Angiographic criteria for prediction of early graft failure of secondary infrainguinal bypass surgery

Complete intraoperative postreconstruction angiograms were obtained during 93 reoperations after failed femoropopliteal and femorodistal bypass grafts to evaluate the predictive value of a new method of angiographic runoff assessment. Good runoff was defined as patency of two or three lower leg arteries to the foot, or one patent vessel continuous with an intact anterior or posterior foot arch in femoropopliteal and proximal femorodistal bypasses, and integrity of both arches in low femorodistal bypasses. All other outflow patterns were considered poor. The cumulative 1-year patency rate was 61% with a 79% limb salvage rate after reoperations performed in limbs with good runoff. In reoperations with poor runoff, the patency rate was only 5% with a 22% limb salvage rate. In reoperations with good runoff, and 85% patency rate of vein grafts compared to 43% of prosthetic grafts clearly demonstrated the importance of graft material on early outcome. The improved prediction of early outcome with this new method of angiographic runoff evaluation might allow more rational management of patients with failed infrainguinal grafts.     

Arm veins for arterial revascularization of the leg: arteriographic and clinical observations

The results of 160 infrainguinal bypasses with arm vein grafts were analyzed. Seventy-three arteriograms were reviewed to identify early and late graft defects; arteriographic findings paralleled those described for saphenous vein grafts. Intimal fibrosis during the first postoperative year, observed in 16 grafts, was the most common defect. Aneurysmosis and elongation were rare, resulting in two graft replacements. Patency and limb salvage rates were calculated for 88 single-length femorodistal bypass grafts; the other 72 were inflow (eight) or outflow (22) jump grafts, sequential (eight) and composite autogenous vein grafts (34). The primary and secondary patency rates for single-length grafts were 74% and 80% at 1 year and 51% and 57% at 5 years, respectively. The limb salvage rate at 5 years was 82%. The survival rate for all patients was 44% at 5 years. These findings reconfirm our use of arm veins as bypass grafts when the saphenous vein is unavailable.     

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

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

Autogenous composite vein bypass graft for infrainguinal arterial reconstruction

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

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.     

Infrapopliteal bypass for established gangrene of the forefoot or toes

This study was undertaken to assess factors affecting limb salvage after femorodistal bypass in patients with established gangrene. From January 1977 through June 1983, 361 patients underwent infrapopliteal bypasses; 58 patients (59 limbs) had forefoot and/or toe gangrene. There were 33 men and 25 women (mean age 67.6 years), and 40 patients (69%) were diabetic. A total of 71 femorodistal bypass procedures were performed in these patients: a single bypass in 49, repeat procedure in eight, and multiple bypasses in two patients. Graft material was autogenous saphenous vein in 22 cases, polytetrafluoroethylene (PTFE) in 39 cases, and a composite graft in 10 procedures. After bypass 50 patients underwent limited toe or forefoot amputation with uncomplicated healing. Limb salvage by life-table analysis was 70% at 1 year, 60% at 3 years, and 28% at 5 years. The graft patency at 3 years was 65% for vein grafts and 30% for PTFE grafts. In the entire series the operative mortality rate was 1.7%. Age, sex, hypertension, or diabetes mellitus did not influence the result of surgery. Similarly, failure of a previous femoropopliteal or tibial graft did not reduce the likelihood of limb salvage. Graft patency, however, is prerequisite for limb salvage, and graft patency can be maintained by thrombectomy or repetitive bypass. The present study suggests that limb salvage is possible in as many as two thirds of limbs with established gangrene. Although saphenous vein remains the graft material of choice, its absence should not preclude attempts at limb salvage. Repetitive grafting did not jeopardize patient safety but contributed significantly to extended limb survival.     

Comparative analysis of autogenous infrainguinal bypass grafts in African Americans and Caucasians: the association of race with graft function and limb salvage

