Validation of the Finnvasc score in infrainguinal percutaneous transluminal angioplasty for critical lower limb ischemia

The aim of the present study was to validate the Finnvasc score for prediction of immediate outcome after infrainguinal percutaneous transluminal angioplasty (PTA) for critical lower limb ischemia (CLI). Our registry included prospective data on 512 patients who underwent isolated infrainguinal PTA revascularization procedures for CLI. The Finnvasc score herein evaluated was calculated by assigning one point each to diabetes, coronary artery disease, foot gangrene, and urgent operation. Early mortality and major limb amputation rates after PTA revascularization were 2.5% and 12.3%, respectively. Seventy-two patients (14.1%) died and/or had lower limb amputation. Diabetes (p = 0.001), foot gangrene (p = 0.047), urgent operation (p < 0.0001), and preoperative renal failure (p = 0.001) were independent predictors of postoperative mortality and/or major limb amputation. Finnvasc score was predictive of major lower limb amputation (p = 0.003), mortality (p < 0.0001), and mortality and/or major amputation (p < 0.0001) after PTA. Mortality, major lower limb amputation, and combined end point rates in patients with a Finnvasc score of 3-4 were 12.8%, 25.6%, and 35.9%, respectively. The Finnvasc score is a simple risk scoring method which can be useful to estimate the risk of immediate postprocedural mortality and/or major lower limb amputation also in patients undergoing infrainguinal PTA for CLI.     

Isolated popliteal arteries: results of surgical treatment and causes of failure

Isolated popliteal artery is defined as an obstruction of a superficial femoral artery with a patent popliteal segment followed by an obstructed distal popliteal artery or a patent leg artery less than 5 cm long. PURPOSE: The aim of this retrospective study was to report the results of surgical treatment and the causes of failures. PATIENTS AND METHODS: From 1988 to 1996, 31 patients with isolated popliteal artery were operated on with femoropopliteal bypass. The age of the patients ranged from 45 to 92 years, (mean: 79 years); all had critical ischemia that threatened limb viability. All underwent preoperative arteriography and diagnosis was confirmed by intraoperative arteriography. RESULTS: In the postoperative course, there were 22 patent bypasses (68%) with minor amputation in five patients, and nine thromboses that required a major amputation in seven patients, a trans-metatarsal amputation in one, and a medical treatment in one. With a mean 37-month follow-up, seven thromboses required a major amputation in five patients, a new bypass in one and a medical treatment in one. The death rate was 34% at two years. The actuarial patency rates of the bypasses were 51% at one year, 38% at two years and 25% at five years. The limb salvage rate was identical. The patency rates were 65% at one, two and five years for venous bypasses and 38%, 13% and 0% respectively for PTFE bypasses. Statistical analysis showed two causes of failure: the absence of a run-off branch and the use of PTFE prostheses. No other statistically significant cause of failure was demonstrated among those analysed. Favourable anatomic conditions for a bypass to a leg artery were not predictive of failure of a femoro-popliteal bypass on the isolated arterial segment. CONCLUSION: Bypass to isolated popliteal artery is indicated in patients whose limb viability is jeopardized. Results may be considered as satisfactory especially if there is a run-off branch and if a venous graft is available for the bypass.     

