Composite sequential arterial reconstruction for limb salvage

OBJECTIVE: Autogenous vein is the conduit of choice in patients presenting for infrainguinal arterial reconstruction. Venous conduit may be limited because of inadequacy or prior utilization. Our group and others use prosthetics to maximize limb salvage with moderate results. However, in cases where patients present with an isolated popliteal segment that may extend below the knee, we have performed prosthetic bypasses to this above-knee segment and then used a venous reconstruction from the native arterial circulation to a more distal outflow tract. In this report, we will analyze our results using this type of reconstruction in patients who present for limb salvage with no all-autogenous option. METHOD: From 1992 to 2000, 27 patients presented for limb salvage with an isolated popliteal artery and inadequate vein for continuous bypass. There were 106 patients in this period without an isolated popliteal segment or adequate vein who underwent prosthetic bypass with distal vein cuff or arteriovenous fistula. The vascular registry and patient charts were reviewed for indication, demographics, and type of composite reconstruction. Outcomes were calculated with use of life table methods and compared by log rank analysis. RESULTS: Demographics revealed 16 (59%) men, 16 (59%) patients with diabetes, and 4 (15%) smokers with a mean age of 71 years (range, 51-87 years). The venous reconstructions had the inflow taken from the distal native popliteal artery in 26 (above knee in 8 and below knee in 18) and the peroneal artery in one. The outflow involved the below-knee popliteal in one (4%), a tibial in 23 (85%), and the dorsalis pedis artery in 3 (11%). Morbidity included bleeding (4%), wound infection (4%), and limb loss (4%). Mortality occurred in one patient (4%), and no revisions were required in follow-up. Six late failures were identified, one of which resulted in amputation. Primary patency and limb salvage were 80% and 88% at 1 year, respectively. For comparison, our results using prosthetic with vein cuff had a 1-year primary patency of 52% and limb salvage of 92% (P = NS), whereas prosthetic with an arteriovenous fistula was 73% and 84%, respectively (P = NS). CONCLUSIONS: Composite sequential reconstruction using an isolated popliteal segment as inflow for the distal reconstruction is an acceptable option in patients presenting for limb salvage reconstruction with limited venous conduit. This type of reconstruction, when available, may be a better option than pure prosthetic with or without a vein cuff or arteriovenous fistula.