Infragenicular Bypass Graft for Limb Salvage Using Polytetrafluoroethylene and Distal Vein Cuff as the First Alternative in Patients Without Ipsilateral Greater Saphenous Vein

Tapered reinforced graft and vein cuff in the distal anastomosis as adjunct strategies for infrapopliteal prosthetic bypass graft in chronic limb-threatening ischemia: A case report

The great saphenous vein is the optimal conduit for infrapopliteal bypass surgery in chronic limb-threatening ischemia. A prosthetic bypass graft is an acceptable option when the autologous vein is unavailable and the anatomy is not favorable for endovascular therapy. However, the low patency rate of prosthetic grafts calls for adjunct strategies to improve the outcomes. Tapered reinforced grafts and vein cuffs are proposed measures. We herein present a case of a 78-year-old man with chronic limb-threatening ischemia and an extensive necrotic lesion on the dorsum of the left foot. He was successfully treated with a prosthetic bypass using two adjunct strategies to help improve patency: a tapered reinforced graft and a vein cuff in the distal anastomosis. After debridement and partial skin grafting, the wound healed completely in 2 months. The bypass graft was patent for 1 year.

Intercondylar Route of Prosthetic Infragenicular Femoropopliteal Bypass Has Better Primary, Assisted, and Secondary Patency but Not Limb Salvage Rate Compared to the Medial Route

Aim. To compare the differences between medial and intercondylar infragenicular femoropopliteal prosthetic bypasses in terms of their midterm patency and limb salvage rates. Methods. Ninety-three consecutive patients with peripheral arterial disease who underwent a simple distal femoropopliteal bypass using a reinforced polytetrafluorethylene graft were included in this retrospective study. The bypass was constructed in the intercondylar route in 52 of the patients (group A) and in 41 in the medial route (group B). Results. Median observation time of the patients was 12.7 (IQR 4.6-18.5) months. There were 22 and 24 interventional or surgical procedures (angioplasty, stenting, thrombolysis, thrombectomy, or correction of the anastomosis) performed to restore patency of the reconstruction in groups A and B, respectively (p = 0.14). The 20-month primary, assisted, and secondary patency rates and limb salvage rates were 57%, 57%, 81%, and 80% in group A compared to 21%, 23%, 55%, and 82% in group B (p = 0.0012, 0.0052, 0.022, and 0.44, resp.). Conclusion. Despite better primary, assisted, and secondary patency rates in patients with a prosthetic infragenicular femoropopliteal bypass embedded in the intercondylar fossa compared to patients with the medial approach, there is no benefit in terms of the limb salvage rate and the number of interventions required to maintain patency of the reconstruction.

[Critical ischemia in patients over 80: waiting or evidence-based surgical treatment?]

Critical ischemia is defined by continuous pain, impending sleep, with ankle pressure less than 50mm Hg, and/or first toe pressure less than 30 mm Hg (Dormandy et Rutherford, 2000; Norgren et al., 2007). Treatment of patients aged over 80 requires specific knowledge of arteriopathy at this age and an evaluation of co-morbidity factors (diabetes mellitus, renal failure, ischemic cardiopathy). Assessment should include: the degree of ischemia, the extension of arterial disease, the co-morbidity factors, and the diffusion of the atherosclerotic disease. A transatlantic consensus conference has enabled a classification of arterial lesions determining therapeutic indications. Aorto-iliac lesions may be treated by surgery or angioplasty. Femoro-popliteal or crural lesions may be treated by surgery or angioplasty. Type C or D lesions should be treated by femoro-popliteal or crural bypass. Bypass to the ankle or foot are done on high peripheral resistances. These bypasses require a venous graft. Several authors have shown the utility of short grafts: popliteo-tibial, tibiotibial, tibiopedal artery bypass, tibioplantar artery bypass. In patients over 80, the presence of arteriopathy is an important mortality factor, which is four or five times more important than in the normal population. Twenty-five percent of patients will require amputation.

Endothelial cell attachment and shear response on biomimetic polymer-coated vascular grafts

Endothelial cell (EC) adhesion, shear retention, morphology, and hemostatic gene expression on fibronectin (FN) and RGD fluorosurfactant polymer (FSP)-coated expanded polytetrafluoroethylene grafts were investigated using an in vitro perfusion system. ECs were sodded on both types of grafts and exposed to 8 dyn/cm(2) of shear stress. After 24 h, the EC retention on RGD-FSP-coated grafts was 59 ± 14%, which is statistically higher than the 36 ± 11% retention measured on FN grafts (p < 0.02). Additionally, ECs on RGD-FSP exhibited a more spread morphology and oriented in the direction of shear stress, as demonstrated by actin fiber staining. This spread morphology has been observed earlier in cells that are adapting to shear stress. Real-time PCR for vascular cell adhesion molecule 1, tissue factor, tissue plasminogen activator, and inducible nitric oxide synthase indicated that the RGD-FSP material did not activate the cells and that shear stress appears to induce a more vasoprotective phenotype, as shown by a significant decrease in VCAM-1 expression, compared with sodded grafts. RGD-FSP-coating allows for a cell layer that is more resistant to physiological shear stress, as shown by the increased cell retention over FN. This shear stable EC layer is necessary for in vivo endothelialization of the graft material, which shows promise to increase the patency of synthetic small diameter vascular grafts.