Femoropopliteal bypass for claudication: Vein vs. PTFE

The vascular graft of choice for femoropopliteal bypass in patients with intolerable claudication is controversial. We retrospectively reviewed our experience with 239 patients suffering from claudication secondary to superficial femoral artery obstruction. Femoropopliteal reconstruction was performed with saphenous vein to the below-knee popliteal artery in 66 patients (BK-vein). Polytetrafluoroethylene (PTFE) was used in 128 patients as a bypass graft to the above-knee popliteal artery (AK-PTFE) and 45 patients had a PTFE graft to the below-knee popliteal artery (BK-PTFE). All patients were enrolled in a postoperative graft surveillance program with graft revision when appropriate. There was one perioperative death (0.4%). Primary patency at 5 years for AK-PTFE, BK-PTFE, and BK-vein was 58.0%, 55.0%, and 60.3%, respectively, and was not significantly different among the graft groups. Graft revision for failed/failing grafts resulted in 5-year secondary patency rates of 79.2% (AK-PTFE), 73.3% (BK-PTFE), and 74.4% (BK-vein). These secondary patency rates were not statistically different. Eventual conversion to a vein graft in patients initially treated with PTFE maximized patency in the femoropopliteal segment with 5-year patency rates of 84.6% and 93.0% for the AK-PTFE and BK-PTFE graft groups, respectively. Major leg amputation was necessary during the entire course of the study in eight (3.3%) patients. We conclude that long-term patency rates for femoropoliteal bypass in patients with intolerable claudication are similar for PTFE and autologous saphenous vein grafts.Presented at the Twentieth Annual Meeting of the Peripheral Vascular Surgery Society, New Orleans, La., June 10, 1995.     

Preoperative C-reactive protein and outcome after coronary artery bypass surgery

BACKGROUND: C-reactive protein (CRP) is a predictor of early and late outcome after coronary angioplasty, but there is scant data on its impact on the outcome after coronary artery bypass grafting (CABG). METHODS: The predictive value of preoperative CRP was evaluated in a series of 764 patients who underwent on-pump CABG. RESULTS: During the in-hospital stay, 13 patients (1.7%) died, 45 (4.5%) developed low cardiac output syndrome, and 28 (3.7%) suffered minor or major cerebrovascular complications. Patients with a preoperative serum concentration of CRP>/=1.0 mg/dL had a higher risk of overall postoperative death (5.3% vs 1.1%, p = 0.001), cardiac death (4.4% vs 0.8%, p = 0.002), low cardiac output syndrome (8.8% vs 3.7%, p = 0.01), and any cerebrovascular complication (4.4% vs 3.5%, p = 0.66). Preoperative serum concentration of CRP>/=1.0 mg/dL was significantly more frequent among patients with history of myocardial infarction, diabetes, lower limb ischemia, low left ventricular ejection fraction, NYHA class IV, and in those undergoing urgent or emergency operation. At multivariate analysis, preoperative serum concentration of CRP >/= 1.0 mg/dL (p = 0.01, O.R.: 6.97) and left ventricular ejection fraction (p = 0.01, O.R.: 0.95) were independent predictors of postoperative death. Postoperative mortality rate was 0.3% among patients with preoperative CRP < 1.0 mg/dL and an ejection fraction >/=50%, whereas it was 21.4% among those with a preoperative CRP >/= 1.0 mg/dL and an ejection fraction less than 50% (p < 0.0001). CONCLUSIONS: Preoperative serum concentration of CRP in patients undergoing on-pump coronary artery bypass surgery is an important determinant of postoperative outcome.     

Surgical Thrombectomy and Transluminal Balloon Angioplasty for Failed Above-knee Femoropopliteal Polytetrafluoroethylene Bypass Grafts

