The use of arm vein conduits during infrageniculate arterial bypass.

To further examine the use of arm vein for bypass to the popliteal or infrapopliteal arteries, we retrospectively reviewed 43 patients undergoing infrageniculate arterial bypass by use of an arm vein as a conduit. Nine grafts were done to the below-knee popliteal artery and 34 to the infrapopliteal arteries. Six grafts were done by use of a single segment of an arm vein, whereas 37 grafts were composites of either multiple segments of arm vein (n = 19) or segments of saphenous and arm vein (n = 18). Mean follow-up time was 15 1/2 months. Initial (30-day) graft patency and limb salvage were 95%. Primary graft patency by life-table analysis was 67% at 1 year and 49% at 3 years. Follow-up examination detected graft stenosis before occlusion in six patients (all of whom were given anticoagulant medication) and three failing grafts were salvaged. This increased overall 3-year secondary graft patency to 64% and 3-year secondary patency for infrapopliteal bypasses to 66%. Eleven of 12 graft occlusions resulted in major amputations (eight were above the knee, and three were below the knee) so that limb salvage paralleled secondary graft patency (63% at 3 years). Thus arm veins provide an excellent alternative venous conduit for infrageniculate arterial bypass, even when composite venous grafts must be used.     

Late results of two hundred seventeen femoropopliteal bypasses to isolated popliteal artery segments

A 10-year-experience of 217 femoropopliteal bypasses to isolated popliteal artery segments in 207 patients is reported. Thirty-three femoropopliteal bypasses (15%) were performed with reversed saphenous vein and 184 (85%) with polytetrafluoroethylene grafts. Operative indications were gangrene in 121 (56%), nonhealing ulceration in 40 (18%), ischemic rest pain in 51 (24%), and claudication in 5 (2%) cases. The 5-year primary graft patency rate of these bypasses was 59% (reversed saphenous vein, 74%; polytetrafluoroethylene, 55%; p less than 0.05), the secondary 5-year graft patency rate was 61% (reversed saphenous vein, 79%; polytetrafluoroethylene, 56%; p less than 0.05), and the 5-year limb salvage rate was 78% (reversed saphenous vein, 78%; polytetrafluoroethylene, 78%). The 30-day operative mortality rate was 10%, and the 5-year patient survival rate was 38%. Eleven patients (5%) required lower extremity amputation because of progressive gangrene or extensive infection despite a patent bypass to an isolated popliteal artery segment. We conclude that femoropopliteal bypasses to isolated popliteal artery segments (1) have acceptable 5-year graft patency and limb salvage rates; (2) should be performed with reversed saphenous vein grafts when possible; (3) may be performed with polytetrafluoroethylene grafts if necessary, with a resulting limb salvage rate equal to that of reversed saphenous vein grafts; and (4) require sequential extension to an infrapopliteal artery in up to 20% of patients. In addition, the presence of an isolated popliteal artery segment is associated with a high operative mortality rate and limited life expectancy because of coronary artery disease.     

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.     

Distal polytetrafluoroethylene bypasses in patients older than 75 years

HYPOTHESIS: Polytetrafluoroethylene (PTFE) alone is justified for infrapopliteal arterial grafting in elderly patients with critical ischemia of the lower limbs who lack a suitable, autogenous saphenous vein. DESIGN: A consecutive sample clinical study with a mean follow-up of 16 months. SETTING: The surgical department of an academic tertiary care center and an affiliated secondary care center. PATIENTS: Thirty-one patients older than 75 years with critical ischemia of the lower limbs received 34 PTFE bypass grafts to the infrapopliteal arteries: 12 patients to the anterior tibial, 8 to the peroneal, 8 to the posterior tibial, and 2 to the dorsalis pedis artery. MAIN OUTCOME MEASURES: Cumulative survival, primary graft patency, and limb salvage rates expressed by standard life-table analysis. RESULTS: Operative mortality rate was 3%. Cumulative survival rate was 80% at 2 years (SE, 9.2%) and 43% at 3 years (SE, 11.4%). Cumulative primary patency rate was 67% at 2 years (SE 9.1%), and 61% at 3 years (SE, 12.7%). Cumulative limb salvage rate was 77% at 2 years (SE, 8.7%) and 70% at 3 years (SE, 12.8%). CONCLUSION: Polytetrafluoroethylene alone is justified as graft material for infrapopliteal bypass grafts in elderly patients with critical ischemia of the lower limbs and without a suitable autogenous saphenous vein.     

