Umbilical vein bypass in patients with severe lower limb ischemia: a report of 121 consecutive cases

In 112 patients with severe ischemia of the lower limb and without a suitable saphenous vein, 99 femoropopliteal and 22 femorodistal bypass procedures were performed with the modified human umbilical vein (Biograft, Meadox Medicals Inc., Oakland, N.J.). Seventy-eight percent of the operations were performed for limb salvage. In the remaining 22% the indication was severe disabling claudication. Forty-nine percent of the patients had previously undergone arterial reconstruction of the extremity in question. In 36% the distal anastomosis was to the popliteal artery above the knee, in 46% to the popliteal artery below the knee, and in 18% to one of the crural arteries. It was mandatory to perform an additional proximal reconstruction in 38% of the extremities. The observation time ranged from 6 to 60 months, with a mean of 24 months. Two patients died within the first month. The overall cumulative patency rate calculated by the life table method was 67.7% at 1 year, 61.2% at 2 years, and an unchanged 56.6% at 3 to 5 years. The cumulative patency rate in the limb salvage group was higher (58.6%) than the patency rate of the grafts implanted for claudication (46.5%, not significant). Graft patency decreased the more peripherally the distal anastomosis was situated, but we could demonstrate neither a significant relationship between graft patency and runoff nor any prognostic significance in the peroperatively measured flow values. Limb salvage calculated by the life table method was 86% at 1 year and 75.4% at 5 years. It is concluded that the umbilical vein graft is an acceptable alternative for bypass grafting in patients without a suitable autogenous vein.     

Lower extremity revascularization with in situ saphenous vein for critical ischemia

Over a 3 1/2 year period, 55 limbs were revascularized with in situ saphenous vein bypass grafts in 49 patients. Ninety-five percent of grafts were constructed in patients with critical ischemia for limb salvage, and 5 percent were constructed for debilitating claudication. The proximal anastomosis was performed in the groin in all patients. The distal graft was taken to the popliteal artery in 45 percent and to a tibial or isolated popliteal segment in 55 percent, with 55 percent of the grafts having single-vessel runoff. The perioperative mortality rate was 7 percent. The primary immediate patency rate was 91 percent and the secondary immediate patency rate was 98 percent at 1 month. The cumulative patency rate at 42 months was 85.4 percent overall, 86.6 percent for the tibial grafts, and 84 percent for the popliteal grafts. The cumulative limb salvage rate was 100 percent for the popliteal grafts, 90 percent for the tibial grafts, and 94.5 percent overall. All of the patients were followed and 3 required secondary revision. In situ vein bypass is a technically demanding procedure that can be performed successfully in high-risk patients with limbs with minimal runoff and can yield very high long-term patency and limb salvage rates in a community hospital setting.     

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.     

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.     

Pedal arterial bypass for limb salvage in patients with diabetes mellitus.

OBJECTIVE: to evaluate pedal bypass grafting in patients with diabetes mellitus with critical limb ischaemia. PATIENTS AND METHOD: from 1994 to 1999, 49 consecutive pedal bypass grafts were performed in 46 patients with a median age of 69 years (range 37-85 years). The incidence of insulin-dependent diabetes mellitus was 87%. The distal anastomosis was located at the dorsalis pedis artery in 36, at the inframalleolar posterior tibial artery in 9 and at the plantar artery in 4 cases, respectively. RESULTS: one patient died perioperatively. Two bypass occlusions and one major amputation accounted for a primary patency rate of 96% and a limb salvage rate of 98% at 30 days, respectively. During a median follow-up of 28 months (range 1-70 months), 21 patients died of nonrelated causes. Three additional graft occlusions and 4 major amputations were noted resulting in a primary patency rate of 89% and a limb salvage rate of 87% at 48 months, respectively. CONCLUSION: Pedal bypass grafting utilising the greater saphenous vein with in-situ technique is a reliable and effective procedure to achieve durable limb salvage in patients with diabetes mellitus.     

