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.     

上肢人工血管动静脉内瘘通畅率的影响因素分析

回顾性分析本中心建立上肢人工血管动静脉内瘘的123例患者的临床资料,探讨通畅率的影响因素.结果 发现,校正变量后有糖尿病史者和高血压史者初级通畅率降低风险显著增加(P=0.040,P=0.015),而辅助初级通畅率降低风险无明显增加(P=0.288,P=0.155).因此糖尿病史和高血压病史是人工血管动静脉内瘘初级通畅率降低的独立危险因素,由于各纳入分析因素对次级通畅率无明显影响,故患者相关因素不应成为构建人工血管动静脉内瘘评估中的阻碍.     

Factors influencing patency of infrainguinal bypasses with polytetrafluoroethylene

This retrospective study was undertaken to investigate the patency and limb salvage rates of 308 PTFE infrainguinal bypasses in 272 patients over a 5-year period. In addition a univariate analysis was performed to identify factors that could predict the outcome of these operations. Long-term survival was 83% and 50% at one and five years respectively. For the whole series the primary cumulative patency at one and five years was 70% and 41% respectively. Graft revision for failed or failing grafts resulted in secondary patency rates of 78% and 43% for the same periods. The limb salvage rates were 93% and 84% at one and five years. Patency rates showed no statistical significant difference for gender, age at operation or the use of a venous cuff at the distal anastomosis. Although there was a tendency towards better results for above the knee operations, this difference failed to achieve statistical significance. Only redo operations were associated with a significant worse outcome.     

Six year experience with expanded polytetrafluoroethylene arterial grafts for limb salvage

We have used 822 polytetrafluoroethylene (PTFE) grafts in arterial reconstructions for limb salvage over the last 6 years at Montefiore Medical Center-Albert Einstein College of Medicine, Four hundred and twenty-seven femoropopliteal reconstructions with PTFE had a 6 year cumulative life table patency rate of 55% with follow-up of 76 grafts for more than 3 years and 28 grafts for more than 4 years. Seventy-nine bypasses to the isolated popliteal segment had a 6 year cumulative patency rate of 72%. There were 207 bypasses performed to the tibial, peroneal or dorsalis pedis arteries. Life table patency rates were 55% at 1 year, 40% at 2 years and 37% at 4 years. Ninety-two PTFE femorofemoral and 62 axillofemoral bypasses had 5 1/2 year cumulative life table patency rates of 83% and 75%, respectively. Axillopopliteal PTFE bypasses can salvage otherwise doomed limbs. Thirty-four such grafts had 74% 1 year and 45% 5 year patency rates. The overall infection rate in all 822 PTFE grafts was only 0.5%. Thus, PTFE is a promising vascular prosthetic material which facilitates otherwise difficult or impossible limb salvage procedures.     

Infrapopliteal polytetrafluoroethylene and composite bypass: Factors influencing patency

Between January 1, 1979, and December 31, 1988, 149 infrapopliteal polytetrafluoroethylene (PTFE) bypasses were performed in 145 patients with chronic, critical, limb-threatening ischemia. These operations represented 27.9% of 534 infrapopliteal bypasses performed during the same period. There were 92 males and 53 females. Mean age was 71.8±12.3 years. Signs and symptoms of critical ischemia were gangrene, ulceration, and isolated rest pain in 101 (69%), 23 (15.3%), and 25 (16.7%) cases, respectively. A composite (PTFE-saphenous vein) graft was used in 53 (35%) cases. In 96 prosthetic bypasses the distal anastomosis was performed using vein patch angioplasty in 65 (44%) cases and directly in 31 (21%). The in-hospital mortality rate was 3.3%. Patency, limb salvage, and patient survival rates were plotted according to the actuarial method and the curves obtained were compared using the log-rank test. Actuarial survival rates were 68%±5% and 57%±7% at 3 and 5 years, respectively. Primary patency and lower limb salvage rates were 41%±5% and 68%±6% at 3 years and 35%±9% and 65%±10% at 5 years, respectively. There was no statistically significant difference noted in primary patency rates at 3 years according to the type of bypass (composite or all-prosthetic: 36% vs. 44%), the type of distal anastomosis (direct or vein patch angioplasty: 43% vs. 45%), the site of distal anastomosis (upper or lower half of the leg: 38% vs. 46%), lateral or medial placement of the bypass (39% vs. 43%), or according to whether or not it was a repeat operation (40% vs. 44%). In conclusion, patency rates using infrapopliteal PTFE bypasses are low. Certain technical approaches, although they do not seem to improve patency, definitely increase the feasibility of bypass and in our opinion decrease the risk of early failure in unfavorable anatomic settings. The limb salvage rates following infrapopliteal PTFE and composite bypass are encouraging and justify the use of routine distal revascularization, even in the absence of autogenous vein graft.     

