Value and limitations of secondary femoropopliteal bypasses with polytetrafluoroethylene

Endovascular Recanalization of the Chronically Occluded Native Superficial Artery After Failed Bypass Graft: Midterm Results

PURPOSE

To evaluate the safety, effectiveness, and outcomes of endovascular recanalization of chronic total occlusion (CTO) of the superficial femoral artery (SFA) in patients with critical limb ischemia (CLI) after failed surgical bypass graft.

METHODS

Endovascular recanalization of SFA CTO was performed for 26 consecutive CLI patients with failed bypass grafts from 2016 to 2020. Patient demographics, bypass and lesion characteristics, procedural data, technical, and clinical outcomes were evaluated.

RESULTS

The technical success rate was 96.2% (25/26). Retrograde arterial access was used in 16 (61.6%) patients. Additional tibial and iliac angioplasty was performed in 15 and 2 patients, respectively. Fifteen complications occurred in 10 patients, including thrombosis, embolism, vessel rupture, dissection, arteriovenous fistula, and pseudoaneurysm. Pain relief and wound healing were achieved in 22 patients. The primary, assisted primary, and secondary patency rates were 95.5%, 100%, and 100% at 6 months, 81.8%, 95.5%, and 100% at 12 months, and 76.7%, 82.7%, and 87.5% at 24 months, respectively. By univariate analysis, hyperlipidemia (hazard ratio = 7.82; 95% CI: 1.27-48.04, P = .026) was found to be the only significant risk factor related to primary patency loss. Amputation-free survival and limb salvage rates were 100% and 100% at 6 months, 100% and 100% at 12 months, and 87.1% and 93.8% at 24 months, respectively.

CONCLUSIONS

Endovascular recanalization of SFA CTO in CLI patients with graft failures is effective with high technical success rates. Acceptable limb salvage and amputation-free survival rates make this technique a reasonable alternative to repeat surgery for high-risk patients.

Endovascular recanalization of chronic total occlusions of the native superficial femoral artery after failed femoropopliteal bypass in patients with critical limb ischemia

Background

Femoropopliteal bypass occlusions are a significant issue in patients with critical limb ischemia and chronic total occlusion of the native superficial femoral artery, which challenges vascular surgeons and interventional radiologists. Performing a secondary femoropopliteal bypass is still considered the standard of care, although it is associated with a higher complication rate and lower patency rate in comparison with primary bypass. Over the past few years, angioplasty has been commonly used, with the development in endovascular technologies, to treat chronic total occlusions of the native superficial femoral artery, with a good technical success rate and clinical prognosis. The purpose of the study is to assess the outcome of endovascular recanalization of chronic total occlusions of the native superficial femoral artery, in patients unfit for surgery with critical limb ischemia after failed femoropopliteal bypass.

Results

A total of 54 patients were treated. 77.8 % of the conduits were PTFE grafts; the remainder were single-segment great saphenous veins. The most common clinical presentation was rest pain. Technical success was achieved in 51 (94.4 %) of 54 limbs. Angiographically, 77.8 % of the lesions were TASC II category D, while 22.2 % were TASC II category C. The average length of the native SFA lesions was 26.8 cm. Clinical success, with improved Rutherford classification staging, followed each case of technical success. The median follow-up value was 5.75 years (IQR, 1.5–7). By Kaplan-Meier survival analysis, primary patency rates were 61 % (± 0.07 SE) at 1 year and 46 % (± 0.07 SE) at 5 years. Secondary patency rates were 93 % (± 0.04 SE) at 1 year and 61 % (± 0.07 SE) at 5 years. Limb salvage rates were 94 % (± 0.03 SE) at 1 year and 88 % (± 0.05 SE) at 5 years.

Conclusions

The endovascular recanalization of chronic total occlusions (CTO) of the native superficial femoral artery (SFA) after a failed femoropopliteal bypass is a safe and effective therapeutic option in patients unfit for surgery with critical limb ischemia.

Recanalization of native superficial femoral artery chronic total occlusion after failed femoropopliteal bypass in patients with critical limb ischemia

OBJECTIVES

This study aimed to examine the outcomes of endovascular recanalization for native superficial femoral artery (SFA) chronic total occlusion (CTO) in patients with critical limb ischemia (CLI) after femoropopliteal bypass failure with limited surgical revascularization options.

