Femorofemoral bypass for aortofemoral graft limb occlusion: a ten-year experience

Increased collateral flow by rescue femorofemoral bypass dissolved residual thrombus in implanted iliofemoral artery stents: a case report

Background

Failed aortofemoral and femoropopliteal bypass grafts in the lower extremity artery usually result in acute limb ischemia. Endovascular treatment and surgical revascularization have been reported for limb salvage.

Case presentation

A 72-year-old Japanese man was admitted with acute limb ischemia due to failed aortofemoral and femoropopliteal bypass grafts. Endovascular treatment with balloon angioplasty, thrombectomy, and stent implantation in the long chronic total occlusion from the right common iliac artery to the superficial femoral artery did not result in efficient flow due to thrombus transfer from a failed aortofemoral bypass graft. However, a rescue femorofemoral bypass (the left femoral to the right deep femoral artery) improved his symptoms, and implanted in-stent flow was gradually recovered. Lower extremity angiography performed 5 months later confirmed the patency of the iliofemoral in-stent flow. However, the femorofemoral bypass graft was unfortunately occluded due to the progression of left external iliac artery stenosis. The patency of the iliofemoral in-stent flow was confirmed at 1 year by ultrasonography.

Conclusions

Improvement of the deep femoral artery flow plays an important role in the treatment of acute limb ischemia due to failed aortofemoral and femoropopliteal bypass grafts. Thus, increased collateral circulation to the periphery through the deep femoral artery dissolved the remaining in-stent thrombus in the iliofemoral artery.

Evolving Management of Distal Anastomotic Technical Issues During Open Aortic Aneurysm Repair

BACKGROUND

Thrombosis of the iliac anastomosis is an important complication of open aortic aneurysm repair. We evaluated our evolving management of this complication to an endovascular approach and compared it with open revision to the common femoral artery.

METHODS

Consecutive patients undergoing open aortic aneurysm repair from January 2009 through November 2016 at our institution were reviewed. Patients who developed iliac limb flow issues or thrombosis intraoperatively or within 48 hrs postoperatively were identified. Patients were grouped by management strategies of either 1) an endovascular approach including iliac angiography, thrombectomy if needed, and stenting or 2) open surgical revision of the iliac anastomosis with or without bypass to the common femoral artery. Demographics, comorbidities, operative variables, and outcomes were retrospectively analyzed between groups. Primary patency and mortality were assessed by Kaplan-Meier estimates.

RESULTS

There were 711 patients who underwent aortoiliac aneurysm repair during the study period. 43/711 patients (6.0%) developed early perioperative iliac limb flow issues including thrombosis. Twenty-nine patients (31 limbs) were managed by an endovascular approach, and 14 patients (15 limbs) were managed by open surgical revision. The mean age of the cohort was 69 years, and 27 patients (62.8%) were male. Preoperative creatinine and diabetes frequency were higher in patients managed by an endovascular approach, although no other differences existed between preoperative comorbidities. Thrombosis or limb flow issues presented intraoperatively more commonly in the open surgical group and in the first 24 hrs postoperatively in the endovascular group. All patients had complete restoration of outflow as a result of the rescue procedure. Transfusion requirements and crystalloid replacement were significantly higher in the open surgical group. Length of stay, perioperative complications, and mortality were similar between groups. Overall, 21/31 limbs in the endovascular group and 9/15 limbs in the open surgical group had postoperative imaging, with mean follow-up of 35.0 and 55.6 months, respectively. Only one patient in the cohort lost patency: an iliofemoral jump graft that presented with late infection after postoperative wound infection, requiring staged extra-anatomic bypass and explant at 12 months. Three-year primary patency was 100% for the endovascular group and 85.7% for the surgical group by Kaplan-Meier method (P = 0.32). Endovascular management became our institution's primary salvage approach during the study. Whereas 8/15 limbs (53.3%) were managed by an endovascular approach from 2009-2011, 23/31 (74%) were managed by iliac stenting from 2012-2016.

