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.     

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.     

Durability of the tibial artery bypass in diabetic patients

Infrapopliteal bypass in diabetic patients has been associated with lower rates of patency and limb salvage than in nondiabetic patients. We prospectively compared the patency and limb salvage rates of in situ tibial artery bypass in diabetic and nondiabetic patients. Of 681 in situ bypasses performed for limb salvage over a 7 year period, 387 (57 percent) were carried out in diabetic patients and 294 (43 percent), in nondiabetic patients. Indications for operation most commonly included gangrene or ulceration (74 percent of the diabetic group and 49 percent of the nondiabetic group). Otherwise, the two patient groups were similar. Cumulative patency rates at 1 and 5 years were similar (91 and 74 percent for diabetic patients and 90 and 76 percent for nondiabetic patients, respectively). Limb salvage rates were also not significantly different (96 and 86 percent at 1 and 5 years, respectively, for diabetic patients and 99 and 94 percent, respectively for nondiabetic patients). Despite the unfavorable pattern of atherosclerosis in diabetic patients, the results of tibial arterial reconstructions showed patency and limb salvage rates similar to those seen in nondiabetic patients.     

Revascularization of the leg using polytetrafluoroethylene: Cumulative patency in patients with claudication and limb salvage

Of 196 polytetrafluoroethylene bypass grafts in the leg, 113 were placed in the femoropopliteal and 83 in the femorotibial or femoroperoneal position. Claudication was the indication for 31 percent of the grafts, and 67 percent were done for limb salvage. Cumulative patency rates calculated by the life-table method for the femoropopliteal grafts were 66 percent at 1 year, 53 percent at 2 years, and 49 percent at 3 years. Corresponding patency rates for the femorotibial or peroneal grafts were 48, 44, and 36 percent, respectively. An analysis of factors influencing graft patency indicated that the best results were obtained with femoropopliteal grafts done for claudication in the presence of good distal runoff and grafts placed in limbs without previously failed grafts. Graft occlusion was most likely in distal bypasses for limb salvage and limbs with previously failed grafts. It is concluded that alternatives to PTFE bypass should be considered in those patients at greatest risk for graft occlusion. In patients who lack a satisfactory saphenous vein but who must have a bypass graft, polytetrafluoroethylene is an acceptable arterial substitute; however, thrombectomy or revision will be required to maintain patency in a high proportion of cases.     

Adjuncts to improve patency of infrainguinal prosthetic bypass grafts

The superiority of autologous venous conduit for infrainguinal arterial bypass has been well documented, especially when the bypass extends below the knee or to the tibial arteries. Nevertheless, when adequate autologous vein is not available, prosthetic bypasses (eg, polytetrafluoroethylene [PTFE] or Dacron) are often used in limb-salvage situations. The inferior long-term patency of these infrainguinal prosthetic bypasses has been documented by a number of studies. One such study reported a prospective multicenter randomized trial with only a 12% primary patency for infrapopliteal prosthetic bypasses after 4 years. Another study reported a similar experience with infragenicular bypasses with PTFE for limb salvage even for above-knee (27%, 5 year) and below-knee (25%, 5 year) femoral-popliteal bypasses. The reported PTFE graft patency was consistently inferior to that achieved with autologous vein for limb salvage. Dacron grafts appear to have similar patency rates to PTFE. In an attempt to improve prosthetic graft patency, a number of surgical and medical adjuncts have been developed. In this review, the authors discuss these adjuncts and their impact on infrainguinal prosthetic graft patency.     

Comparison of expanded PTFE and vein grafts in lower extremity arterial reconstructions

Polytetrafluoroethylene (PTFE) bypasses were used in a series of arterial reconstructions to the popliteal artery (45) and to arteries below that level (11). These were performed in high-risk situations in patients who lacked a suitable saphenous vein. Vein bypasses were performed in a comparable series of high-risk situations in patients having a suitable autologous saphenous vein (45 to the level of the popliteal artery and 11 to an artery below that level). PTFE patency rates at 4-14 months were 43 to 45 (96%) for the femoro-popliteal reconstructions (with a limb salvage rate of 39 to 45 or 87%) and 5 of 11 (45%) for the distal bypasses. Saphenous vein bypass patency rates at 8-14 months were 39 of 45 (87%) for the femoropopliteal reconstructions (with a limb salvage rate of 36 of 45 or 80%) and 5 of 11 (45%) for the distal bypasses. These results justify continued use of PTFE grafts in patients without saphenous veins who require lower extremity arterial reconstructions for limb salvage. The exact place of PTFE grafts in arterial reconstructive surgery of the lower extremity definition based on longer periods of observation.     