OBJECTIVE: African Americans (AAs) are at risk for developing diabetes mellitus and atherosclerosis. Whether race influences the results of infrainguinal arterial reconstruction is unclear. The purpose of this study was to compare the results of autogenous infrainguinal bypasses in AAs and Caucasians to determine the association of race with graft function and limb salvage. METHODS: This was a retrospective, comparative cohort study of AA and Caucasian patients who had undergone autogenous infrainguinal bypass surgery. Only single-limb bypasses in each patient cohort were considered in this analysis. In patients who had undergone bilateral lower limb bypasses, the first limb bypass was chosen as the index bypass procedure. RESULTS: From January 1985 to December 2003, 1459 autogenous infrainguinal bypasses were performed in 1459 patients for lower limb ischemia. Within this group, 89 AA patients/vein grafts formed the study cohort. The control group comprised 1370 Caucasian patients/vein grafts. Compared with the Caucasian cohort, AA patients were significantly younger (median age, 65 vs 70 years, respectively; P = .001) and predominantly female (57% vs 41%, respectively; P = .002). AA patients also had a higher prevalence of diabetes mellitus, hypertension, cerebrovascular disease, congestive heart failure, and dialysis-dependent renal failure. More AA than Caucasian patients presented with gangrene (34% vs 16%, respectively; P = .001), and more underwent bypass surgery for limb salvage indications (91% vs 81%, respectively; P = .01). The venous conduit used was predominantly the greater saphenous vein (AA, 83%; Caucasian, 85%), and the site of distal anastomosis was at the tibial/pedal level in 67% of AA and 61% of Caucasian patients. Overall morbidity (AA, 28%; Caucasian, 23%) and 30-day mortality (AA, 3%; Caucasian, 3%) were similar. Thirty-day graft failure was significantly greater in AAs than Caucasians (12% vs 5%, respectively; P = .003). The overall 5-year primary graft patency (+/-SE) was significantly worse in AA patients (AA, 52% +/- 6%; Caucasian, 67% +/- 2%; P = .009). The 5-year limb salvage rate (+/-SE) was also significantly worse in AA patients (AA, 81% +/- 5%; Caucasian, 90% +/- 1%; P = .04). With the Cox proportional hazard model, significant risk factors associated with primary graft failure were AA race, age younger than 65 years, female sex, secondary reconstructions, tibial bypasses, and critical limb ischemia. Significant risk factors associated with limb loss were age younger than 65 years, female sex, absence of coronary disease, presence of critical limb ischemia, and secondary reconstructions. CONCLUSIONS: Autogenous infrainguinal bypass surgery in AAs is associated with poorer primary graft patency and limb salvage rates compared with those of Caucasians. This may partially account for the higher rate of limb loss in AA patients with peripheral arterial occlusive disease.     

Patency and limb salvage after infrainguinal bypass with severely compromised ("blind") outflow

HYPOTHESIS: Infrainguinal graft patency and limb salvage are adversely affected by severely compromised outflow. DESIGN: Retrospective review of all infrainguinal bypass procedures performed at a single institution during a 5-year period. SETTING: University teaching hospital. PATIENTS: Two hundred seventy-four patients underwent infrainguinal bypass for limb salvage (351 grafts in 307 limbs). INTERVENTIONS: All infrainguinal bypasses originated from a femoral artery. The distal anastomosis in 279 grafts was located in an artery with at least 1 patent outflow vessel with anatomically normal end-artery runoff (Society for Vascular Surgery/International Society for Cardiovascular Surgery ad hoc committee runoff score, 1-9). The distal anastomosis of 72 grafts was located in an artery with only collateral outflow ("blind bypass"; runoff score, 10). MAIN OUTCOME MEASURES: Perioperative morbidity and mortality, primary-assisted and secondary graft patency, limb salvage, and survival. RESULTS: All data are presented as mean +/- SEM. Patients undergoing blind bypass were older (age, 70 +/- 2 vs. 66 +/- 1 years; P <.05) and had a higher incidence of hypertension (90% vs 70%; P <.05) and end-stage renal disease (24% vs. 13%; P <.05). Comparing patients undergoing blind bypass to bypass with at least 1 patent outflow vessel, there were no differences in the use of nonautogenous conduits (50% vs 59%; P =.21) or postoperative warfarin (30% vs 32%; P =.69), or in perioperative mortality rates (2.7% vs 3.2%; P =.79). After a median follow-up of 13 months (range, 0-60 months), 2-year secondary graft patency for the entire group was 63% +/- 4%. The secondary patency rate of blind bypass grafts was no different from that of grafts with at least 1 patent outflow vessel (67% +/- 7% vs. 64% +/- 4%; P was not significant). However, the 2-year limb salvage rate in limbs with blind outflow was significantly worse than in limbs with at least 1 patent outflow vessel (67% +/- 7% vs. 76% +/- 3%; P =.04). CONCLUSION: Acceptable long-term patency rates can be achieved in infrainguinal bypass grafts with blind outflow, although blind outflow remains a marker for subsequent limb loss in the chronically ischemic leg.     