CONCLUSIONS

Endovascular management of iliac limb flow issues or thrombosis after open aneurysm repair is potentially a viable alternative to open surgical revision in the early postoperative period.

Contemporary outcomes of thoracofemoral bypass

OBJECTIVE

Thoracofemoral bypass (TFB) is an alternative to aortofemoral bypass (AFB) or extra-anatomic bypass for severe aortoiliac occlusive disease (AIOD). TFB may be particularly useful in select patients with concurrent visceral aortic branch vessel disease, infrarenal aortic occlusions, or after failed AFB. However, there are few contemporary series describing the indications and outcomes for TFB. Therefore, the purpose of this analysis was to review our experience with TFB.

METHODS

All patients undergoing TFB for occlusive disease from 2002 to 2017 were reviewed. All patients underwent left thoracoretroperitoneal exposure of the supraceliac aorta with division of the diaphragmatic crus and supraceliac cross-clamping. An end-to-side aortic anastomosis was created and each graft limb was tunneled in the retroperitoneum to the femoral bifurcation. Adjunctive visceral/infrainguinal revascularization was performed selectively based on symptoms, end-organ function, and/or preoperative imaging. The primary end points were major complications and 30-day mortality. Secondary end points included limb patency, freedom from major adverse limb events, and survival. Kaplan-Meier methodology was used to characterize the end points.

RESULTS

Forty-one patients (age 61 ± 9 years; 54% female; 7% in a hypercoaguable state) underwent TFB. The mean preoperative ankle-brachial index was 0.4 bilaterally. Indications included critical limb ischemia (56%), claudication (30%), acute limb ischemia (7%), and combined AIOD and mesenteric ischemia (7%). Seven patients (17%) had previously undergone AFB and 15 (38%) had previously undergone any prior aortic operation. Adjunctive visceral bypass occurred in 8 patients (20%; N = 14 grafts, n = 6 renal, n = 5 superior mesenteric artery, and n = 3 celiac). The postoperative duration of stay was 11 days (interquartile range [IQR], 7-16 days) and the 30-day mortality was 5% (n = 2). Major complications occurred in 34% of patients (N = 14; pulmonary, 15%; cardiac, 12%; bleeding, 7%; accidental splenectomy, 5%; renal, 5%; wound, 2%). The mean postoperative ankle-brachial index was 0.9 bilaterally. At a median follow-up of 7 months (IQR, 1-17 months), 5 patients (12%) underwent some form of reintervention (graft/limb related, n = 4 [n = 2 graft thrombosis, n = 2 graft infection], n = 1 mesenteric bypass revision). The estimated 3-year primary limb patency and freedom from major adverse limb events were 80 ± 10%, and 70 ± 10%, respectively. The estimated 5-year survival was 93 ± 5% (median, 27.3; IQR, 14.5-35.2; 95% confidence interval, 17.9-32.8).

CONCLUSIONS

This experience represents one of the largest and most current series of retroperitoneal TFB. We demonstrate that TFB can be performed with good outcomes for patients with severe AIOD, especially if concomitant visceral/infrainguinal reconstruction is warranted. These results support a continued role for TFB in select patients.

Long Term Outcomes of Femorofemoral Crossover Bypass Grafts

PURPOSE

Femorofemoral crossover bypass (FCB) is a good procedure for patients with unilateral iliac artery disease. There are many articles about the results of FCB, but most of them were limited to 5 years follow-up. The purpose of our study was to analysis the results of FCB with a 10-year follow-up period.

MATERIALS AND METHODS

Between January 1995 and December 2010, 133 patients were operated in Samsung Medical Center (median follow-up: 58.8 months). We retrospectively analysed patient characteristics, the preoperative treatment, the operative procedure, and material used.

RESULTS

The indications for FCB were claudication in 110 and critical limb ischemia in 23 patients. Three patients were died due to myocardiac infarction, intracranial hemorrhage, and acute respiratory failure within 30 days after surgery. The one-year primary and secondary patency rates were 89% and 97%, the 5-year primary and secondary patency rates were 70% and 85%, and the 10-year primary and secondary patency rates were 31% and 67%. The 5-year and 10-year limb salvage rates were 97% and 95%, respectively.