Durability of the in situ saphenous vein arterial bypass: a comparison of primary and secondary patency

The use of the saphenous vein in situ is associated with unique problems that decrease primary graft patency (patency uninterrupted by revision). During the past 5 years, we have performed 192 in situ saphenous vein bypasses in 182 patients, including 61 to the popliteal artery, 128 to infrapopliteal arteries, and three to isolated popliteal artery segments. The operative indications were critical limb ischemia in 178 cases (93%), popliteal aneurysm in eight cases (4%), and disabling claudication in six cases (3%). A progressive decline in primary patency occurred after operation. The primary patency rate at 36 months was only 48% for femoropopliteal bypasses and was 58% for femorotibial bypasses. In contrast, the secondary patency rate (patency maintained by thrombectomy, thrombolysis, or revision) at 36 months was 89% and 80% for femoropopliteal and femorotibial bypasses, respectively. The improved secondary patency was due to postoperative surveillance of graft hemodynamics and the success of graft revision. Problems unique to the in situ technique (incomplete valve incision, residual arteriovenous fistula, graft torsion and entrapment) accounted for 58% of early (less than 30 days) graft revisions and 52% of late revisions. The use of Doppler spectral analysis at operation and duplex scanning after operation can locate unsuspected technical errors and identify grafts with low flow at increased risk for failure. The primary patency of the in situ bypass mandates objective assessment of valve incision sites at operation and a protocol of postoperative surveillance to identify grafts that require revision. Early surgical intervention of hemodynamically abnormal but patent in situ bypasses is rewarded by excellent secondary patency.     

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.     

Reversed vein bypass to infrapopliteal arteries. Modern results are superior to or equivalent to in-situ bypass for patency and for vein utilization.

In recent years many reports have attributed improved patency and improved vein utilization with lower extremity arterial bypass to infrapopliteal arteries to the use of the in-situ vein graft technique (ISVB). This report describes 110 reversed vein bypasses (RVB) to infrapopliteal arteries performed from 1980-1986. Thirty-three per cent of these patients did not have an intact ipsilateral greater saphenous vein. One hundred per cent of patients had autogenous RVB performed using a variety of techniques, including vein splicing, use of arm veins, lesser saphenous veins, branch veins, and use of graft origins distal to the common femoral artery. The life table patency figures for these grafts are 90%, 85%, and 85% at 1 year, 3 years, and 5 years, respectively. The life table limb salvage at 5 years is 93%. These figures for patency, vein utilization, and limb salvage for modern RVB to infrapopliteal arteries are clearly equal to or superior to any reported figures for ISVB. Results for RVB are greatly improved when compared with historic controls, as are results for ISVB. There is no evidence to date demonstrating superiority of one technique versus another.     

Composite sequential grafts for femorocrural bypass reconstruction: experience with a modified technique

BACKGROUND: To evaluate the efficacy of a modification of the composite sequential femorocrural bypass graft that we adopted in 1985, a retrospective case-note study was undertaken. The grafts combined a prosthetic femoropopliteal section with a popliteal to crural section with autologous vein, linked via a common intermediate anastomosis sited on the above-knee popliteal artery. PATIENTS AND METHODS: Between 1985 and 2000, 68 grafts of this type were constructed in 65 patients with critical ischemia of the lower limb and insufficient autologous vein for construction of an all venous bypass. Reasons for insufficient long saphenous vein included previous lower limb bypass in 33 cases, phlebitis in 16 cases, venous hypoplasia in eight cases, and previous varicose vein surgery in seven cases. Distal anastomoses were carried out to the peroneal artery in 26 cases, the anterior tibial artery in 17 cases, the posterior tibial artery in 17 cases, and the pedal arteries in eight cases. Sources of vein included the long saphenous vein in 26 cases, the arm vein in 38 cases, and the short saphenous vein in two cases. In 22 limbs (32%), angiography had shown an occluded segment of above-knee popliteal artery, and in these cases, local popliteal disobliteration was performed to receive the composite anastomosis and to provide additional outflow. RESULTS: The 2-year cumulative primary patency, secondary patency, and limb salvage rates were 68%, 73%, and 75%, respectively. Localized popliteal disobliteration did not compromise graft patency (P =.07, with log-rank test). CONCLUSION: In the absence of sufficient autologous vein, patients needing bypass to crural arteries can be offered reconstruction with composite sequential grafting with satisfactory results. Furthermore, an occluded above-knee popliteal segment is not a contraindication for composite sequential bypass reconstruction.     

