Early results of a reinforced biosynthetic ovine collagen vascular prosthesis for small arterial reconstruction

The efficacy of a reinforced biosynthetic ovine collagen (RBOC) vascular prosthesis developed for small arterial reconstruction was assessed by examining 30 grafts in 29 patients with arteriosclerosis obliterans. The operative procedures performed were femorofemoral bypass in 2 patients, above-knee femoropopliteal bypass in 28 patients, and below-knee femoropopliteal bypass in 1 patient. Femoropopliteal bypass was simultaneously performed in two patients undergoing femorofemoral bypass using one or two grafts. The indications for surgery were intermittent claudication in 27 patients and to salvage the limb in 2 patients. The longest follow-up period was 49 months, and there were six graft failures, occurring 1, 1, 9, 17, 17, and 23 months after implantation, respectively; caused by compression of the graft from outside in two, infection in one, anastomotic intimal hyperplasia in one, and unknown factors in two. Thus, the primary cumulative patency rate for above-knee femoropopliteal bypass at 3 years was 83.7%, and the secondary patency rate was 91.2%. No aneurysmal change was observed. Moreover, the RBOC was able to be used without preclotting, and its handling and suturing characteristics were satisfactory. Our findings suggest that this vascular prosthesis may be an acceptable alternative for above-knee femoropopliteal bypass.     

Proximal percutaneous balloon angioplasty and distal bypass for multilevel arterial occlusion

Multiple sites of atherosclerotic occlusion in high risk patients may be treated by angioplasty of the iliac obstruction and distal reconstruction. We report 18 male patients with symptomatic peripheral vascular disease in whom proximal iliac percutaneous transluminal angioplasty was combined with femoropopliteal bypass (11), femorotibial bypass (2), or femorofemoral bypass (5). There were no operative deaths. The pretreatment ankle brachial index of 0.40 ± 0.04 was increased to 0.64 ± 0.04 by discharge (p=0.0001), and remained significantly increased through 27 months (0.65 ± 0.07) (p=0.0001). During the follow-up period of 2–57 (mean 27 months) one dilated iliac artery required repeated percutaneous transluminal angioplasty and revision of the femoropopliteal bypass at three months. Two late amputations of study limbs occurred at two years and three years due to progression of distal disease in the infrapopliteal segment. Four patients died during the follow-up period of ischemic heart disease (3) and lung carcinoma (1). Life table analysis shows a 76% success rate for the combined procedures at two years. In selected, high risk patients, proximal iliac dilatation and distal bypass is an acceptable alternative reconstruction for multilevel occlusion.     

ANALYSIS OF 274 OMNIFLOW VASCULAR PROSTHESES IMPLANTED OVER AN EIGHT-YEAR PERIOD

Background : Polytetrafluoroethylene (PTFE), dacron, and, more recently, collagen prostheses are finding increasing use for femoropopliteal reconstruction when a suitable vein is not available. The main factors to be considered when choosing a prosthesis are patency, susceptibility to infection and formation of aneurysms. Methods : Sheep collagen prostheses were implanted on 274 occasions in the femoropopliteal or crural regions. Results : The patency rate for supragenual bypass after 3 years was 61.9% with good vascular periphery and 44% with poor vascular periphery. If the prosthesis extended below the knee, the patency rate was 55.4% with good and 35.3% with unfavourable vascular periphery. Patency for the femorocrural bypass was 28.7% after 2 years. The rate of infection was 0% and an aneurysm occurred in three patients (1.1%). Conclusions : With this low infection rate and the very slight danger of aneurysm, the long-term results suggest that the ovine collagen prosthesis can be recommended for use when no suitable vein is available.     

Revascularization of popliteal and below-knee arteries with polytetrafluoroethylene

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

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

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

Aortofemoral bypass and the role of concomitant femorodistal reconstruction

A consecutive series of 200 patients having aortofemoral bypass grafts were studied in order to determine the effect of femoropopliteal occlusive disease on the results and the role of concomitant femorodistal bypass. Bifurcated aortic grafts were used in 177 patients and unilateral aortofemoral grafts in 23 giving 377 limbs for study. Of the 377 limbs, 184 (49 per cent) had minimal femoropopliteal disease (Group 1), 24 (6.4 per cent) had a femoropopliteal stenosis (Group 2) and 169 (44.6 per cent) had complete femoropopliteal occlusion (Group 3). In Group 3 aortofemoral bypass was carried out alone in 106 cases (Group 3a): in the other 63 cases femorodistal bypass was carried out at the same time as aortoiliac reconstruction (Group 3b). The cumulative patency at 5 years for all aortofemoral grafts together was 91 per cent. However, that for grafts in Group 3a was only 65 per cent compared with 98 per cent for Groups 1 and 3b and 94 per cent for Group 2. The cumulative patency rate for grafts in Group 3a was significantly lower than for all other groups (P less than 0.001). The operative mortality for those patients who had concomitant aortofemoral and femorodistal grafts (Group 3b) did not differ significantly from that of any of the other groups (P greater than 0.1). Of the cases in Group 3a, 21 (26 per cent) required femoropopliteal reconstruction at a later date. The results indicate that in the presence of combined aortoiliac and femoropopliteal occlusive disease concomitant reconstruction of both arterial segments yields significantly better results than aortoiliac bypass alone.     

