A 5 year follow-up of Dacron femoropopliteal bypass grafts

Over a 5 1/2 year period, 66 Dacron femoropopliteal grafts were performed for patients with an absent or unsuitable long saphenous vein. The minimum follow-up has been 6 months and cumulative patency was 50 per cent at 5 years. Twenty-five patients had critical ischaemia (preoperative Doppler ankle pressure less than 40 mmHg) and 41 patients had severe ischaemia (pre-operative ankle pressure greater than 40 mmHg). The procedure significantly improved ankle pressures in both groups and this was maintained at follow-up. In the group of 25 patients with critical ischaemia there were three operative deaths and in 10 the graft subsequently occluded, precipitating an amputation. In the group of forty-one patients with severe ischaemia, there was one operative death and in two patients the graft occluded at 18 and 24 months. In this small series there was no significant difference in patency, whether the graft was placed to the popliteal artery above or below the knee joint, or whether the popliteal had less than three patent branches at its trifurcation.     

Hemodynamic studies before and after extended bypass grafts to the tibial and personeal arteries.

Thirty-ones limbs of 29 consecutive patients undergoing bypass grafts to the tibial or peroneal arteries were studied. Twenty-five limbs had ischemic rest pain with or without localized gangrene, and six had incapacitating claudication. The mean segmental pressure indices were upper thigh, 1.16 +/- 0.36; above knee, 0.71 +/- 0.30; below knee 0.51 +/- 0.23; and ankle, 0.28 +/- 0.21. Indices at the ankle were significantly lower (P less than 0.005) than those obtained from limbs that were candidates for simple femoropopliteal bypass. Three grafts failed immediately (initial patency rate of 90%). In the surviving grafts, ankle pressures rose from 39 +/- 26 to 145 +/- 29 mm Hg, and the ankle pressure index increased from 0.27 +/- 0.20 to 1.03 +/- 0.15 mm Hg. Consistent with these hemodynamic changes, all patients but one initially were relieved of their symptoms, and all ischemic lesions were treated successfully. Thirteen grafts failed subsequently (21 days to 34 months). Compared with preoperative values, ankle pressures after failure were either increased or unchanged in 75% of these limbs. Early occlusion could not be predicted on the basis of a low preoperative pressure index. During follow-up, impending graft failure was detected by a fall in ankle pressure in three patients and successfully prevented.     

Femoro-popliteal versus femoro-distal bypass grafting for limb salvage in patients with an "isolated" popliteal segment

In a prospective, multicentre trial, 59 patients with an ischaemic limb and an "isolated" popliteal segment on angiography were randomised to undergo infrainguinal bypass grafting to either the popliteal segment or to a reconstituted distal vessel lower in the calf. Limb salvage was attained with 88% of the femoro-popliteal grafts and 80% of the femoro-distal grafts. There was no difference in the one year graft patency rate between the femoro-popliteal group (79%) and the femoro-distal group (70%). Mean postoperative increase in ankle/brachial pressure index was similar in the two groups despite the presence of occluded or significantly diseased vessels distal to the popliteal anastomoses. Technical difficulties were encountered in 8% of the popliteal group and 24% of the distal group. Femoro-distal bypass grafting confers no apparent benefit over femoral bypass grafting into a patent popliteal segment, even though the popliteal run-off is impaired or occluded.     

Natural history of above- and below-knee femoropopliteal grafts

Postoperative physiologic data were reviewed in 74 patients with 85 femoropopliteal bypass grafts. Documented progression of atherosclerosis occurred in the aortoiliac segment in 18 limbs and in the popliteal and tibioperoneal vessels in 14 limbs, although aortoiliac disease was more often responsible for graft failure. Grafts with good postoperative runoff as determined by hemodynamic measurements had a statistically significant higher patency rate than those with poor runoff. Nearly half of the limbs with a progressive postoperative decline in the ankle-arm index ultimately had graft occlusion. Rapid progression of popliteal artery atherosclerosis distal to an above-knee graft was not a significant problem.     

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.     

