Compliance changes in in-situ femoropopliteal bypass vein grafts

Changes in wall structure, including neo-intimal proliferation and medial fibrosis, have been implicated as a cause of late occlusion in reversed femoropopliteal vein grafts. These changes can be measured indirectly as a fall in compliance. It has been suggested that long-term patency might be improved by the in situ technique because the nutrient vasa vasorum are left intact and therefore wall structure preserved. We have measured the compliance of 62 in situ vein grafts, with times after operation ranging from 2 days to 6 years, and also compared the compliance changes, in the first 3 months after operation, of 15 undisturbed in situ vein grafts with 15 fully mobilized in situ vein grafts. Compliance was derived non-invasively from the pulse wave velocity using Doppler ultrasound. There was a significant fall in compliance after operation (P less than 0.001) and no difference could be found between the undisturbed and mobilized in situ vein grafts (P greater than 0.1). Histological examination of 6 grafts suggested that the fall in compliance was due to neo-intimal proliferation which still occurred although medial fibrosis was reduced. Any potential improvement in long-term patency rates using the in situ technique must be due to other factors.     

Long term results of autogenous vein bypass grafts in femoropopliteal arterial occlusion

The results of 329 consecutive autogenous vein grafts carried out between January 1962 and June 1973 have been reviewed. The 5- and 10-year mortality rates were 14.6 per cent and 18.7 per cent respectively. The corresponding patency rates were 70 per cent at 5 years and 34 per cent at 10 years, the lowest patency (27.8 per cent) occurring in below-knee anastomoses with grafts of 5 mm or less in diameter. As other have noted, the state of the popliteal--tibial run-off vessels had a considerable influence on long term patency rates. In severely ischaemic limbs, the limb salvage rate following this operation was 77 per cent. An analysis of symptoms, associated disease and complications is presented and discussed. No valid conclusions could be made regarding the effect of lumbar sympathectomy and postoperative anticoagulants on long term patency. This review has confirmed the findings of earlier studies that a satisfactory 5-year patency rate and a gratifying limb salvage rate can be achieved with an extremely low operative mortality rate of 0.37 per cent. Despite the presence of widespread atherosclerotic arterial disease, the 5-year mortality rate is 14.6 per cent, indicating that an attempt at reconstructive surgery is usually well worth while.     

Durability of femoropopliteal reconstructions. Endarterectomy versus vein bypass grafts

Eighty-seven endarterectomies and 345 saphenous vein bypass grafts were carried out from 1955 to 1967 because of atherosclerotic femoropopliteal occlusive disease. The follow-up period ranged from three to fifteen years and accumulative patency rates were calculated by the life table method. Patency rates at three, five, and seven years for vein grafts were 74 per cent, 68 per cent, and 63 per cent, respectively. The patency rates for endarterectomy at these periods were 38 per cent, 33 per cent, and 23 per cent, respectively. In our experience once a vein bypass graft has been successfully implanted, the long-term success rate is little altered by pre-existing disease of the outflow vessels.     

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.     

Comparison between saphenous vein and Dacron Velour grafts for femoropopliteal bypass.

One hundred and thirty-eight femoropopliteal grafts were performed for arteriosclerotic occlusive disease of the femoral artery in a five-year period. One group of patients who had 81 saphenous vein grafts was compared with a similar group who had 57 Dacron Velour grafts. At three years 90% of the vein grafts were patent, compared to 45% of the Dacron Velour grafts. Twenty-seven per cent of all patients presented with threatenened limb loss. Amputation was averted in all but 5%. Intraoperative flow measurement did not prove to be a reliable indicator of long-term patency.     

Sparks mandril, velour Dacron and autogenous saphenous vein grafts in femoropopliteal bypass.

Ninety-nine consecutive vascular reconstructions with femoropopliteal bypass performed during 1973--6 have been reviewed. A Sparks mandril was used in 11 patients, reversed autogenous saphenous vein in 30 and velour Dacron prostheses in 58. The indication for operation was severe ischaemia in 79 per cent. The overall patency rate at 12 months was 70 per cent for autogenous vein, 46 per cent for velour Dacron prosthesis and 18 per cent for Sparks mandril. When the distal anastomosis was located above the knee the patency rate was 100 per cent and 87 per cent for autogenous vein and velour Dacron graft respectively, while the corresponding figures for distal anastomosis below the knee were 58 per cent and 11 per cent. At follow-up 60 per cent of the patients showed improvement owing to the vascular reconstruction.     