A five-to seven-year experience with externally-supported Dacron prostheses in axillofemoral and femoropopliteal bypass

We have examined the clinical results of 56 externally-supported (EXS) Dacron grafts in the axillofemoral position and 117 in the femoropopliteal position. Results have been analyzed from two perspectives: primary patency concerns only those grafts that had never occluded; extended patency refers to all open grafts including those whose continued patency is the result of thrombectomy. The 5-to 7-year life-table patency rates are: axillofemoral 8 mm and 6 mm bypass: primary 75% and extended 97%; above-knee femoropopliteal 6 mm bypass: primary 78% and extended 93%; below-knee 6 mm femoropopliteal bypass: primary 41% and extended 91%. In contrast, the results for the 5 mm grafts used for femoropopliteal bypass were inferior to the 6 mm grafts: femoropopliteal 5 mm bypasses had an above-knee primary patency rate of 44% and an extended rate of 55%, with a below-knee primary patency rate of 15% and an extended rate of 32%. Rendering the noncrimped porous Dacron prosthesis kink and compression resistant by an external support coil appears to increase its potential for successful use, especially in 8 mm axillofemoral and 6 mm femoropopliteal bypasses. Presented to the Western Vascular Society, January 1986, Laguna Niguel, California.     

A prospective randomized trial comparing vein with polytetrafluoroethylene in above-knee femoropopliteal bypass grafting

OBJECTIVE: Despite many clinical studies, there is still uncertainty as to whether venous material is superior to polytetrafluoroethylene for femoropopliteal reconstruction proximal to the knee joint. Supported by early satisfactory results with thin-walled, stretched polytetrafluoroethylene for suprageniculate bypass grafts, a prospectively randomized clinical trial was designed to evaluate the effectiveness of reversed saphenous vein in comparison with that of polytetrafluoroethylene in above-knee arterial reconstruction. METHODS: In a 3-year period, 151 above-knee femoropopliteal bypass graft operations were performed in 136 patients (77 male, 59 female). The indication for operation was severe claudication in 120 cases, rest pain in 20 cases, and ulceration in 11 cases. For the bypass graft, a reversed saphenous vein was used in each of 75 cases, and a polytetrafluoroethylene prosthesis was used in each of 76 cases. Preoperative risk factors were diabetes (24%), a history of myocardial infarction (23%), and current status with respect to smoking (74%). There was no hospital mortality; 5% of patients had minor postoperative complications. RESULTS: After 2 years, the primary patency was 83% for saphenous vein and 67% for polytetrafluoroethylene (P =.065); the secondary patency was 83% for saphenous vein and 77% for polytetrafluoroethylene (P =.298). During a follow-up period of 2 years, we found no statistically significant difference in primary and secondary patency between saphenous vein and polytetrafluoroethylene. We found no predictive factor for occlusion of either bypass graft. CONCLUSION: The use of polytetrafluoroethylene above the knee is a reasonable alternative in femoropopliteal bypass grafting that is associated with acceptable short-term patency rates.     

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

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

Bypass to the Genicular Arteries for Revascularisation of the Lower Limb

OBJECTIVE: To describe an initial experience with infrainguinal bypass grafts inserted distally in a genicular artery. DESIGN: Retrospective case series study. SUBJECTS AND METHODS: Eleven patients with Grade III chronic limb ischaemia in whom arteriography showed femoropopliteal occlusive disease and at least one genicular branch suitable for receiving a bypass. Bypass grafts were done to the descending genicular artery (n=4) or the medial sural artery (n=6) using segments of autologous veins; one bypass was not completed. RESULTS: Primary graft patency and foot salvage rates were 73% at 1 month and 24 months of follow-up. Patient survival rate was 100% and 90%, respectively. Major amputation was required in two of three patients following early graft failure. Of the eight patients who had a patent graft, the Doppler ankle-brachial systolic pressure index showed no change in one patient, an increase of 0.13-0.66 in six patients, and was not measured in one patient. The former patient underwent a below-knee amputation whereas the other seven patients showed complete healing of their skin ulcers and sites of minor amputation. CONCLUSION: The genicular bypass is a useful alternative that may extend the limits of infrainguinal arterial reconstruction with autologous tissue and the potential for long-term patient benefit.     