Isolated femoropopliteal bypass graft for limb salvage after failed tibial reconstruction: a viable alternative to amputation

PURPOSE: Femoropopliteal bypass grafting procedures performed to isolated popliteal arteries after failure of a previous tibial reconstruction were studied. The results were compared with those of a study of primary isolated femoropopliteal bypass grafts (IFPBs). METHODS: IFPBs were only constructed if the uninvolved or patent popliteal segment measured at least 7 cm in length and had at least one major collateral supplying the calf. When IFPB was performed for ischemic lesions, these lesions were usually limited to the digits or small portions of the foot. Forty-seven polytetrafluoroethylene grafts and three autogenous reversed saphenous vein grafts were used. RESULTS: Ankle brachial pressure index (ABI) increased after bypass grafting by a mean of 0.46. Three-year primary life table patency and limb-salvage rates for primary IFPBs were 73% and 86%, respectively. All eight IFPBs performed after failed tibial bypass grafts remained patent for 2 to 44 months, with patients having viable, healed feet. CONCLUSION: In the presence of a suitable popliteal artery and limited tissue necrosis, IFPB can have acceptable patency and limb-salvage rates, even when a polytetrafluoroethylene graft is used. Secondary IFPB can be used to achieve limb salvage after failed tibial bypass grafting.     

Bypass grafting to the popliteal artery in limbs with occluded crural arteries

Intraoperative completion angiograms of 47 femoropopliteal bypasses in limbs with occluded crural arteries were reviewed to identify the angiographic determinants of early outcome. Of 28 limbs in which the foot vessels were available for analysis, only 2 (7%) had an intact pedal circulation, and 18 limbs demonstrated no crural arteries suitable for distal reconstruction. The overall cumulative patency rate was 51% with a 76% limb salvage rate at 12 months. All seven grafts performed onto a popliteal artery segment of less than 8 cm occluded in the early period. The status of crural and foot arteries and the number of collaterals did not correlate well with early patency. Limbs with no patent crural artery that were analyzed in the poor angiographic runoff group, according to our previously reported classification, demonstrated relatively higher patency rates than the other subgroups with poor runoff. In cases where angiography demonstrates a poor runoff for distal revascularization, popliteal bypass with occluded crural arteries might achieve acceptable patency rates.     

Value and limitations of secondary femoropopliteal bypasses with polytetrafluoroethylene

Secondary femoropopliteal bypasses with polytetrafluoroethylene (PTFE) grafts are widely regarded to be of questionable value. This has prompted some to abandon all attempts at secondary revascularization with PTFE and others to recommend that primary femoropopliteal bypasses be performed preferentially with PTFE grafts so that vein may be used for secondary procedures. Because we questioned both of these views, we reviewed all femoropopliteal bypasses done at our institution in the past 12 years and identified 73 secondary PTFE femoropopliteal procedures performed after a failed ipsilateral infrainguinal bypass (69 failed femoropopliteal; 4 failed femorodistal). Seventy (96%) secondary bypasses were performed for limb salvage and 3 (4%) for severe disabling claudication. Insertion of grafts to the popliteal artery was above the knee in 26 (36%) and below the knee in 47 (64%). Primary life-table graft patency at 4 years was only 38%. Forty-eight reinterventions in 34 limbs were required to restore or maintain graft patency in thrombosed or failing grafts. For thrombosed grafts, 20 interventions consisted of 9 simple thrombectomies and 11 thrombectomies with additional revision procedures (5 distal or proximal extensions, 6 patch angioplasties). Twenty-eight lesions threatening graft patency were treated by percutaneous transluminal angioplasty in 3, proximal or distal extensions in 20, and patch angioplasty in 5. As a result of these reinterventions, the overall secondary patency rate was 55% at 4 years, and the limb salvage rate was 74% at 4 years. Although aggressive follow-up and reintervention may be required, the use of secondary PTFE conduits in the femoropopliteal position is a viable option in patients undergoing limb salvage procedures who are at high risk.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Aortofemoral bypass and the role of concomitant femorodistal reconstruction

A consecutive series of 200 patients having aortofemoral bypass grafts were studied in order to determine the effect of femoropopliteal occlusive disease on the results and the role of concomitant femorodistal bypass. Bifurcated aortic grafts were used in 177 patients and unilateral aortofemoral grafts in 23 giving 377 limbs for study. Of the 377 limbs, 184 (49 per cent) had minimal femoropopliteal disease (Group 1), 24 (6.4 per cent) had a femoropopliteal stenosis (Group 2) and 169 (44.6 per cent) had complete femoropopliteal occlusion (Group 3). In Group 3 aortofemoral bypass was carried out alone in 106 cases (Group 3a): in the other 63 cases femorodistal bypass was carried out at the same time as aortoiliac reconstruction (Group 3b). The cumulative patency at 5 years for all aortofemoral grafts together was 91 per cent. However, that for grafts in Group 3a was only 65 per cent compared with 98 per cent for Groups 1 and 3b and 94 per cent for Group 2. The cumulative patency rate for grafts in Group 3a was significantly lower than for all other groups (P less than 0.001). The operative mortality for those patients who had concomitant aortofemoral and femorodistal grafts (Group 3b) did not differ significantly from that of any of the other groups (P greater than 0.1). Of the cases in Group 3a, 21 (26 per cent) required femoropopliteal reconstruction at a later date. The results indicate that in the presence of combined aortoiliac and femoropopliteal occlusive disease concomitant reconstruction of both arterial segments yields significantly better results than aortoiliac bypass alone.     

