Distal venous patch improves results in PFTE bypasses to tibial arteries

In recent years, the management of limb-threatening ischemia has involved the use of distal bypasses to vessels beyond the popliteal trifurcation. Excellent patency rates and limb salvage data are achieved through the use of autologous long saphenous vein. However, an increasing number of patients in need of tibial bypass do not have adequate saphenous vein due to previous procedures, thrombophlebitis, or inadequate vein. In such cases alternative conduits have been proposed including lesser saphenous vein, arm vein, composite veins, composite vein with polytetrafluoroethylene (PTFE), and PTFE with or without a distal arteriovenous fistula. Unfortunately these alternative conduits have not resulted in equivalent results when used for distal bypass to tibial arteries. Several authors have reported upon the use of venous tissue at the distal anastomosis in the form of cuffs, collars, and boots to improve the results of prosthetic grafts in this challenging patient population. These techniques have been proposed as an option for revascularization in patients without adequate saphenous vein in an attempt to obtain limb salvage. The purpose of this review is to examine some of those techniques and focus on distal vein patch configuration with its perceived advantages and drawbacks.     

Below-knee bypass for limb salvage. Comparison of autogenous saphenous vein, polytetrafluoroethylene, and composite dacron-autogenous vein grafts

Autogenous saphenous vein was used preferentially for 92 below-knee bypass procedures (44 femoral-distal popliteal and 48 femoral-distal tibial or peroneal) performed for limb salvage in 87 adult male patients during a 30-month period of study. When a saphenous vein was unavailable or of unsuitable length or diameter, we randomly used expanded polytetrafluoroethylene (PTFE) and composite Dacron-autogenous vein (DV) grafts. With good run-off, all grafts have remained patent. However, with poor run-off, cumulative patency by the life table method decreased to 54% for autogenous saphenous vein and 45% for PTFE, which was not significantly different. All composite DV grafts used with poor run-off became occluded within the first ten months of the study. We continue to recommend use of autogenous saphenous vein for revascularization of the ischemic lower extremity. When a suitable saphenous vein is unavailable, PTFE is a satisfactory alternative graft that is superior to composite DV grafts.     

Staged infrainguinal revascularization: initial prosthetic above-knee bypass followed by a distal vein bypass for recurrent ischemia. A valid concept for extending limb salvage?

Optimal infrainguinal revascularization should provide limb salvage for the longest duration of time. It is not known whether limb salvage is longer with an initial below-knee popliteal or tibial in situ saphenous vein graft or with staged bypasses; that is, an initial above-knee popliteal prosthetic bypass if feasible, followed by a more distal vein graft should the above-knee prosthetic graft fail. A retrospective review of 197 lower extremity vascular reconstructions performed since 1976 utilizing polytetrafluoroethylene (PTFE), umbilical vein, or in situ saphenous vein was completed. The data were analyzed for differences in limb salvage and prevention of limb threatening ischemia among three subgroups: above-knee prosthetic bypass, below-knee or tibial in situ saphenous vein bypass, and staged reconstructions (above-knee prosthetic bypass with subsequent in situ bypass). The groups were similar with respect to severity of limb threatening ischemia as indicated by mean preoperative ankle-brachial indices. Cumulative secondary limb salvage at 36 months was 73 percent for prosthetic grafts in the above-knee position, 78 percent for in situ saphenous vein grafts in the below-knee or tibial position, and 87 percent for staged reconstruction with an initial prosthetic graft to the above-knee position followed by a distal in situ vein bypass when the prosthetic graft fails.     

Expanded microporous polytetrafluoroethylene as a vascular substitute: a two year follow-up.

Since 1974, 131 femoropopliteal, distal popliteal, and tibial bypasses have been performed using expanded microporous polytetrafluoroethylene (PTFE). Forty patients were operated on for limb salvage, and 21 had had previous bypass procedures. The overall patency rate was 82%. Early occlusions possibly were related to technical error, but most probably were due to severity of disease and poor runoff. Late occlusions were related to progressive atherosclerosis in the proximal or distal arterial tree. A 75.7% cumulative patency rate was noted at 28 months. In man the PTFE prosthesis demonstrates a smooth intimal lining with fibroblastic ingrowth into the interstices of the graft. These results are considered to be excellent in this high-risk patient population. The patency rates achieved with PTFE are better than those accomplished with alternative conduits and approach the patency rates reported with autogenous saphenous vein. Expanded microporous polytetrafluoroethylene with its high patency, pliability, and tissue incorporation is an excellent arterial substitute. Only with continued use of this material and a more uniform patient selection can more equitable comparisons be made between expanded PTFE and the autogenous vein.     