Short-term and midterm results of an all-autogenous tissue policy for infrainguinal reconstruction

Saphenous vein is the optimal conduit for infrainguinal vascular reconstruction. In instances in which this vein is unavailable or of "poor quality," reliance has been placed on a variety of prosthetic materials for bypass grafting. However, long-term patency with these prosthetic grafts has been disappointing. In January 1985 we instituted a policy of using exclusively autogenous tissue for infrainguinal arterial reconstruction. During the ensuing 3-year period, 203 patients underwent 266 arterial operations below the inguinal ligament, with a prosthetic graft used in only 11 instances (4%). No patient was denied surgery for limb salvage because of a lack of available autogenous vein. Thirty-three percent of procedures were performed for failure of prior revascularization and 73% for limb salvage. The 3-year cumulative primary patency rate for all autogenous procedures was 72%. Procedures were divided into those that used greater saphenous vein (patency 77%) vs autogenous alternatives such as bypass with arm vein or lesser saphenous vein, vein patch angioplasty, and endarterectomy (patency 64%). The operative mortality rate was 1.4% and the 3-year limb salvage rate was 89%. Autogenous infrainguinal reconstruction can be performed in almost every instance with acceptable results, suggesting that the need for prosthetic bypass grafts in the lower extremity is less than has been previously reported.     

Results of arterial reconstruction of the foot

Sixty-five patients with critical ischemia required bypass to foot vessels. These procedures were performed by five different techniques: (1) femoral-foot bypass with in situ saphenous vein; (2) femoral-foot bypass with reversed autogenous saphenous vein; (3) femoral-foot bypass with polytetrafluoroethylene (PTFE); (4) popliteal-foot bypass with reversed autogenous saphenous vein; and (5) popliteal-foot bypass with PTFE. The two-year patency rate of femoral-foot bypass with in situ vein (96%) was significantly higher than femoral-foot bypass with reversed vein (42%), while both procedures demonstrated significantly higher patency than femoral-foot bypass with PTFE (0%). Popliteal-foot bypass with reversed vein (92%) was superior to both popliteal-foot bypass with PTFE (27%) and femoral-foot bypass with PTFE (0%). Femoral-foot bypass with in situ vein and popliteal-foot bypass with reversed vein have appreciably increased vein utilization, graft patency, and limb salvage.     

Autogenous composite vein bypass graft for infrainguinal arterial reconstruction

PURPOSE: Lower extremity arterial reconstruction in the absence of adequate greater saphenous vein remains a challenging problem in contemporary vascular practice. The purpose of this review is to evaluate the long-term results of autogenous composite vein grafts used for infrainguinal arterial bypass grafting. METHODS: We retrospectively evaluated a prospective vascular registry and reviewed inpatient and office records. RESULTS: From June 1983 to September 1999, 165 autogenous composite vein infrainguinal bypass grafts were performed in 154 patients (87 men, 67 women; mean age, 69 years). The mean follow-up was 25 months (range, 3-147). Patients had the usual risk factors, including a 30% incidence of prior coronary bypass grafting. Forty-eight percent of bypass grafts were performed after failed previous reconstructions, and 90% were performed for limb salvage. The conduits were comprised of 2 segments (75%), 3 segments (23%), and 4 segments (2%). The distal anastomosis was at the popliteal level in 17% and the tibial/pedal level in 83%. The 30-day operative mortality rate was 1.8%. Perioperative graft failure (< 30 days) occurred in 18 bypass grafts (11%), resulting in early amputation (< 30 days) in 1.2%. The overall 5-year cumulative patency rates were 44% +/- 5% for primary patency, 63% +/- 5% for primary-assisted patency (PAP), and 65% +/- 5% for secondary patency (SP). A high revision rate for stenosis or thrombosis was required during follow-up to maintain patency of the grafts (27%). Limb salvage was 81% +/- 5% at 5 years. Primary reconstructions with composite vein fared significantly better than secondary reconstructions (SP 76% vs 54% at 5 years, P <.01). Arm vein composites showed superior patency compared with greater saphenous vein composites (SP 79% vs 61% at 5 years, P <.05). CONCLUSIONS: Infrainguinal reconstruction with autogenous composite vein results in durable graft patency and limb salvage rates in patients with few alternatives for revascularization. Intensive graft surveillance with aggressive graft revision is necessary to achieve these results.     

Femoral-distal bypass with in situ greater saphenous vein. Long-term results using the Mills valvulotome.

During a 7-year period, 440 consecutive in situ saphenous vein grafts originating in the groin were performed in 371 patients, exposing the entire vein for valvulotomy with a modified Mills valvulotome. critical ischemia was the indication for bypass in 68%, and the distal anastomosis was to an infrapopliteal artery in 46%. Thirty-day operative mortality was 2.0%. Postoperative surveillance identified 18 stenotic grafts (4.1%), which were revised while still patent (primary revised patency); 36 grafts (8.2%) underwent revision after graft occlusion (secondary patency). Five-year life-table analysis showed overall primary revised patency of 78%, secondary patency of 83%, limb salvage of 88%, and patient survival of 66%. Femoroperoneal and inframalleolar bypasses fared well. The presence of diabetes did not diminish late graft patency. In contrast to reversed vein grafts, long infrapopliteal in situ grafts had long-term secondary patency similar to shorter femoropopliteal bypass grafts (p greater than 0.05). These results, coupled with the versatility and simplicity of the technique as used in the present series, suggest that in situ vein grafting is the procedure of choice for long infrapopliteal bypass.     