BACKGROUND

Endovascular recanalization of native artery occlusions has been recently used as a new alternative for threatened limbs after bypass graft occlusion. The feasibility and efficacy has not been widely reported.

METHODS

We retrospectively analyzed 45 consecutive patients (45 limbs) undergoing endovascular recanalization of native SFA occlusion following failed femoropopliteal bypass between June 2010 and December 2016.

RESULTS

All limbs had Transatlantic Inter-Society Consensus class C (26.7%, 12/45) or D (73.3%, 33/45) lesions with a mean lesion length of 29.8 cm. The technical success rate was 95.6% (43/45 limbs). The ABI showed a significant increase from 0.3 ± 0.1 pre-procedure to 0.7 ± 0.1 post-procedure (P < 0.01). Two early (<30 days) below-knee amputations due to acute thrombotic ischemia occurred during perioperative period and resulted in one death due to myocardial infarction. The mean follow-up was 42.7 months (1-62 months). Two patients were lost to follow up. The primary patency rates at 12 and 36 months were 54% and 51%, respectively. Secondary patency rates at 12 and 36 months were 78% and 61%, respectively. Limb salvage rate was 95% and amputation-free survival rate was 88% at both 12 and 36 months.

CONCLUSION

Recanalization of native SFA CTO due to failed femoropopliteal bypass offers a feasible and safe alternative to surgical reconstruction with acceptable limb salvage.

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.

Redo infrainguinal bypass: factors predicting patency and limb salvage

The increased complexity of redo infrainguinal bypass procedures can result in prolonged operative time and increased morbidity. This review was undertaken to compare outcomes from primary and redo bypass procedures and to identify factors predictive of graft failure and limb loss after redo bypass. All infrainguinal bypasses ( n = 468) from 1995 to 1999 were reviewed. A total of 367 primary bypasses in 317 patients were compared to 101 redo grafts in 84 patients with previously failed bypasses. Risk factors and types of procedures were compared using Student's t-test and the chi(2) test. Patency and limb salvage were compared using life-table analysis. Patients requiring redo bypasses were less likely to have diabetes and end-stage renal disease. Two-year patency (66 +/- 4% primary vs. 55 +/- 7% redo, p = 0.13) and limb salvage (75 +/- 3% primary vs. 72 +/- 6% secondary, p = 0.43) were comparable between primary and redo bypass groups. Female gender was predictive of redo graft failure (2-year patency 73 +/- 8% male vs. 39 +/- 9% female, p = 0.01). Clinical indications that predicted failure of a redo bypass included thrombosis of an autologous graft (1-year patency 71 +/- 7% previous prosthetic vs. 49 +/- 10% previous autologous, p = 0.004), thrombosis of an infrageniculate bypass (2-year patency 65 +/- 10% suprageniculate vs. 46 +/- 9% infrageniculate, p = 0.044), and a limb salvage indication for the primary operation (2-year patency 86 +/- 9% claudication vs. 44 +/- 8% limb salvage, p = 0.008). When a primary bypass fails despite the use of optimal conduit (autologous vein) and an infrageniculate target vessel, the redo bypass has a higher risk of failure, particularly in female patients. Nonetheless, patency and limb salvage rates justify an attempt at revascularization after failed primary bypass.

Tissue loss, early primary graft occlusion, female gender, and a prohibitive failure rate of secondary infrainguinal arterial reconstruction

PURPOSE

This study tested the hypothesis that a subset of secondary infrainguinal arterial reconstructions show prohibitive failure rates.

METHODS

Records of 79 consecutive patients, 44 men and 35 women, with a mean age of 60 years, who underwent secondary infrainguinal bypass from 1992 to 2000 at the University of Michigan Hospital, were reviewed. Data were analyzed with life-table analysis, logistic regression, and descriptive statistics.