Long-term results of infrainguinal arterial reconstruction with spliced veins are equal to results with non-spliced veins.

OBJECTIVES: to determine the long term patency of spliced and non-spliced infrainguinal vein grafts. METHODS: a prospective registry of all patients undergoing infrainguinal arterial reconstruction with autogenous vein material was retrospectively interrogated. RESULTS: between October 1988 and August 2000, 515 infrainguinal arterial reconstructions were performed on 472 patients. A total of 429 bypasses were performed with uninterrupted greater saphenous vein, 86 reconstructions using spliced vein segments. There was no significant difference in primary (63% vs 57%) and primary assisted patency (81% vs 81%) of limb salvage (88% vs 91%) at 5 years. Limb salvage was not different (88% and 91% respectively). CONCLUSION the splicing of vein grafts does not compromise patency of limb salvage.     

Bypass in the absence of ipsilateral greater saphenous vein: safety and superiority of the contralateral greater saphenous vein

PURPOSE: The purposes of this study were to evaluate the long-term results of different autogenous conduits used for infrainguinal bypass when ipsilateral greater saphenous vein (IGSV) is absent or inadequate and to determine the impact on the contralateral lower extremity. METHODS: The study was performed as a retrospective evaluation of a prospective vascular registry together with review of patient records and telephone follow-up. RESULTS: From January 1990 to June 2000, 226 autogenous infrainguinal reconstructions were performed in 203 patients without adequate IGSV. The patients consisted of 128 men and 98 women, with a mean age of 69 years. Prevalent risk factors included diabetes (51%) and prior coronary bypass (46%). Limb salvage was the predominant indication (93%), and 59% of the procedures were secondary reconstructions. All bypasses were completed with autogenous vein, which included contralateral greater saphenous vein (CGSV; 31%), single-segment lesser saphenous vein (5%), single-segment arm vein (19%), and autogenous composite vein (45%). Bypasses were performed to the tibial and pedal arteries in 84% of the cases. The 30-day mortality and graft occlusion rates were 1% and 9%, respectively. The overall postoperative morbidity rate was 24%, with a 7% rate of major complications. Follow-up was complete in 95% of patients over a mean period of 24 months (range, 0.1 to 106 months). The 5-year primary patency rates were significantly better for CGSV compared with autogenous composite vein grafts (61% +/- 7% versus 39% +/- 6%; P <.009). The 5-year secondary patency (60% to 73%) and limb salvage (78% to 81%) rates did not differ significantly between the three groups. Follow-up of the contralateral lower limb revealed that nine of 226 limbs (4%) were amputated at a mean of 36 months after the ipsilateral bypass. The overall 5-year contralateral limb preservation rate was 90% +/- 3%. Contralateral vein harvest and the presence of diabetes did not affect the need for bypass or amputation of the contralateral limb. CONCLUSION: For most patients with inadequate IGSV, the CGSV is the alternative conduit of choice because of its length, superior performance, ease of harvest, and minimal risk to the donor limb.     

What is the proper role of polytetrafluoroethylene grafts in infrainguinal reconstruction?

Polytetrafluoroethylene grafts have been used extensively for infrainguinal vascular reconstruction either as the conduit of choice or as a substitute when saphenous vein is unavailable. Although numerous studies have shown satisfactory early patency rates, the long-term efficacy of these grafts in a large number of patients for specific indications and in various positions has been less well defined. From 1977 to 1987 we used four PTFE grafts from three different manufacturers to perform 300 infrainguinal reconstructions on 240 patients on our vascular service. The indications for surgery were disabling claudication in 28% and limb salvage in 72%. The 30-day operative mortality of 1% was not different from the 1.4% associated with infrainguinal autogenous vein grafting. The 5-year cumulative patency rate achieved with all infrainguinal polytetrafluoroethylene grafts was 35%, significantly higher for grafts placed for claudication (57%) than those placed for limb salvage (24%). There were no significant differences between the above-knee and below-knee locations for distal anastomoses regardless of indication, but femoropopliteal grafts provided significantly higher 5-year patency (37%) than infrapopliteal grafts (12%). Comparison of the 5-year patency rates among the three manufacturers of polytetrafluoroethylene grafts showed no significant differences. Fifty-four polytetrafluoroethylene grafts that failed underwent 67 revisions after catheter thrombectomy or thrombolysis, which resulted in a minimal 11% 5-year patency rate. Based on this experience, it is concluded that infrainguinal polytetrafluoroethylene prostheses provide significantly inferior results when compared with autogenous reconstruction.     