CONCLUSION

Our long term analysis suggests that FCB might be a valuable alternative treatment modality in patients with unilateral iliac artery disease.

Femorofemoral Arterial Bypass: Subcutaneous or Preperitoneal

A salutary, long-term result, using preperitoneal placement in a patient transferred after repeated failure of subcutaneous prosthetic femorofemoral bypass, prompted a review of this procedure by the authors.

From 1972 to 1996, 61 men and 1 woman, aged 28 to 80 years, received 67 initial or “redo” interpositions for unilateral, predominately-sinistral ischemia, 45% being operated on as emergencies. They were considered unfit for the preferred direct transabdominal reconstruction under general anesthesia because of cardiopulmonary comorbidity. Follow up, extending to 20 years, was complete in 93.5%. Operative mortality was 6.6%, all from cardiogenic shock after atherothromboembolism secondary to transfemoral intraaortic balloon pulsation after myocardial infarction (MI) or coronary artery bypass graft (CABG). Most bypasses were subcutaneous; however, 17% were preperitoneal. The author's cumulative initial patency was similar for those operated on with primary (23) and postaortofemoral bypass graft (post-AFBG) (29) ischemia. Preperitoneal placement (10) was associated with better primary prosthetic patency and less infection than subcutaneous (42) insertion.

Outcomes after redo aortobifemoral bypass for aortoiliac occlusive disease

OBJECTIVE

Patients presenting with occluded aortobifemoral (ABF) bypass grafts are managed with a variety of techniques. Redo ABF (rABF) bypass procedures are infrequently performed because of concerns about procedural complexity and morbidity. The purpose of this analysis was to compare midterm results of rABF bypass with those of primary ABF (pABF) bypass for aortoiliac occlusive disease to determine if there are significant differences in outcomes.

METHODS

A retrospective review was performed of all patients undergoing ABF bypass for occlusive disease between January 2002 and March 2012. A total of 19 patients underwent rABF bypass and 194 received pABF bypass during that period. Data for an indication- and comorbidity-matched case-control cohort of 19 elective pABF bypass patients were collected for comparison to the rABF bypass group. Primary end points included rate of major complications as well as 30-day and all-cause mortality. Secondary end points were amputation-free survival and freedom from major adverse limb events.

RESULTS

The rABF bypass patients more frequently underwent prior extra-anatomic or lower extremity bypass operations compared with pABF bypass patients (P = .02); however, no difference was found in the incidence of prior failed endovascular iliac intervention (P = .4). By design, indications for the rABF and pABF bypass groups were the same (claudication, n = 6/6 [31.6%]; P = 1; critical limb ischemia, n = 13/13 [78.4%]; P = 1). Aortic access was more frequently by retroperitoneal exposure in the rABF bypass group (n = 13 vs n = 1; P < .0001), and a significantly higher proportion of the rABF bypass patients required concomitant infrainguinal bypass or intraprocedural adjuncts such as profundaplasty (n = 14 vs n = 5; P = .01). The rABF bypass patients experienced greater blood loss (1097 ± 983 mL vs 580 ± 457 mL; P = .02), received more intraoperative fluids (3400 ± 1422 mL vs 2279 ± 993 mL; P = .01), and had longer overall procedure times (408 ± 102 minutes vs 270 ± 48 minutes; P < .0001). Length of stay (days ± standard deviation) was similar (pABF bypass, 11.2 ± 10.4; rABF bypass, 9.1 ± 4.5; P = .7), and no 30-day or in-hospital deaths occurred in either group. Similar rates of major complications occurred in the two groups (pABF bypass, n = 6 [31.6%]; rABF bypass, n = 4 [21.1%]; observed difference, 9.5%; 95% confidence interval, -17.6% to 36.7%; P = .7). Two-year freedom from major adverse limb events (±standard error mean) was 82% ± 9% vs 78% ± 10% for pABF and rABF bypass patients (log-rank, P = .6). Two-year amputation-free survival was 90 ± 9% vs 89 ± 8% between pABF and rABF bypass patients (P = .5). Two-year survival was 91% ± 9% and 90% ± 9% for pABF and rABF bypass patients (P = .8).