Endovascular therapy offers an alternative to redo bypass or surgical graft revision for failed above-knee femoropopliteal PTFE bypass grafts. We evaluated the outcome of surgical thrombectomy and balloon angioplasty for the treatment of thrombosed bypass grafts. Thirty selected patients with thrombosed above-knee femoropopliteal PTFE bypass grafts were treated. Under local anesthesia, a surgical thrombectomy followed by bypass graft angiography and balloon angioplasty of perianastomotic stenoses was performed. Stents were used selectively for suboptimal angioplasty results. Patients underwent duplex scanning of the bypass graft postoperatively and at 6-month intervals. Life-table analysis and log-rank (Mantel-Cox) comparisons were performed. Patients were categorized into two groups on the basis of time elapsed from initial bypass graft construction to graft failure. Group 1 included 21 patients with a mean time to graft failure of 10 months (range, 0-20). Surgical thrombectomy was successful in 20 grafts (95%) and 17 patients had a stent placed after angioplasty. Rethrombosis occurred within 30 days in seven grafts (33%) in group 1 and major amputations were performed in six patients (28%). Group 2 included nine patients with a mean time to initial bypass graft failure of 48 months (range, 29-96). All patients in group 2 had a successful surgical thrombectomy and all received a stent. None of the grafts treated in group 2 reoccluded within 30 days of intervention and one patient (11%) went on to require a major amputation. By life-table analysis, the 6- and 12-month patency for group 1 was 15.3% and 5.1%, compared to 58.3% and 38.9% for group 2 (p = 0.027). Surgical thrombectomy along with balloon angioplasty has an unacceptably high rate of failure and limb loss in patients treated for early (<2 years) femoropopliteal PTFE bypass graft thrombosis. Surgical graft revision or redo bypass is recommended to achieve successful revascularization in these patients. Treatment with surgical thrombectomy and balloon angioplasty achieves significantly greater short-term patency results in patients with late (>2 years) bypass graft failure and may be a reasonable alternative for patients who cannot tolerate reoperation or lack autogenous conduit.Presented at the Twenty-eighth Annual Meeting of the Peripheral Vascular Surgery Society, Chicago, IL, June 7, 2003.     

Long-term results of above knee femoro-popliteal bypass depend on indication for surgery and graft-material.

OBJECTIVE To determine the long-term results of above-knee femoro-popliteal bypass with autologous saphenous vein (SV) or expanded polytetrafluoroethylene (ePTFE) in routine surgical practice. METHODS: Data from the Swedish vascular registry, Swedvasc, was reviewed retrospectively. Patients with bypass surgery in 1996 and 1997 were assessed 5-7 years later. Data were gathered from the case-records and from clinical follow-up. The composite endpoint of graft failure included death within 30 days, occlusion, major amputation, extension of the graft to below-knee position and removal of an infected graft. Kaplan-Meier curves and Cox' proportional hazard ratios were calculated. RESULTS: Four hundred and ninety-nine patients undergoing bypass for critical limb ischemia (CLI) (56%) or claudication (44%), SV (28%) or ePTFE (72%), were included. There were no significant differences in patient characteristics between patients with SV or ePTFE. CLI and ePTFE were risk factors for graft failure. For patients with both claudication and CLI SV grafts yielded better long-term results than ePTFE grafts ( p <0.03) and ( p <0.003), respectively. Symptom aggravation after graft occlusion was almost exclusively restricted to ePTFE grafts. CONCLUSIONS: Femoro-popliteal bypass above-knee with SV gives good long-term results, especially for claudication. ePTFE grafts cannot be recommended in claudicants, since occlusion occurs often and frequently leads to CLI.     

Serial noninvasive studies do not herald postoperative failure of femoropopliteal or femorotibial bypass grafts.

We performed a 5-year retrospective case-control study of 232 patients undergoing femoropopliteal (n = 188) or femorotibial (n = 44) bypass to determine if serial noninvasive studies herald postoperative graft failure. We correlated serial ankle/arm pressure indices (API) with graft patency. An interval drop in API of greater than or equal to 0.20 was considered hemodynamically significant, but interventional therapy was carried out only for clinically symptomatic graft failure and an API less than 0.20 above the preoperative value. The cumulative 5-year limb salvage rate was 82% and the patient survival was 63%. A significant drop in API did not correlate with cumulative 5-year graft patency. The 5-year cumulative primary graft patency rates were 60% and 62% in patients with stable and interval drops in API, respectively (Z = 0.15, p = N.S.) These results suggest that a significant drop in postoperative API does not predict patients with impending femoropopliteal or femorotibial graft failure. We believe that routine noninvasive surveillance and prophylactic intervention on detected asymptomatic lesions in leg bypass grafts may not be justified.     

Preoperative C-reactive protein level and outcome following coronary surgery.