Which distal anastomosis should be used in PTFE femoro-tibial bypass?

AIM: The PTFE prosthesis represents an alternative to the autologous saphenous vein in femoro-tibial revascularization for limb salvage in the absence of venous material in the patient. The aim of our study is to confirm the validity of PTFE revascularization and determine the best distal anastomosis in terms of patency using 3 different techniques. We carried out a retrospective analysis, evaluating patients who underwent PTFE femoro-tibial revascularization for critical ischemia. METHODS: Between January 1998 and June 2002 we performed 46 femoro-tibial revascularizations at the Vascular Surgery Division of the Poliambulanza Hospital in Brescia using a PTFE prosthesis, from a total of 192 infrainguinal revascularizations (24%). All patients presented a critical ischemia, with trophic lesions or gangrene in 76% of the cases (35/46) and who were previously treated unsuccessfully with medical therapy. Seventeen cases (36%) were a redo bypass due to previously failed revascularization. In all cases the saphenous vein was not available due to past peripheral or coronary revascularization (45%), saphenectomy (20%) or inadequate diameter (35%). The distal anastomoses were performed on the peroneal artery in 29 cases, on the anterior tibial artery in 14 cases and on the posterior tibial artery in 3 cases. The distal anastomosis was performed by interposing a segment of vein between the prosthesis and the tibial artery in 12 cases; in 22 cases the interposition was performed using a vein patch, and in the remaining 12 cases a PTFE prosthesis provided with a premanufactured expanded anastomosis (Distaflo(c)) was used. RESULTS: Average follow-up was 22.5 months (range: 3-48 months). The primary and secondary patency rate at 48 months, calculated with the Life table method, was 35% and 47%, respectively. Limb salvage in the same time period was 56%. Depending on the anastomosis performed (Distaflo(c), vein patch, distal vein) we obtained a secondary patency rate of 31%, 62%, and 44% respectively after 48 months with a significant difference between distal vein patch and the other two anastomoses (p<0.001). CONCLUSIONS: The PTFE bypass on the tibial artery performed for limb salvage in the absence of a saphenous vein represents a valid alternative to other types of prostheses with a patency percentage that is acceptable in the medium term. Within our study population, anastomosis by vein patch interposition gave better results than other types of tibial anastomosis.     

The multiple sequential distal bypass graft: seven-year follow-up

Thirty-nine infrainguinal bypass grafts with multiple sequential distal anastomoses were performed on 35 patients ranging in age from 32 to 79 years (mean 65.8 years) with severe femoropopliteal occlusive disease. Thirty-eight procedures were performed for limb salvage indications. Distal anastomoses were performed to the popliteal-anterior tibial arteries in seven procedures, the popliteal-posterior tibial arteries in six, the popliteal-peroneal arteries in six, the anterior tibial-peroneal arteries in eight, the posterior tibial-peroneal arteries in 10, and the posterior tibial-anterior tibial arteries in two. Saphenous vein was the graft material in 31 procedures (in situ in two), polytetrafluoroethylene (PTFE) in four, and saphenous vein-PTFE composite in four. The mean Doppler ankle-arm index was 0.38 +/- 0.14 preoperatively and 0.89 +/- 0.13 postoperatively. The early (30-day) graft patency rate was 93%. With life-table analysis, the long-term primary patency rate was 70% at 1 year, 61% at 3 years, and 52% at 7 years for saphenous vein grafts; the secondary patency rate was 65% at 7 years for saphenous vein grafts. The secondary patency rate for PTFE and PTFE-vein composite grafts was 75% at 1 year, 50% at 3 years, and 17% at 5 years. Cumulative life-table limb salvage rates were 91% at 1 year, 85% at 5 years, and 61% at 7 years. The multiple sequential distal bypass graft is durable and highly efficacious in achieving limb salvage.     