The consequences of a failed femoropopliteal bypass grafting: comparison of saphenous vein and PTFE grafts

OBJECTIVES: Although there are numerous reports comparing saphenous vein (SV) and polytetrafluoroethylene (PTFE) with respect to the patency rates for femoropopliteal bypass grafts, the clinical consequences of failed grafts are not as well described. This study compares the outcomes of failed SV and PTFE grafts with a specific emphasis on the degree of acute limb ischemia caused by graft occlusion. METHODS: Over a 6-year period, 718 infrainguinal revascularization procedures were performed, of which 189 were femoropopliteal bypass grafts (SV, 108; PTFE, 81). Society for Vascular Surgery/International Society for Cardiovascular Surgery (SVS/ISCVS) standardized runoff scores were calculated from preoperative arteriograms. Clinical categories of acute limb ischemia resulting from graft occlusion were graded according to SVS/ISCVS standards (I, viable; II, threatened; III, irreversible). Primary graft patency and limb salvage rates at 48 months were calculated according to the Kaplan-Meier method. RESULTS: Patients were well matched for age, sex, and comorbidities. Chronic critical ischemia was the operative indication in most cases (SV, 82%; PTFE, 80%; P =.85). Runoff scores and preoperative ankle-brachial index measurements were similar for the two groups (SV, 6.0 +/- 2.5 [SD] and 0.51 +/- 0.29; PTFE, 5.3 +/- 2.8 and 0.45 +/- 0.20; P =.06 and P =.12). The distal anastomosis was made below the knee in 60% of SV grafts and 16% of PTFE grafts (P <.001). Grade II ischemia was more likely to occur after occlusion of PTFE grafts (78%) than after occlusion of SV grafts (21%; P =.001). Emergency revascularization after graft occlusion was required for 28% of PTFE failures but only 3% of SV graft failures (P <.001). Primary graft patency at 48 months was 58% for SV grafts and 32% for PTFE grafts (P =.008). Limb salvage was achieved in 81% of SV grafts but only 56% of PTFE grafts (P =.019). CONCLUSIONS: Patients undergoing femoropopliteal bypass grafting with PTFE are at greater risk of ischemic complications from graft occlusion and more frequently require emergency limb revascularization as a result of graft occlusion than patients receiving SV grafts. Graft patency and limb salvage are superior with SV in comparison with PTFE in patients undergoing femoropopliteal bypass grafting.     

Outflow resistance measurement during infrainguinal arterial reconstructions: a reliable predictor of limb salvage

Criteria for abandoning infrainguinal arterial reconstructions in favor of major amputations should include reliable predictors not only of graft patency, but more importantly, of limb salvage. To evaluate the efficacy of intraoperative outflow resistance measurements in predicting limb salvage after infrainguinal bypasses, we have reviewed 134 such operations (64 femoropopliteal and 70 femorodistal bypasses) performed for critical ischemia. Outflow resistance measurements were divided into quartiles for femoropopliteal bypasses (Group A 0.17 mm Hg/ml/min or less, Group B 0.18 to 0.24 mm Hg/ml/min, Group C 0.25 to 0.4 mm Hg/ml/min, and Group D greater than 0.4 mm Hg/ml/min) and femorodistal bypasses (Group A 0.4 mm Hg/ml/min or less, Group B 0.4 to 0.58 mm Hg/ml/min or less, Group C 0.6 to 1 mm Hg/ml/min, and Group D 1 mm Hg/ml/min or greater). One year limb salvage rates for patients who underwent femoropopliteal bypass were 95 percent, 92 percent, 87 percent, and 67 percent from the lowest to the highest quartile (difference not statistically significant), and for those who had femorodistal bypass, they were 51 percent, 75 percent, 48 percent, and 0, respectively (p less than 0.05). Interestingly, 12 month graft patency and limb salvage rates for patients who underwent femorodistal bypass with outflow resistances between 0.59 and 1 mm Hg/ml/min did not correlate well (22 percent and 48 percent, respectively), whereas for those with outflow resistance greater than 1 mm Hg/ml/min, they were 22 percent and 22 percent, respectively. Thus, measurement of intraoperative outflow resistance is a very accurate predictor of limb salvage after infrainguinal bypass operations.     