OBJECTIVE: It has been suggested that a preoperative level of C-reactive protein (CRP)>5mg/l is predictive of postoperative complications in cardiac surgery patients. MATERIAL AND METHODS: Among 113 primary isolated coronary artery bypass patients, CRP was determined preoperatively and fibrinogen, interleukine 6, plasminogen activator inhibitor-1, prothrombin time, activated partial thromboplastin time, platelets and white blood cells count measured before surgery, 24, 48 and 72h thereafter and at hospital discharge. The clinical course of all cases was prospectively recorded. Data were then analysed according to the preoperative CRP level by dividing the patients into two groups (CRP>5mg/l or CRP<5mg/l). RESULTS: The in-hospital results were similar between the two patients groups. Even the postoperative haematic inflammatory markers did not significantly differ according to the preoperative CRP level. CONCLUSION: In this prospective study, a preoperative level of CRP>5mg/l did not predict in-hospital postoperative complications nor influence the extent of the inflammatory activation in primary isolated coronary bypass patients.     

Vascular laboratory prediction of pedal pressure following femoropopliteal bypass

This study examines the hypothesis that postoperative ankle-brachial pressure index (postop ABI) can be accurately predicted using noninvasive preoperative segmental leg pressure measurements. Seventy-three patients who underwent successful reverse autogenous vein femoropopliteal bypass and who had pre- and postoperative segmental leg pressure measurements were examined. Predicted postop ABI was estimated using the following formula: Postop ABI = 1 + (Preop ABI) - (Preop BKI). (BKI = below-knee brachial pressure index). Using this formula, 56 out of 73 (81%) patients had a measured postop ABI +/- 20% of predicted postop ABI. Five out of 73 (7%) patients had postop ABI less than 80% predicted, while 12 out of 73 (16%) patients had postop ABI greater than 120% of predicted. All patients with postop ABI greater than 120% of predicted had apparent tibial artery occlusive disease as indicated by preoperative gradients (BKI-ABI) greater than 0.15.     

Outcome After Occlusion of Infrainguinal Bypasses in the Dutch BOA Study: Comparison of Amputation Rate in Venous and Prosthetic Grafts

OBJECTIVE: To compare the consequences of occlusion of infrainguinal venous and prosthetic grafts. METHODS: In total, 2690 patients were included in the Dutch BOA study, a multicenter randomised trial that compared the effectiveness of oral anticoagulants with aspirin in the prevention of infrainguinal bypass graft occlusion. Two thousand four hundred and four patients received a femoropopliteal or femorodistal bypass with a venous (64%) or prosthetic (36%) graft. The incidence of occlusion and amputation was calculated according to graft material and the incidence of amputation after occlusion was compared with Cox regression to adjust for differences in prognostic factors. RESULTS: The indication for operation was claudication in 51%, rest pain in 20% and tissue loss in 28% of patients. The mean follow up was 21 months. After venous bypass grafting 171 (15%) femoropopliteal and 96 (24%) femorodistal grafts occluded. After prosthetic bypass grafting 234 (30%) femoropopliteal and 25 (38%) femorodistal grafts occluded. Patients with occlusions in the venous group had more severe ischemia, less runoff vessels and were older than the patients with prosthetic grafts. In the venous occlusion group 54 (20%) amputations were performed compared to 42 (16%) in the prosthetic occlusion group; crude hazard ratio 1.17 (95% CI 0.78-1.75). After adjustment for above mentioned differences in patient characteristics the hazard ratio was 0.86 (95% CI 0.56-1.32). CONCLUSION: The need for amputation after occlusion is not influenced by graft material in infrainguinal bypass surgery.     

