The use of spliced vein bypasses for infrainguinal arterial reconstruction

Purpose: The use of autogenous vein, whether in situ or excised, for arterial bypass procedures is well accepted. However, this usually requires the presence of a length of good-quality vein of adequate diameter. In patients lacking sufficient length of vein, two or more pieces of vein may be spliced together to complete the reconstruction. The effect of vein splicing on vein bypass patency is not well studied.Methods: Over a 14-year period, 1956 lower extremity revascularizations were performed with a single autogenous vein, 1806 in situ and 150 excised veins. During the same time, 184 bypasses required splicing vein segments together, of which 111 were in situ bypass procedures, which required splicing of one or more pieces of excised vein to complete the reconstruction (partial in situ bypass). Seventy-three bypasses were completed with multiple pieces of spliced excised vein. The source for the excised, spliced vein segments was the distal ipsilateral greater saphenous vein (GSV) in 40%, accessory ipsilateral GSV in 8%, contralateral GSV in 13%, lesser saphenous vein in 28%, and arm vein in 11%.Results: The 1- and 4-year primary patency rates for the entire spliced vein group were 72% and 45%, with secondary patency rates of 79% and 61%. The 1- and 4-year secondary patency rates of partial in situ bypasses were 80% and 70%, compared with 91% and 83% for in situ bypasses completed without a spliced segment (p < 0.0001). The 1- and 4-year secondary patency rates were 78% and 67% in the spliced excised vein group and 85% and 75% in the single excised vein group (p = not significant). The 4-year limb salvage rates were as follows: in situ (96%), partial in situ (85%), single excised vein (95%), and spliced excised vein (90%).Conclusions: We conclude that the use of excised vein segments to complete partial in situ bypasses may be associated with a decrement of bypass patency. Use of spliced excised vein segments of good quality for arterial bypass can produce acceptable patency rates. Such spliced autogenous conduits are clearly preferable to prosthetic bypasses for infrageniculate arterial reconstructions. Meticulous technique is a prerequisite for the successful performance of vein-to-vein anastomoses. (J VASC SURG 1995;21:403-12.)     

Long-term results of revised infrainguinal arterial reconstructions

PURPOSE: Infrainguinal arterial reconstruction with vein as the conduit has been regarded as the gold standard within the past two decades. However, as many as 20% of patients undergoing these bypass grafting procedures may need secondary interventions for continued patency. Once these reconstructions have been altered, there is concern about the continued patency of these types of revascularizations. In this study, we evaluated the long-term patency of venous reconstructions that had been revised, compared them with those bypass grafting procedures that did not require any intervention, and analyzed long-term outcome. METHODS: In the past 15 years, 3944 infrainguinal arterial reconstructions were completed with vein as the conduit. A total of 2780 were performed with the vein in situ, and 1164 were performed by using excised vein in a single piece or spliced configuration. Indication, risk factors, and patient demographics were evaluated. Grafts were stratified into revised and unrevised, in situ and excised; excised vein was then stratified into spliced and non-spliced. All grafts were followed with duplex ultrasound scans performed at 3, 6, and 12 months in the first year and every 6 months thereafter. Statistical analysis was performed by using Gehan's generalized Wilcoxon test. RESULTS: Demographics and indications were similar between groups. Nine percent of all excised veins required some revision, compared with 10% of all in situ reconstructions. When the excised veins were further stratified, 6% of single-piece venous conduits were revised, as opposed to 14% of reconstructions with spliced venous reconstruction. The 5-year patency rates were 67% for revised reconstructions and 78% for unrevised reconstructions (P <.0001). The 5-year patency rate of unrevised in situ bypass grafts was 81%, as compared with 69% for revised in situ reconstruction (P <.0001), and the 5-year patency rate for unrevised excised veins was 68%, with revised excised vein having a 5-year patency rate of 59% (P = not significant). CONCLUSION: Venous conduits that require revision have a significantly lower long-term patency rate than those that were unrevised. Grafts that require revision may be best suited for aggressive surveillance protocol to maximize long-term patency.     