Basic data related to surgical infrainguinal revascularization procedures: a twenty year update

In 1990, Dalman and Taylor published a compilation of reported data that were identified by them as related to infrainguinal revascularization procedures in peripheral vascular surgery during the decade of the 1980s. The intervening 20 years has seen revolutionary advances in the field of peripheral vascular surgery, especially in the adoption of endovascular techniques, and an explosion of data related to emerging technologies in the field of infrainguinal revascularization. The tables in this manuscript reflect the evolution of our surgical knowledge during the turn of the 21st century. The superior patency of autologous saphenous vein in all positions is reaffirmed.

Are femorodistal bypass grafts for acute limb ischemia worthwhile?

Background: It has been shown that autogenous veins are associated with the best limb salvage rates for femorodistal bypass surgery. However, in emergency settings, when an autogenous vein is unavailable, use of synthetic graft material or amputation is a critical decision to make. Objective: To assess the appropriateness of femorodistal bypass grafts for acute limb ischemia in emergency settings. Methods: Patients who underwent emergent bypass and elective femorodistal bypass surgery between 1996 and 2006 were reviewed retrospectively in a single center. Results: There were 147 patients of which 84 had elective and 63 had emergent bypass. The graft patency rates for elective admissions were 44 and 25% vs. 25 and 23% for admissions for acute femorodistal graft surgery at 2 and 4 years, respectively (p < 0.004). Admissions for acute ischemia who were treated with prosthetic grafts had a primary patency of 24 vs. 27% for vein grafts at 2 years and 24 vs. 23% at 4 years (p = 0.33). In the acute femorodistal grafts group, primary patency at 2 years for vein and prosthetic grafts was 27 and 24% as compared to 42 and 32% for electives. These values for cumulative limb salvage rates for elective bypasses were 73 and 63% as compared to 52% at both time points in the acute femorodistal graft group (p < 0.004). In emergency settings, the limb salvage rate for acute femorodistal bypass with prosthetic grafts was 38%, and for vein grafts it was 62% at both time points (p = 0.08). Conclusion: The long term limb salvage rate of 38% suggests that emergent femorodistal revascularization is worthwhile.

Infrapopliteal composite bypass with autologous vein and second generation glutaraldehyde stabilized human umbilical vein (HUV) for critical lower limb ischaemia

OBJECTIVE

To audit a single center consecutive series of infrapopliteal composite bypasses with second generation glutaraldehyde stabilized human umbilical vein.

DESIGN

Retrospective study.

PATIENTS

From January 1996 to July 2006 89 femoro-distal bypasses were constructed in 85 patients with HUV and residual vein segments as composite grafts in the absence of sufficient length of autologous vein.

METHODS

All patients with infrainguinal bypass operations were registered prospectively. Bypasses to infrapopliteal arteries performed with HUV-composite grafts were reviewed for graft patency, limb salvage, patient survival and possible biodegeneration of the HUV.

RESULTS

Early graft thrombosis was noted in 21.3%, necessitating revision surgery. Primary, primary assisted and secondary patency rates were 35%, 40% and 42% respectively, with a limb salvage rate of 87% after 5 years. Graft infection occurred in 7 limbs. Aneurysmal HUV graft degeneration was not detected by duplex scanning.

CONCLUSION

HUV-composite bypasses provide acceptable patency and favorable limb salvage rates. Patency was similar to previous series using PTFE-composite bypasses but was significantly inferior to vein bypass. Possible biodegradation of the HUV grafts seems to be of minor clinical relevance.

Subintimal Angioplasty of Supra- and Infrageniculate Arteries

We retrospectively reviewed our experience with subintimal angioplasty for chronic limb ischemia. Hospital records and films of all subintimal angioplasty procedures performed between October 2002 and December 2004 were reviewed and analyzed for demographic data, clinical data, and comorbid condition status. Thirty-nine subintimal angioplasties were performed in 37 patients (65% male, 35% female), with a median age of 73 years. Median follow-up was 9 months. The 30-day mortality rate was 8%. All-cause mortality was 33% after 24 months. In 23 cases (59%), a subintimal angioplasty of the superficial femoral artery (SFA) alone was performed. Both the SFA and popliteal/crural vessels were used in nine limbs (23%), the popliteal artery alone in three limbs (8%), and the crural arteries alone in four limbs (10%). Initial technical and clinical success rates were 67% and 49%, respectively. The complication rate was 28%. Twenty-four additional surgical interventions were performed after the initial angioplasty procedure, of which 12 were major amputations. Amputation-free survival (limb-salvage rate) was 69% at 12 months [95% confidence interval (CI) 52-85%], and overall survival was 69% (95% CI 52-85%) at 12 months. In patients with critical limb ischemia, subintimal angioplasty is feasible and in most cases technically successful. In these high-risk patients, often with combined cardiac, pulmonary, and diabetic risk and considered unfit for bypass surgery, subintimal angioplasty offers a safe and effective alternative.