Three year experience with expanded polytetrafluoroethylene arterial grafts for limb salvage

Polytetrafluoroethylene grafts were used for 175 femoropopliteal reconstructions with a cumulative 3 year life table patency rate of 77 percent. Reoperation for early or late failure was required in 27 patients to achieve this patency rate. If these 27 failures were calculated as nonpatent grafts, 3 year patency would be 62 percent. Thirty month life table patency rates were 94 and 91 percent for polytetrafluoroethylene axillofemoral and femorofemoral bypasses, respectively. Twenty-two polytetrafluoroethylene axillopopliteal bypasses were performed because of infection in the groin, previously failed reconstructions or unavailability of femoral vessels due to disease. The 2 year life table patency rate was 69 percent, with nine of the grafts patent for more than 1 year. Forty polytetrafluoroethylene bypasses to arteries at the ankle or in the foot resulted in a 2 year life table patency rate of 48 percent. Thus, polytetrafluoroethylene grafts show early promise as a vascular prosthesis. Although further study will be required to define the exact role of this new arterial substitute, it already can facilitate the performance of otherwise difficult or impossible limb salvage procedures.     

肿瘤型假体翻修手术的相关策略

[目的]分析肿瘤型假体置换术后翻修手术的原因，探讨手术的策略。[方法]10a间完成5例患者的肿瘤性假体翻修手术。男4例，女1例；平均年龄41．2岁。股骨远端4例，胫骨近端1例。再手术时间3．29a。翻修手术的原因均为假体松动，其中2例患者伴有窦道，1例假体远端断裂。翻修手术时2例应用原假体，3例应用新制作的假体，改为旋转铰链膝关节。[结果]本组5例均获得随访，最长为5a，最短为1a，平均为2a 4个月。5例均无瘤生存，假体无松动，切口愈合良好，关节功能的评分为21．5分。[结论]对于出现假体松动的患者，应及时行翻修手术，可获得较理想的肢体功能。     

Tibial bypass for limb salvage using polytetrafluoroethylene and a distal vein patch

OBJECTIVE: Tibial artery bypass for limb salvage may be required in patients without adequate autogenous vein. The interposition of venous tissue at the distal anastomosis has been advocated to improve the results of prosthetic grafts to tibial arteries. Having reported on technical feasibility and an early experience with polytetrafluoroethylene (PTFE) and a distal vein patch (DVP), we examine the results of this technique with 4-year follow-up. METHODS: From July 1993 to July 1999, 514 tibial bypass grafts were performed, with 80 bypass grafts in 79 patients with PTFE/DVP as the conduit. Patient demographics included 39 men and 40 women (mean age, 67 years); 42 had diabetes mellitus (53%), 16 had renal failure (20%), and 48 had Eagle criteria for increased cardiac risk (60%). Indications for revascularization were rest pain in 39 (49%) and tissue loss in 41 (51%). Lack of adequate vein resulted from previous failed lower extremity bypass graft (47 [59%]), previous coronary bypass graft (21 [26%]), unsuitable vein (8 [10%]), and absent vein due to ligation and stripping (4 [5%]). Follow-up ranged from 1 to 48 months. Results are reported as primary patency or limb salvage +/- SE. RESULTS: Bypass grafts originated from the common femoral artery (40 [50%]), the superficial femoral artery (6 [8%]), and the external iliac artery (34 [43%]). Recipient arteries included anterior tibial (17 [21%]), posterior tibial (28 [35%]), and peroneal (35 [44%]). Four-year primary patency and limb salvage rates were 62.89% +/- 10.6% and 79.21% +/- 8.45%, respectively. There was a 24% mortality rate during the follow-up period. Acute failure occurred in 7 grafts with 5 immediate amputations and 2 revisions. A total of 17 grafts failed during the follow-up period, leading to 11 amputations. CONCLUSION: The DVP technique allows PTFE bypass grafts to tibial arteries with acceptable long-term patency and limb salvage.     