Mesh tube--constricted varicose veins used as bypass grafts for infrainguinal arterial reconstruction.

Varicose veins are generally deemed inappropriate graft material for arterial reconstructions despite their physiologic flow surface because of their large and irregular caliber. Size reduction by threading such veins in constricting tubes may create bypass grafts of suitable caliber as long as redundant wall material does not cause stenoses. Sixteen human varicose veins (mean +/- SD, 13 +/- 3 mm diameter) obtained after stripping operations were inserted into Dacron mesh tubes of 6 mm internal diameter. Paraffin casts of the distended veins showed a size reduction of 6.9 +/- 2.6 mm. Wall material formed folds in only two veins. In both cases, diameter reduction was more than 10 mm. However, the folds did not result in significant stenoses. Mesh-constricted varicose veins were used as bypass material in 11 infrainguinal arterial reconstructions. All externally supported segments showed satisfactory size reduction without stenoses or folds. One graft occluded 2 months after surgery. Two patients had to undergo reoperation after 2 and 16 months, respectively. None of the complications could be attributed to the constriction of veins. The remaining grafts are patent and functional after a mean of 17 months (range, 6 to 42 months). Considerable size reduction by external wrapping of varicose veins is possible without adverse side effects. Such constricted veins were used successfully as bypass grafts for infrainguinal arterial reconstructions.     

Early results of infrainguinal arterial reconstruction with a modified biological conduit

We implanted 112 glutaraldehyde-fixed bovine carotid artery grafts (BioPolyMeric [BPM]) for infrainguinal reconstruction in 107 legs of 98 patients. Indications for surgery were disabling claudication in 28%, rest pain in 33% and tissue loss in 39%. In 32%, BPM bypass followed failed ipsilateral reconstruction. Autologous vein was either absent or inadequate in 60% of cases. BPM was used preferentially over vein in above-knee bypasses. The distal anastomosis was to the above-knee popliteal artery in 40%, to the below-knee popliteal artery in 35%, and to the tibial arteries in 25%. Follow-up was available from one to 25 months, with a mean of nine months. Wound complications developed after 9% of operations, including seven (6%) graft infections. Both patent grafts that became infected were salvaged. Four patients (4%) died within 60 days of surgery due to cardiac complications. Life-table primary and secondary patencies of all grafts were 64% and 65% at one year, and 48% and 62% at two years, respectively. The only factor significantly affecting graft patency was the location of the distal anastomosis (p<.01). Primary patencies at one and two years to the above-knee popliteal artery were 90% and 80%, to the below-knee popliteal artery were 56% and 37%, and to the infrapopliteal arteries were 34% and 26%. Bypass to 16% of extremities resulted in amputation, including 5% that were amputated with patent grafts. No limb loss occurred as a result of operation for claudication. In conclusion, BPM grafts provide early results comparable to saphenous vein above the knee. Future randomization with synthetic grafts is necessary to define the role of BPM grafts below the knee.Presented at the Tenth Annual Meeting of the Southern California Vascular Surgical Society, September 27–29, 1991, Marina Del Rey, California.     

Current techniques for infrainguinal arterial reconstruction

Infrainguinal reconstruction for peripheral vascular occlusive disease comprises an increasingly complex array of interventions which provide unparalleled options for the salvage of threatened limbs. Conventional autogenous saphenous vein bypass remains the most durable revascularization with anticipated graft patency rates approaching 80 per cent after five years and excellent long term limb salvage. These excellent results are equally applicable to vein grafts carried to infrapopliteal and even inframalleolar levels, possibly reflecting increased utilization of thein situ method. Although 20 per cent of grafts fail within five years, secondary intervention results in sustained limb salvage in the majority of patients. In the absence of autogenous vein, however, prosthetic material performs poorly such that new interventions consisting of percutaneous transluminal angioplasty, rotary atherectomy devices and laser systems are under aggressive development. Although initial results with these devices are encouraging, longterm patency rates remain poor largely due to restenosis. Further progress seems to depend primarily on an increased understanding of the natural healing response of the injured artery. This report is the gist of a paper read by A.D.W. at the 90th Annual Meeting of the Japanese Surgical Society, Sapporo, Japan, 1990     