Totally autogenous venovenous composite bypass grafts. Salvage of the almost irretrievable extremity

When a suitable single length of saphenous or arm vein is unavailable, the elderly patient with a profoundly ischemic extremity, poor runoff, and a distal outflow vessel frequently undergoes amputation. Rather than performing primary amputation or resorting to nonautogenous conduites, we used 21 different combinations of available vein segments of ipsilateral or contralateral greater saphenous, lesser saphenous, cephalic, and basilic veins as composite autogenous bypass grafts. Fifty-four extremities, of which 21 (39%) had one or more failed previous bypasses, were revascularized. Tissue necrosis necessitated operation in 74% (40 instances) and rest pain in 19% (ten instances). All grafts extended below the knee, 22% (12 grafts) to the infrageniculate popliteal artery, 78% (42 grafts) to an infrapopliteal runoff vessel, and 28% (15 grafts) to the ankle or foot. The patency rate at one month was 81%. Thrombectomy alone or with local graft repair increased the one-month patency rate to 96%. At one year, the patency and limb salvage rates were 74% and 82%, respectively.     

High early patency of saphenous vein graft for coronary artery bypass harvested with surrounding tissue

BACKGROUND: Surgical trauma to the saphenous vein, used as a conduit for coronary artery bypass grafting, affects their occlusion rate. This study evaluates the early patency of saphenous vein grafts harvested with a pedicle of surrounding tissue that protects the vein from spasm and trauma. METHODS: Fifty-two patients underwent coronary artery bypass grafting with saphenous veins harvested with surrounding tissue. Forty-five patients, who received a total of 124 vein grafts and 42 left internal mammary arteries, underwent angiographic follow-up at a mean of 18 months (9 to 24 months). RESULTS: Patency for saphenous vein grafts was 95.4% and for left internal mammary arteries, it was 93.3%. Twenty-nine of 30 (96.7%) vein grafts anastomosed to arteries 2.0 mm or more, 65 of 67 (97%) grafts to 1.5 mm, and 10 of 13 (77%) anastomosed to 1-mm arteries were patent. Nineteen of 22 (86.4%) vein grafts with flow rates 20 mL/min or less, 32 of 34 (94.1%) with flow between 20 and 40 mL/min, and 50 of 51 (98%) with flow more than 40 mL/min were patent. Other registered surgical and clinical factors did not contribute to vessel occlusion. CONCLUSIONS: Early patency rate of saphenous veins harvested with surrounding tissue is very high, even in saphenous vein grafts demonstrating low blood flow. Preservation of graft endothelium using our harvesting technique may be the explanation of this success.     

Six-year prospective multicenter randomized comparison of autologous saphenous vein and expanded polytetrafluoroethylene grafts in infrainguinal arterial reconstructions

Autologous saphenous vein (ASV) and polytetrafluoroethylene (PTFE) grafts were compared in 845 infrainguinal bypass operations, 485 to the popliteal artery and 360 to infrapopliteal arteries. Life-table primary patency rates for randomized PTFE grafts to the popliteal artery paralleled those for randomized ASV grafts to the same level for 2 years and then became significantly different (4-year patency rate of 68% +/- 8% [SE] for ASV vs. 47% +/- 9% for PTFE, p less than 0.025). Four-year patency differences for randomized above-knee grafts were not statistically significant (61% +/- 12% for ASV vs. 38% +/- 13% for PTFE, p greater than 0.25) but were for randomized below-knee grafts (76% +/- 9% for ASV vs. 54% +/- 11% for PTFE, p less than 0.05). Four-year limb salvage rates after bypasses to the popliteal artery to control critical ischemia did not differ for the two types of randomized grafts (75% +/- 10% for ASV vs. 70% +/- 10% for PTFE, p greater than 0.25). Although primary patency rates for randomized and obligatory PTFE grafts to the popliteal artery were significantly different (p less than 0.025), 4-year limb salvage rates were not (70% +/- 10% vs. 68% +/- 20%, p greater than 0.25). Primary patency rates at 4 years for infrapopliteal bypasses with randomized ASV were significantly better than those with randomized PTFE (49% +/- 10% vs. 12% +/- 7%, p less than 0.001). Limb salvage rates at 3 1/2 years for infrapopliteal bypasses with both randomized grafts (57% +/- 10% for ASV and 61% +/- 10% for PTFE) were better than those for obligatory infrapopliteal PTFE grafts (38% +/- 11%, p less than 0.01). These results fail to support the routine preferential use of PTFE grafts for either femoropopliteal or more distal bypasses. However, this graft may be used preferentially in selected poor-risk patients for femoropopliteal bypasses, particularly those that do not cross the knee. Although every effort should be made to use ASV for infrapopliteal bypasses, a PTFE distal bypass is a better option than a primary major amputation.     