Infrapopliteal composite bypass with autologous vein and second generation glutaraldehyde stabilized human umbilical vein (HUV) for critical lower limb ischaemia.

OBJECTIVE: To audit a single center consecutive series of infrapopliteal composite bypasses with second generation glutaraldehyde stabilized human umbilical vein. DESIGN: Retrospective study. PATIENTS: From January 1996 to July 2006 89 femoro-distal bypasses were constructed in 85 patients with HUV and residual vein segments as composite grafts in the absence of sufficient length of autologous vein. METHODS: All patients with infrainguinal bypass operations were registered prospectively. Bypasses to infrapopliteal arteries performed with HUV-composite grafts were reviewed for graft patency, limb salvage, patient survival and possible biodegeneration of the HUV. RESULTS: Early graft thrombosis was noted in 21.3%, necessitating revision surgery. Primary, primary assisted and secondary patency rates were 35%, 40% and 42% respectively, with a limb salvage rate of 87% after 5 years. Graft infection occurred in 7 limbs. Aneurysmal HUV graft degeneration was not detected by duplex scanning. CONCLUSION: HUV-composite bypasses provide acceptable patency and favorable limb salvage rates. Patency was similar to previous series using PTFE-composite bypasses but was significantly inferior to vein bypass. Possible biodegradation of the HUV grafts seems to be of minor clinical relevance.     

Effect of inflow and outflow sites on the results of tibioperoneal vein grafts

We have reviewed our experience with the tibial vessel bypass operation and have found the overall patency and limb salvage rates to be acceptable. Patients were divided into two groups based on the site of the proximal anastomosis. In Group I, the proximal anastomosis was at the common femoral artery and in Group II, the proximal anastomosis was at the distal superficial femoral artery or the popliteal artery. The patients in the two groups were similar with regard to indications for operation, age, and sex. However, in Group I, 35 percent of the patients were diabetic and in Group II, 74 percent of the patients were diabetic. In the Group I patients, the 72 month graft patency rate was 65 percent with a limb salvage rate of 75 percent. In the Group II patients, the 72 month patency rate was 81 percent with a limb salvage rate of 89 percent. Some possible explanations for this slightly better result in Group II patients are discussed. All tibial bypasses were divided into three groups based on the recipient tibial artery. Analysis revealed that the 72 month patency rates were as follows: the anterior tibial artery 63 percent, the posterior tibial artery 81 percent, and the peroneal artery 80 percent. These differences were not significant but indicate, as others have recently pointed out, that the peroneal artery is indeed an acceptable recipient artery for tibial bypass surgery.     

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.     

Popliteo-distal and tibio-tibial bypasses: a viable alternative for the revascularisation of the critically ischaemic limb

BACKGROUND: The aim of the present study was to evaluate graft patency and limb salvage rates of popliteo-distal and tibio-tibial bypasses performed for critical ischaemia of the lower limb. METHODS: Thirty short bypasses performed during a five-year period (1994-1998) were reviewed. The inflow source was the supragenicular popliteal artery in 14 patients, the infragenicular popliteal artery in 12 patients and a tibial artery in four patients. Distal outflow was to a pedal vessel in 14 patients, and above the malleolus in 16 patients. Autogenous vein was used as conduit (saphenous vein in 28 patients and cephalic vein in two patients). RESULTS: Operative mortality was 3.3%. Early graft patency and limb salvage rates were 90 and 93%, respectively. Late primary and secondary patency, and limb salvage rates were 77%, 80 and 76% at 12 months, and 71, 74 and 76% at 24 months, respectively. These rates showed no differences attributable to diabetes, inflow or outflow site, surgical technique or slight proximal involvement. There was no progression of disease in the superficial femoral artery, even in the presence of moderate preoperative lesions. CONCLUSIONS: Popliteo-distal and tibio-tibial bypasses are durable procedures which yield good bypass patency and limb salvage rates.     