RESULTS

Secondary infrainguinal reconstructions were performed in patients who had undergone earlier ipsilateral bypasses once (n = 35) or twice (n = 44). Among the prior procedures, 68% (n = 54) were done at an institution other than the authors'. Comorbidities included coronary artery disease (72%), tobacco use (77%), and diabetes mellitus (34%), but no patient had hemodialysis-dependent renal failure. Disabling claudication, with average ankle brachial index of 0.48, had been the indication for the primary operation in 77% of cases. Femoral-popliteal bypass was the primary procedure in 67%, with a prosthetic graft used in 62%. The mean patency duration of these earlier bypasses was 25 months. The indication for the final bypass was rest pain or tissue loss in 51% of patients, with an average ankle brachial index of 0.37. The most common procedure was a femoral-distal bypass with autologous vein (63%). Mean patency duration of the secondary bypasses was 30 months. Graft failure within 30 days of operation occurred in 22 patients (28%), and amputation was necessitated in 86% of these patients. The presence of rest pain or tissue loss, when accompanied with a history of early prior graft thrombosis in female patients, correlated with worse mean patency rates, recurrent graft failure (P </=.05), and a 94% amputation rate. Men in a similar setting incurred a 57% amputation rate. No association of final patency existed with regard to age, number of prior bypasses, conduit types, tobacco use, or diabetes.

CONCLUSION

Secondary infrainguinal bypasses are associated with an increased rate of graft failure and significant limb loss, particularly in those with a history of rest pain or tissue loss, female gender, and early prior graft failure. More appropriate initial operations in carefully selected patients and aggressive postoperative graft surveillance is speculated to improve these outcomes.

Conduit choice for above-knee femoropopliteal bypass grafting in patients with limb-threatening ischemia

Many surgeons consider PTFE to be the conduit of choice for above-knee femoropopliteal bypass grafting, since PTFE is relatively easy to implant and spares autogenous saphenous vein (ASV) for subsequent peripheral or coronary artery bypass grafting (CABG). This practice has recently been challenged, as some studies have suggested that ASV may exhibit superior patency in certain patient subgroups. The purpose of this retrospective study was to examine the contemporary outcome of above-knee femoropopliteal bypass grafting in patients with limb-threatening ischemia. Between January 1995 and December 2000, 159 above-knee femoropopliteal bypass grafts were created for limb-threatening ischemia (rest pain or tissue loss). There was a high incidence of comorbid illness, including open foot wounds at the time of operation (62%), hypertension (58%), coronary artery disease (53%), diabetes mellitus (36%), cerebrovascular disease (23%), prior contralateral bypass or amputation (21%), disadvantaged or "blind" outflow (19%), prior ipsilateral bypass (14%), prior CABG (11%) end-stage renal failure (7%). The use of PTFE predominated (n = 11), with a minority of grafts comprising single-segment ipsilateral or contralateral ASV (n = 18). Although the small number of patients undergoing ASV grafting limited the statistical power of comparison, our results suggest that above-knee ASV performs better than PTFE in patients with limb-threatening ischemia.

Management of Failed or Failing Infrainguinal Bypasses with Distal Correctable Lesions

The goal of this study was to assess the management of failed or failing infrainguinal bypasses with distal correctable lesions. A retrospective analysis of 94 procedures was performed for 72 (77%) failed and 22 (23%) failing infrainguinal bypasses with distal correctable lesions in 94 patients. The 94 procedures included 50 (53%) balloon angioplasties and 44 (47%) distal vein graft extensions from the previous graft to the distal artery. Preprocedural thrombolytic therapy was performed in 62 of 94 limbs with a failed graft, and complete thrombolysis was achieved in 30 of 94. The results of thrombolytic therapy (complete or incomplete thrombolysis) or the means of revision procedure (balloon angioplasty or distal vein graft extension) did not affect the patency. Lower patency was observed for women, patients with a secondary bypass, and grafts with multiple episodes of revision. We conclude that the patency of failing infrainguinal bypasses after revision of distal lesions was affected not by means of therapy but by previous vascular procedures, the usual risk factors, and female gender.

Redo bypass surgery to the infrapopliteal arteries for critical leg ischaemia

OBJECTIVES

to evaluate the results of redo bypass surgery to the infrapopliteal artery and the value of adjuvant arteriovenous fistula (AVF) in this setting.

DESIGN

retrospective study.

