative and intraoperative evaluations. A PTFE extension or interposition graft was used for the necessary reconstruction in all cases.Results: Ten lesions were within the vein graft, 11 were proximal to the graft in the femoral or popliteal artery segments, and one was distal to the graft in the popliteal artery. The treatment of these lesions included 19 extensions and three mid graft interpositions. The vein graft lesions developed significantly sooner (mean 10.6 ± 2.5 months) after the bypass ( p < 0.05) than the arterial lesions (mean 28.0 ± 6.1 months). The 3-year cumulative secondary patency rate for these vein grafts treated with PTFE extensions or interpositions was 84% ± 8%. This was not significantly different from the 3-year cumulative secondary patency rate for vein grafts treated with vein extensions or interpositions at our institution over the same time period (82% ± 10%). The 3-year limb salvage rates were 95% and 89%, respectively.Conclusions: These results indicate that PTFE extensions and interpositions can be used successfully to maintain the patency of failing vein grafts and may serve to prolong limb salvage in patients without any usable autogenous vein. Early reintervention with a PTFE conduit in this difficult group of patients is appropriate to salvage a failing vein graft. (J VASC SURG 1996;23:329-35.)     

Axillopopliteal bypass grafting: indications, late results, and determinants of long-term patency

In the last 12 years we have performed 55 axillopopliteal bypass graftings with 6 mm polytetrafluoroethylene grafts for limb salvage in 50 patients who were at high risk for limb loss. Indications for this procedure were (1) severe atherosclerotic disease of the common, superficial, and deep femoral arteries (33 cases); (2) failed aortofemoral bypass grafting with sufficient fibrosis or disease progression in the deep femoral artery (five cases); (3) insufficient hemodynamic and clinical improvement after axillofemoral bypass grafting (10 cases); and (4) sepsis in the groin from a previously infected graft (seven cases). The 30-day operative mortality rate was 8%, and the 5-year cumulative patient survival rate was 40%. Overall 1-, 3-, and 5-year cumulative primary graft patency rates were 58%, 45%, and 40%, respectively. Comparable limb salvage rates were 83%, 68%, and 58%. Repeat operations increased 5-year patency rates from 40% to 59% (p less than 0.05). Three-year patency rate for grafts placed in the presence of poor angiographic runoff in one vessel was 62% and for good angiographic runoff (two to three vessels) it was 57% (NS). Grafts to the above-knee popliteal artery had a patency rate of 67% at 3 years, whereas for grafts that crossed the knee joint it was 51% (NS). Three-year patency rate for 24 straight axillopopliteal grafts was 42%, and for 31 sequential axillofemoral-popliteal grafts it was 74% (p less than 0.05). These results show that axillopopliteal bypass grafting is justified when other standard operations are not possible in patients who are in imminent danger of limb loss, and that every possible effort should be made to use the common or deep femoral artery as part of a sequential axillofemoral-popliteal procedure.     

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.     

Value and limitations of secondary femoropopliteal bypasses with polytetrafluoroethylene

Secondary femoropopliteal bypasses with polytetrafluoroethylene (PTFE) grafts are widely regarded to be of questionable value. This has prompted some to abandon all attempts at secondary revascularization with PTFE and others to recommend that primary femoropopliteal bypasses be performed preferentially with PTFE grafts so that vein may be used for secondary procedures. Because we questioned both of these views, we reviewed all femoropopliteal bypasses done at our institution in the past 12 years and identified 73 secondary PTFE femoropopliteal procedures performed after a failed ipsilateral infrainguinal bypass (69 failed femoropopliteal; 4 failed femorodistal). Seventy (96%) secondary bypasses were performed for limb salvage and 3 (4%) for severe disabling claudication. Insertion of grafts to the popliteal artery was above the knee in 26 (36%) and below the knee in 47 (64%). Primary life-table graft patency at 4 years was only 38%. Forty-eight reinterventions in 34 limbs were required to restore or maintain graft patency in thrombosed or failing grafts. For thrombosed grafts, 20 interventions consisted of 9 simple thrombectomies and 11 thrombectomies with additional revision procedures (5 distal or proximal extensions, 6 patch angioplasties). Twenty-eight lesions threatening graft patency were treated by percutaneous transluminal angioplasty in 3, proximal or distal extensions in 20, and patch angioplasty in 5. As a result of these reinterventions, the overall secondary patency rate was 55% at 4 years, and the limb salvage rate was 74% at 4 years. Although aggressive follow-up and reintervention may be required, the use of secondary PTFE conduits in the femoropopliteal position is a viable option in patients undergoing limb salvage procedures who are at high risk.(ABSTRACT TRUNCATED AT 250 WORDS)     

Is infrapopliteal bypass compromised by distal origin of the proximal anastomosis?

Distal origination of the proximal anastomosis (DOPA) of an infrapopliteal bypass beyond the adductor hiatus minimizes the length of graft required and optimizes use of scarce autogenous conduit. Sixty-two DOPA infrapopliteal revascularizations using autogenous vein performed for limb salvage over a 7-year period were reviewed and compared with 203 concurrent infrapopliteal bypasses originating more proximally (POPA). Life-table analysis revealed no difference at 54 months between DOPA and POPA bypass with regard to primary patency (57% vs. 50%, respectively) or secondary patency (67% vs. 65%, respectively). Differences in limb salvage at 54 months between DOPA and POPA bypasses did not reach statistical significance (53% vs. 66%,p=0.12), although DOPA fared worse. Inferior limb salvage results in all infrapopliteal bypasses were correlated with the presence of tissue necrosis (52% vs. 70%,p<0.001), which was more prevalent in patients undergoing DOPA bypass (71% vs. 49%,p<0.01). The long-term patency of infrapopliteal bypass appears only marginally affected by DOPA. However, the prognosis for limb salvage in this setting is compromised as a result of the virulent behavior of the atherosclerotic disease that spares the superficial femoral artery while predominantly involving the popliteal and tibial vessels.Presented at the Fourth Annual Winter Meeting of the Peripheral Vascular Surgery Society, Breckenridge, Colo., January 21, 1994.