In vivo patency of endothelial cell-lined expanded polytetrafluoroethylene prostheses in an ovine model

The performance of small-diameter vascular prostheses may be improved by implantation of grafts lined with endothelial cells. Expanded polytetrafluoroethylene (ePTFE) prostheses (4 mm x 40 mm) were coated with fibronectin (20 micrograms/ml), seeded with endothelial cells, and cultured for 48 h to produce a confluent, autologous endothelial cell lining. They were implanted as carotid interposition grafts in sheep. Seeded ePTFE grafts were compared with nonseeded ePTFE grafts and autologous carotid artery grafts. No anticoagulant or antiplatelet therapy was administered, making this a stringent test model for the thromboresistance of a small-diameter prosthesis. After 13 weeks the patencies of seeded, nonseeded, and autologous artery grafts were 16% (1/6), 0% (0/6), and 100% (6/6), respectively. The one seeded graft that was patent was fully lined with endothelial cells and showed no stenosis. The remaining five seeded grafts were occluded by fibrous tissue and displayed substantial spindle cell hyperplasia. There was no apparent difference between the autologous artery grafts and normal arterial tissue, and the anastomoses showed no stenosis. The ovine model provides a conservative test of prosthesis survival and may be useful for study of graft failure.     

Distal arterial reconstruction: patency and limb salvage in diabetics

Controversy regarding efficacy and durability of distal bypass grafting of the diabetic patient exists. A 22-year-long series of 259 vascular procedures with 100% follow-up (57% in diabetic individuals) is examined to compare these results with those of non-diabetic patients. Extensive review of predisposing factors, operative indications, preoperative medical evaluation, as well as techniques and peculiarities of angiography is rendered. Peripheral arterial case mix between the two groups is examined. The high utilization rate of solely venous conduits (94%) in diabetics compared with 76% in nondiabetics, along with anastomosis site selection, provides the most reasonable explanation for the successful outcome in both groups. Modifications in revascularization techniques contributing to successful outcome are presented. In the diabetic patients, both the cumulative graft patency rate (63%) and the limb salvage rate (77%) at 6 years were superior to those of the non-diabetics (52% and 65%, respectively). Diabetes mellitus does not predispose the person requiring revascularization for limb salvage to a lesser likelihood of success.     

Single limb patency of polytetrafluoroethylene dialysis loop grafts maintained by traumatic fistulization

The purpose of this report is to describe an unusual presentation of obstructive neointimal hyperplastic lesions in loop prosthetic dialysis grafts. The case histories and imaging studies of two patients with partial graft thrombosis are presented. The literature of unexpected fistulae from prosthetic dialysis grafts to adjacent veins is reviewed. Signs and symptoms that would lead a clinician to suspect the diagnosis are emphasized. There were two dialysis grafts with partial thrombosis and arterial limb patency maintained by iatrogenic fistula. These fistulae occurred from the erosion of pseudoaneurysms in one case and an apparent needle stick without pseudoaneurysm in the other. Both grafts had high-grade stenotic lesions affecting the venous outflow. In the first case this was not recognized until the graft reclotted 2 days after thrombectomy. In the most extreme cases of graft/vein fistulae, i.e., partial graft thrombosis with arterial limb patency maintained by the fistula there is always associated venous anastomotic or outflow stenoses which must be addressed. Correspondence to: A. Hooson, Oregon Surgical Consultants, P.C., 1130 NW 22nd Avenue #300, Portland, OR 97210, USA.     