CONCLUSIONS

Patients undergoing rABF bypass have higher procedural complexity compared with pABF bypass as evidenced by greater operative time, blood loss, and need for adjunctive procedures. However, similar perioperative morbidity, mortality, and midterm survival occurred in comparison to pABF bypass patients. These results support a role for rABF bypass in selected patients.

The importance of antegrade completion angiography in aortobifemoral bypass limb revision

Aortobifemoral bypass is a durable arterial reconstruction with well-defined failure modes. Management of graft limb thrombosis requires restoration of inflow and correction of any causative outflow lesions. Successful, minimally invasive inflow restoration with catheter thrombectomy can become problematic if assessment of technical adequacy is deficient or reveals causal lesions within the graft body. We describe a case illustrating the potential shortfall of retrograde graft limb completion angiography in depicting neointimal flaps, the benefit of antegrade angiography in depicting these flaps, and a novel utilization of a standard endovascular method to correct flaps that involve the graft body.

Primary stent placement for late complete occlusion after aortoiliac reconstructive surgery: report of a case

We report a case that was successfully treated by primary stent placement without thrombolysis or thrombectomy for graft thrombosis after aortoiliac reconstructive surgery. A 79-year-old man presented with a 2-month history of severe intermittent claudication of the right leg. He had undergone a surgical repair of abdominal aortic aneurysm with a bifurcated polyester graft 3 years before presentation. Digital subtraction angiography revealed total occlusion of the right limb of the graft. He underwent primary stent placement on the lesion, and completion angiography showed revascularization of the right limb. Primary stent placement can be performed to decrease the risks of surgery and increase the salvage of a graft with chronic total occlusion.

Evaluation of neointimal hyperplasia on tranilast-coated synthetic vascular grafts: an experimental study

Tranilast is an antiallergic drug that interferes with proliferation and migration of vascular smooth muscle cell induced by platelet-derived growth factor (PDGF) and transforming growth factor-beta1 (TGF-beta1). We investigated the local effect of tranilast on neointimal hyperplasia using tranilast-coated prosthetic grafts. The inner sides of the thin-walled polytetrafluoroethylene (PTFE) grafts were coated with chitosan and tranilast containing chitosan solution. Wistar albino rats (32) were used in the study. Patches (1 x 2 mm) for vascular grafts were prepared. Three groups were tested: group 1 (n = 12; tranilast coated), group 2 (n = 10; adhesive-only film-layer-coated), and group 3 (n = 10; normal ePTFE patch grafts sutured to the carotid arteries of the rats). Recipient sites of the carotid arteries were excised 4 weeks after surgery. All sections were examined histologically for graft patency, thrombus formation, and neointimal thickness. Expression of PDGF, fibroblast growth factor, and TGF-beta1 on cross-sections of the neointima were evaluated by immunohistochemistry. No significant differences were found regarding mean neointimal thicknesses. PDGF and TGF-beta-1 expressions were significantly lower in group 1. Although a decrease in local effect of tranilast was observed for growth factor expressions at a drug concentration of 0.05 mg/cm(2), a significant reduction in neointimal hyperplasia was not achieved. The coating concentration of 0.05 mg/cm(2) may have been too low to produce an antiproliferative effect. Given our promising results, further studies are recommended and planned using different drug concentrations and time intervals.

