Vascular surgical society of great britain and ireland: limb outcome following failed femoropopliteal polytetrafluoroethylene bypass for intermittent claudication

Trends and outcomes after surgical lower limb revascularization in England

Background

The aim was to analyse contemporary data on the number of surgical revascularization procedures performed each year in England, and their outcome.

Methods

Hospital Episode Statistics and Office for National Statistics data were used to quantify numbers and identify factors associated with outcome after all femoropopliteal and femorodistal bypass procedures performed between 2002 and 2006. Outcome measures were repeat bypass, major amputation, death and a composite measure. Single-level multivariable logistic regression modelling was used to quantify the effect of these variables on outcome.

Results

A total of 21 675 femoropopliteal and 3458 femorodistal bypass procedures were performed. Mean in-hospital mortality rates were 6·7 and 8·0 per cent respectively. One-year survival rates were 82·8 and 79·1 per cent; both increased over the study interval. The mean 1-year major amputation rate after femoropopliteal bypass was 10·4 per cent, which decreased significantly over the 5 years (P < 0·001); after distal bypass the rate of 20·8 per cent remained unchanged (P = 0·456). Diabetes mellitus and chronic kidney disease were significant predictors of adverse outcome for both procedures: odds ratio (OR) at 1 year 1·56 (95 per cent confidence interval 1·46 to 1·67; P < 0·001) and 2·15 (1·88 to 2·45; P < 0·001) respectively for femoropopliteal bypass. Previous femoral angioplasty was associated with an increased rate of major amputation 1 year after proximal bypass (OR 1·18, 1·05 to 1·33; P = 0·004).

Conclusion

Although all mortality rates are improving, the major amputation rate remains high after femorodistal bypass. Adverse events occurred after 37·6 per cent of femoropopliteal and 49·7 per cent of femorodistal bypasses; diabetes and chronic renal failure were the main predictors of poor outcome.

The Outcome of Occluded Above-knee Femoropopliteal Prostheses Implanted for Critical Ischaemia

OBJECTIVES

To investigate the impact of patient characteristics and treatment modality (graft thrombectomy vs thrombolysis) on the results of redo procedures for occluded above-knee prosthetic femoropopliteal grafts implanted for critical ischaemia.

MATERIAL AND METHODS

Fifty-five procedures (thrombolysis 24 and thrombectomy 31) were performed on 24 prostheses (23 patients, 24 limbs) between January 1990 and December 2001. All cases were prospectively registered. Graft patency, limb salvage and survival rates were studied and subgroups of patients were compared. Risk factors were analysed with the use of log rank test and Cox proportional hazard analysis.

RESULTS

Half of the 24 initial procedures to restored patency failed within one month. The outcome of second- or third-time redo procedures was similar. The primary patency rates of all 55 redo procedures were 32% at three months, 28% at six months and 12% at 12 months. The results of thrombectomy and thrombolysis were similar. Re-opened grafts additionally treated for an underlying anastomotic stenosis had significantly better patency as compared with re-opened grafts without a pre-existing stenosis on both univariate analysis (p = 0.024) and multivariate analysis (p = 0.027, hazard ratio 2.813). The one-year limb salvage rate was 76%. The one- and five-year survival rates were 87% and 52%, respectively.

CONCLUSIONS

The results of redo procedures for occluded above-knee prosthetic grafts were disappointing. Grafts in which a graft-related stenosis was treated performed better than grafts in which occlusion could not be attributed to an underlying stenosis. Such cases should most likely be offered conservative treatment, amputation or a new arterial reconstruction.

Remote superficial femoral artery endarterectomy: medium-term results

BACKGROUND

the aim of this study is to determine the medium-term results following successful remote superficial-femoral endarterectomy (RSFE).

SETTING

district general hospital in United Kingdom.

METHODS

RSFE comprises a single incision over the origin of the superficial femoral artery. The endarterectomy is carried out in a closed fashion from above. The cut end of distal atheroma is secured with a stent. Twenty-five limbs were followed up with three monthly duplex scans and angiography if any abnormality was suggested. All patients presented with intermittent claudication; in addition three had rest pain and three ulceration or gangrene. The length of atheromatous core removed was 10-30 cm.

RESULTS

all patients had a follow-up of at least one year (range 12-27 months). Eleven arteries developed 14 stenoses. Nine became apparent within nine months of RSFE. The cumulative risk of stenoses developing in patent arteries was 24% at 6 and 63% at 12 months. Eleven angioplasties (PTA) of these stenoses were undertaken. Nine of these remain patent at a median of 12 months after PTA. At one year primary patency was 10 of 25 (40%), primary-assisted patency 18 of 25 (72%) and secondary patency 19 of 25 (76%) and at two years 29%, 57% and 57% respectively.

CONCLUSIONS

RSFE is worth considering for superficial femoral artery occlusive disease, particularly in high-risk patients without suitable vein and with limited life expectancy. Careful duplex surveillance is important. Until stenoses can be prevented, the widespread use of RSFE cannot be recommended.