The Advantages of the Great Saphenous Vein as a Femoropopliteal Graft: A Report on Its Clinical Use

As a majority of vascular surgeons prefer the autologous saphenous vein as a bypass graft below the inguinal ligament, the need of alternative graft materials or reconstructive techniques is confined to patients with unavailable or unsuitable saphenous veins. The aim of this investigation was to ascertain how often these alternative procedures are necessary. From 1973 to June 1979, the great saphenous vein was used as a femoropopliteal graft without regard to fixed limitations in the diameter and the quality of the vein. During this period, vascular reconstruction was required in 148 limbs due to symptomatic atherosclerotic occlusion of the superficial femoral artery. In 144 of these cases, the ipsilateral (138) or the contralateral (6) great saphenous vein was used for a femoropopliteal bypass reconstruction. Thus, the vein could not be utilized in only 4 of 148 cases (2.7%).

As graft patency rate was not subject to the size and quality of the vein and as cumulative patency rates in the 144 grafts were most satisfactory (97.9, 92.0 and 81.9% at 1 month, 1 year and 5 years, respectively), although all these veins were used regardless of their calibre and quality, we conclude that the great saphenous vein can be used more liberally as a graft for femoropopliteal occlusion In approximately only 3% of patients requiring operation, alternative reconstructive techniques, such as ‘non-vein’ bypass grafts and thrombendarterectomy are needed.     

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

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

ARTERIAL RECONSTRUCTION WITH POLYTETRAFLUOROETHYLENE: A PRELIMINARY REPORT

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

Arterial reconstruction with polytetrafluoroethylene: a preliminary report.

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

Prosthetic above-knee femoropopliteal bypass grafting: five-year results of a randomized trial

PURPOSE: This trial was designed to identify factors affecting patency rates of primary prosthetic above-knee femoropopliteal bypass grafts at 5 years. METHODS: A multi-institutional, prospective trial randomized 240 patients to compare patency rates of Gore-tex and Hemashield above-knee femoropopliteal bypass grafts at 5 years. Univariate comparisons of patency between levels of each prognostic variable were made with the Kaplan-Meier method. Variables that had a univariate P value less than.25 or those known to be important were submitted to a Cox regression analysis. RESULTS: The patient survival rate at 5 years was 59.4%. There were no differences in primary or secondary patency rates at 5 years between the two graft materials (primary, 45% vs 43% and secondary, 68% vs 68%). The risk for graft occlusion was significantly increased for patients younger than 65 years (2.1; P =.001) and for grafts with a diameter less than 7 mm (1.65; P =.0219). Variables with no apparent independent effect on patency rates were smoking status, runoff, diabetes mellitus, sex, presenting symptoms, and postoperative treatment with aspirin or Coumadin. Noninvasive test results were not predictive of subsequent graft function. CONCLUSION: Although the type of prosthetic used for above-knee femoropopliteal bypass grafts does not affect 5-year patency rates, age and graft size do influence results. These factors should be considered before a prosthetic bypass grafting procedure. Furthermore, these data should serve as a contemporary standard, with which evolving and conventional procedures can be compared.     

358例下肢动脉硬化闭塞症外科治疗效果分析

目的 分析慢性下肢动脉硬化闭塞症外科治疗方法及疗效.方法 回顾性分析2002年1月至2007年7月序贯治疗的358例慢性下肢动脉硬化闭塞症患者接受动脉搭桥或介入治疗后远期疗效.结果 男293例,女65例,年龄(66 ±10)岁.本组接受了包括搭桥手术、介入治疗、截肢(趾)等外科治疗共413例(次).失访48例,随访率86.6%,随访时间6～64个月.髂动脉支架介入治疗术后1、2、3年初次开通率高于腹主-髂-股动脉人工血管搭桥,差异无统计学意义(P＞0.05),也高于股(腘)动脉支架介入治疗术后初次开通率,但差异有统计学意义(P＜0.05).股-腘动脉膝上人工血管搭桥术后1年的初次开通率略高于膝下搭桥,但差异无统计学意义(P＞0.01);术后2、3年初次开通率均高于膝下搭桥,差异有统计学意义(P＜0.01).股浅动脉球囊扩张成形术术后1年通畅率略低于腘动脉以远的球囊扩张术,但差异无统计学意义(P＞0.05).全组截肢率为10.3%(37/358),围术期死亡率3.9%(14/358),随访期死亡率6.4%(23/358).结论 下肢动脉硬化患者根据病情选择适当的外科治疗方式,可以获得较高的术后通畅率.     