Present status of reversed vein bypass for lower extremity revascularization

During the past 4 years we have performed 239 reversed vein bypasses for leg ischemia in 196 patients including 45 to the above-knee popliteal artery, 118 to the below-knee popliteal artery, and 76 to infrapopliteal arteries. The cumulative primary patency results by the life-table method through 24 months are 97% at 6 months, 91% at 1 year, and 88% at 2 years. No difference was evident in patency rates with respect to site of distal anastomosis or reason for graft performance (i.e., for claudication [31%] or for limb salvage [69%]). Twenty-two percent of these patients did not have an intact ipsilateral greater saphenous vein. By a variety of techniques including the use of cephalic and lesser saphenous veins, vein splicing, and proximal superficial femoral endarterectomy, we have been able to perform autogenous vein bypass in 94% of all patients who require lower extremity revascularization. The patency of bypasses made from conduits other than greater saphenous vein does not differ from that of the entire series. Both the graft patency and vein utilization rates in the present report are equal to those of recently published series of in situ saphenous vein bypasses and are clearly better than the published results with reversed vein bypass a decade and more ago. We conclude that, although in situ saphenous vein bypass is a good procedure, it is not superior to reversed vein bypass performed in the same time period. This report again emphasizes the hazards of evaluating any new treatment by use of historic controls.     

Non-greater saphenous vein grafting for infrageniculate bypass

Infrainguinal bypass grafting with greater saphenous vein has proven to be a highly effective procedure with primary 5-year patency and limb salvage rates exceeding 80 per cent. However, because of prior usage or intrinsic venous disease the greater saphenous vein is often not available as a conduit. Numerous studies have shown that patency rates for prosthetic bypass grafting to the infrageniculate vessels are clearly inferior to that reported for greater saphenous vein bypass. In this report we summarize our experience with the use of alternate autogenous vein grafting to the infrageniculate vessels. The records of all patients undergoing autogenous bypass grafting to the infrageniculate vessels using a conduit other than the greater saphenous vein between 1992 and 1999 were reviewed. Graft survival curves were plotted using the Kaplan-Meier method and results are reported using the Society for Vascular Surgery/International Society for Cardiovascular Surgery guidelines. Forty-eight patients underwent a total of 51 infrageniculate bypass procedures using non-greater saphenous autogenous conduits. Thirty-nine patients had reconstructions performed with single segments of arm vein, two had their operations performed with lesser saphenous vein, and ten had grafts created with two segments of non-greater saphenous autogenous vein. Twenty-one grafts were performed to the infrageniculate popliteal artery and 30 were performed to the tibial vessels. Primary and primary assisted patency rates at 30 months were 49 and 75 per cent. Limb salvage was 87 per cent. Infrainguinal bypass grafting using non-greater saphenous autogenous conduits can yield quite satisfactory intermediate limb salvage and patency rates. However, close graft surveillance and prompt intervention are required to avoid graft failure.     

Results of 100 consecutive femoropopliteal vein grafts for limb salvage.

One hundred consecutive patients with femoropopliteal autogenous vein grafts for limb salvage were reviewed five years later. In this group 40% died and 30% of the limbs had been lost at the end of five years. Limb survival correlated best with adequacy of distal run-off, but not with the presence or absence of diabetes. Forty-seven per cent of the grafts were still patent among surviving patients, and when combined with the limbs that were viable despite failure of the original graft, 70% of the limbs were salvaged among the survivors at five years. Temporary graft patency was effective in preserving ischemic tissue by facilitating healing of ulcers or limited amputations. Femoral-popliteal bypass grafting in the presence of advanced ischemia is capable of improving the quality of life for many of these patients.     