Redo bypass surgery to the infrapopliteal arteries for critical leg ischaemia.

OBJECTIVES: to evaluate the results of redo bypass surgery to the infrapopliteal artery and the value of adjuvant arteriovenous fistula (AVF) in this setting. DESIGN: retrospective study. MATERIALS: fifty-one redo reconstructions to the infrapopliteal arteries were done for critical leg ischaemia in 45 patients who have had primary infrainguinal reconstructions to the popliteal artery in 20 cases (39%), the crural arteries in 18 (35%), and the pedal arteries in 13 (25%). METHODS: a PTFE prosthesis was used in 21 cases (41%). A Miller cuff was used in 16 prosthetic grafts. Adjuvant AVF was added to three autogenous vein and 12 prosthetic grafts. RESULTS: at 2 years, the primary patency rate was 42%, the secondary patency was 43%, the limb salvage was 67%, the survival was 77%, and 53% of patients were alive with salvaged leg. The primary patency rate with a vein graft was 44% at 1 year, with prosthesis plus AVF 67%, but with prosthesis without AVF only 19%. Secondary patency rates were similar. Prosthetic graft with AVF and those without AVF achieved a 1-year leg salvage rate of 100% and 51%, respectively (p =0.01). Patients with adjuvant AVF had a worse 2-year survival rate that those without AVF (31% vs 89%) (p =0.007; RR: 8.87, CI 95%: 1.62-48.42). CONCLUSIONS: redo bypass surgery using autogenous vein graft may achieve satisfactory long-term results. The use of adjuvant AVF may improve patency of redo infrapopliteal prosthetic bypass grafts.     

56例腘动脉以下肢体动脉缺血的血管重建术分析

目的总结腘动脉水平动脉闭塞血运重建术治疗的临床疗效。方法对2001年7月至2005年8月56例累及腘动脉及腘动脉以下三分支病变重建肢体血运进行回顾性分析。根据病变阻塞平面不同,采用不同的血管架桥,对多平面、多节段动脉闭塞采用聚四氟乙烯人工血管和自体静脉桥复合序贯架桥血运重建。结果术后平均随访17个月,移植血管一期通畅率67．3％,二期通畅率78．8％。结论复合序贯搭桥术治疗累及股浅-腘动脉水平以下多节段（平面）动脉闭塞症是一种较实用的方法,可有效解决自体血管不足和单纯使用人工血管腘动脉以下血管重建通畅率差的问题。     

Randomization of autogenous vein and polytetrafluorethylene grafts in femoral-distal reconstruction

A randomized, prospective, controlled study comparing autogenous saphenous vein and polytetrafluoroethylene (PTFE) grafts in infrainguinal arterial reconstructions has been initiated in three different institutions. A total of 446 operative procedures were divided into six groups, depending on the site of distal bypass insertion into the popliteal or an infrapopliteal artery and on whether the patient received a randomized vein or PTFE graft or an obligatory PTFE graft. The randomized saphenous vein graft patency to infrapopliteal arteries was significantly better (P less than 0.005) at 2 1/2 years than the patency of randomized or obligatory PTFE grafts to the same level. No significant differences between randomized vein grafts and randomized or obligatory PTFE grafts in the femoropopliteal position could be demonstrated up to 2 1/2 years, either above or below the knee. The need for such a study and the limitations of this preliminary report are discussed. The requirement for longer observation of greater numbers of cases is stressed. A current plan for usage of the PTFE graft in the lower extremity is presented.     

Natural history of infrainguinal vein graft stenosis relative to bypass grafting technique