Analysis of factors influencing early patency of saphenous vein grafts

To determine factors affecting early patency of saphenous vein grafts, 140 grafts in 65 patients were studied angiographically within 2 months after operation. Twenty of the 140 grafts were occluded. Sixteen variables were extracted from the angiographic findings, intraoperative measurements, clinical characteristics, and biochemical data. The univariate and multivariate analyses were performed to assess their predictive value. Of 16 variables, 3 (coronary artery internal diameter, graft flow, and coronary artery resistance) correlated significantly with graft patency in the univariate analysis. The multivariate analysis selected coronary artery resistance, coronary artery internal diameter, and degree of proximal stenosis as predictors of early graft patency. Of these 3 factors, the coronary artery resistance influenced graft patency mostly. Therefore, the coronary artery resistance was considered to be the most reliable predictor of early graft patency.     

Survival and limb salvage in patients with infected arterial prostheses

A series of 590 cases with a 2.5% rate of infection of arterial prostheses is presented. When one of the anastomoses was in the inguinal area, the incidence of prosthetic infection was higher. Two infections not involving the anastomotic site healed with conservative management. The three patients with aortoduodenal fistulas died. The long-term survival was 62%, and the amputation rate was 31%. During the last two years, a more aggressive surgical approach of total removal of the infected prosthesis and its replacement with an extraanatomic bypass has been instituted. With this approach, only one death and one amputation has occurred in six patients.     

The use of expanded microporous polytetrafluoroethylene for limb salvage: a preliminary report.

Initial laboratory and clinical evaluations of a new prosthetic material, expanded microporous polytetrafluoroethylene (PTFE), for small vessel replacement is promising and encourages further clinical trial. Frequently the autogenous saphenous vein is not available for bypass procedures, and alternative arterial substitutes have not proved reliable for replacement of small vessels. In this study, 15 patients with impending loss of limb and no available saphenous vein underwent revascularization of the lower extremity with expanded microporous PTFE grafts. Thirteen of 15 patients now demonstrate viable extremities with a resulting over-all early patency and limb salvage rate of 87 percent for this series. Follow-up ranges from one to 8 months. Seven patients had diabetes mellitus and eight had atherosclerotic heart disease. Nine grafts crossed the knee joint. In all patients arterial runoff was poor. Six patients had previous femoropopliteal bypasses, five with autogenous veins and one with Dacron velour. Two patients had multiple previous operations that failed, first with autogenous vein and later with fabric grafts. The current limb salvage and patency rate of 87 percent in high-risk patients suggests that expanded PTFE may be the prosthesis of choice when an autogenous vein is not available and possibly an equally good substitute when the venous autograft is available.     

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.     

Analysis of factors affecting limb salvage and mortality after embolectomy.

A series of 108 arterial embolectomies in 91 patients performed during 1960-64 and 1970-74 is presented. The Fogarty catheter was introduced in our clinic between these periods. Early mortality was 56 and 29%, respectively. Limb salvage rate according to our definition was 38 and 53%, respectively. We found a significantly higher mortality when embolies were located proximal to the profunda femoral artery compared to more distally located embolies. Amputation frequency was 4% after embolectomies performed within 12 hours, but 27% with longer duration of symptoms. Limb salvage rate was significantly higher in patients treated with anticoagulation. In conclusion it is stressed that local surgical therapy should be combined with adequate measures against cardiac failure and other systemic complications. This therapeutic principle is particularly important in cases with proximal embolies.     

Initial experience with the polytetrafluoroethylene graft for limb salvage. A report on twenty patients

The early results of the bypass procedures for limb salvage using the new polytetrafluoroethylene (PTFE) graft are analyzed. Of twenty patients presenting with either severe rest pain or gangrene, patency has been maintained in fourteen for a mean period of thirteen months to date. Particularly satisfying results have been achieved when bypassing into single dominant arteries below the knee where limb salvage and graft patency was obtained in all cases.     

Profundoplasty for limb salvage

Profundoplasty was performed in 26 legs because of rest pain or gangrene; previous arterial reconstruction had been done in 12 of them. In 16 limbs the popliteotibial segment was patent; profundoplasty was successful in each case. In 10 limbs the popliteotibial segment was occluded, and profundoplasty failed in one instance. One patient died. The authors believe that re-establishing blood flow and pressure to the deep femoral artery, especially to the descending branch of the lateral circumflex artery and the distal part of the deep femoral artery can effectively improve the condition of ischemic legs.