Heparin-bonded Dacron or polytetrafluoroethylene for femoropopliteal bypass grafting: a multicenter trial

BACKGROUND: Dacron (polyester fiber) was largely abandoned for femoropopliteal bypass grafts 30 years ago because saphenous vein achieved better patencies. However, in patients taking aspirin, patency in above-knee femoropopliteal bypass grafts has recently been shown to be equivalent to that with saphenous vein. We compared heparin-bonded Dacron (HBD) and polytetrafluoroethylene (PTFE) in a randomized multicenter trial including below-knee popliteal or tibioperoneal trunk bypass graft where the long saphenous vein was absent or inadequate. METHODS: Over 28 months, 209 patients undergoing femoropopliteal bypass grafts (180 above-knee, 29 below-knee) were randomized to HBD (n = 106) or PTFE (n = 103). Each patient was given aspirin (300 mg/d) before surgery, and this continued unless the patient had intolerance to the aspirin. RESULTS: The mean follow-up was 42 months (range, 28-55). Fifteen (7.1%) patients died with patent grafts, and three (1.4%) infected grafts were removed. Patency (measured with Kaplan-Meier survival analysis) at 1, 2, and 3 years for HBD was 70%, 63%, and 55% compared with 56%, 46%, and 42%, respectively, for PTFE (P =.044). A total of 67 secondary interventions were performed on 48 thrombosed grafts; long-term patency was achieved in only three. Risk factors for arterial disease did not significantly influence patency. Amputations have been performed in 23 patients, six after HBD and 17 after PTFE bypass grafts (P =.015). CONCLUSIONS: HBD achieved better patency than PTFE, which carried a high risk of subsequent amputation.     

Postoperative and amputation-free survival outcomes after femorodistal bypass grafting surgery: findings from the Department of Veterans Affairs National Surgical Quality Improvement Program

PURPOSE: A noncardiac surgery risk model was used as a means of analyzing variations in postoperative mortality and amputation-free survival for older veterans undergoing femorodistal bypass grafting surgery. METHODS: A prospective cohort study was undertaken in 105 Veterans Affairs (VA) hospitals at the time of index operation from 1991 to 1995. Each patient was linked to subsequent hospitalizations, major amputation surgery, and survival through 1999. Logistic regression and proportional hazards models were used as a means of developing risk indices on the basis of risk factors from the VA National Surgical Quality Improvement Program. A total of 4288 male veterans 40 years or older underwent artificial, vein, or in situ bypass grafting surgery at the femoral to tibial level. The main outcome measures were 30-day postoperative mortality and amputation-free survival. RESULTS: Approximately half of all patients had undergone an earlier revascularization or amputation at any level for vascular disease. The 30-day postoperative mortality rate was 2.1% and varied greatly between mortality risk index quartiles (0.6%-5.2%). In a median 44.3 months of follow-up, surviving patients had 17,694 subsequent VA hospitalizations, 1147 patients (26.7%) underwent subsequent major amputation, and 1913 patients (44.6%) died. The overall survival probability was 88% at 1 year and 63% at 5 years; 1- and 5-year (any sided) limb salvage rates were 87% and 74%, respectively, for patients who underwent a femoropopliteal bypass grafting procedure, compared with 77% and 63%, respectively, for patients who underwent a tibial bypass grafting procedure. When amputation and death were combined as end points, amputation-free survival probability rates at 1, 3, and 7.5 years were 74%, 56%, and 29%, respectively. Patients with the best 20% survival risk scores had observed mean survival probability rates 30% higher than patients in the poorest 20% of survival risk. CONCLUSION: Risk indices derived from the preoperative workup may be of use to clinicians in assessing and communicating risk and prognosis. Risk-adjustment of outcomes is critical for evaluating future disease management initiatives for patients with advanced peripheral arterial disease.     

Case–control comparison of profundaplasty and femoropopliteal supragenicular bypass for peripheral arterial disease

Background:

The aim of this study was to compare preoperative and postoperative findings, and clinical progress in patients with peripheral arterial occlusive disease undergoing femoropopliteal supragenicular bypass or profundaplasty in a case–control study.

Methods:

Between January 2001 and June 2004, 171 patients with occlusion of the superficial femoral artery underwent surgery. A retrospective analysis of 28 matched patient pairs was performed. Endpoints were bypass occlusion, surgical revision, amputation and death. Mean length of follow‐up was 36 months.