Influence of vein size (diameter) on infrapopliteal reversed vein graft patency

We reviewed 239 infrapopliteal reversed greater saphenous vein graft bypasses placed for critical ischemia over a 7-year period to determine the influence of vein diameter on graft patency and limb salvage. Grafts were assigned to four groups based on the minimum external diameter measured during operation: less than 3.0 mm, n = 18; 3.0 mm, n = 59; 3.5 mm, n = 67; and greater than or equal to 4.0 mm, n = 145. A pattern of increasing graft patency and limb salvage among the four groups was noted as the minimum external diameter increased from less than 3.0 mm to greater than or equal to 4.0 mm. When compared to the larger grafts greater than or equal to 4.0 mm, primary graft patency was significantly lower both for less than 3.0 mm grafts (0% for less than 3.0 mm vs 65% for greater than or equal to 4.0 mm at 3 years, p less than 0.001) and for long (greater than 45 cm) 3.0 mm grafts (38% for long 3.0 mm vs 75% for greater than or equal to 4.0 mm at 2 years, p less than 0.005). All 3.5 mm and short (less than 45 cm) 3.0 mm grafts had patency rates similar to greater than or equal to 4.0 mm veins. Thus long 3.0 mm and all less than 3.0 mm reversed saphenous vein grafts should be considered at high risk for failure. Veins with fibrotic, thick-walled segments identified during operation (n = 19) had patency rates significantly lower than nonfibrotic veins (n = 270; p less than 0.01), and this may play a role in the failure of some less than 3.0 mm minimum external diameter vein grafts.     

Arm vein conduit is superior to composite prosthetic-autogenous grafts in lower extremity revascularization

PURPOSE: Various alternative conduits have been used for lower extremity revascularization when an adequate ipsilateral greater saphenous vein is absent. This study compared the effectiveness of all-autogenous multisegment arm vein bypass grafts with that of composite grafts composed of combined prosthetic and autogenous conduits. METHODS: One hundred fifty-three lower extremity revascularization procedures performed between 1990 and 1998 were followed up prospectively using a computerized vascular registry. The grafts were composed of spliced arm vein segments with venovenostomy in 122 and of composite prosthetic-autogenous conduit in 31. Arm vein conduit was prepared by means of intraoperative angioscopy for valve lysis and identification of luminal abnormalities in 47.7% of cases. RESULTS: Bypass graft configurations were as follows: femoropopliteal (12 arm vein, 2 composite); femorotibial (75 arm vein, 23 composite); femoropedal (14 arm vein, 6 composite), and popliteo-tibial/pedal (21 arm vein, 0 composite). The indication for surgery was limb salvage in 98% and disabling claudication in 2% of cases. The mean follow-up was 25.1 months (range, 1 month to 7.9 years). Overall survival at 4 years was 51%. Overall patency and limb salvage rates were as follows: primary patency, at 1 year-arm vein, 76.9% +/- 4.8%; composite, 59. 5% +/- 9.6% (P =.02); at 3 years-arm vein, 70.0% +/- 8.0%; composite, 43.7% +/- 12.4% (P <.01); and at 5 years-arm vein, 53.8% +/- 8.7%; composite, 0%; secondary patency, at 1 year-arm vein, 77.5% +/- 4. 6%; composite, 59.8% +/- 9.5% (P =.02); at 3 years-arm vein, 70.7% +/- 7.5%, composite, 44.9% +/- 13.1% (P <.01); at 5 years-arm vein, 57.7% +/- 8.0%; composite, 0%; limb salvage, at 1 year-arm vein, 89. 3% +/- 3.7%; composite, 73.9% +/- 8.9% (P <.01); at 3 years-arm vein, 80.5% +/- 7.0%; composite, 49.6% +/- 14.3% (P <.01); at 5 years-arm vein, 76.3% +/- 9.9%; composite, 0%. CONCLUSION: In this study, multisegment autogenous arm vein was used successfully in a wide variety of lower extremity revascularization procedures and achieved good long-term patency and limb salvage rates, well in excess of those achieved with composite prosthetic-autogenous grafts. The use of autogenous conduit appears to offer superior results to composite conduit in lower extremity revascularization. The superior durability of arm vein makes it one of the alternative conduits of choice when an adequate greater saphenous vein is not available.     

Patency and limb salvage after distal prosthetic bypass associated with vein cuff and arteriovenous fistula.