Salvage of ischemic diabetic feet: role of transcutaneous oxygen mapping and multiple configurations of in situ bypass

Salvage of ischemic diabetic feet with advanced infrapopliteal and pedal arch atherosclerosis requires distal revascularization to heal skin envelope injuries. A series of 60 consecutive diabetic extremities with 41 nonhealing skin envelopes requiring distal tibial or pedal bypass in 83 percent has been reported. Four configurations of in situ bypass, including femoropopliteal, femorotibial, femoral sequential popliteal-tibial, and popliteal-tibial [3,9,11,17] were utilized with reversed and nonvein bypass to achieve a 93 percent hospital survival rate and 90 percent limb salvage with 80 percent graft patency at 36 months. Transcutaneous oxygen mapping was used to predict the healing of skin envelope injuries and late amputations after bypass. Postoperatively, limbs with transcutaneous oxygen values at the midfoot and surrounding skin injuries of more than 30 mm Hg rapidly healed, whereas those with midfoot values of more than 30 mm Hg but transcutaneous values surrounding skin injuries of less than 30 mm Hg had wound complications (p less than 0.001). Optimal limb salvage can be achieved with in situ bypass, sequential grafting, and high forefoot amputations if necessary. Transcutaneous mapping accurately predicts tissue healing and allows planning of the site and timing of late amputations.     

The myth of the in situ graft: superiority in infrainguinal bypass surgery?

OBJECTIVES: to compare the clinical outcome of in situ and reversed bypass grafting. DESIGN: multicentre, prospective, non-randomised study. PATIENTS AND METHODS: five-hundred patients with an in situ graft and 955 patients with a reversed graft were compared regarding graft occlusion, the need for graft revision, and limb salvage. RESULTS: two-year assisted primary patency of femoropopliteal bypass procedures was 82% for in situ and 82% for reversed grafts. The corresponding hazard ratio (HR) for occlusion was 1.27 (95% CI 0. 91-1.77). The 2-year assisted primary patency of femorocrural bypass procedures was 69% for in situ vs. 70% for reversed grafts. The corresponding HR was 1.13 (95% CI 0.73-1.75). Adjustment for relevant baseline variables did not change the results. More reinterventions were needed to maintain integrity and patency of the in situ graft especially in crural bypasses. No differences in limb salvage rates were seen. CONCLUSIONS: reversed and in situ vein grafts have similar patency and limb salvage rates for both femoropopliteal and femorocrural bypass procedures. The in situ graft needs more secondary interventions.     

Polytetrafluoroethylene grafts as the first-choice arterial substitute in femoropopliteal revascularization

We studied a series of femoropopliteal bypass operations in which polytetrafluoroethylene (PTFE) grafts were used as the first choice, regardless of the availability of saphenous vein. From Jan 1, 1979 to Dec 31, 1982, 63 PTFE femoropopliteal bypass grafts were placed in 55 patients without exploration of the saphenous vein. Forty-three grafts were placed for limb salvage, and 20 grafts were placed for disabling claudication. Patients were followed up for nine to 53 months (average, 23 months). The operative mortality was 1.8%. There were no infections. The overall patency at 30 months was 76.1%. The 30 months' cumulative patency rate for patients with claudication was 89.3%, and there were no amputations. The cumulative 30-month patency for limb salvage was 70.1%, and there was a limb salvage rate of 81.2%. Because the 30-month results were comparable with reported series using autogenous saphenous vein, we concluded that PTFE conduits may be considered the first-choice arterial substitute for femoropopliteal reconstruction. Until longer follow-ups are available, reversed autogenous saphenous vein should probably be the graft of first choice in younger patients (less than 60 years of age) without coronary artery disease who are undergoing femoropopliteal revascularizations.     

Autogenous arterial bypass grafts: durable patency and limb salvage in patients with inframalleolar occlusive disease and end-stage renal disease