Homologous veins as an arterial substitute: Long-term results

From 1968 through 1982, 129 homologous vein grafts were used in 91 patients in the following positions: 75 in the femoropopliteal, tibial, or peroneal artery; 38 in the aortocoronary artery; 13 in the aortopulmonary artery; and one each in the atrioventricular fistula, carotid-subclavian artery, and brachial-radial artery. In the lower extremity patency ranged from 0 to 121 months (mean 22.4 ± 4.4 months). All grafts were performed for limb salvage, and 75% of the patients had undergone previous operations. Cumulative patency by the life-table method showed that while 50% of grafts occluded by 1 year, 60% of the remaining grafts continued to be functional for more than 5 years. Fifty percent of the aortocoronary bypass grafts studied were occluded at 1 year. Eight of the 13 systemic pulmonary artery shunts were patent at time of death, revision, or total correction. Multiple revisions and thrombectomies are required to maintain patency of homograft veins. The outcome is variable and unpredictable. The inconsistency is due to the antigenicity of the graft. If one is committed to the necessary efforts required to ensure long-term patency, the homologous saphenous vein is a suitable substitute when autogenous tissue is unavailable. (J VASC SURG 1984;1:306-13.)     

Late results and clinicopathological study of vein graft failure in infrainguinal arterial reconstruction

Long-term follow-up study of 79 infrainguinal arterial bypasses with autogenous vein graft in 62 patients was undertaken to clarify the cause of late graft occlusion. Thirty grafts failed during the follow-up period, including 7 early and 23 late occlusions. The overall cumulative patency rate at 5 years was 58.6%. The analysis of angiograms of 33 limbs revealed the long-term morphological changes which included 1 occlusion of the femoral artery proximal to the vein bypass, 8 graft stenosis, and 5 atherosclerotic progressions of the outflow tract. The causes of 8 graft stenoses consisted of 5 anastomotic intimal hyperplasia (ANIH), 2 atherosclerotic changes, and 1 external compression of the graft by tendons. All of four histologically examined stenosed anastomoses had marked peri-anastomotic fibrosis, which was suspected to be caused by extensive circumferential dissection of the host artery at the initial operation. In 3 stenosed anastomoses with arteriosclerosis obliterans, the luminal diameter was the narrowest at the arterial side with intimal hyperplasia over remnant atheromatous lesion. In conclusion, ANIH is the most influential cause of graft occlusion, and perianastomotic local factors such as initial anastomotic deformity, periarterial fibrosis, and remnant arterial lesion at anastomosis, revealed to have much influence on the cause of ANIH.     

Arm veins for peripheral arterial reconstruction.

The ipsilateral saphenous vein has become accepted as the best available material for femoropopliteal bypass and for arterial patch grafts as well as for visceral and cardiac bypasses. However, in a few patients, nonavailability or nonsuitability of the saphenous vein forces use of some other material. We report an experience with 32 operations using arm veins. Among the 11 long vein grafts, seven composite vein-Dacron or vein-vein grafts, and 14 vein patch grafts during the past six years, there were no infections or aneurysms and only nine thrombotic failures have been detected to date, to our knowledge. Our present indications are (1) ipsilateral saphenous vein is not available or is not suitable, (2) only a short graft or patch is needed and the saphenous vein may therefore be saved for the future, (3) to join to a saphenous graft or to a Dacron composite graft for additional length, and (4) to reconstruct an arm artery. Our experiences using cephalic and basilic veins confirms them as a useful source of autogenous material for arterial reconstruction.     

Long-term results of infrainguinal revascularization with polytetrafluoroethylene: a ten-year experience.