Infragenicular Bypass Graft for Limb Salvage Using Polytetrafluoroethylene and Distal Vein Cuff as the First Alternative in Patients Without Ipsilateral Greater Saphenous Vein

The objectives of this study were to evaluate the results of polytetrafluoroethylene infragenicular bypass grafts with a distal interposition vein cuff in patients with critical limb ischemia in the absence of ipsilateral greater saphenous vein. From January 1997 to June 2002, 58 consecutive below-knee bypass grafts with PTFE and distal interposition vein cuff were performed in 57 patients with a median age of 70.8 years. The distal anastomosis was located at the infragenicular popliteal artery in 18 cases and at tibial vessels in 40. Primary patency, secondary patency, and limb salvage were analyzed using the Kaplan-Meier method. During a median follow-up of 14.4 months (range, 1-50) 26 cases of graft occlusion and 19 major amputations were registered. The primary and secondary patency rates at 12, 24, and 36 months were 57%, 54%, and 47% and 61%, 58%, and 50%, respectively. Limb salvage rates reached 69%, 69%, and 59% at 12, 24, and 36 months. When below-knee revasculanzation is required in patients with limb-threatening ischemia, in the absence ipsilateral greater saphenous vein, PTFE grafts with a distal vein cuff are a reasonable substitute with acceptable long-term patency and limb salvage rates.     

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.     

Technical modifications in endoscopic vein harvest techniques facilitate their use in lower extremity limb salvage procedures

OBJECTIVE: We describe and report our results using endoscopic vein harvest (EVH) for lower extremity arterial bypass procedures, following the implementation of technical modifications specific to patients undergoing limb salvage procedures. METHODS: We underwent training in EVH, followed by implementation of the technique in patients requiring limb salvage for lower extremity ischemia and aneurysms. After technical modifications in the technique were developed for limb salvage, we reviewed our experience in all patients who underwent minimally invasive distal bypass with EVH. RESULTS: Technical modifications include limited arterial dissection before vein harvest, the use of proximal and distal leg incisions for both exposure of arterial vessels and saphenous vein harvest, improved hemostasis techniques in the vein graft tunnel, avoidance of compression wraps to the ipsilateral harvest tunnel, complete removal of the vein with either reversed or nonreversed graft placement, and use of the endoscopic tunnel for conduit placement. Thirteen patients (14 limbs) have undergone minimally invasive distal bypass since technical modifications were implemented. Indications for EVH were rest pain (n = 12; 85.7%) and tissue loss (n = 8; 57.1%). Veins harvested were the ipsilateral great saphenous vein (n = 10; 71.4%), contralateral great saphenous vein (n = 2; 14.3%), and short saphenous vein (n = 2; 14.3%). No venous injuries occurred during endoscopic harvest, and all were used for bypass. Thirty-day primary and primary assisted patency rates were 85.7% and 92.9%, respectively. The limb salvage rate was 100%. Two patients developed postoperative hematomas, one early and one late, as a result of anticoagulation for cardiac comorbidities. Both patients required reoperation for successful re-establishment of patency. There were no perioperative deaths and no postoperative wound infections or complications. Two patients required a later prosthetic bypass, and two required a vein graft angioplasty. Complete wound healing was achieved in 75% of patients with preoperative tissue loss. CONCLUSIONS: Technical modifications in endoscopic saphenous vein harvest techniques facilitate their use in lower extremity limb salvage procedures. Vascular surgeons should become familiar with these techniques to minimize vein harvest wound complications and extend the options for limb salvage conduits, including use of both the ipsilateral and contralateral saphenous vein and the short saphenous vein. Meticulous hemostasis within the tunnel after endoscopic conduit harvest and avoidance of postoperative anticoagulation should help to prevent postoperative hematoma formation and early graft occlusion.     

Cryopreserved saphenous vein homografts for femoral-distal vascular reconstruction

Cryopreserved saphenous vein homografts may serve as an alternative for femoral distal bypass conduits when suitable endogenous vein is not available. In a preliminary study, 6 patients underwent femoral distal bypass for limb salvage with cryopreserved saphenous vein with patency in 2 patients at 18 and 20 months, respectively. One graft, occluded at 14 months, was salvaged with thrombolytic therapy and percutaneous angioplasty, and is patent 7 months post intervention. Occlusion occurred in 3 grafts at 1 day, 7 days and 4 months, respectively. Reasons for reduced patency of cryopreserved grafts are related to destruction of the cellular components and fibrosis as a result of the cryopreservation and poor distal run-off present in these patients. Due to lower patency as compared to autogenous vein grafts, cryopreserved veins should be reserved for limb salvage when no autogenous vein is available for revascularization.     