Eschaemia during arterial reconstructive surgery. Biochemical changes as reflected in popliteal vein samples.

Blood gases, electrolytes, metabolites and enzymes were studied in the venous effluate from the leg and in the systemic blood of 8 patients suffering from obliterating arteriosclerosis, during and after reconstructive arterial surgery. The common femoral artery was clamped for 50 to 180 min. Marked hypoxia and acidosis, together with a rise in lactate, phosphate and creatinine concentrations were found in the popliteal vein samples. Changes in the electrolyte concentrations were also observed. The rises in K+ and Mg++ were most pronounced. None of the changes wre correlated to the occlusion time and only small inter-individual variations were recorded. Only minor systemic change occurred after restoration of blood flow. The maximum postoperative CPK-activity, however, was closely correlated to the occlusion time, but judging by the level of this activity the actual muscular damage caused by the ischaemia was moderate, even after prolonged arterial clamping.     

Meta-analysis of femoropopliteal bypass grafts for lower extremity arterial insufficiency

BACKGROUND: In femoropopliteal bypass surgery, the use of saphenous vein grafts is preferable, but synthetic grafts are widely used above the knee. The objective of this meta-analysis was to assess the long-term patency of femoropopliteal bypass grafts classified as above-knee polytetrafluoroethylene, above-knee saphenous vein, or below-knee saphenous vein. METHODS: Studies published from 1986 through 2004 were identified from electronic databases and reference lists; 73 articles contributed 1 or more series that used survival analysis, assessed femoropopliteal bypasses in one of the foregoing configurations, reported a 1-year graft patency rate, and included at least 30 bypasses. The series with a predominance of claudicant patients were included in meta-analysis C, and the series in which critical ischemia predominated were included in meta-analysis CI. Pooled survival curves of graft patency were constructed. RESULTS: In meta-analysis C, the pooled primary graft patency was 57.4% for above-knee polytetrafluoroethylene, 77.2% for above-knee vein, and 64.8% for below-knee vein at 5 years; there was a significant difference between above-knee grafts at 3, 4, and 5 years (P < .05). The corresponding pooled secondary graft patency was 73.2%, 80.1%, and 79.7%, respectively (P > .05). In meta-analysis CI, the pooled primary graft patency was 48.3% for above-knee polytetrafluoroethylene, 69.4% for above-knee vein, and 68.9% for below-knee vein at 5 years; there was a significant difference between above-knee grafts until 4 years (P < .05). The corresponding pooled secondary graft patency was 54.0%, 71.9%, and 77.8%, respectively, with a significant difference between above-knee grafts at 2, 3, and 4 years (P < .05). CONCLUSIONS: The great saphenous vein performs better than polytetrafluoroethylene in femoropopliteal bypass grafting and should be used whenever possible.     

Neuropathic pain after femoropopliteal bypass surgery

OBJECTIVE: This retrospective study was performed to investigate prolonged postoperative pain in the area of the proximal or distal scar or the bypass tunnel after femoropopliteal bypass surgery to treat symptomatic peripheral arterial disease. PATIENTS AND METHODS: Ninety-three patients with peripheral arterial disease who underwent femoropopliteal bypass surgery between January 2000 and December 2002 were included in the study. The short-form McGill Pain Questionnaire was used to score pain. Ultrasound examination of the soft tissue around the graft was performed to exclude other pathologic conditions responsible for pain, such as inflammatory processes, perigraft reactions, swollen lymph nodes, and hematomas. RESULTS: Pain in at least one scar existed in 22 patients on average 13.9 +/- 9.8 months after surgery. In 10 patients pain existed simultaneously along the inguinal scar and the above-knee or below-knee scar. Pain along the bypass tunnel was experienced by seven patients. Most patients had mild to moderate pain. The mean numeric ranking score of pain severity in patients with pain was 4.2 +/- 2.3. The occurrence of prolonged postoperative pain was not associated with age, gender, diabetes, indication for surgery, material or type of bypass, number of preceding operations, or postoperative wound complications. Only follow-up time after femoropopliteal bypass surgery tended to be lower in patients with pain compared with those without pain. CONCLUSION: Prolonged postoperative neuropathic pain along the distal and proximal incision or the bypass tunnel exists in one fourth of patients after femoropopliteal bypass surgery. Patients should be informed of this kind of complication before surgery. The results of our study justify further investigations of the origin and treatment of this pain, to find effective methods to reduce the incidence of prolonged postoperative pain after femoropopliteal bypass surgery.     