Four years' results of a prospective, randomized clinical trial comparing polytetrafluoroethylene and modified human umbilical vein for below-knee femoropopliteal bypass

Polytetrafluoroethylene (PTFE) (Gore-Tex) and human umbilical vein (Biograft) arterial grafts were compared for below-knee femoropopliteal bypass grafting in a prospective randomized clinical trial. One hundred five patients (105 limbs) entered the trial. Seventy-six percent suffered from rest pain, ulceration, or gangrene. The median postoperative ankle-arm blood pressure index was 0.36. Twenty-three limbs had three patent tibial arteries, 46 limbs had two tibial arteries, 31 limbs had one patent artery, and five limbs had isolated popliteal segments. Thirty-four percent were repeat operations. Fifty-five patients were allocated to receive PTFE grafts and 50 to receive human umbilical vein grafts. The two groups were comparable as to preoperative risk factors and operative and postoperative treatment. During the first 4 years (maximum 1609 days) 40 PTFE grafts and 24 umbilical veins occluded. At 1 year the PTFE patency rate was 53% and at 4 years was 22%. For umbilical vein the corresponding figures were 74% and 42% (p = 0.005, Gehan test). During follow-up the incidence of PTFE failure was on the average 2.1 times higher than that of umbilical vein failure (95% confidence limits 1.2 to 3.4).     

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.     

Should polytetrafluoroethylene grafts be used in preference to saphenous vein for femoropopliteal arterial bypass?

Some surgeons have advocated using polytetrafluoroethylene (PTFE) as the graft material of choice for femoropopliteal arterial bypass so that the saphenous vein could be preserved for future cardiovascular surgery. We have examined our results to see if this approach could be justified in our patient population. PTFE was used for 101 femoropopliteal reconstructions in 96 patients (56 male and 40 female). Thirty-eight (40%) complained of debilitating claudication and 58 (60%) had limb-threatening ischaemia. There were 83 primary PTFE femoropopliteal reconstructions and 18 repetitive procedures after failure of an earlier ipsilateral bypass. Twenty-nine of the 101 PTFE grafts were anastomosed distally to the popliteal artery above knee and the remaining 72 below knee. At 5 years, the cumulative patency for all grafts was only 11%. The 4 year cumulative patency was better for claudicants (40%) than for those with threatened limb loss (11%) but two of the 38 claudicants required amputation when their grafts failed. Patency rates were not significantly affected by the site of the distal anastomosis or by a previous failed ipsilateral femoropopliteal bypass. Worthwhile limb salvage was achieved only by frequent re-operation. Our results with PTFE are not good enough to use it in preference to an adequate saphenous vein for femoropopliteal bypass.     

Clinical results of femoropopliteal bypass using externally supported (EXS) Dacron grafts: with a comparison of above- and below-knee anastomosis

As of the end of September 1989, 52 EXS Dacron grafts had been implanted for femoropopliteal bypass operations. The distal ends of 27 grafts were anastomosed to above-knee popliteal arteries and those of 25 grafts to below-knee popliteal arteries. The cumulative patency rate of above-knee grafts was 71.3% at 54 months, and that of below-knee grafts was 78.8% at 48 months (n.s.). Kinking and stenosis of the arteriosclerotic proximal and/or mid popliteal artery when the knee was bent were angiographically remarkable. These changes may explain why some femoropopliteal grafts occlude with time and why the late results of above-knee grafts are not much better than those of below-knee grafts.     

Tibial and peroneal bypass in severe occlusive disease of the lower extremities.

Symptomatic arteriosclerotic occlusive disease involving the femoral and proximal popliteal arteries is currently best treated by reversed autogenous saphenous vein bypass graft. Severe occlusive disease frequently includes the popliteal and/or origin of the trifurcation vessels with reconstitution of one or more of the vessels in the lower leg. We have used distal bypass 97 times in 90 patients during the past decade. There was only one postoperative death in the series in spite of the advanced age and concurrent disease in the majority of the patients. Our indications for operation continue to be relief of pain or salvage of an extremity. We rely on high quality preoperative angiograms for selection of vessels to receive the bypass. The posterior tibial artery was used in 63 of the cases, while the anterior tibial and peroneal were used in 24 and 10 cases, respectively. There were 11 immediate inhospital failures in this series of 97 cases requiring amputation in five. Three additional patients had amputations during the ensuing several months. Of the 85 grafts functioning at the time of discharge from the hospital, 16 or (18.8%) failed during the first years. Grafts that remained patent for one year have a high incidence of long term patency which is in keeping with other reported series.     