复合血管序贯式旁路移植术治疗慢性肢体缺血的临床分析

目的:探讨复合血管序贯式下肢动脉旁路术治疗慢性下肢缺血的效果。方法:回顾性分析3年内采用复合式血管序贯式动脉血管重建的25例慢性下肢缺血患者的临床资料。复合血管由聚四氟乙烯（PTFE）人工血管及自体静脉组合而成。PTFE近心端与股总动脉吻合，远端与孤立腘动脉吻合；自体静脉从PTFE血管远端发出并与小腿的胫或腓动脉吻合。结果:自体静脉远端吻合口止于胫前动脉5例，胫后动脉8例，腓动脉12例。术后1，2，3年累积通畅率分别为78%， 72%， 61%。二期累积通畅率分别为83%，77%，68%。救肢率分别为83%，83%，73%。结论:复合血管序贯旁路术治疗慢性肢体缺血远期通畅率较高，具有较好的救肢效果，是解决自体静脉不足的合理选择。     

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

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

Patency of infrainguinal polytetrafluoroethylene bypass grafts with distal interposition vein cuffs

Polytetrafluoroethylene (PTFE) prosthetic bypasses in the lower extremity have poor patency rates, particularly in limb salvage cases. Patency and limb salvage rates of PTFE bypasses supplemented by distal interposition vein cuffs were assessed in patients requiring revascularization for critical limb ischemia, in the absence of a suitable autologous saphenous vein. Between October 1993 and April 1996, 163 patients underwent 185 infrainguinal bypasses. Forty-three limbs in 42 patients (12 women, 30 men; mean age 67 years) did not have a suitable autologous saphenous vein (24%) and had femoropopliteal (20) and infrapopliteal (23) bypasses performed. Patients were examined prospectively at 3-month intervals during the first year and at 6-month intervals thereafter to determine graft patency and limb salvage. Postoperative anticoagulation with warfarin was used in 26 patients. Indications for operation included limb salvage in 41 extremities (21 rest pain/ulceration or gangrene, 20 rest pain alone), and disabling claudication in two. Patients were followed clinically for 2–30 months (mean 10 months). Cumulative 2-year life-table patencies for all grafts, femoropopliteal and infrapopliteal bypasses were 64%, 75% and 62%, respectively. Previous primary patencies at the authors' institution for PTFE bypasses without vein cuffs were 35%, 46% and 12% for the same categories. Cumulative life-table limb salvage for all PTFE/vein cuff bypasses in the present series was 76% compared with 37% in previous PTFE bypasses without vein cuffs. Adjunctive use of distal interposition vein cuffs improves prosthetic graft patency, while producing satisfactory limb salvage. Postoperative anticoagulation did not influence graft patency. PTFE/vein cuff for lower-extremity revascularization shows good 2-year patency and is an acceptable alternate conduit in patients with critical limb ischemia when autologous saphenous vein is absent.     

Comparison of Preoperative Standard Angiography with Preoperative Balloon Occlusion Femoral Angiography of the Lower Extremity

The use of saphenous vein in situ bypass for limb salvage has increased the need for adequate visualization of distal lower extremity vessels. Preoperative angiographic techniques are often inadequate, requiring multiple films, extensive patient manipulation, or excessive dye loads. Intraoperative prereconstructive angiography permits adequate distal vessel visualization, but at a significant waste of time and expense if no usable distal vessels are found. There is a need for a reliable means of preoperative angiography in patients being evaluated for saphenous vein in situ bypass. Preoperative balloon occlusion femoral angiography was compared to preoperative standard angiography of the lower extremity in 39 patients referred to the University of Minnesota for limb salvage. Balloon occlusion femoral angiography significantly improved the preoperative ability to visualize lower extremity vessels distal to the superficial femoral artery in this group of patients.     

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.     

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.     

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.     

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.     