Iatrogenic entrapment of femoropopliteal saphenous vein bypass grafts by the gastrocnemius muscle.

Two patients are described in whom saphenous vein grafts placed distal to the knee joint were "entrapped" by the medial gastrocnemius tendon. In one, the superficial position of the graft was detected by postoperative angiography. In the other, a true aneurysm of the vein graft developed over a 3 year period. The similarity between the iatrogenic and congenital forms of the popliteal entrapment syndrome is noted.     

Great saphenous vein protection in arterial reconstructive surgery

An original method of great saphenous vein bypass protection during reconstructive arterial surgery is described. The use of a reinforced prosthetic support (Ringed PTFE), surrounding the vein, avoids possible compression by anatomical structures and strangulation by scar tissue after reoperation. This technique can also prevent eventual dilatation of the vein graft. Since 1981, this technique has been successfully applied to 30 selected patients. On the basis of clinical experience, the authors conclude that this method is safe and effective, and may increase the long-term patency rate of saphenous vein grafts.     

True aneurysm formation in femoropopliteal autogenous vein bypass grafts: two cases

This paper describes two cases of true atheromatous aneurysm formation within reversed autogenous saphenous vein used for femoropopliteal bypass graft. We note the rarity of this complication and review the literature for true aneurysm formation within vein grafts used for this and other bypass procedures.     

Femoropopliteal and femorotibial arterial reconstructive surgery. Special reference to the autogenous venous bypass procedure using unreversed vein after eversion valvectomy.

The outcome of 127 femoropopliteal and 23 femorotibial arterial reconstructions carried out between January 1960 and December 1972 has been reviewed. The operative method was autogenous saphenous vein bypass in 109 cases, 82 of which were performed using unreversed vein with eversion valvectomy. The indication for reconstruction was advanced ischemia in 39%. Two patients died primarily and 23 late deaths have occurred subsequently. 19 grafts or reconstructed segments became occluded primarily. Most of them were femorotibial reconstructions of Dacron bypass reconstructions. Most of the failures occurred within 1 year of surgery. Using eversion valvectomy technique, the 1- and 5-year patency rates were 57 and 50% respectively. In femorotibial reconstructions the 1-year patency rate was 36%. There was a distinct difference in patency between the cases with excellent of good outflow and those with fiar or poor outflow. The difference was less distinct between patients with claudication and those with advanced ischemia. Eight limbs needed major amputation.     

Comparison of the flow capacity of free arterial grafts and saphenous vein grafts for coronary bypass surgery

There is controversy regarding the flow reserve and capacity of arterial conduits to meet the needs of the myocardium. This study compared flow in 22 free arterial bypasses to 15 saphenous vein grafts in procedures involving twenty patients. To assess the maximal flow possible, (flow capacity) graft flow was measured using a calibrated pump while perfusing blood cardioplegia through the conduit and distal anastomosis during cardiac arrest (no competitive flow). This assessment was subsequently confirmed with whole blood during myocardial contraction while on cardiopulmonary bypass. Twenty-two free arterial grafts were used; 15 right internal mammary artery grafts, 4 right gastroepiploic grafts, 3 inferior epigastric artery grafts, and 3 sequential bypasses. Free arterial conduit flow ranged from 50 to 180cc/ml, with an average flow of 102.5+/-28.5ml/min as compared to saphenous vein graft flow, 102+/-28 ml/min. No correlation of flow with the conduit size was found. Arterial graft flow demonstrated a mild correlation with the size of the native coronary artery bypassed (R=0.47, P相似文献