MATERIALS

fifty-one redo reconstructions to the infrapopliteal arteries were done for critical leg ischaemia in 45 patients who have had primary infrainguinal reconstructions to the popliteal artery in 20 cases (39%), the crural arteries in 18 (35%), and the pedal arteries in 13 (25%).

METHODS

a PTFE prosthesis was used in 21 cases (41%). A Miller cuff was used in 16 prosthetic grafts. Adjuvant AVF was added to three autogenous vein and 12 prosthetic grafts.

RESULTS

at 2 years, the primary patency rate was 42%, the secondary patency was 43%, the limb salvage was 67%, the survival was 77%, and 53% of patients were alive with salvaged leg. The primary patency rate with a vein graft was 44% at 1 year, with prosthesis plus AVF 67%, but with prosthesis without AVF only 19%. Secondary patency rates were similar. Prosthetic graft with AVF and those without AVF achieved a 1-year leg salvage rate of 100% and 51%, respectively (p =0.01). Patients with adjuvant AVF had a worse 2-year survival rate that those without AVF (31% vs 89%) (p =0.007; RR: 8.87, CI 95%: 1.62-48.42).

CONCLUSIONS

redo bypass surgery using autogenous vein graft may achieve satisfactory long-term results. The use of adjuvant AVF may improve patency of redo infrapopliteal prosthetic bypass grafts.

Secondary distal extension of infrainguinal bypass: long-term limb and patient survival

The potential benefits of secondary distal extension vein grafts required after failing or failed initial infrainguinal bypasses were evaluated. Outcomes of secondary distal extension bypass procedures (n = 58) performed between July 1983 and March 1993 were reviewed. Patients (n = 51) had critical ischemia or tissue loss, with an average of 2.8 previous vascular procedures. The 58 initial infrainguinal bypasses included 38 above-the-knee and 13 below-the-knee femoropopliteal, 5 femorodistal, and 2 popliteal-distal. Thirty-nine of the 58 femoropopliteal grafts were prosthetic. The extension bypasses included popliteal-tibial, graft-tibial, and peroneal-plantar. They were performed for recurrent or persistent ischemia after failed initial infrainguinal bypasses in limbs, and with still-patent bypasses. All extension bypasses were vein conduits. Mean follow-up was 59 (range: 6 to 164) months. The cumulative life-table 5-year survival rate for all patients was 95%. The 27-month limb-salvage rate was 70%. Our findings indicate that patients with advanced peripheral vascular disease may have prolonged survival, and extension bypasses contribute significantly to their limb salvage. Thus, aggressive application of extension bypass to save threatened limbs is supported.

Long-term outcome after early infrainguinal graft failure

PURPOSE

To determine the long-term outcome and prognostic factors after early infrainguinal graft failure (< 30 days).

METHODS

Retrospective analysis of limb salvage data, patency data, and prognostic risk factors in 112 new infrainguinal bypass grafts from 1985 to 1995 that occluded within 30 days of operation.

RESULT

Thirty-six femoropopliteal and 76 femorotibial/femoropedal arterial bypass ("index") procedures were performed for rest pain (50%), tissue loss (31%), or disabling claudication (19%). In 103 patients, an immediate additional revascularization ("takeback") procedure was performed at the time of early graft failure. Life table analysis of the takeback procedures for threatened limbs (n = 84) revealed limb salvage rates of 74%, 54%, 40%, and 31% at 1 month, 1 year, 3 years, and 5 years, respectively. The 1-month limb salvage rate (threatened limbs) was 12% (1 of 8) in patients who were not taken back for revascularization and 33% (4 of 12) in patients who had undergone more than one takeback procedure within 30 days. The secondary graft patency rates for the takeback procedures (n = 103) were 70%, 37%, 27%, and 23% at 1 month, 1 year, 3 years, and 5 years, respectively. Univariate and life table analysis revealed that patients who were given anticoagulation medication after the index procedure (before graft thrombosis) or patients who had undergone previous ipsilateral leg revascularization had significantly lower rates of limb salvage and graft patency (p < 0.05). The limb salvage rate was also significantly worse in patients who had single-vessel runoff compared with those who had multiple-vessel runoff (p < 0.01). Thrombectomy and revision or complete graft replacement had a better secondary patency rate than thrombectomy alone (p < 0.05). Autogenous vein grafts had better outcome than polytetrafluoroethylene-containing grafts, but statistical significance was not achieved. No significant differences in limb salvage or graft patency rates were found between femoropopliteal versus femorotibial/femoropedal bypass grafting, age, gender, previous inflow surgery, diabetes, hypertension, smoking, or cardiac, renal, or pulmonary disease.

