Aortofemoral or femoropopliteal revascularization? A prospective evaluation of the papaverine test

Role of Duplex Arteriography as the Sole Preoperative Imaging Modality Prior to Lower Extremity Revascularization Surgery in Diabetic and Renal Patients

The limitations and complications associated with contrast angiography (CA) prior to lower extremity revascularization have led to an increased interest in duplex arteriography (DA) as a potential replacement. We report our experience with DA in patients with diabetes and/or chronic renal insufficiency (CRI) that would particularly benefit from a noninvasive approach to preoperative evaluation of the arterial tree. From January 1998 to November 2000, DA was performed in 145 patients with diabetes mellitus and/or CRI prior to 180 arterial reconstructions. One hundred twenty-one procedures were performed on 91 patients with diabetes alone, 41 on 33 patients with diabetes and CRI, and 18 on 15 patients with CRI alone. Patient ages ranged from 36 to 98 years (mean 72 +/- 12 years). Indications for surgery were severe claudication in 33 (18%), rest pain in 37 (21%), nonhealing ischemic ulcers in 52 (29%), and limb gangrene in 58 (32%). Optimal inflow and outflow anastomotic sites were selected according to a diagram based on DA that included arterial tree imaging from mid-aorta to the pedal vessels. Preoperative contrast arteriography was performed in 16 cases (9%) because of extremely poor runoff based on DA and limited visualization of outflow vessels. The distal anastomosis was to the popliteal artery in 89 cases (49%) and to the tibial and pedal arteries in 91 (51%). Intraoperative findings confirmed the preoperative DA results with the exception of one (0.6%) where the distal anastomosis was placed proximal to a significant stenosis requiring an extension graft. The use of DA presents a safe and reliable option to prebypass CA for many patients with diabetes or CRI. The ease of use and favorable patient outcomes achieved by this imaging modality may rival the use of CA for these patients.

Eighteen-year experience with femoro-femoral bypass

BACKGROUND

The role of femoro-femoral bypass in the management of aorto-iliac occlusive disease has evolved during the past two decades. The aim of the present study was to evaluate the early and long-term outcomes of femoro-femoral bypass grafts performed at the University of Hong Kong Medical Centre during an 18-year period.

METHODS

From 1981 to 1998, a retrospective analysis of 61 patients who underwent femoro-femoral bypass at the University of Hong Kong Medical Centre was undertaken. Data on demographic features and results of surgical intervention were reviewed. Early outcomes (morbidity, mortality and improvement of clinical category) and long-term outcomes (graft patency, patient survival and limb salvage rates) were analysed.

RESULTS

The postoperative morbidity and mortality rates were 16% and 7%, respectively. Clinical success was achieved in 48 patients (79%) after operation. The primary patency of femoro-femoral bypass was 86%, 79% and 71% at 1, 3 and 5 years, respectively. The limb salvage rate was 85% at 3 years. The cumulative survival rate of the study population was 89%, 82% and 73% at 1, 3 and 5 years, respectively.

CONCLUSIONS

Femoro-femoral bypass was successful in relieving ischaemic pain and limb salvage in approximately 80% of patients. A 5-year patency rate of 71% was achieved. Femoro-femoral bypass remains a valuable surgical procedure for limb salvage in poor-risk patients with unilateral iliac artery occlusion.

Duplex scanning for grading aortoiliac obstructive disease and guiding treatment

Standard assessment of aortoiliac obstructive disease (AIOD) includes arteriography preferably supplemented with femoral artery pressure (FAP) measurements. This study investigated the value of Duplex scanning in classifying AIOD and compared the outcome of Duplex scanning with clinical decision making. One-hundred-and-fifty-three aortoiliac segments of 87 patients were prospectively examined by Duplex scanning, arteriography, and FAP measurements to establish the presence or absence of significant AIOD. The results of these tests were compared to each other and to the subsequent vascular interventions and their success rates. Excellent agreement (kappa 0.82) was found between Duplex scanning and arteriography. The agreement between Duplex scanning and FAP measurements was much lower (kappa 0.52). The correlation between the performed treatment and the assessment of AIOD by Duplex scanning or arteriography was good, whereas the FAP results correlated only moderately with the performed treatment. Endovascular or operative treatment was actually performed in only 63% of the aortoiliac segments with an abnormal FAP test (success rate 80%). Aortoiliac segments with significant AIOD according to arteriography or Duplex scanning were treated invasively in 86% (success rate 81%) and 82% (success rate 80%), respectively. In conclusion, Duplex scanning can replace arteriography as a screening tool for the identification of treatable aortoiliac lesions whereas the value of FAP measurements in the decision making process is limited.

Femorofemoral versus aortobifemoral bypass: outcome and hemodynamic results

PURPOSE

Femorofemoral bypass (FFB) is used in selected patients when aortobifemoral bypass (AFB) is believed to be inappropriate because of high operative risk or predominantly unilateral iliac artery occlusive disease. We examined concurrent patients who underwent either FFB or AFB to better understand the appropriate use of FFB.