OBJECTIVE: To assess the usefulness of vein cuff with or without arteriovenous fistula interposition as adjuvant techniques for improving patency and limb salvage in patients undergoing femorodistal bypass surgery using prosthetic grafts. METHOD: We undertook a retrospective study of 65 consecutive patients treated over a 5-year period with 67 prosthetic femorodistal bypasses with vein cuff, in whom an arteriovenous fistula was constructed at the distal anastomosis in 35. Patients were followed for a median time period of 23 months. RESULTS: Primary patency rates were 68, 53 and 44% at 1, 2 and 3 years, respectively. The corresponding figures for secondary patency, limb survival and patients' survival were 73, 64 and 58% for 1 year, 78, 76 and 73% for 2 years and 72, 66 and 63% for 3 years. None of the criteria analyzed influenced patency or limb salvage on prosthetic bypasses using adjuvant techniques. No statistical differences were found between patency and limb salvage rates in patients for whom the vein cuff was constructed with or without an arteriovenous fistula. But patients who managed with a supplementary arteriovenous fistula had significantly fewer distal residual arteries in the limb (p=0.001). CONCLUSION: Although results in patients treated with adjunctive techniques differed little from those in patients treated with direct prosthetic bypasses procedures, those who eventually had an adjunctive procedure had inferior runoff. This indicates that an arteriovenous fistula might be a valuable supplement in patients with poor runoff who have distal revascularisation using a prosthetic graft.     

Infrainguinal revascularisation in the era of vein-graft surveillance--do clinical factors influence long-term outcome?

OBJECTIVES: To investigate the variables affecting the long-term outcome of infrainguinal vein bypass grafts that have undergone postoperative surveillance. DESIGN: A retrospective analysis. PATIENTS AND METHODS: Details of 299 consecutive infrainguinal vein grafts performed in 275 patients from a single university hospital were collected and analysed. All grafts underwent postoperative duplex surveillance. Factors affecting patency, limb salvage and survival rates were examined. These factors were gender, diabetes, hypertension, aspirin, warfarin, ischaemic heart disease, run-off, graft type, early thrombectomy, level of anastomoses and indication for surgery. RESULTS: The 6-year primary, primary assisted and secondary patency rates were 23, 47, and 57%, respectively. Six-year limb salvage and patient survival were 68 and 45%, respectively. Primary patency was adversely influenced by the use of composite vein grafts. Early thrombectomy was the only factor that significantly influenced secondary patency. Limb salvage was worse in diabetic limbs, limbs with poor run-off and in grafts that required early thrombectomy. Postoperative survival was better in males, claudicants and in patients who took aspirin. CONCLUSIONS: Although co-morbid factors did not influence graft patency rates, diabetes did adversely effect limb salvage. This study, like others before it, confirms that aspirin significantly reduces long-term mortality in patients undergoing infrainguinal revascularisation.     

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.     

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.     

Present status of reversed vein bypass grafting: five-year results of a modern series

From January 1980 through December 1988, 564 limbs in 434 patients were treated for infrainguinal arterial ischemia. Of these, 516 limbs in 387 patients underwent reversed vein bypass grafting. The remainder were treated by primary amputation (11 limbs, 1.9%) or by prosthetic bypass (37 limbs, 6.4%). The indications for operation were limb salvage in 80% of limbs and claudication in 20%. Adequate ipsilateral greater saphenous vein was available for 285 (55%) grafts, with reversed vein bypass achieved in the other 231 operations by use of distal graft origins (151 grafts), use of alternate vein sources (120 grafts), and splicing of venous segments (81 grafts). Seventy-six grafts (15%) were to the above-knee popliteal artery, 199 grafts (37%) were to the below-knee popliteal artery, and 241 grafts (47%) were to infrapopliteal arteries, 26 of which (11%) were to inframalleolar arteries. The primary and secondary patencies for all grafts at 5 years were 75% and 81%, respectively. Grafts to infrapopliteal arteries had significantly worse primary patency (69%) at 5 years than did grafts to the popliteal artery (77%, above knee; 80%, below knee) and grafts formed of adequate ipsilateral greater saphenous vein had significantly better primary patency (80%) than did grafts performed when this conduit was not available (68%). Secondary patency of all graft categories ranged from 76% to 85%, and there were no significant differences regardless of site of distal anastomosis, source of venous conduit, or site of graft origins. We prefer the use of reversed vein bypass grafting for lower extremity revascularization both because of the excellent patency results and because the technique can be applied to the larger number of patients in our practice who lack intact ipsilateral greater saphenous vein, in contrast to in situ vein bypass procedures.