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

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

Sequential femoral-tibial bypass grafting for limb salvage.

Bypass grafting to distal lower extremity vessels continues to be associated with a high rate of graft occlusion. By utilizing a sequential side-to-side anastomosis between saphenous vein and popliteal artery in femoral-tibial bypass grafts, runoff can be increased and graft patency thereby improved. Sequential femoral-tibial grafts were employed in seven patients with gangrene, trophic changes, or restpain, all of whom had single-vessel runoff by arteriography. All seven sequential grafts established to a distal vessel in addition to the popliteal artery have remained open for periods of five to 27 months as determined by palpable graft or foot pulses. Two patients undersent below-knee amputation within six months of operation but had patent grafts at the time of amputation. In three patients ischemic ulcers resolved and in two patients toe amputations healed successfully. Sequential bypass grafting is a technique aimed at improving the patency rate of femoral-tibial bypass grafts by augmenting runoff.     

Long-term evaluation of composite sequential bypass for limb-threatening ischemia.

When sufficient vein for a completely autogenous femorotibial artery bypass is not available, composite sequential grafting by using vein combined with polytetrafluoroethylene material is a surgical option. This study reviews what is currently the largest collection of these grafts and focuses on technical aspects and long-term patency characteristics. During a 7-year period 67 composite sequential bypasses were used to manage rest pain (38), ulcer (18), or gangrene (11) in 62 patients (mean age, 66 years). Fifty-two percent were men, and 51% had diabetes. This method was used as a primary reconstruction in 30, a second bypass in 16, and in 21 it was used after multiple other failed bypasses. Femoral to above-knee popliteal (44) and below-knee popliteal (23) 6 mm polytetrafluoroethylene grafts were placed. Then extensions of greater saphenous (57) or lesser saphenous (10) vein were anastomosed to the anterior tibial (19), posterior tibial (26), or peroneal (22) arteries. Fifty-three percent were maintained on long-term warfarin (Coumadin) anticoagulation, and 33% were maintained on aspirin. No deaths occurred in the perioperative period. Bypass patency was ascertained by a Doppler pressure and waveform analysis, with mean follow-up of patency or to the time of graft failure of 33 months (1 to 91 months). Three-year patient survival was 72%. Cumulative life-table primary patency of 72% (1-year), 64% (2-year), and 48% (3-year) was calculated. Two grafts are functioning 7 years after placement. Limb salvage was 84% at 2 years and 70% at 4 years. At the time of failure, five grafts retained a patent venous bypass segment, which allowed prompt reconstruction of the proximal portion. In a comparison of grafts with early failure and those with long-term patency, the SVS/ISCVS runoff score, vein diameter, tibial artery diameter, and coagulation status were similar. However, patients with the popliteal anastomosis above the knee had 2-year patency of 72% compared with 46% for those with below-knee anastomoses. This technique, when possible, appears preferable to an all prosthetic tibial 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.     

Distal femoropopliteal bypass using a composite graft of PTFE and non-reversed saphenous vein

The results of femoropopliteal bypass to the infragenicular popliteal artery, in the absence of suitable saphenous vein have, in the main, been disappointing. We present a new type of composite graft, for use when the distal anastomosis is below the knee, which avoids the potential problems of prosthetic graft alone. The graft consists of a proximal segment of 6 mm expanded PTFE (Gore-Tex; or Impra), anastomosed to transposed non-reversed autologous saphenous vein. Forty-two patients were studied following unilateral, below knee composite femoropopliteal graft surgery for severe claudication or critical ischaemia. Pressure indices were calculated along with intraoperative flow rate, and all patients were followed up at regular intervals to assess graft patency. During the study period three patients died and graft occlusion occurred in a further eight. Analysis of the cumulative patency curve revealed that the majority of occlusions occurred in the first 3 months. The patency at 12 and 18 months was encouraging with values of 84% and 79% respectively. Comparison of pressure indices revealed a significant increase following surgery (P less than 0.001). The postoperative pressure index appeared to predict the grafts likely to occlude and the intraoperative flow rates mirrored a similar trend. Grafts which occluded had a significantly lower pressure index and flow rate (P less than 0.01, P less than 0.002, respectively). Our results suggest that for infragenicular femoropopliteal bypass grafting where full length in-situ vein graft is not possible; a composite graft using PTFE with non-reversed vein is a good alternative.     