Two hundred fifty-eight patients underwent 322 infrainguinal revascularizations with use of polytetrafluoroethylene (PTFE) between 1978 and 1988. The indication was limb salvage in 190 (59%) reconstructions. Two hundred nineteen (68%) were above-knee, and 75 (23%) were below-knee femoropopliteal bypasses. Twenty-eight (8.6%) were femoral-infrapopliteal bypasses, all done for limb salvage. Follow-up ranged from 24 to 144 months (mean, 66 months). The perioperative mortality rate (1 to 30 days) was 3.4% (9 patients), with no significant difference according to indication (2.9% vs 3.7%). Actuarial primary patency at 8 years for the entire series of femoropopliteal bypasses was 53% (above knee 53%; below knee 39%; p less than 0.05), and improved with additional procedures for a secondary patency of 72%. Femoropopliteal bypasses done for severe claudication had an 8-year actuarial primary patency of 63%, compared with 38% for limb salvage (p less than 0.02). Actuarial limb salvage in the latter group at 8 years was 66%. Femoral-infrapopliteal reconstructions with PTFE had a significantly lower primary patency at 3 years (22%, with a 37% limb salvage). Sixty-four percent of the failures for all reconstructions (N = 111) occurred within 12 months, with remarkable stabilization of patency curves beyond that interval. This experience represents the largest reported series of PTFE reconstruction with longest follow-up to date and may serve as a basis for comparison of other conduits. These results suggest an important role for PTFE in femoropopliteal revascularization and a limited role of this prosthetic conduit in femoral-infrapopliteal arterial reconstructions.     

A meta-analysis of infrainguinal arterial reconstruction in patients with end-stage renal disease.

OBJECTIVES: to determine graft patency, limb salvage, and patient survival following infrainguinal bypass grafting in patients with end-stage renal disease (ESRD). METHODS: studies published from 1987 through 2000 were identified from the PUBMED database and pertinent original articles. Sixteen studies were found that used survival analysis to report the outcomes of interest. Two investigators independently extracted the data from standard life-tables, survival curves and texts. A new method was developed for meta-analysis of uncontrolled studies that use survival analysis with different follow-up intervals. RESULTS: random-effects modelling yielded the following summary estimates at one- and two-year follow-up: 79% (95% CI, 70-87%) and 74% (63-85%) for graft patency; 77% (69-84%) and 73% (64-81%) for limb salvage; and 59% and 42% for patient survival. CONCLUSION: despite a severely limited life span, infrainguinal bypass grafting for the treatment of critical ischaemia is worthwhile in selected patients with ESRD.     

Cryopreserved saphenous vein allografts in infrainguinal arterial reconstruction

Cryopreserved saphenous vein allografts (cryografts) have been used as conduit in infrainguinal revascularization when autogenous vein is inadequate or unavailable. Numerous reports on the subject exist, however most are hampered by small sample size or retrospective design. Despite poor patency rates, limb salvage in patients undergoing cryograft bypass is acceptable. In this article we review the literature of cryograft use in infrainguinal revascularization and define its role in the armamentarium of the modern vascular surgeon.     

Long-term results of hemipelvis reconstruction with allografts.

Thirteen patients underwent pelvic reconstruction by massive allografts after resection of a malignant tumor (primary in 10 patients and metastatic in three patients). In 10 patients, the tumor involved the acetabulum and iliac wing and was reconstructed by a hemipelvic allograft; this was accompanied by a hip arthroplasty in nine of the patients. In three patients, a femoral metaphyseal tumor extending to the acetabulum was reconstructed by a total acetabular allograft and a composite proximal femoral allograft prosthesis. Two patients (20%) had a local recurrence, and one patient died of massive pulmonary embolism. Postoperative complications were one infection and two dislocations. At 3 years, one cup loosening and one acetabular fatigue fracture required surgery. The functional result was excellent in two patients whose gluteal muscles could be spared, good (allowing a normal family life) in six patients, fair in two patients, and poor in two patients. Seven patients had a Musculoskeletal Tumor Society rating greater than 60% of normal (the mean rating in 12 patients was 56.4%). No evidence of long-term deterioration was seen in the patients with the longest followups (7, 8, 10, and 14 years). Reconstruction of the hemipelvis with massive allografts and arthroplasty is a rewarding but demanding procedure and should be reserved for physically active patients who are in good general health and are expected to have a response to anticancer therapy. The procedure is particularly suitable for patients with primary tumors.     