The mid-distal deep femoral artery: few important centimeters in vascular surgery

The deep femoral artery is an important artery in lower-limb revascularization. Employing its initial centimeters as either an inflow or an outflow site has been advocated by many authors. The purpose of this work was to highlight the importance of the mid-distal section of the deep femoral artery, underlining its indications and advantages. From January 1998 to December 2004, we performed, at the Misericordia Hospital Vascular Surgery Unit in Grosseto, Italy, 45 bypasses employing the mid-distal deep femoral artery as an inflow or outflow site. Twenty patients (44.4%) had nonhealing ulcers and/or gangrene, while the remainder (25 patients, 55.6%) presented with rest pain or severe claudication. In 41 cases (91.1%), the mid-distal deep femoral artery was used as the inflow site for peripheral bypasses. In four cases (8.9%), the mid-distal deep femoral artery was employed as the outflow site, twice (4.4%) after aortobifemoral branch thrombosis and twice (4.4%), in the same patient, after inguinal prosthetic infection healing. When the mid-distal deep femoral artery was employed as the inflow site, primary and secondary patency at 1 and 5 years were 92.72% vs. 95.20% and 57.39% vs. 72.81%, respectively. We had two early (<30 days) failures (4.4%) in patients with posterior tibial distal anastomosis, which required above-knee amputation. In two cases (4.4%), we had to perform a transmetatarsal amputation. In one patient, after healing of the inguinal prosthetic infection of an aortobifemoral bypass, we employed the mid-distal deep femoral artery both as inflow and as outflow site. This patient required a monolateral above-knee amputation after 5 months. The mid-distal deep femoral artery is a good outflow and inflow site in patients who have previously undergone surgical interventions in Scarpa's triangle, in those having inadequate vein segment, in those with local inguinal healed infection, and in obese patients. The surgical technique is a practical, easy, elegant, and fast procedure, along with being an optimal alternative to reexploration of scarred inguinal tissue.

Femorofemoral bypass with femoral popliteal vein

BACKGROUND

The femoropopliteal vein (FPV) has been used successfully for vascular reconstructions at multiple sites. To date, there have been no studies documenting patency of the FPV graft in the femorofemoral position. Our goal was to assess long-term patency of the FPV graft used for femorofemoral bypass (FFBP).

METHODS

Patients undergoing FFBP over a 10-year period were studied. Those in whom the FPV was used as a conduit were analyzed for runoff resistance score to assess how patients with poor runoff fared. Poor runoff was defined as a runoff resistance score of > or =7 (1 = normal runoff, 10 = total occlusion of all runoff vessels).

RESULTS

Fifty-four patients underwent FPV FFBP as a sole procedure (n = 16, 30%) or as a portion of an aortofemoral reconstruction with a FFBP component (n = 38, 70%). Mean (+/- SD) follow-up was 47 +/- 33 months. The 1-, 3-, and 5-year primary patencies were 97%, 93%, and 76%. The 5-year assisted primary and secondary patency rates were 85% and 90%. Among 27 patients with poor runoff (runoff resistance score of > or =7), the cumulative 40 month patency rate was 90%. Among patients in whom FPV FFBP was performed as a primary procedure (no aortofemoral component), there were no graft failures.

CONCLUSIONS

FFBP performed with FPV has excellent 1-, 3, and 5-year patency rates. FPV has sustained patency for FFBP in patients with poor runoff.

Critical appraisal of femorofemoral crossover grafts

Background

The aim of this study was to determine how often femorofemoral crossover grafting for critical ischaemia or intermittent claudication gives an ideal result. An ideal result is an uncomplicated operation with primary wound healing, relief of ischaemic symptoms without recurrence and no need for further intervention.

Methods

All patients undergoing primary femorofemoral crossover grafting between January 1988 and December 2003 were studied.

Results

Some 144 operations were analysed; 51 patients had critical ischaemia and 93 claudication. There was one postoperative death (0·7 per cent). Complications occurred within 30 days in 32 patients (22·2 per cent), including graft occlusion in three (2·1 per cent); six patients (4·2 per cent) required early reoperation. Primary patency for patients with critical ischaemia was 88, 82 and 74 per cent at 1, 3 and 5 years respectively. Respective figures for those who presented with claudication were 93, 92 and 90 per cent (P = 0·034). Late symptoms included graft occlusion (20 patients), disease progression (25), ongoing ulceration (six), graft infection (nine), false aneurysm formation (two) and late donor-site stenosis (two).