Distal in situ saphenous vein grafts for limb salvage. Increased operative blood flow and postoperative patency

Early failure remains a major obstacle to successful distal bypass surgery using vein grafts for limb salvage. Thirty distal bypass graft procedures were performed for limb salvage using the in situ technique. Grafts were anastomosed to the distal popliteal artery in 13 patients and to the infrapopliteal artery in 17 patients. Sixteen patients had inadequate saphenous veins for reversed vein grafts. The mean blood flow measured through these grafts (n = 20) was 164 +/- 22 ml/min and increased to 278 +/- 31 ml/min after administration of 30 mg of papaverine. All grafts were patent at the time of hospital discharge and patients were followed for 1 to 28 months. Life table analysis of the 30 procedures shows a patency of 100 percent at 18 months follow-up. One graft subsequently failed at 22 months. Long-term limb salvage was achieved in 100 percent of the patients in this series. The excellent blood flow through these grafts suggests that the in situ vein graft technique may be more favorable for arterial reconstruction than the reversed vein graft technique. Our preliminary data confirm the observations of Leather et al [3,4], that the rates of vein utilization and graft patency are higher with the in situ technique.     

Randomized clinical trial of distal anastomotic interposition vein cuff in infrainguinal polytetrafluoroethylene bypass grafting

BACKGROUND: The aim was to examine the effect of a Miller vein cuff at the distal anastomosis on the medium- to long-term patency and limb salvage rates of femoral to above-knee and femoral to below-knee popliteal artery polytetrafluoroethylene (PTFE) bypasses. METHODS: This study involved extended follow-up of the original cohort of patients included in a previously reported multicentre randomized clinical study. Outcome measures were bypass graft patency and limb salvage. RESULTS: Two hundred and sixty-one bypass operations were originally randomized. For this study, full data were available on 235 (120 with a Miller cuff, 115 without). The cumulative 5-year patency rate for above-knee bypasses with a Miller cuff was 40 per cent, compared with 42 per cent for non-cuffed bypasses (P = 0.702). The cumulative 3-year patency rate for below-knee bypasses with a Miller cuff was 45 per cent, compared with 19 per cent for non-cuffed bypasses (P = 0.018). A Miller cuff had no significant effect on limb salvage for above-knee or below-knee bypasses. CONCLUSION: Three-year patency rates of femoral to below-knee popliteal PTFE bypasses were improved by a Miller cuff. Miller cuffs had no effect on patency rates for femoral to above-knee popliteal bypasses at 5 years and did not improve limb salvage in either group.     

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.     

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.     

Ankle bypass: should we go the distance?

This report reviewed the results of 47 distal arterial reconstructions to or below the level of the malleolus. The operations were performed by the techniques of popliteal-to-distal bypass (20 procedures) and in situ bypass (27 procedures). Seventy-five percent of patients had gangrene of ischemic ulceration, and all procedures were performed for limb salvage. Seventy-three percent of all patients were diabetic. The patency rates for popliteal-to-distal bypass with reversed saphenous vein were 92 percent at 24 months and 57 percent at 60 months, with a limb salvage rate of 70 percent at 60 months; the patency rates for popliteal-to-distal bypass with PTFE were 53 percent at 12 months and 0 at 36 months, with a limb salvage rate of 53 percent at 36 months; and the patency rate for in situ saphenous vein bypass was 96 percent at 24 months, with a limb salvage rate of 80 percent at 24 months. Early results are promising for ankle bypass using the techniques of popliteal-to-distal and in situ bypass.     

Is long vein bypass from groin to ankle a durable procedure? An analysis of a ten-year experience.

Long vein bypass from the femoral artery to the level of the ankle may be performed with good initial success despite extreme bypass length and limited outflow tracts. However, the long-term performance of these bypasses remains to be defined. During the last 10 years we have performed single greater saphenous vein in situ bypass to the ankle level in 270 patients. There were 187 male and 83 female patients, and 61% of the patients were diabetic. The operative mortality rate was 3.7%. Cumulative bypass patency was 79% at 3 years and 73% at 5 years. In a similar manner, limb salvage was 93% at 3 years and 89% at 5 years. The patency rate was similar for various inflow arteries (common femoral, 88 cases; proximal superficial femoral, 135 cases; and deep femoral, 41 cases) and outflow tracts (dorsal pedal, 72 cases; anterior tibial, 59 cases; posterior tibial, 72 cases, and peroneal, 67 cases). Short bypasses, composite bypasses, free-vein grafts, and bypasses proximal to 10 cm above the ankle were excluded from this analysis. These data show that a long bypass to the ankle level for limb salvage is a durable procedure. The basic concept of bypassing all occlusive disease to the distal open artery in patients undergoing limb salvage should be an acceptable dictum. Excellent long-term patency and limb salvage rates are achievable by following this principle.     