OBJECTIVE: The purposes of this study were to determine whether autogenous arterial grafts to distal pedal arteries improve the patency of grafts and limb salvage in patients with end-stage renal disease and nonhealing ischemic wounds and to better define the indications for autogenous arterial grafts. DESIGN: A review of consecutive patients with end-stage renal disease undergoing autogenous arterial grafts from 1994 through 1999 was carried out. The setting was a university hospital. All 11 patients with end-stage renal disease and nonhealing, ischemic wounds (stage IV SVS-ISCVS classification) undergoing autogenous arterial grafting from 1994 to 1999 were evaluated. Noninvasive studies confirmed inadequate perfusion pressures in all patients. Pre-bypass arteriography identified no major arteries patent at the level of the malleolus, with reconstitution of only a distal or branch pedal or plantar vessel less than 1 mm in diameter. Five patients with patent tibial vessels to just above the ankle underwent bypass surgery with autogenous arterial grafts alone. Six patients also had proximal occlusive disease that required grafts longer than the autogenous arterial grafts; in each of these six patients, an autogenous vein graft proximal to the autogenous arterial graft was placed through use of a composite technique. Inflow was from the common femoral artery in one patient, the popliteal artery in five patients, and a tibial artery in five patients. Outflow was to the medial plantar artery in five patients, the distal dorsalis pedis artery in three patients, the lateral plantar artery in two patients, and the superficial arch in one patient. The conduit was the subscapular artery in four patients, the deep inferior epigastric artery in four patients, the superficial inferior epigastric artery in two patients, and the radial artery in one patient. The main outcome measures were assisted primary graft patency and functional limb salvage rate. RESULTS: Follow-up ranged from 6 to 63 months (mean, 20 months); graft patency was determined by means of duplex scanning. All 11 patients are alive, and nine grafts are patent, including three after revision for graft stenosis. Assisted primary patency was 82% at 3 years. All nine patients with patent grafts remained ambulatory and had healed wounds or limited forefoot amputations. CONCLUSION: Autogenous arterial grafts were effective in treating limb-threatening ischemia in patients with end-stage renal disease and inframalleolar arterial insufficiency. Graft patency and limb salvage rates were higher than those reported for autogenous vein graft in these patients. Autogenous arterial grafting may therefore prove to be an effective alternative to autogenous vein grafting in selected patients.     

Early results of a prospective randomized trial of spliced vein versus polytetrafluoroethylene graft with a distal vein cuff for limb-threatening ischemia

OBJECTIVE: Single-piece vein remains the conduit of choice in patients who need bypass grafting for limb salvage. When this option is not available, two of the remaining options are prosthetic bypass graft or several segments of vein spliced together. In this study, we compare spliced vein bypass grafting versus polytetrafluoroethylene grafting with a distal vein cuff in patients with limb-threatening ischemia. METHODS: Between 1996 and 2000, 39 bypass grafting procedures in 36 patients were performed for limb-threatening ischemia. These procedures were prospectively randomized to either spliced vein bypass grafting (spliced group, 19 bypass grafts) or polytetrafluoroethylene grafting with a distal vein cuff (cuff group, 20 bypass grafts). All the patients in the cuff group underwent anticoagulation therapy with warfarin sodium after surgery. The inclusion criteria included: no single-piece vein option for bypass grafting, adequate vein for splice, no composite sequential option, and limb-threatening ischemia. The demographics were similar between the two groups. RESULTS: The primary patency rate at 2 years was 44% and 49% for the spliced and cuff groups, respectively. In the spliced group, seven of 19 bypass grafts underwent revision in the follow-up period, and two of 20 cuffed bypass grafts were successfully revised. The secondary patency rate was 87% and 59% (P <.05), with limb salvage rates of 94% and 85% for spliced and cuff groups, respectively. Four patients in the spliced vein group needed reoperation for wound complications related to vein harvest. One polytetrafluoroethylene graft needed removal for infection. Two early mortalities occurred in the spliced group, one from myocardial infarction and one from stroke. The overall survival rate at 2 years between the two groups was 67% and 100% for the spliced and cuff groups, respectively (P <.05). CONCLUSION: Although this is a preliminary report, it appears that both spliced vein bypass grafting and polytetrafluoroethylene bypass grafting with a distal vein cuff produce acceptable limb salvage rates. The secondary patency rate for spliced vein is better, but these bypass grafts more often need revision or reoperation for wound complications.     

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.     

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.     

In situ tibial reconstruction. State-of-the-art or passing fancy.

To further evaluate the efficacy of in situ saphenous vein bypass, the authors have reviewed their experience with in situ bypass. Between October 1981 and December 1985, 120 in situ saphenous vein bypass were performed; 81 were to infrapopliteal vessels. All procedures were performed for limb salvage. The mean patient age was 74 years, and 74% were men, 57% had diabetes mellitus, 92% were smokers, and 72% had hypertension and/or coronary artery disease. All patients were evaluated by preoperative noninvasive testing and biplanar angiography. All procedures were performed by the valve incision technique. The vein utilization rate was 91%. Grafts were routinely placed into isolated tibial segments and foot vessels without evidence of a patent pedal arch. Follow-up information was obtained at 3-month intervals. Patency and limb salvage data were calculated by life-table analysis. The cumulative patency rates were 98% at 1 month, 88% at 12 months, and 82% at 50 months. These data demonstrate that the in situ bypass maintains an excellent patency rate and provides durable limb salvage.