Conclusion

When obtaining informed consent, simply describing patency and limb salvage rates does not provide an accurate picture of the outcome of femorofemoral grafting.

Small-caliber heparin-coated ePTFE grafts reduce platelet deposition and neointimal hyperplasia in a baboon model

PURPOSE

Intimal hyperplasia and graft thrombosis are major causes of graft failure. Heparin prolongs graft patency and inhibits neointimal hyperplasia in animal models. The purpose of this study was to evaluate the effect of a heparin-coated expanded polytetrafluoroethylene (ePTFE) graft on platelet deposition and anastomotic neointimal hyperplasia after aortoiliac bypass grafting in a baboon model.

METHODS

Heparin-coated ePTFE grafts (4-mm diameter) were incorporated into exteriorized femoral arteriovenous shunts placed in five baboons. Platelet deposition was analyzed by measuring the accumulation of indium 111-labeled platelets on the grafts, with dynamic scintillation camera imaging. Eight adult male baboons (mean weight, 9.3 kg) underwent bilateral aortoiliac bypass grafting with ePTFE grafts (4-mm internal diameter). In each animal a heparin-coated ePTFE graft was placed in one aortoiliac artery, and an uncoated graft, which served as the control, was placed in the contralateral aortoiliac artery. All grafts were harvested at 4 weeks, and were analyzed quantitatively for neointimal hyperplasia at graft-vessel anastomoses.

RESULTS

Early platelet deposition on heparin-coated grafts after 1 to 4 hours of ex vivo circuitry was significantly reduced. All the harvested aortoiliac grafts were patent at 4 weeks. There was a significant reduction in neointimal area at both proximal (0.26 +/- 0.11 mm(2)) and distal (0.29 +/- 0.14 mm(2)) anastomoses in the heparin-coated grafts, compared with proximal (0.56 +/- 0.18 mm(2)) and distal (0.63 +/- 0.21 mm(2)) anastomoses in the untreated control grafts (P <.05). In addition, neointimal cell proliferation assayed with bromodeoxyuridine (BrdU) incorporation was reduced in the graft neointima (3.47% +/- 0.43%) in heparin-coated grafts compared with the graft neointima (6.21% +/- 0.59%) in untreated control grafts (P <.05).

CONCLUSIONS

Small-caliber heparin-coated ePTFE grafts significantly reduce platelet deposition and anastomotic neointimal hyperplasia and cell proliferation, without measurable side effects, in baboons. Surface coating with heparin in small-caliber ePTFE grafts is useful for improving prosthetic bypass graft patency.

CLINICAL RELEVANCE

An autologous vein graft is the ideal bypass conduit in peripheral arterial reconstruction; however, many patients who undergo bypass grafting do not have adequate or available autologous vein graft. As a result surgeons often must rely on prosthetic grafts as an alternative conduit in arterial bypass procedures. Clinical outcomes with prosthetic grafts in peripheral arterial reconstruction are generally inferior to those with autologous vein bypass grafts, in part because of anastomotic neointimal hyperplasia. This study evaluated the effect of small-caliber heparin-coated expandable polytetrafluoroethylene (ePTFE) grafts in aortoiliac reconstruction in a baboon model. The study found that heparin-coated ePTFE grafts resulted in less intimal hyperplasia and less platelet deposition after implantation, compared with noncoated control ePTFE grafts.

[Cross over bypasses ilio-femoral and femoro-femoral. Indications and results about 60 cases]

The goal of this retrospective study is to review indications and results of cross over bypasses.

METHODS AND MATERIAL

between January 1990 and December 2000, 60 patients (all males with mean age = 60 years) underwent cross over bypass for unilateral iliac occlusive disease: femoro-femoral in 48%, ilio-femoral in 44% and ilio-popliteal in 8%.