Prospective randomized study on bilateral above-knee femoropopliteal revascularization: Polytetrafluoroethylene graft versus reversed saphenous vein

OBJECTIVE: Some controversy exists as to whether polytetrafluoroethylene (PTFE) is equivalent to reversed saphenous vein (SV) as bypass graft material for above-knee femoropopliteal revascularization. We compared the 5-year patency rate with reversed SV and PTFE grafts in patients with claudication who underwent bilateral above-knee femoropopliteal revascularization. METHODS: Between January 1994 and December 1997, 51 patients (102 limbs) with bilateral disabling claudication due to superficial femoral artery occlusion underwent above-knee femoropopliteal bypass grafting, with SV in one limb and PTFE graft in the other limb. Patients were randomly selected for sequential surgical treatment with either SV-PTFE or PTFE-SV. Kaplan-Meier analysis was used to estimate patency rate, and various factors were analyzed to ascertain any association with revascularization failure. RESULTS: There was no perioperative (30 day) limb loss or death, but five late deaths (late survival rate, 90%). Mean follow-up was 59 months. In the SV group, three bypass grafts failed, requiring repeat operation in only one patient. In the PTFE group, eight bypass grafts failed, leading to five repeat operations. There was no statistically significant difference in primary "assisted" patency rate for the two grafts: 100%, 98%, and 94% for SV grafts, and 96%, 84%, and 84% for PTFE grafts (P =.09), after 1, 3, and 5 years, respectively. CONCLUSIONS: The overall results of this randomized study show that SV and PTFE grafts have a statistically comparable patency rate when used above the knee in patients with claudication. Use of SV, however, leads to fewer occlusions and repeat operations.     

In situ femoropopliteal and infrapopliteal bypass. Two-year experience

We describe 83 in situ femoropopliteal and infrapopliteal artery bypass grafts. The in situ technique involved the valve incision method using scissors, the valvulotome (Leather), and a modified valve cutter (Hall). Arteriovenous fistulae were detected intraoperatively by angiography and/or the Doppler method and ligated. The operative indications were rest pain, ulcer, and gangrene in 88% of cases, and claudication in 7.2%. The mean preoperative ankle pressure was 61.3 mm Hg and the ankle-brachial index was 0.43. The mean postoperative ankle pressure was 125.3 mm Hg and the ankle-brachial index was 0.97. The vein utilization rate was 96%. One-year patency for popliteal anastomoses was 85.7%, for peroneal anastomoses it was 100%, and for infrapopliteal anastomoses it was 89.6%. The data suggest that the practicing vascular surgeon can adopt the in situ technique and can expect high graft patency rates even in limb salvage situations with poor distal outflow.     

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.     

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.     

Evaluation of proposed standards for runoff in femoropopliteal arterial reconstructions: correlation between runoff score and flow waveform pattern. A preliminary report

The Ad Hoc Committee on Reporting Standards of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery (SVS/ISCVS) proposed a new angiographic scoring system that grades the quality of vessels distal to the expected bypass site and calculates an overall runoff score. To assess the predictability of the bypass grafts by this runoff scoring system, we compared this runoff score with postoperative increase in the ankle/brachial index (delta ABI) and intraoperatively measured flow waveform patterns in 60 patients undergoing femoropopliteal bypass grafts. No correlation was found between delta ABI and the runoff score. Graft-patent survival time correlated with the runoff score (r = 0.44, p = 0.02). Grafts with type 0 or I flow waveform pattern with a satisfactory long-term patency had a significantly lower runoff score than grafts with type II, III or IV flow waveform pattern (p less than 0.05). When all the grafts were arbitrarily divided into two groups (grafts with a runoff score over 4.5 and those with a score of less than 4.0), a superior long-term patency was obtained in the low runoff score group with polytetrafluoroethylene (p less than 0.01) and saphenous vein grafts (p = 0.04), but not in the group with composite grafts (p = 0.25). Thus, the SVS/ISCVS runoff scoring system can be used to predict the fate of bypass grafts in femoropopliteal arterial reconstructions.