METHODS

The characteristics and outcomes of patients who underwent FFB and AFB during 1986 to 1991 at our institution were retrospectively reviewed. Primary measures of outcome included patient survival, graft patency, limb salvage, and hemodynamic performance of FFB and AFB. Further analysis was performed after substratification for low versus high risk and claudication versus limb threat as the indication for surgery.

RESULTS

FFB was performed in older patients with more medical comorbidities when compared with AFB. Long-term graft patency was inferior after FFB compared with AFB (60% vs 85% at 3 years, p < 0.01). However, both FFB and AFB achieved limb salvage in more than 85% of patients at 3 years. When patients at low risk undergoing nonemergency AFB were compared with patients at low risk who underwent FFB and who had no contraindication to AFB, FFB proved inferior to AFB as measured by graft patency (primary patency 61% vs 87% at 3 years, p < 0.03) and hemodynamic performance (predicted ankle-brachial index with perfect outflow 0.82 after FFB vs 1.03 after AFB). On the basis of a detailed analysis of patient and graft risk factors, we could not explain the inferior patency rate of FFB, although our analysis suggested that inadequate inflow may contribute.

CONCLUSIONS

FFB is inferior to AFB as measured by patency and hemodynamic function. This inferior performance is independent of indications for FFB. AFB should remain the standard therapy for patients at low risk with iliac occlusive disease, but FFB provides adequate function and limb salvage in patients at high risk.

How accurate are high thigh narrow cuff pressure measurements in the assessment of aorto-iliac obstructive disease?

Thigh cuff pressure measurements are commonly used as a diagnostic method in the assessment of the aorto-iliac (AI) segment of patients with arterial obstructive disease. For a reliable assessment of the AI segment the use of a narrow cuff placed high on the thigh has been advocated. Although this method is commonly used, opinions on its diagnostic value are very divergent. To investigate its diagnostic value the pressure measured with a high thigh narrow cuff was compared with the intra-arterial pressure of the common femoral artery measured at rest and during reactive hyperaemia. Furthermore, the accuracy of these thigh pressures for detecting haemodynamically significant (HDS) AI stenoses was examined. The influence of an occlusion of the superficial femoral artery (SFA) on the pressure measurements was also studied. A correlation coefficient of 0.64 (P less than 0.05) was found between the femoro-brachial index (FBI) at rest and the thigh-brachial index (TBI). Using the TBI as a criterion for detecting a HDS AI stenosis, an accuracy of 73% could be obtained. Furthermore, it appeared that an occluded SFA could influence the pressure measurements dramatically. For clinical practice a TBI less than 0.90, in the presence of a patent SFA, ensures the presence of an HDS AI stenosis. A TBI greater than 1.35 suggests that the AI tract is normal, irrespective of the condition of the SFA. All other values of TBI should be interpreted with caution and only used as a decisive diagnostic method for the assessment of the haemodynamics of the AI segment in combination with other tests.

Vascular laboratory prediction of pedal pressure following femoropopliteal bypass

This study examines the hypothesis that postoperative ankle-brachial pressure index (postop ABI) can be accurately predicted using noninvasive preoperative segmental leg pressure measurements. Seventy-three patients who underwent successful reverse autogenous vein femoropopliteal bypass and who had pre- and postoperative segmental leg pressure measurements were examined. Predicted postop ABI was estimated using the following formula: Postop ABI = 1 + (Preop ABI) - (Preop BKI). (BKI = below-knee brachial pressure index). Using this formula, 56 out of 73 (81%) patients had a measured postop ABI +/- 20% of predicted postop ABI. Five out of 73 (7%) patients had postop ABI less than 80% predicted, while 12 out of 73 (16%) patients had postop ABI greater than 120% of predicted. All patients with postop ABI greater than 120% of predicted had apparent tibial artery occlusive disease as indicated by preoperative gradients (BKI-ABI) greater than 0.15.

The current role for femorofemoral bypass

We reviewed our experience with femorofemoral bypass during the past 10 years to define its role relative to other methods in the treatment of aortoiliac occlusive disease. The cumulative patency rate for 82 patients was 80% +/- 5% at 1 year and 67% +/- 7% at 2 and 3 years. The operation was most likely to be successful if the indication was claudication (p less than 0.05) and if the operation was performed as the primary procedure (p less than 0.01). There was no significant difference when patients with or without profundaplasty were compared. It is concluded that femorofemoral bypass is indicated to treat symptomatic unilateral iliac disease when transluminal dilatation is not possible. Femorofemoral bypass is also the procedure of choice for aortofemoral graft occlusion when the thrombosed limb cannot be reopened. Femorofemoral bypass is recommended for both high- and low-risk patients when indicated.