Results:

At 3 years after surgery there was no statistically significant difference in outcome between femoropopliteal bypass surgery and profundaplasty. There was a trend towards improved results in patients who had bypass surgery for critical leg ischaemia. Preoperative patency of the crural outflow arteries was an independent prognostic factor in multivariable analysis.

Conclusion:

There were no significant outcome differences between supragenicular bypass surgery or profundaplasty in patients who had surgery for intermittent claudication or ischaemic rest pain. Patients with a single patent tibial artery and gangrene or ulceration appeared to benefit more from bypass surgery. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Bypass to the Genicular Arteries for Revascularisation of the Lower Limb

OBJECTIVE: To describe an initial experience with infrainguinal bypass grafts inserted distally in a genicular artery. DESIGN: Retrospective case series study. SUBJECTS AND METHODS: Eleven patients with Grade III chronic limb ischaemia in whom arteriography showed femoropopliteal occlusive disease and at least one genicular branch suitable for receiving a bypass. Bypass grafts were done to the descending genicular artery (n=4) or the medial sural artery (n=6) using segments of autologous veins; one bypass was not completed. RESULTS: Primary graft patency and foot salvage rates were 73% at 1 month and 24 months of follow-up. Patient survival rate was 100% and 90%, respectively. Major amputation was required in two of three patients following early graft failure. Of the eight patients who had a patent graft, the Doppler ankle-brachial systolic pressure index showed no change in one patient, an increase of 0.13-0.66 in six patients, and was not measured in one patient. The former patient underwent a below-knee amputation whereas the other seven patients showed complete healing of their skin ulcers and sites of minor amputation. CONCLUSION: The genicular bypass is a useful alternative that may extend the limits of infrainguinal arterial reconstruction with autologous tissue and the potential for long-term patient benefit.     

Sequential grafts for limb salvage in the presence of widespread occlusive vascular disease. A review of twenty patients.

Twenty patients with widespread occlusive vascular disease received sequential bypass grafts for lower-limb salvage. In 16 patients an isolated common femoral or profunda segment was perfused by a proximal graft and run-off was augmented by femoropopliteal bypass. In 4 a femoropopliteal bypass constituted the proximal component perfusing an isolated popliteal segment, run-off being increased by a popliteal-to-tibial graft. Dacron, expanded polytetrafluoroethylene (PTFE) (Gore-Tex), and autogenous vein grafts were used. The mean period of follow-up was 10.6 +/- 7 months and 70% of the limbs were salvaged. Thirteen graft systems remain currently patent, 4 have thrombosed, 2 patients died with patent grafts, and 1 required amputation despite graft patency.     

Can duplex scan arterial mapping replace contrast arteriography as the test of choice before infrainguinal revascularization?

Purpose: Arteriography is the diagnostic test of choice before lower extremity revascularization, because it is a means of pinpointing stenotic or occluded arteries and defining optimal sites for the origin and termination of bypass grafts. We evaluated whether a duplex ultrasound scan, used as an alternative to arteriography, could be used as a means of accurately predicting the proximal and distal anastomotic sites in patients requiring peripheral bypass grafts and, therefore, replace standard preoperative arteriography. Methods: Forty-one patients who required infrainguinal bypass grafts underwent preoperative duplex arterial mapping (DAM). Based on these studies, an observer blinded to the operation performed predicted what operation the patient required and the best site for the proximal and distal anastomoses. These predictions were compared with the actual anastomotic sites chosen by the surgeon. Results: Whether a femoropopliteal or an infrapopliteal bypass graft was required was predicted correctly by means of DAM in 37 patients (90%). In addition, both anastomotic sites in 18 of 20 patients (90%) who had femoropopliteal bypass grafts and 5 of 21 patients (24%) who had infrapopliteal procedures were correctly predicted by means of DAM. Conclusion: DAM is a reliable means of predicting whether patients will require femoropopliteal or infrapopliteal bypass grafts, and, when a patient requires a femoropopliteal bypass graft, the actual location of both anastomoses can also be accurately predicted. Therefore, DAM appears able to replace conventional preoperative arteriography in most patients found to require femoropopliteal reconstruction. Patients who are predicted by means of DAM to require crural or pedal bypass grafts should still undergo preoperative contrast studies to confirm these results and to more precisely locate the anastomotic sites. (J Vasc Surg 1999;29:100-9.)     