RESULTS

mortality was 5% while complications occurred in 13.3%. Early limb salvage rate was 92%. During follow-up (mean: 32 months) we noticed 13 late thrombosis. The actuarial patency rate being at 83.5%, 74% and 67% at 1 year, 3 years and 5 years respectively.

CONCLUSION

cross over bypasses are technically simple with low morbidity and acceptable results. In addition to widely accepted indications (general or local unfavourable conditions to approach abdominal aorta), cross over bypasses may be considered as satisfactory challenge even in young patients with how operative risk.

Durability of femorofemoral bypass grafting after aortouniiliac endovascular aneurysm repair

INTRODUCTION

Endovascular aneurysm repair (EVAR) with aortouniiliac prostheses extends the morphologic range of aneurysms that can be treated and is potentially a more rapid and simple operation than bifurcated endovascular repair. It may, however, be limited by durability of the femorofemoral extra-anatomic bypass graft required to revascularize the contralateral lower limb. Previous studies of femorofemoral bypass grafts were performed almost exclusively in patients with occlusive disease. An 8-year single center experience with use of the femorofemoral bypass graft in aneurysmal disease is reported.

METHODS

All patients undergoing EVAR with an aortouniiliac endovascular stent graft over eight years (1994-2002) at a single institution were included in a retrospective study. Patient data were collected from a prospectively maintained local endovascular database. All patients gave informed consent and were part of an endovascular program approved by the local ethics committee.

RESULTS

Over the 8 years, 231 patients underwent EVAR with an aortouniiliac endovascular stent-graft. Median follow-up was 22 months. Localized wound complications were observed in 25 patients (11%). Cumulative 3-year patency rate for the femorofemoral bypass graft was 91%. At the end of 5 years 83% of grafts remained patent.

CONCLUSIONS

The femorofemoral bypass graft used during EVAR with aortouniliac stent grafts offers encouraging medium and long-term patency. When graft occlusion occurs, it is usually directly attributable to inadequate inflow from the endovascular stent graft itself or to endoluminal damage of the external iliac artery. Awareness and early detection of stent-graft distortion or complications in the external iliac artery may result in improved patency rates.

Diagnosis and treatment of chronic lower extremity ischemia

Chronic lower extremity ischemia is due to progressive atherosclerosis of the aorto-iliac and/or infrainguinal arteries. This disease process is of great importance as millions of patients are affected by lower extremity arterial occlusive disease. Most of these patients are asymptomatic but a growing number of them are symptomatic, with complaints ranging from mild claudication to gangrene. The increasing number of patients affected by lower extremity atherosclerosis is, in part, due to the 'graying' of the general population and to the medical improvements of the past three decades that have allowed patients with generalized atherosclerosis to survive longer. Fortunately, the diagnosis and management of peripheral arterial occlusive disease has also significantly progressed leading to improved graft patency, limb salvage rates, and quality of life for patients.

The significance of donor leg distal runoff in femorofemoral bypass grafting

BACKGROUND

The aim of this study is to determine if femorofemoral bypass grafting is an effective operation for unilateral iliac occlusive disease, and to assess for factors that may predict a poorer outcome. A retrospective review was conducted of cases identified from a prospective audit database.

METHODS

Information was obtained from the clinical notes of 97 patients who had 100 femorofemoral bypass graft operations. All living patients were invited for assessment which included colour duplex sonography of the graft and measurement of the ankle brachial index.

RESULTS

Using life-table analysis, the five-year graft secondary patency for claudicants was 79% and for those with critical ischaemia 78%. Five-year survival for claudicants was 65% and for those with critical ischaemia, 38%. Poor distal runoff in the infrapopliteal arteries of the donor limb adversely affected graft patency. Graft survival was not affected by the indication for operation, by donor or recipient superficial femoral artery patency, or by the need for endarterectomy, pre-operative angioplasty or the graft material.

CONCLUSIONS

Femorofemoral bypass grafting is the procedure of choice for all patients who require surgical intervention for unilateral iliac occlusion and donor limb distal runoff may be an important determinant of graft patency.