Successful long-term limb salvage using cephalic vein bypass grafts.

Successful long-term limb salvage using cephalic vein bypass grafts was attained in 70 limbs of 67 patients over the past 11 years. The saphenous vein was absent in 76% and inadequate in 24% of the cases. Revascularization for limb salvage was carried out in 83%. Ninety per cent of the grafts were extended to the infrageniculate level while 56% were to a tibial vessel. Patency rates at 1, 3, and 5 years were 85%, 72%, and 68%, respectively. Limb salvage rate was 85% at 5 years and thereafter. There were no operative deaths or upper extremity morbidity. The 5-year survival rate was 50%. The results obtained with cephalic vein were comparable to those reported using saphenous vein but superior to those reported for nonautogenous bypass grafts.     

In situ saphenous vein bypass grafts for limb salvage: A current fad or a viable alternative to reversed vein bypass grafts?

Revascularization of the lower extremity using the in situ saphenous vein bypass graft has resurfaced as a clinical alternative to reversal of the saphenous vein. Early patency rates have been excellent, however, concern has been raised about the durability of the in situ technique. Our total experience with this technique has been reviewed to evaluate its effectiveness on a teaching vascular service. Seventy-six limbs in 71 patients were revascularized using the in situ technique. The distal anastomosis was created at the below-the-knee popliteal level in 26 limbs and at the infrapopliteal level in 50 limbs. Operative assessment of the vein quality showed 42 percent to be phlebitic or less than 4 mm in diameter. Hospital mortality was 0 and late mortality was 8 percent. Cumulative life table analysis showed the graft patency rate to be 89 percent 1 month postoperatively, 82 percent at 1 year, 77 percent at 2 years, and 72 percent up to 4 year postoperatively. Patency was independent of runoff to the pedal arch and the level of the distal anastomosis. Limb salvage at 4 years was 83 percent for distal popliteal grafts and 79 percent for infrapopliteal reconstructions. Our results indicate that the long-term durability of the in situ saphenous vein graft is excellent despite suboptimal veins and poor runoff. When performed properly, it is the preferred technique for arterial reconstruction below the knee joint.     

Popliteal-to-distal bypass grafts for limb salvage in diabetics

Between January 1984 and August 1989, 117 diabetic patients with a palpable popliteal pulse but distal limb threatening ischaemia underwent 124 popliteal artery (or below) to distal bypass grafts. All grafts were intra-operatively monitored. The operative mortality was 0.8% and the 30 day primary patency 93%. Primary patencies at 1 and 3 years were 88.6 and 85.2%, respectively. The results of using the popliteal artery as the proximal graft inflow site in diabetes are comparable to other patient groups and to alternative more proximal inflow sites, but require a shorter length of vein graft with a shorter vein harvesting incision, avoid groin disection and result in a more peripheral operation.     

Arterial grafts in microscope-assisted pedal bypass for limb salvage

Leg amputations are associated with marked morbidity and mortality in the atherosclerotic population. The survival in patients undergoing lower extremity amputations is 50% at 3 years and 30% at 5 years. Despite excellent reported results with pedal bypass, some patients are "nonbypassable" with traditional techniques because of very small, short target vessels in the pedal arch. The authors report six cases of microscope-assisted inframalleolar bypass using autogenous artery in 5 patients presenting with threatened limb loss, with 83% graft patency at 52 months average follow-up. They hypothesize that the success in these patients is the result of less surgical trauma and less compliance mismatch at the distal anastomosis, and perhaps the result of vasoactive substances secreted by the arterial grafts. Microscope-assisted pedal bypass with autogenous artery should be considered for "nonbypassable" patients with tissue necrosis or rest pain who do not appear to have sufficient inflow to heal a forefoot amputation.     

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.     

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.     

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.     

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.     

Infrainguinal bypass grafting using lyophilized saphenous vein allografts for limb salvage

Critical ischemia in patients with extensive femoropopliteal occlusive disease often ends in amputation in the absence of a suitable autologous vein for reconstruction. Cryopreserved vascular allografts have been used as an alternative conduit with poor results. Antigenicity and rejection are assumed to account for graft failure. Lyophilized vessels have demonstrated patency and structural integrity in the vascular system in our previous experimental studies. We report four patients that underwent femorodistal bypass grafting with lyophilized saphenous veins who lacked usable autologous vein for arterial reconstruction. Early graft thrombosis occurred in three patients who required major amputations. Duplex scans for graft surveillance did not reveal previous significant abnormalities. These cases demonstrate that the clinical use of lyophilized venous allografts for infrainguinal arterial reconstructions failed to yield satisfactory patency and limb salvage. Lyophilized veins therefore are not useful alternative conduits in patients with critical ischemia and no suitable autologous vein grafts.     