Infragenicular polytetrafluoroethylene bypass with distal vein cuffs for limb salvage: a contemporary series

HYPOTHESIS: Infragenicular polytetrafluoroethylene (PTFE)-venous cuff bypass grafting provides acceptable graft patency and limb salvage rates for limb salvage. DESIGN: Retrospective clinical review of a consecutive series. SETTING: Vascular surgical practice during the interval October 1, 2000, to September 1, 2004. PATIENTS: Fifty-one male and 49 female patients whose mean age was 76.9 years were operated on for tissue loss (67%), chronic rest pain (28%), and severe claudication (6%). Fifty-two percent of patients were diabetic and 49% had undergone previous leg bypass surgery. All patients had absent or inadequate greater saphenous vein, and 84 patients had absent or inadequate arm vein. INTERVENTIONS: One hundred five infragenicular PTFE bypasses were performed in these 100 patients. Distal targets were the infragenicular popliteal (40), posterior tibial (35), anterior tibial (16), and peroneal arteries (14). Sixty-eight venous cuffs were constructed from lesser saphenous vein. MAIN OUTCOME MEASURES: Graft patency, limb salvage, and patient survival were analyzed. RESULTS: Twelve early graft failures resulted in 7 leg amputations. The mean +/- SE 3-year primary patency and limb salvage rates were 64.4% +/- 12.8% and 74.4% +/- 11.9%, respectively. Perioperative mortality was 2.9% and 3-year survival was 38%. Graft follow-up ranged from 1 to 47 months with a mean of 13 months using life-table methods. CONCLUSIONS: For patients requiring arterial revascularization for limb salvage, in which autologous venous conduit is unavailable, distal venous cuff-PTFE bypass provides acceptable patency and limb salvage rates when viewed in the context of short life expectancy for these elderly patients.     

Adjuncts to improve patency of infrainguinal prosthetic bypass grafts

The superiority of autologous venous conduit for infrainguinal arterial bypass has been well documented, especially when the bypass extends below the knee or to the tibial arteries. Nevertheless, when adequate autologous vein is not available, prosthetic bypasses (eg, polytetrafluoroethylene [PTFE] or Dacron) are often used in limb-salvage situations. The inferior long-term patency of these infrainguinal prosthetic bypasses has been documented by a number of studies. One such study reported a prospective multicenter randomized trial with only a 12% primary patency for infrapopliteal prosthetic bypasses after 4 years. Another study reported a similar experience with infragenicular bypasses with PTFE for limb salvage even for above-knee (27%, 5 year) and below-knee (25%, 5 year) femoral-popliteal bypasses. The reported PTFE graft patency was consistently inferior to that achieved with autologous vein for limb salvage. Dacron grafts appear to have similar patency rates to PTFE. In an attempt to improve prosthetic graft patency, a number of surgical and medical adjuncts have been developed. In this review, the authors discuss these adjuncts and their impact on infrainguinal prosthetic graft patency.     

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.     

The posterior approach to popliteal-crural bypass

Purpose: An evaluation of the posterior approach to popliteal-crural bypass was performed to assess the feasibility and results of this technique.Methods: A posterior approach to the popliteal and crural vessels was performed in 21 patients in the prone position over a 24-month period, with use of lesser saphenous vein and a novel exposure of the crural arteries through the vein harvest incision.Results: Diabetes mellitus was present in 17 (81%) patients, and all had limb-threatening ischemia with rest pain (15 patients, 71%), ulceration (7 patients, 33%), and gangrene (8 patients, 38%). The inflow site was the supragenicular popliteal artery in four patients (19%) and the infragenicular popliteal artery in 17 patients (81%). The outflow sites were the tibioperoneal trunk in six patients (29%), the peroneal artery in nine patients (43%), the posterior tibial artery in four patients (19%), and the anterior tibial artery in two patients (10%). The distal anastomosis was performed in the proximal one third of the crural artery in 16 (76%) of the patients, with a mean lesser saphenous vein graft length of 11.2 ± 1.7 cm. The toe-brachial pressure indexes rose from 0.20 ± 0.07 to 0.77 ± 0.16 (p = 0.001), all wounds healed without complication, and 19 patients (90%) were discharged with open bypass grafts and salvaged extremities. The 6-, 12-, and 18-month primary graft patency rates were 88%, 88%, and 83%, respectively (Kaplan-Meier methods).Conclusions: Thus the posterior approach to infragenicular occlusive disease represents a durable alternative to traditional approaches; sparing the greater saphenous vein, facilitating exposure of the proximal crural arteries, and minimizing the wound healing problems commonly experienced with standard techniques. (J VASC SURG 1994;19:74-80.)     

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.     