Purpose: To determine whether the incidence of vein graft stenosis is related to bypass grafting technique and thus modification of postoperative surveillance protocols may be required.Methods: From 1991 to 1996, 338 infrainguinal vein bypasses constructed using in situ (n = 131), reversed (n = 120), nonreversed translocated (n = 48), or spliced/upper extremity vein (n = 39) grafting techniques were evaluated by intraoperative duplex scanning to optimize bypass construction and serially thereafter to detect developing vein graft stenoses. Bypass procedures were performed in 322 patients for critical limb ischemia (83%), claudication (13%), or popliteal aneurysm (4%). Using life-table analysis, graft patency and revision/failure rates were compared relative to grafting technique, need for operative revision, and intraoperative duplex scan results.Results: Three-year primary and secondary graft patency rates were higher (p < 0.001) for in situ bypass grafts (85%/97%) compared with reversed (57%/83%), nonreversed translocated (62%/78%), or alternative (51%/76%) vein bypass grafts. During a mean follow-up interval of 19 months, the incidence of graft revision was higher for reversed saphenous (23%) and alternative (28%) vein bypass grafts compared with in situ (10%) or nonreversed (16%) saphenous vein bypass grafts. Despite a normal intraoperative graft duplex scan, the revision/failure rate of reversed vein grafts was 2.5 times greater than in situ/nonreversed translocated vein conduits (primary patency rate at 3 years, 60% vs 87%, p = 0.009). Bypass grafts modified at operation on the basis of duplex scanning were two times more likely to require postoperative revision than grafts with normal intraoperative scans.Conclusions: The incidence of postoperative graft stenosis and need for revision varies with bypass grafting technique. Reversed vein bypasses and grafts modified at operation may be more prone than in situ vein bypass grafts to develop stenosis and thus require intensive surveillance. Infrainguinal vein graft failure and the need for revision may be reduced by the adoption of bypass grafting techniques that include valve lysis and intraoperative duplex scan assessment. (J Vasc Surg 1997;25:211-25.)     

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.     

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.     

In situ saphenous vein for lower extremity revascularization.

BACKGROUND. During a 6-year period, 349 in situ saphenous vein bypass grafts were performed for limb salvage by three surgeons. METHODS. Outflow anastomoses were constructed to the infrageniculate popliteal (25%), posterior tibial (20%), peroneal (20%), anterior tibial (19%), and dorsal pedal arteries (7%). Mean patient age was 70 1/2 years. RESULTS. The 30-day mortality rate was 3.2%, and 19% died during the ensuing 68-month interval. At 1, 24, and 60 months primary graft patency was 89%, 77%, and 74%, secondary graft patency was 91%, 80%, and 78%, and cumulative limb survival was 94%, 88%, and 84%, respectively. Cumulative patency rates at 60 months depending on outflow site were as follows: popliteal (85%), anterior tibial (80%), posterior tibial (70%), dorsal pedal (68%), and peroneal (60%). Patency at the peroneal position was significantly inferior to that of other infrapopliteal sites combined (p less than 0.05). Cumulative limb survival at 60 months, according to outflow site, was as follows: popliteal (95%), anterior tibial (85%), posterior tibial (78%), dorsal pedal (73%), and peroneal (67%). There was no significant difference in limb salvage among infrapopliteal outflow sites. However, patency rates and limb salvage were significantly better for the popliteal outflow site than the infrapopliteal outflow sites (p less than 0.01). CONCLUSIONS. (1) A 5-year graft patency rate of 78% and a limb salvage rate of 84% are achievable, (2) peroneal bypass is associated with a lower rate for graft patency but not limb salvage, and (3) popliteal bypass has the best graft patency and limb salvage rates.     

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.     

Meta-analysis of alternate autologous vein bypass grafts to infrapopliteal arteries

BACKGROUND: Several studies have described acceptable results for infrapopliteal bypass surgery that uses an autogenous vein other than the greater saphenous vein but is still no reliable prediction of outcomes. The objective of this study was to use meta-analysis to assess the long-term outcomes after infrapopliteal bypass grafting done with alternate autologous veins. METHODS: Studies published from 1982 through 2004 were identified from electronic databases and pertinent original articles. Thirty-two series were selected, all of which had used survival analysis and had reported a 1-year graft patency rate, with at least 15 bypasses. An interval success rate was calculated for each month in each series of grafts by using data from life tables, survival curves, and texts. Monthly success rates were combined across series to obtain a pooled estimate of success for each month. Pooled survival curves were then constructed for graft patency and foot preservation. RESULTS: The 5-year pooled estimates were 46.9% (95% confidence interval [CI] = 35.5%-58.3%) for primary patency, 66.5% (95% CI = 54.9%-78.2%) for secondary patency, and 76.4% (95% CI = 68.0%-84.8%) for foot preservation. These results were far superior to those reported for nonautologous grafts. Intensive duplex surveillance had a favorable impact on graft patency and foot preservation. No publication bias was detected. CONCLUSIONS: When the greater saphenous vein is unavailable, alternate autologous veins are preferable to other graft materials in bypass surgery to infrapopliteal arteries.