Long-term results of arterial allograft below-knee bypass grafts for limb salvage: a retrospective multicenter study

PURPOSE: Arterial allografts (AAs) have been recently reconsidered in the treatment of critical limb ischemia when vein material is absent, because of the disappointing results with artificial grafts. The aim of this study was to report the results observed in three centers where AAs were used for infrainguinal reconstruction in limb-threatening ischemia. METHODS: Between 1991 and 1997, 165 AA bypass procedures were performed in 148 patients (male, 90) with a mean age of 70 years (range, 20-93 years). Indications for operation were rest pain in 54 cases and tissue loss in 111 cases. Mean resting ankle pressure was 53 mm Hg in 96 patients who did not have diabetes and mean transcutaneous pressure of oxygen was 10 mm Hg in 52 patients who did have diabetes. In 123 cases (75%), there was at least one previous revascularization on the same limb. AAs were obtained from cadaveric donors. The distal anastomosis was to the below-knee popliteal artery in 34 cases, to a tibial artery in 114 cases, and to a pedal artery in 17 cases. RESULTS: At 30 days, the mortality rate was 3.4%; the primary patency rate was 83.3%; the secondary patency rate was 90%; and the limb salvage rate was 98%. During follow-up (mean, 31 months), 65 grafts failed primarily. Causes of primary failure were thought to be progression of the distal disease in 15 cases, myointimal hyperplasia in 16 cases, graft degradation in 10 cases (four dilations, three stenoses, two ruptures, and one dissection), miscellaneous in eight cases, and not known in 16 cases. Primary patency rates at 1, 3, and 5 years were, respectively, 48.7% +/- 4%, 34.9% +/- 6%, and 16.1% +/- 7%. Secondary patency rates at 1, 3, and 5 years were, respectively, 59. 8% +/- 4%, 42.1% +/- 5%, and 25.9% +/- 8%. Limb salvage rates at 1, 3, and 5 years were, respectively, 83.8% +/- 3%, 76.4% +/- 5%, and 74.2 % +/- 8%. CONCLUSION: AA leads to an acceptable limb salvage rate but poor patency rates. A randomized trial that will compare AAs and polytetrafluoroethylene should be undertaken.     

Axillofemoral bypass for limb salvage

Objective : To evaluate the early and long‐term outcomes of axillofemoral bypass performed at a tertiary referral vascular centre over a 17‐year period. Methods : From 1982 to 1998, 30 patients underwent axillofemoral bypass at the University of Hong Kong Medical Centre. A retrospective analysis of all these records was undertaken. Data on demographic features and results of surgical intervention were reviewed. Early outcomes were analyzed with respect to morbidity, mortality and improvement of clinical category (according to the Reporting Standards of the Society for Vascular Surgery/North American Chapter, International Society for Cardiovascular Surgery). Long‐term outcomes were documented with respect to graft patency, patient survival and limb loss rates. Results : Clinical success was achieved in 22 patients (73%) after operation. The postoperative morbidity and mortality rates were 30% and 20%, respectively. The primary patency of axillofemoral bypass was 62%, 51% and 45% at 1, 2 and 3 years, respectively. Limb loss rate was 23% at 3 years. The cumulative survival rate of the study population was 67%, 57% and 57% at 1, 2 and 3 years, respectively. Conclusions : Axillofemoral bypass is a valuable limb‐salvaging surgical option for revascularization of lower limbs in high‐risk patients with aorto‐iliac occlusive disease.      

Popliteal-to-tibial in situ saphenous vein bypass for limb salvage in diabetic patients

This study has summarized our results with popliteal-tibial in situ saphenous vein bypass in 26 patients, 25 of whom were diabetic, over a 2 year period. Both above- and below-knee popliteal inflow sites were used for bypass of limb-threatening ischemia. Distal calf or pedal outflow sites were required in all but two patients who had sequential bypass performed to tibial sites. Postoperative ankle-brackial indices were calculated. Eleven patients had transcutaneous mapping surrounding the pedal skin envelope injuries. The mean lowest and highest transcutaneous oxygen values have been reported as a guide to successful healing.     

Analysis of autogenous vein femoral-infrapopliteal bypass for limb salvage in the elderly

The hypothesis that older patients undergoing femoral-infrapopliteal bypass have a similar outcome as a matched younger group of patients undergoing the same operation was tested. Seventy-six femoral-infrapopliteal autogenous saphenous vein bypasses for critical limb ischemia were performed from 1985 to 1990. By using the life-table method, the primary and secondary patency, limb salvage and survival rates are analyzed and compared for older and younger age groups. Forty cases (53%) were performed in an elderly group, defined as age 70 or older. At 4 years, there was no significant difference between age groups in limb salvage and patency rates. However, operative mortality for the older age group was 12%, compared with 0% in the younger group (P = 0.0004). Thus, femoral-infrapopliteal autogenous vein bypass can be performed with comparable limb salvage and patency rates for an older age group, but the risk of operative mortality appears to be increased with age.     