复合血管序贯式旁路移植术治疗慢性肢体缺血的临床分析

目的:探讨复合血管序贯式下肢动脉旁路术治疗慢性下肢缺血的效果。方法:回顾性分析3年内采用复合式血管序贯式动脉血管重建的25例慢性下肢缺血患者的临床资料。复合血管由聚四氟乙烯（PTFE）人工血管及自体静脉组合而成。PTFE近心端与股总动脉吻合，远端与孤立腘动脉吻合；自体静脉从PTFE血管远端发出并与小腿的胫或腓动脉吻合。结果:自体静脉远端吻合口止于胫前动脉5例，胫后动脉8例，腓动脉12例。术后1，2，3年累积通畅率分别为78%， 72%， 61%。二期累积通畅率分别为83%，77%，68%。救肢率分别为83%，83%，73%。结论:复合血管序贯旁路术治疗慢性肢体缺血远期通畅率较高，具有较好的救肢效果，是解决自体静脉不足的合理选择。     

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

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

Early results for below-knee bypasses using Distaflo

In patients who require lower extremity revascularization, prosthetic graft is a reasonable alternative in the absence of a suitable autologous vein conduit. However, prosthetic bypass grafts have limited patency, especially for infrageniculate reconstruction. Polytetrafluoroethylene grafts were geometrically modified at the distal end to increase their patency. The authors reviewed their experience with the Distaflo graft in patients who required lower extremity below-knee popliteal and tibial bypasses when no suitable autologous vein conduit was available. Chart review was conducted of the 57 patients who underwent 60 lower extremity bypasses over a 3-year period between June 2003 and April 2006. Twenty-four revascularizations were constructed to the tibial outflow sites, whereas the remaining grafts were placed to the below-knee (28) and above-knee (8) popliteal artery, respectively. Study endpoints were primary, assisted primary, secondary patency, and limb salvage at the time of follow-up. Distaflo bypass was performed at the infrageniculate level in 86.7% of cases (28 below-knee popliteal, 24 tibial). Mean follow-up time was 12 months (range, 0.5-37.5 months). At 1 year, primary, assisted primary, and secondary patencies and limb salvage rates for below-knee popliteal bypasses were 83.5%, 89.5%, 94.7%, and 94.4%, respectively. Primary, assisted primary, and secondary patencies and limb salvage rates for tibial bypasses were 44.4%, 44.4%, 63.2%, and 74.9%, respectively. Distaflo precuffed graft is a good alternative conduit for below-knee popliteal and tibial lower extremity reconstructions in the absence of an autologous vein and appears to have promising early patency and limb salvage rates even when used for tibial bypasses.     

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.     

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.     

Cuffed anastomosis for above-knee femoropopliteal bypass with a stretch expanded polytetrafluoroethylene graft

PURPOSE: To evaluate the patency and limb-salvage rates associated with cuffed anastomosis in above-knee femoropopliteal (FP) bypasses using prosthetic grafts. METHODS: Between January 1997 and December 2005, 96 patients (99 limbs) underwent above-knee FP bypass grafting for peripheral vascular disease, with disabling claudication in 81%. All grafts were 6-mm, thin-walled, ringed, expanded polytetrafluoroethylene (ePTFE) stretch grafts anastomosed to the above-knee segment of the popliteal artery in an end-to-side fashion, with a protruding area created around the anastomotic toe and an angle of less than 30 degrees between the graft and the artery. Postoperatively, graft patency was monitored by several objective methods. Patency and limb-salvage rates were calculated by actuarial methods and Kaplan-Meier analysis. RESULTS: The mean follow-up period was 40.4 months; 15 patients were lost to follow-up. The 1-, 3-, and 5-year primary graft patency rates were 94.5%, 88.2%, and 85.7%, respectively. The 1-, 3-, and 5-year secondary patency rates were 95.6%, 94.1%, and 90.8%. The 1-, 3-, and 5-year limb-salvage rates were 98.9%, 97.3%, and 97.3%. There were three graft infections. CONCLUSION: The use of a cuffed anastomosis in FP bypass with an ePTFE stretch prosthesis appears to increase graft patency rates.     