Outcomes of combined superficial femoral endovascular revascularization and popliteal to distal bypass for patients with tissue loss

Over the last 5 years there has been a significant shift toward lower limb revascularization using endoluminal techniques. However, in many instances endoluminal techniques alone are unable to salvage limbs that exhibit tissue loss. Many of these patients do not have adequate conduit for a long leg bypass, while tibial angioplasty does not appear to restore adequate perfusion to heal many significant foot lesions, making combined procedures attractive. However, previously available data evaluating combined endoluminal and bypass procedures have been too anatomically heterogeneous to be easily applied to patients with infrainguinal disease and tissue loss. From January 2002 to December 2005, intraoperative superficial femoral artery (SFA) percutaneous transluminal angioplasty (PTA) with selective stenting combined with simultaneous popliteal to distal vein bypass was evaluated in 22 limbs of 22 patients with isolated infrainguinal disease and tissue loss. There were 12 men and 10 women, average age 69. All the patients were diabetic, all had tissue loss, and three had end-stage renal disease (ESRD). Four patients underwent common femoral endarterectomy at the time of the SFA PTA; all had the PTA performed first, with antegrade punctures and flow maintained. Fourteen patients had PTA without stenting, eight had self-expanding stents placed for residual stenosis or dissection. There were no failures, with three TASC A, 13 TASC B, and six TASC C lesions addressed. The origin of the bypass was the above-knee popliteal in eight patients and the below-knee popliteal in 14 patients. The target vessel was the dorsalis pedis in six patients, the posterior tibial at the malleolus in three, the proximal posterior tibial in five, the peroneal in five, and the anterior tibial in three. The conduit was greater saphenous vein in 16 cases, femoral vein in three cases, and arm vein in three cases. Follow-up ranged from 3 months to 4 years. The primary patency rate was 21/22 (95%), and the secondary patency rate was 22/22 (100%). There was one amputation for ongoing gangrene in an ESRD patient with a patent bypass, resulting in an early limb salvage rate of 95%. For patients with inadequate conduit and tissue loss secondary to multilevel infrainguinal disease, simultaneous angioplasty with selective stenting of the SFA followed by distal vein bypass is a viable long-term solution that allows for limb salvage. Simultaneous performance is not associated with increased morbidity and decreases overall hospital use.     

Infrapopliteal-lower extremity revascularization with prosthetic conduit: a 20-year experience

The use of prosthetic conduits for lower extremity revascularization in the infrapopliteal location remains controversial. The objective of this report is to describe the immediate and long-term results in a series collected over two decades. Of the approximately 1,500 lower extremity revascularizations performed between 1978 and 1998, 81 infrapopliteal bypass cases using polytetrafluoroethylene (PTFE) as conduit in 77 patients were identified. Autogenous conduit was unavailable (86%) due to prior surgery: coronary artery bypass graft (25%), femoro-popliteal bypass (60%), or femoro-distal bypass (23%). All cases were done for critical ischemia using PTFE (6 mm, 95%; ring reinforced, 54%) under general (75%) or regional (25%) anesthesia. The distal anastomosis was to the anterior tibial artery (43%), posterior tibial artery (28%), tibioperoneal trunk (16%), or peroneal artery (12%), and vein patch was used in 25% of cases. Postoperative features included acute graft thrombosis in 11 cases (14%), all done under general anesthesia, perioperative death in 3 (4%), and a mean in-hospital stay of 17 days. Long-term follow-up has ranged from 1 to 144 months (mean, 22 months). At 36 months, primary patency was 20%, secondary patency 42%, and limb salvage 55% calculated by the Kaplan-Meier method. Univariate analyses revealed regional anesthesia was associated with prolonged primary patency (35% vs 15%, p=0.026) while the use of ring-reinforced PTFE conduit was associated with prolonged limb salvage (65% vs 40%, p=0.042). All other variables including gender, smoking, diabetes mellitus, renal failure, decade of operation, use of vein patch or postoperative warfarin were not significantly associated with either prolonged patency or limb salvage. Despite poor primary patency, distal prosthetic bypass can lead to long-term limb salvage. These data suggest distal anastomotic vein patches and postoperative anticoagulation may not be beneficial adjuncts. However, the use of regional anesthesia may decrease the incidence of perioperative thrombosis and the use of ring reinforced conduit may prolong limb salvage.