Aortic Graft Infection from Appendicitis. A Case Report

Fifteen years after aortobifemoral bypass and five years after left femoropopliteal bypass, a 73-year old man presented with a vague abdominal pain syndrome. After an extensive work-up, aortobifemoral graft infection was suspected ; an appendiceal abscess infiltrating the prosthesis was discovered during exploratory laparotomy. Appendectomy was performed followed by removal of the vascular graft, the latter being replaced by a bilateral axillofemoral prosthesis. Aortic graft infection from appendicitis is an extremely rare condition ; a review of similar cases is presented.     

Can duplex scan arterial mapping replace contrast arteriography as the test of choice before infrainguinal revascularization?

Purpose: Arteriography is the diagnostic test of choice before lower extremity revascularization, because it is a means of pinpointing stenotic or occluded arteries and defining optimal sites for the origin and termination of bypass grafts. We evaluated whether a duplex ultrasound scan, used as an alternative to arteriography, could be used as a means of accurately predicting the proximal and distal anastomotic sites in patients requiring peripheral bypass grafts and, therefore, replace standard preoperative arteriography. Methods: Forty-one patients who required infrainguinal bypass grafts underwent preoperative duplex arterial mapping (DAM). Based on these studies, an observer blinded to the operation performed predicted what operation the patient required and the best site for the proximal and distal anastomoses. These predictions were compared with the actual anastomotic sites chosen by the surgeon. Results: Whether a femoropopliteal or an infrapopliteal bypass graft was required was predicted correctly by means of DAM in 37 patients (90%). In addition, both anastomotic sites in 18 of 20 patients (90%) who had femoropopliteal bypass grafts and 5 of 21 patients (24%) who had infrapopliteal procedures were correctly predicted by means of DAM. Conclusion: DAM is a reliable means of predicting whether patients will require femoropopliteal or infrapopliteal bypass grafts, and, when a patient requires a femoropopliteal bypass graft, the actual location of both anastomoses can also be accurately predicted. Therefore, DAM appears able to replace conventional preoperative arteriography in most patients found to require femoropopliteal reconstruction. Patients who are predicted by means of DAM to require crural or pedal bypass grafts should still undergo preoperative contrast studies to confirm these results and to more precisely locate the anastomotic sites. (J Vasc Surg 1999;29:100-9.)     

Functional outcomes and donor site morbidity following circumferential pharyngoesophageal reconstruction using an anterolateral thigh flap and salivary bypass tube

BACKGROUND: This study reports our experience with fasciocutaneous reconstruction of circumferential pharyngoesophageal defects using an anterolateral thigh flap wrapped around a salivary bypass tube. METHODS: The charts of 14 patients were reviewed. All patients who had reconstruction of a pharyngoesophageal defect using an anterolateral thigh flap with a salivary bypass tube between 2001 and 2005 were included. RESULTS: There were 10 men and 4 women (mean age, 61 years). There were no fistulae reported, and the stricture rate was 14%. Eleven patients achieved oral diet sufficient to have the gastrostomy or jejunal tube removed. The patients who had tracheoesophageal puncture for voice developed functional speech. There were no flap losses. However, problems with salivary tube migration in the early cases have led to technique refinement. CONCLUSIONS: The low complication rates and the excellent functional outcomes make the anterolateral thigh flap in combination with a salivary bypass tube a viable option for reconstruction of these difficult defects.     

Late results of coronary bypass in patients presenting with lower extremity ischemia: the cleveland clinic study

Cardiac catheterization was performed in a prospective series of 1000 patients under consideration for elective peripheral vascular reconstruction from 1978–1982. Of these, 381 (mean age 62) presented primarily because of lower extremity ischemia. Severa, surgically correctable coronary artery disease (CAD) was documented in 79 (21 %) of the leg group, and 68 (18 %) received myocardial revascularization, with three fatal complications (4.4 %). In this subset, 39 patients have had uneventful aortoiliac, femoropopliteal or distal extremity procedures, compared to an operative mortality of 23 % for 13 others with uncorrected or inoperable CAD (p=0.015). A total of 286 patients have undergone 407 peripheral vascular operations with eight early daths (2.8 %). An additional 114 patients (30 %) died during the late follow-up interval, including 48 (13 %) with cardiac events. Both the cumulative 5-year survival (72 %) and cardiac mortality (16 %) after coronary bypass are superior to comparable figures (21 % and 56 %, respectively) among 36 other patients with severe, uncorrected or inoperable CAD (p=0.0001). Five-year survival appears to be improved by myocardical revascularization in men (p=0.0027), hypertensives (p=0.0001), nondiabetics (p=0.0002) and those over 60 years of age (p=0.0072).