Randomized clinical trial of distal anastomotic interposition vein cuff in infrainguinal polytetrafluoroethylene bypass grafting

BACKGROUND: The aim was to examine the effect of a Miller vein cuff at the distal anastomosis on the medium- to long-term patency and limb salvage rates of femoral to above-knee and femoral to below-knee popliteal artery polytetrafluoroethylene (PTFE) bypasses. METHODS: This study involved extended follow-up of the original cohort of patients included in a previously reported multicentre randomized clinical study. Outcome measures were bypass graft patency and limb salvage. RESULTS: Two hundred and sixty-one bypass operations were originally randomized. For this study, full data were available on 235 (120 with a Miller cuff, 115 without). The cumulative 5-year patency rate for above-knee bypasses with a Miller cuff was 40 per cent, compared with 42 per cent for non-cuffed bypasses (P = 0.702). The cumulative 3-year patency rate for below-knee bypasses with a Miller cuff was 45 per cent, compared with 19 per cent for non-cuffed bypasses (P = 0.018). A Miller cuff had no significant effect on limb salvage for above-knee or below-knee bypasses. CONCLUSION: Three-year patency rates of femoral to below-knee popliteal PTFE bypasses were improved by a Miller cuff. Miller cuffs had no effect on patency rates for femoral to above-knee popliteal bypasses at 5 years and did not improve limb salvage in either group.     

Infrainguinal ePTFE vascular graft with bioactive surface heparin bonding. First clinical results

AIM: The ultimate aim of improved expanded polytetrafluoroethylene (ePTFE) vascular graft design is to achieve patency rates in femoropopliteal bypass grafting comparable with autologous saphenous vein grafts. Enhanced thromboresistance of the ePTFE material by bioactive surface heparin bonding is one conceivable path toward this goal. This retrospective study was performed to collect the first clinical data for a new ePTFE graft with bioactive surface heparin immobilization. METHODS: Between March 2003 and February 2004, 43 femoropopliteal or femorocrural ePTFE vascular prostheses with bioactive end-point immobilized heparin (Gore-Tex Propaten Vascular Graft), using the Car-meda BioActive Surface technology, were implanted in 40 patients. Twelve prostheses were implanted in above-knee and 31 in below-knee position. The indication for bypass grafting was limb-threatening ischemia in 88% of the patients. The mean follow-up was 16.6 months. RESULTS: The primary 1-year patency was 91% for above-knee bypass grafts and 92% for below-knee bypass grafts. The 2-year primary patency rate for above-knee bypass grafts was 68% and 81% for below-knee bypass grafts. Limb salvage was achieved in 98%. The perioperative mortality was 0%, but during follow-up 22% of the patients died with patent bypass grafts. CONCLUSIONS: While conventional ePTFE grafts, particularly in the below-knee position, have shown poor results even in the short-term, the bioactive heparinized ePTFE graft evaluated in this study provides patency rates comparable with autologous vein grafts. Because the influence of luminal heparin bonding is not only limited to thromboresistance but has impact on, amongst other elements, protein adsorption (thereby improving hemocompatibility), a continuous effect for long-term patency could also be expected.     

Long-term Outcome of Femoral Above-knee Popliteal Artery Bypass Using Autologous Saphenous Vein Versus Expanded Polytetrafluoroethylene Grafts

Despite a recent flurry of publications on preferred techniques for femoral above-knee popliteal artery bypass, controversy persists over the use of autologous saphenous vein and expanded polytetrafluoroethylene (ePTFE) grafts. The purpose of this study was to compare our long-term results using these two bypass materials. In a series of 474 infrainguinal bypasses performed between January 1993 and December 1998, we performed a total of 75 femoral above-knee popliteal artery bypass using an autologous saphenous vein graft in 48 cases (64%) and an ePTFE graft in 27 cases (36%). Prosthetic grafts were used by choice in 17 cases and by necessity due to the absence of useable vein in 10 cases. There were 55 men and 18 women with a mean age of 70 years. The indication for bypass was lower extremity arterial occlusive disease at stage II in 17 cases (22.7%), stage III in 9 cases (12%), and stage IV in 36 cases (48%); subacute ischemia in 8 cases (10.7%); and femoropopliteal aneurysm in 5 cases (6.7%). Preoperative arteriography demonstrated three patent leg arteries in 15.5% of cases, two patent leg arteries in 43.5%, and one patent leg artery in 41%. There was no significance difference between the vein graft and ePTFE graft groups with regard to indications and arteriographic findings. No patient died during the immediate postoperative period. The mean duration of follow-up was 25.5 months (range, 3 to 108 months). The primary patency rate at 4 years was 82.2 ± 8% for venous bypass vs. 80.6 ± 11.8% for ePTFE bypass (p = 0.42). The secondary patency rate at 4 years was 84.7 ± 7.4% for vein bypasses and 79.5 ± 12% for ePTFE bypasses (p = 0.26). In our experience, there was no statistically significant difference in long-term outcome of femoral above-knee popliteal artery bypass using autologous vein grafts or prosthetic ePTFE grafts. Presented at the Seventeenth Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 29-31, 2002, Liege, Belgium.     

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.