Axillopopliteal bypass for limb salvage.

Forty-one axillopopliteal bypass grafts have been placed in 30 patients for limb salvage in the past 12 years. The mean patient age was 65.6 years; 8 were women; 19 smoked; and six had diabetes. Sixteen grafts were straight axillopopliteal bypass grafts, and 25 were sequential axillopopliteal bypass grafts. Cumulative life-table primary patency rates at 1, 2, and 3 years were 70%, 56%, and 43%, respectively; secondary patency rates were 73%, 57%, and 50%, respectively. Corresponding limb salvage rates were 86%, 69%, and 69%, respectively. Ringed polytetrafluoroethylene (PTFE) graft patency at 3 years was 61% versus 40% for unsupported PTFE grafts (p = 0.35). Ringed PTFE axillofemoral grafts with sequential femoropopliteal saphenous vein grafts had a 3-year patency of 67%. Graft patency was restored in 25% of occluded grafts by thrombectomy and in 80% of occluded grafts by thrombectomy with graft revision (p = 0.21). Cumulative 3-year patient survival was 48%. The 30-day operative mortality rate was 20%; patients operated on for graft infection had a 30-day operative mortality rate of 36%. The data support the use of axillopopliteal bypass for limb salvage when standard revascularization techniques are contraindicated. Long-term patency is enhanced by use of externally supported PTFE and sequential femoropopliteal saphenous vein.     

Upper extremity limb salvage accomplished by in situ vein bypass graft

The need for revascularization procedures in individuals with hand ischemia is uncommon. Previous reports describe the successful utilization of reversed saphenous vein to reconstruct the distal vasculature of the arm. This case report details the use of in situ arm vein to restore perfusion to a threatened hand.     

Popliteal-crural bypass through the posterior approach with lesser saphenous vein for limb salvage

PURPOSE: A review of popliteal-crural bypasses via the posterior approach was done to evaluate the results of this technique. METHODS: During a period of 36 months, 21 patients with limb-threatening ischemia underwent 21 popliteal-crural bypasses via the posterior approach in the prone position with reversed lesser saphenous vein. All patients had limb-threatening ischemia, with rest pain in five patients, ulceration in nine patients, and gangrene in seven patients. Diabetes mellitus was present in 17 patients. RESULTS: The inflow site was the supragenicular popliteal artery in 12 patients and the infragenicular popliteal artery in nine patients. The outflow sites were the tibioperoneal trunk in five patients, the posterior tibial artery in six patients, the peroneal artery in eight patients, and the anterior tibial artery in two patients. Of the seven patients with gangrene, three patients underwent transmetatarsal amputation and four underwent toe amputation. The limb salvage rate for the entire group was 100% at 24 months. No early graft failures were seen, and the 12-month and 24-month primary graft patency rates were 89% and 77%, respectively, with life-table analysis. The primary assisted patency rate was 95% at 12 and 24 months. Patency was determined with duplex scan graft surveillance. CONCLUSION: The posterior approach to popliteal-distal bypass is an acceptable alternative to traditional bypass procedure with excellent early patency and limb salvage results. The approach has the advantage of better utilization of lesser saphenous vein and easier operative exposure in patients with short segment infrapopliteal occlusive disease.     

Pedal branch arterial bypass for limb salvage

In patients with critical lower extremity ischemia and occlusion of the distal tibial and pedal arteries bypasses to pedal artery branches may offer the only alternative to primary amputation. The results of 22 pedal branch arterial bypasses are reported, and a review of the literature is offered. The charts of 22 patients undergoing pedal branch arterial bypass during a 12-year period were retrospectively reviewed. The results of six additional reports of this technique were also evaluated. In the present series the cumulative primary graft patency rate was 72 per cent after 2 years. The cumulative limb salvage rate during this interval was 82 per cent. Similar graft patency and limb salvage rates were obtained with the approximately 200 other bypasses of this nature as reported in six other series. Pedal branch arterial bypass offers limb salvage results that are comparable to perimalleolar and pedal artery bypasses. In patients with critical limb ischemia and occlusion of distal tibial and pedal arteries, pedal artery branches should be sought as potential outflow sites. Bypasses to these arteries result in good long-term limb salvage, improved survival, and good functional ability for amputation. Pedal artery branch bypasses are a superior alternative to primary amputation.