Need for late lower limb revascularization and major amputation after coronary artery bypass surgery.

OBJECTIVES: The aim of the present study was to estimate the need for late lower limb revascularization and/or major amputation after coronary artery bypass grafting (CABG). DESIGN: Retrospective study. PATIENTS AND METHODS: 1307 residents of Oulu who underwent CABG from 1990 to 2006 formed the basis of this community-wide study. RESULTS: During a mean follow-up of 7.1+/-4.5 years, 111 patients (8.5%) underwent 251 vascular procedures for lower limb ischemia and 25 major amputations. In four patients, revascularization was done for complicated wound after vein graft harvesting. Freedom rates from lower limb revascularization and/or major amputation at 5-, 10- and 15-year were 92.9%, 88.4% and 85.1%, whereas freedom rates from lower limb revascularization for critical ischemia and/or major amputation were 98.1%, 95.2% and 94.7%. Age (p=0.013, HR 1.05), extracardiac arteriopathy (p<0.0001, HR 5.39), left ventricular ejection fraction classes (p=0.03), diabetes (p<0.0001, HR 5.78), and estimated glomerular filtration rate<60mg/min/m(2) (p=0.02, HR 2.22) were independent predictors of lower limb revascularization for critical leg ischemia and/or major amputation. CONCLUSIONS: Patients with extracardiac arteriopathy, diabetes and decreased glomerular filtration rate at the time of CABG are at risk for late lower limb ischemia. These patients would most benefit of a closer follow-up for prevention of peripheral vascular disease and its related complications.     

The effect of anticoagulation therapy and graft selection on the ischemic consequences of femoropopliteal bypass graft occlusion: results from a multicenter randomized clinical trial

OBJECTIVE: A recent retrospective study showed that the ischemic consequences of femoropopliteal bypass graft occlusion were more severe with polytetrafluoroethylene (PTFE) than with vein. This study examines this conclusion and whether oral anticoagulation therapy reduces the degree of ischemia after occlusion of PTFE and vein femoropopliteal bypass grafts. METHODS: Four hundred two patients who underwent femoropopliteal bypass grafting (233 PTFE and 169 vein) were randomized to a postoperative regimen of either warfarin (international normalized ratio, 1.4 to 2.8) and aspirin (WASA; 325 mg daily) therapy or aspirin alone (ASA) therapy. The grade of acute ischemia at the time of graft occlusion was assessed with the Society of Vascular Surgery recommended reporting standards (I, viable; II, threatened). Early graft occlusions (<30 days) were excluded. RESULTS: There were 100 graft occlusions (67 PTFE and 33 vein) during a mean follow-up period of 36 months (PTFE) and 39 months (vein). Forty-eight patients were randomized to WASA therapy, and 52 were randomized to ASA therapy. The patients were well matched for age, atherosclerotic risk factors, operative indication, and preoperative ankle-brachial index. Overall, a greater percentage of the PTFE occlusions caused grade II ischemia than did the vein graft occlusions (48% versus 18%; P =.005). The ankle-brachial index at the time of graft occlusion was significantly lower in the PTFE grafts than in the vein grafts (0.28 versus 0.45; P =.001). The patients with PTFE who were undergoing WASA therapy at the time of graft occlusion had less grade II ischemia than did those patients who were undergoing ASA therapy (28% versus 55%; P =.057). However, the incidence rate of severe ischemia after graft occlusion remained greater with PTFE grafts and WASA therapy as compared with all the vein grafts (28% versus 18%). The vein graft occlusions had the same incidence rate of grade II ischemia with WASA therapy as with ASA therapy (20% versus 17%; P = 1.0). CONCLUSION: The ischemic consequences of femoropopliteal bypass graft occlusion are worse with PTFE than with vein. Treatment with WASA therapy lessens the severity of acute ischemia after the occlusion of PTFE graft as compared with ASA therapy but not to the degree seen with vein graft occlusion. Occlusion of femoropopliteal vein grafts is seldom accompanied by severe ischemia and is not improved with WASA therapy.     