Infragenicular polytetrafluoroethylene bypass with distal vein cuffs for limb salvage: a contemporary series

HYPOTHESIS: Infragenicular polytetrafluoroethylene (PTFE)-venous cuff bypass grafting provides acceptable graft patency and limb salvage rates for limb salvage. DESIGN: Retrospective clinical review of a consecutive series. SETTING: Vascular surgical practice during the interval October 1, 2000, to September 1, 2004. PATIENTS: Fifty-one male and 49 female patients whose mean age was 76.9 years were operated on for tissue loss (67%), chronic rest pain (28%), and severe claudication (6%). Fifty-two percent of patients were diabetic and 49% had undergone previous leg bypass surgery. All patients had absent or inadequate greater saphenous vein, and 84 patients had absent or inadequate arm vein. INTERVENTIONS: One hundred five infragenicular PTFE bypasses were performed in these 100 patients. Distal targets were the infragenicular popliteal (40), posterior tibial (35), anterior tibial (16), and peroneal arteries (14). Sixty-eight venous cuffs were constructed from lesser saphenous vein. MAIN OUTCOME MEASURES: Graft patency, limb salvage, and patient survival were analyzed. RESULTS: Twelve early graft failures resulted in 7 leg amputations. The mean +/- SE 3-year primary patency and limb salvage rates were 64.4% +/- 12.8% and 74.4% +/- 11.9%, respectively. Perioperative mortality was 2.9% and 3-year survival was 38%. Graft follow-up ranged from 1 to 47 months with a mean of 13 months using life-table methods. CONCLUSIONS: For patients requiring arterial revascularization for limb salvage, in which autologous venous conduit is unavailable, distal venous cuff-PTFE bypass provides acceptable patency and limb salvage rates when viewed in the context of short life expectancy for these elderly patients.     

Secondary femoral-distal bypass

Thirty-nine secondary femoral-distal (femorotibial and femoroperoneal) bypasses were reviewed and compared to 89 primary femoral-distal bypasses (done during the same time period) to investigate the efficacy of secondary femoral-distal bypass. Graft patency at 2 years by life table analysis was similar in both groups (38% primary group vs 36% secondary group). However, limb salvage was significantly less in the secondary group (52% vs 68% at 2 years, p less than 0.05). This decrease was primarily due to poorer limb salvage using composite grafts (prosthetic/vein) compared to vein grafts in patients who underwent secondary femoral-distal bypasses (37% vs 76% at 2 years, p less than 0.05). Postoperative wound infections and mortality were similar in both groups. Thus, femoral-distal bypass after failure of a previous infrainguinal reconstruction offers good long-term limb salvage with acceptable surgical risk when autologous vein is available for use as the arterial conduit.     

Dorsalis pedis arterial bypass: Durable limb salvage for foot ischemia in patients with diabetes mellitus

Purpose:Although the technical feasibility of pedal artery bypass for limb salvage is now well established, questions remain about its most appropriate use and its long-term durability.Methods:We reviewed our experience over an 8-year period in 367 consecutive patients undergoing 384 vein bypass grafts to the dorsalis pedis for limb salvage.Results:Ninety-five percent of the patients had diabetes mellitus. Infection complicated ischemia at initial presentation in 55.2% of patients. The preoperative arteriogram demonstrated a patent dorsalis pedis in 362 extremities (92.8%). Four hundred two patients underwent exploration for bypass, including 29 patients without demonstrated arteries on the arteriogram but audible pedal Doppler signals. Successful bypasses were carried out in 357 of 362 cases, where preoperative arteriography demonstrated a patent dorsalis pedis artery (98.6%), 16 of 28 cases explored on the basis of a Doppler signal alone (57%), and 11 of 12 patients where angiographic status was unknown. All procedures were performed with vein: in situ 38.5%, reversed 29%, onreversed 18%, arm vein 7%, and composite vein 8%. Inflow was taken from the common femoral artery in 34%, superficial femoral or popliteal arteries in 60%, a previously placed graft in 5%, and a tibial artery in 1%. There were seven erioperative deaths (1.8%) and 21 myocardial infarctions (5.4%). Twenty-nine grafts failed within 30 days (7.5%), but 19 were successfully revised. Eight of the 10 failed grafts resulted in major amputation (80%). Over the remaining study period, there were 39 additional graft failures, of which 17 were successfully revised, and 17 additional major amputations. Actuarial primary and secondary patency and limb salvage rates were 68%, 82%, and 87%, respectively, at 5 years' followup. The actuarial patient survival rate was 57% at 5 years. Patency rates were similar for in situ and translocated saphenous vein grafts.Conclusions:Dorsalis pedis arterial bypass is an effective limb salvage procedure with long-term durability comparable to distal vein grafts placed into more proximal arteries. (J VASC SURG 1995;21:375-84.)     

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.