CONCLUSION

The long-term limb salvage and graft patency rates after takeback revascularization procedures for early graft failure are poor. Despite poor outcome, a single takeback procedure appears warranted in all patients. Multiple takeback procedures, however, do not appear to be justified, especially in patients who are given anticoagulation medication after the index bypass procedure, repeat leg bypass procedures, or if there is no potential for graft revision.

Results of a policy with arm veins used as the first alternative to an unavailable ipsilateral greater saphenous vein for infrainguinal bypass

PURPOSE

Aggressive policies for distal bypass and coronary revascularization increase the need to identify alternatives to autologous saphenous vein grafts. We examined the performance of arm vein as the primary alternative to contralateral saphenous vein when the ipsilateral saphenous vein was not available.

METHODS

A total of 250 arm vein grafts were studied retrospectively in 224 patients (143 men, 81 women, 82.6% with diabetes, mean age 68.3 years) from February 1989 to April 1994. Intraoperative angioscopy was carried out to observe valve lysis, remove abnormalities, and select optimal vein segments.

RESULTS

A total of 85 primary, 103 repeat, and 62 graft revision procedures were done for limb salvage in 99.2% of the patients. A total of 41 femoropopliteal, 114 femorotibial-pedal, 33 popliteodistal, and 62 jump or interposition grafts were constructed. A total of 199 grafts were single vein, and 51 were composite vein. The source was cephalic vein alone in 50.4%, cephalic and basilic vein in 35.6%, and basilic vein only in 14%. The contralateral saphenous vein as an alternative conduit was available in 97 (38.8%) instances. Interventions guided by angioscopy to "upgrade" the graft were necessary in 51.6%. Overall early patency (< or = 30 days) was 94.8% (n = 13 occlusions). The cumulative primary patency rate at 1 year was 70.6%, the secondary patency rate was 76.9%, and the limb salvage rate was 88.2%. The 3-year patency rate (limb salvage) was 51.9% (92.4%) for primary grafts, 56.7% (67.1%) in revision grafts, and 42.4% (79.9%) in repeat grafts. In 22.7% (22 of 97) the available contralateral saphenous vein was used for distal revascularization within the follow-up period.

CONCLUSIONS

Arm veins are an easily accessible autologous conduit of sufficient length to reach the midtibial level. Excellent patency rates allow durable limb salvage in otherwise difficult circumstances. Vein configuration and splicing do not affect patency rates, but vein quality and repeat operations do. Angioscopy is a valuable adjunct to upgrade graft quality. The contralateral saphenous should be saved for subsequent contralateral revascularization or coronary artery bypass grafting.

The upper arm basilic-cephalic loop for distal bypass grafting: technical considerations and follow-up

PURPOSE

The performance of a graft created from the upper arm basilic and cephalic veins in continuity was investigated.

METHODS

Retrospective analysis of 50 patients, who underwent 54 distal reconstructions with an upper arm vein loop graft between February 1989 and October 1993 (male-to-female ratio of 30/20; mean age of 69.2 years, range 39 to 87; 74% had diabetes) was undertaken. Vein grafts were harvested through a near continuous incision, leaving a skin bridge in the cubita. Intraoperative angioscopy was used to exclude endoluminal disease and to directly observe valvulotomy of the nonreversed part of the graft.

RESULTS

Operations were performed for limb salvage in 98.2% of 17 primary and 37 reoperative procedures. Eleven femoropopliteal, 33 femorotibial-pedal, seven popliteal-distal, and two outflow jump grafts were performed. The ipsilateral saphenous vein was unavailable because of previous infrainguinal bypass in 35, coronary artery bypass grafting in 14, and unsuitable quality in 5 cases. Thirty-eight grafts were used in continuity, and 16 grafts required repair or splicing with additional vein segments. Primary 30-day patency rate was 92.6% (n = 4 occlusions). No operative deaths occurred. The cumulative patency rate at 1 year was 74.4%, the limb salvage rate 90.7%.