Surgical treatment of methicillin-resistant Staphylococcus aureus infection following infrainguinal arterial reconstruction.

A 64-year-old man was referred to our hospital with Methicillin-resistant Staphylococcus aureus (MRSA) infection following infrainguinal arterial reconstruction. As repeated MRSA sepsis occurred, we decided to remove the infected graft with distal revascularization via circuitous graft tunneling to avoid serious infections and allow limb salvage. An iliofemoro bypass was performed via an extra-anatomical bypass, from just below the iliac crest into the musculus quadriceps femoris using an 8 mm-ringed polyester gelatin polypropylene tube graft, with complete debridement of a groin infection. Postoperative 3-dimentional CT angiography revealed that the prostheses was patent and the patient had an uneventful postoperative course. We concluded that this extra-anatomical bypass was a safe procedure and an excellent option for patients with an infected vascular prosthetic graft in the groin after previous revascularization, like in our case with no available autogeneous vein grafts.     

Long-term results justify autogenous infrainguinal bypass grafting in patients with end-stage renal failure.

INTRODUCTION: Infrainguinal bypass grafting for limb-threatening ischemia in patients with end-stage renal disease is generally thought to be associated with increased operative risk and poor long-term outcome. This retrospective study was undertaken to examine the modern-era, long-term results of infrainguinal bypass grafting in dialysis-dependent patients. METHODS: Over the past 5 years in a single institution, 425 lower extremities (368 consecutive patients) were revascularized for the indication of limb salvage. Sixty-four patients (82 limbs) were dialysis-dependent at the time of revascularization, and this group was analyzed separately. They exhibited statistically significant higher incidences of diabetes (83% vs 56%; P <.001), hypertension (91% vs 74%; P <.001), and more distal vascular disease, which required a greater proportion of proximal anastomoses at the popliteal level (24% vs 11%; P <.01) and distal anastomoses at the infrapopliteal level (75% vs 65%; P <.05). RESULTS: Despite the higher prevalence of comorbid conditions and distal disease in patients with renal failure, their perioperative 30-day mortality rate remained low (4.9%) and was not significantly different from that in patients with functioning kidneys (2.9%; P = not significant). After a median follow-up of 11 months (range, 0-60 months), the 3-year autogenous conduit secondary graft patency in patients with renal failure was no different than in patients with functioning kidneys (67% +/- 9% vs 64% +/- 5%; P = not significant). Nonautogenous conduits in dialysis-dependent patients exhibited a significantly poorer outcome with only 27% +/- 12% remaining secondarily patent at 2 years. As expected, both limb salvage and patient survival were significantly less in patients with renal faiture, although both exceeded 50% at 3 years (limb salvage 59% +/- 8% vs 68% +/- 5%; P <.05; patient survival 60% +/- 8% vs 86% +/- 4%; P <.001). The often-quoted phenomenon of limb loss, despite a patent bypass graft, occurred infrequently in this study (n = 3 of 82 limbs). CONCLUSION: Infrainguinal revascularization can be performed in dialysis-dependent patients with acceptable perioperative and long-term results, especially in patients in whom adequate autologous conduit is available.     

Long-term prognosis for reconstruction of arterial lesions due to arteriosclerosis.

Out of 769 patients with arterial diseases, reconstructive surgery was performed on 100 limbs of 79 patients for arteriosclerosis. The overall patency rate was 59 per cent over a period of 3 to 8 years. Long-term patency was influenced by the condition of the run-off arteries, the site of the operation, and the method of surgery. No relation was found between patency rate and hypertension, cardiac insufficiency, total serum cholesterol, diabetes mellitus, or age. The survival rate was 62 per cent at 5 years and 48 per cent at 7 years. These rates were significantly poor (p less than 0.001), compared with those in the normal population. Mortality was related to the degree of hypertension, with cardiac and renal failure being responsible for 72 per cent of deaths. Aggressive reconstruction may be indicated in cases with hypertension of stage 2 or below based on the WHO classification. However, especially in patients with associated diabetes mellitus close long-term observation of the cardiovascular system is necessary.     