Gender differences in outcome after stent treatment of lesions in the femoropopliteal segment

Background and Aims: Although endovascular stent treatment is increasingly used in infrain-guinal atherosclerotic occlusive disease, outcome with focus on gender differences has not been reported in detail.Material and Methods: One hundred and twelve consecutive patients (67 [60%]) women, un-dergoing endovascular nitinol stent treatment of atherosclerotic lesions in the femoropopliteal segment were analysed concerning improvement in ankle brachial index (ABI), reinterventions, complications, amputation and survival rates up to 12 months after intervention. Risk factors for amputation and death were analyzed with logistic regression.Results: At presentation, women showed critical limb ischemia (CLI) more often than men (87% vs. 58 %; P = 0.001). After 12 months ABI had improved (from 0.40 ± 0.26 at baseline to 0.86 ± 0.22 after 12 months, P < 0.001), but 16 patients (15%) had been amputated and 27 patients (24 %) had died. After adjustment for age, diabetes mellitus and smoking, female gender was an independent risk factor for amputation (OR 9.0; 95% CI 1.1-76.5; P = 0.045).Conclusions: Stent treatment of lesions in the femoropopliteal segment had favourable effects on ABI and limb salvage. Treated women more often had CLI and ran a higher risk for amputation within 12 months than men. This might reflect failure of clinicians to adequately appreciate symptoms of atherosclerotic leg artery disease in women.     

Subscapular artery Y-shaped flow-through muscle flap: a novel one-stage limb salvage procedure

OBJECTIVES: Major tissue loss caused by the critical limb ischemia requires improvement of distal perfusion and cover of large tissue defects. We propose a new method, the y-shaped subscapular artery flow-through (Y-SCAFT) muscle flap using the subscapular artery that yields an arterial graft and a free muscle flap sustained by a collateral branch of this artery. This prospective study evaluated the feasibility of this technique and analyzed wound healing, graft patency, and limb salvage. METHODS: Between 2002 and 2007, 20 patients, mean age 64 years (range, 55-79 years), were treated with this technique. All presented with critical ischemia and major tissue loss, with exposure of the tendons, bones, or joint, and were candidates for major amputation. Revascularization and cover of tissue loss with the same Y-SCAFT anatomic unit was used for all patients. The distal anastomosis was performed between the distal branch of the Y-SCAFT and the pedal artery in 9, posterior tibial artery in 4, peroneal artery in 1, lateral tarsal artery in 3, and the plantar artery in 3. In four patients, the distal part of the arterial graft, including the anastomosis, was covered with the muscle flap because the tissue loss was nearby. The proximal anastomosis was performed between a leg artery and the arterial graft in 10 patients. A venous graft was necessary in 10 patients to extend the bypass proximally. RESULTS: One patient died during the postoperative period. Duplex control evidenced patency all the Y-SCAFT muscle flaps. Healing was achieved in all patients. Mean follow-up was 31 months (range, 6-58 months). No patients died during follow-up. One patient presented occlusion of the Y-SCAFT muscle flap and underwent amputated. One patient had major amputation despite a patent graft. At 2 years, leg salvage was 85%, patency was 94%, and survival was 94%. At the end of the follow-up, 17 patients (1 death, 2 amputations) had a patent graft, a viable muscle flap, wound healing, and a functional leg. CONCLUSION: We showed the clinical feasibility of the technique of Y-SCAFT muscle flap, which allows for revascularization and cover of major tissue loss with one anatomic unit. This method is particularly useful in selected cases with poor run-off and large ischemic lesions.