CONCLUSIONS

The upper arm vein loop is a durable graft with excellent short-term and midterm patency rates. Sufficient vein length can be obtained to reach the below-knee and midtibial levels. Angioscopic quality assessment is a valuable adjunct to exclude endoluminal disease most commonly occurring in the median cubital vein. Straightening the curve of the median cubital vein and valvulotomy do not influence patency rates. This is a valuable technique for vascular surgeons that enables rescue of ischemic limbs under otherwise difficult circumstances.

Preferred strategies for secondary infrainguinal bypass: lessons learned from 300 consecutive reoperations

PURPOSE

To determine the optimal surgical strategies in reoperative infrainguinal bypass, we reviewed our results in 300 consecutive secondary bypasses in 251 patients operated on between Jan. 1, 1975, and Nov. 1, 1993.

METHODS

There were 168 men (67%) and 83 women (33%), with a mean age of 64.8 years and a typical distribution of risk factors including smoking (76.4%), diabetes (33.7%), and coronary artery disease (47.1%). The indications for surgery were limb-threatening ischemia in 83.5% and severe claudication in 16.5% of patients. The majority of conduits (n = 213) were autogenous vein and were composed of a single segment of greater saphenous vein in 121 bypasses (57%) and various alternative veins including composite, arm, and lesser saphenous vein in 92 bypasses (43%). Prosthetic conduits included 69 polytetrafluoroethylene, 16 umbilical vein, and two Dacron grafts.

RESULTS

There was one perioperative death (0.3%) and a 25% total morbidity rate including a 1.7% myocardial infarction rate. There was a 28.6% early (< 30 days) graft failure and 10.7% early amputation rate for prosthetic bypass grafts compared with 13.6% early graft failure and 5.6% early amputation rates for vein grafts. Autogenous vein bypasses had higher 5-year secondary patency rates than had prosthetic grafts (51.5% +/- 4.6% vs 27.4% +/- 6.1%, p < 0.001). Results with autogenous vein bypass improved significantly from the 1975 to 1984 to the 1985 to 1993 interval with 5-year secondary patency rates increasing from 38.3% +/- 6.9% to 59.1% +/- 5.8% (p = 0.017) and 5-year limb-salvage rates increasing from 40.4% +/- 7.6% to 72.4% +/- 6.6% (p < 0.001). Vein grafts to the popliteal and tibial outflow levels had equivalent long-term results. Vein grafts completed for claudication demonstrated results superior to those for limb salvage, with a 5-year secondary patency rate of 75.8% +/- 8.1% versus 52.3% +/- 7.9% (p = 0.048). Secondary autogenous vein bypass grafting performed after early primary graft failure (< 3 months) did particularly poorly, with only a 27.2% +/- 7.7% 4-year secondary patency rate. Greater saphenous veins tended to perform better than alternative vein bypasses, with a 5-year secondary patency rate of 68.5% +/- 6.0% compared with 48.3% +/- 10.5% (p = 0.09) and a 5-year limb-salvage rate of 77.8% +/- 7.4% versus 54.2% +/- 11.8% (p = 0.046).

CONCLUSIONS

When patients suffer a recurrence of limb-threatening ischemia at the time of infrainguinal graft failure, aggressive attempts at secondary revascularization with autogenous vein are warranted based on the low surgical morbidity and mortality rates and the improved patency and limb salvage rates that are currently attainable.

Femoropopliteal bypass with either adequate ipsilateral reversed saphenous vein or obligatory polytetrafluoroethylene