An updated meta-analysis of infrainguinal arterial reconstruction in patients with end-stage renal disease

BACKGROUND: A previous meta-analysis reported on the mid-term outcomes of infrainguinal bypass grafts in patients with critical limb ischemia and end-stage renal disease. Given the competing interest in endovascular procedures, the results of bypass surgery must be assessed as precisely as possible for future comparison. In this study, the original meta-analysis was refined and updated by increasing the number of studies reviewed, estimating primary graft patency, extending follow-up time, and investigating the problem of early amputation despite a patent graft. METHODS: Studies published from 1987 through 2005 were identified from two electronic databases. Two investigators independently extracted the survival data from life tables, survival curves, and texts. Pooled survival curves were then constructed for graft patency, limb salvage, and patient survival according to a random-effects protocol for meta-analysis. RESULTS: Of 28 articles included, 18 reported amputation despite a patent graft in 84 (10%) out of 844 limbs, and 25 described a perioperative mortality of 88 (8.8%) out of 996 patients. The 5-year pooled estimate (SE) was 50.4% (15.4%) for primary patency, 50.8% (19.0%) for secondary patency, 66.6% (11.2%) for limb salvage, and 23.0% (11.7%) for patient survival. No publication bias was detected. CONCLUSIONS: Limb salvage can be achieved in most end-stage renal disease patients who undergo bypass surgery for critical ischemia, but survival is poor. To avoid early amputation despite a patent graft, bypass grafting should not be offered to patients with a great amount of tissue loss or extensive infection.     

Digestive arterial bypass. Long-term clinical results

In the period between September 1966 and December 1988, 69 patients were operated, including 92 cases of restorative surgery on celiac, hepatic or superior mesenteric arteries. This is a presentation, of the detailed retrospective analysis of 12 years' experience with more homogeneously matched indications and technics. Only indirect, venous or prosthetic bypasses and reimplants are discussed; excluded are all other digestive revascularization procedures, as well as acute ischemic surgery cases. 31 patients (28 men, 3 women) of mean age 59.8 years (47-80) have undergone consecutive surgery: 11 presented with symptoms of predominantly digestive origin; 18 had a combined aortoiliac bypass operation; radiological signs of disease occurred in 46 cases. (celiac artery): 22 including 14 stenoses, 5 thrombotic cases and 3 aneurysms; superior mesenteric artery: 21 including 13 stenoses and 8 thrombotic cases; inferior mesenteric: 3 thrombotic cases). A restorative operation was carried out on 45 patients, 6 of whom had had previous surgery. 21 patients had a single artery restored: celiac (3), hepatic (9), superior mesenteric (9). Double artery surgery was performed in 12 cases. The procedures most commonly used on the hepatic and superior mesenteric arteries were indirect reimplantation and bypass surgery, respectively. Evolution showed increased numbers of anterograde constructions. No deaths were recorded in the perioperative period. Two patients had early recurrences of thrombosis at D10, which required new bypassing. During the mean retrospective period of 6.1 years, we recorded 6 cases of blindness, 8 secondary deaths, 1 single case of mesenteric infarction 18 months after a repeated restorative operation on the superior mesenteric artery; 17 patients remained symptom-free.     

Indications and results with cryoplasty in the treatment of infrainguinal arterial occlusive disease

Percutaneous transluminal angioplasty of the superficial femoral and popliteal arteries has been an accepted therapy for short focal stenosis. Elastic recoil and flow-limiting dissection have limited the durability of angioplasty, especially in long lesions and total occlusions. Cryoplasty couples cold therapy with angioplasty to induce mechanical and biologic effects to reduce elastic recoil and potentially to reduce restenosis. The mechanical and biologic mechanisms of this therapy are discussed. The results of cryoplasty for femoropopliteal lesions from a single-center series and a multicenter registry are reviewed. Cryoplasty appears to improve patency over conventional angioplasty and to reduce the need for bailout stenting in femoropopliteal stenoses and occlusions < 10 cm in length. Cryoplasty appears to be promising to treat critical limb ischemia in patients with tibial disease.