The results are presented of a 10-year experience with 312 femoropopliteal bypasses performed in 285 patients using ipsilateral autologous reversed greater saphenous vein when available and adequate and polytetrafluoroethylene (PTFE) when not. The indications for operation were severe claudication in 121 (39%), rest pain in 95 (30%), and minor tissue loss in 96 (31%) limbs. There were 235 (75%) saphenous vein bypasses, of which 157 were above and 78 below the knee, and 77 (25%) PTFE bypasses, 58 above and 19 below the knee. Of these, 232 (79%) saphenous vein and 62 (21%) PTFE bypasses were primary procedures. The 30-day mortality rate was 3% (7/285) and the 30-day amputation rate was 2% (6/312). Overall, 24 (10%) saphenous vein and 30 (39%) PTFE grafts ultimately failed. The cumulative primary patency of all bypasses was 77% +/- 4% (mean +/- 1 SE) (85% to 69%, 95% confidence interval) at 3 years and 75% +/- 4% (86% to 64%) at 5 years. Saphenous vein primary patency was superior to that of PTFE at 3 years, 87% +/- 4% (97% to 77%) vs. 54% +/- 12% (65% to 41%), (p < 0.01), and at 5 years, 81% +/- 6% (96% to 67%) vs. 48% +/- 16% (63% to 33%) (p < 0.01). Above-knee saphenous vein bypass primary patency was slightly better than below-knee patency at 3 years, 89% +/- 4% vs. 84% +/- 6%, and at 5 years, 83% +/- 7% vs. 80% +/- 8%. This was superior to above-knee PTFE patency at 3 years, 54% +/- 14%, and at 5 years, 34% +/- 16% (p < 0.01). The overall PTFE failure rate was three to four times that of the saphenous vein rate. These results strongly support the use of autologous greater saphenous vein for all femoropopliteal bypasses when it is available and of good quality. PTFE grafts are valuable secondary conduits when the vein is not available or is inadequate. This series was not randomized since PTFE was used only in patients with inadequate or unavailable ipsilateral greater saphenous veins. When this protocol was followed, the patency rate for greater saphenous vein was excellent and its use is recommended for femoropopliteal bypass when it is available and of good quality.

Further experience with an all-autogenous tissue policy for infrainguinal reconstruction

PURPOSE

Between 1985 and 1991 a policy of strong preference for autogenous methods of infrainguinal reconstruction was followed to assess the efficacy of this strategy.

METHODS

A total of 585 autogenous infrainguinal reconstructions were performed on 537 limbs in 448 patients between 1985 and 1991. Thirty-eight additional revascularizations were performed with prosthetic materials and seven patients underwent primary amputation during this interval. Of the autogenous reconstructions, 74% were primary and 26% were secondary procedures, 71% were for limb salvage, and 48% were to infrapopliteal arteries. Greater saphenous vein was used for 447 bypass grafts. Other autogenous methods included bypass with lesser saphenous (21), arm (20), and composite (30) veins, endarterectomy of the common femoral (18) and superficial femoral (40) arteries, and isolated profundaplasty (9).

RESULTS

Major operative morbidity occurred in 41 patients (7%), early graft failure in 47 (8%), and death in 12 (2%). At 5 years, the overall cumulative primary patency rate was 63% and the secondary patency rate was 72%. The 5-year secondary patency rate for the subgroup in which greater saphenous vein was used was 79% and for alternative autogenous methods the rate was 49% (p < 0.001). During the period of follow-up, major amputation was performed in 45 (7.9%) of the operated limbs.

CONCLUSION

This experience supports continued preferential use of autogenous methods for infrainguinal reconstruction.

Thrombolytic therapy of synthetic graft occlusions before vascular reconstructive procedures

The objective of this study was to evaluate the impact of thrombolysis of synthetic grafts before urgent vascular reconstruction. In 29 patients, 41 thrombosed synthetic grafts that underwent intraarterial thrombolysis were studied. The cases were divided into three groups: group I--complete thrombolysis followed by reconstruction; group II--complete thrombolysis alone; and group III--incomplete lysis requiring reconstruction or sympathectomy. Follow-up ranged from 1 to 556 days (mean: 149 days). Kaplan-Meier analysis was used to determine patency and limb salvage rates. One-year patency and limb salvage rates were 53% and 95%, 34% and 67%, and 38% and 48%, respectively, for groups I, II, and III. Eighteen complications occurred in 16 of the 41 (39%) episodes. One patient died of intracranial hemorrhage. The best results were achieved when complete lysis was followed by appropriate reconstruction. Patency was equally poor in complete thrombolysis alone and reconstructions required by incomplete thrombolysis. Limb salvage was better after complete thrombolysis, regardless of the appropriate reconstruction.