The current role for femorofemoral bypass

Crossover femoropopliteal bypass: single graft or double grafts

BACKGROUND

Both single-graft crossover femoropopliteal (COFP) bypass and crossover femorofemoral plus femoropopliteal bypasses using double grafts may be performed for patients with a medical history of abdominal vascular operations or comorbidity, thereby ineligible for retroperitoneal or transperitoneal approaches. In this study, these two methods were compared.

METHODS

A total of 15 patients who were operated on between February 2002 and March 2010 were included and studied retrospectively. Eight of them underwent crossover femorofemoral bypass plus femoropopliteal bypass with double grafts (group 1), whereas the rest seven underwent single-graft COFP bypass (group 2). All the patients were included either in class 3 or class 4 according to Fontaine classification. Preoperative arterial Doppler ultrasound and arteriography were obtained from every patient. Pre- and postoperative ankle-brachial indices were measured. Postoperative clinical parameters were obtained from medical records.

RESULTS

Median primary and secondary patency rates were 40.5 (7-105) months and 58 (7-105) months in group 1, respectively. In group 2, these rates were 42 (2-84) months and 44 (11-84) months, respectively. Two patients in group 1 and one patient in group 2 were amputated. There were no significant differences between both groups in terms of duration of hospital stay, duration of intensive care unit stay, and units of packed red blood cells transfused (P > 0.05). In addition, postoperative ankle-brachial indices were significantly improved in both groups (P < 0.05). COFP bypass can be performed for limb salvage in cases with critical limb ischemia with a medical history of previous vascular surgery or comorbidity, thereby ineligible for aortic reconstruction.

CONCLUSION

This procedure may also be performed as continuous COFP bypass using a single graft.

[Factors influencing early results of femoro-femoral crossover bypass]

INTRODUCTION

Femoro-femoral crossover bypass is an extraanatomic reconstruction used for revascularization of lower limb with contralatateral femoral artery as an inflow vessel, and the graft placed in the suprapubic region. We perform this procedure when anatomic reconstruction is not possible or is contraindicated.

OBJECTIVE

To analyze the influence of different risk factors on early patency of femoro-femoral crossover bypass.

METHODS

This retrospective study analyzed the results of 88 femoro-femoral bypass grafting during an 11-year period. There were 66 (75%) males and 22 (25%) females of average age 64.93 years (42-79 years). In 76 patients the operations were performed due to critical limb ischemia. Revascularization was urgent in 12 patients, while 76 patients were elective. Dacron prosthesis was used in 81 patients, while PTFE was used in 7 patients. Statistical analysis was made by logistic regression.

RESULTS

During hospitalisation the graft remained patent in 82 patients, and graft thrombosis occurred in 6 patients. Limb salvage rate was 90.91%. Early morbidity rate (within the first postoperative month) was 13.64%, while early mortality rate was 4.55%. Using logistic regression we established that early graft patency was statistically more significant in males (p < 0.05). Age (p = 0.07) and hypertension (p = 0.08) appeared to be predicting influence of the graft patency on the border of the accepted statistical significance level.

CONCLUSION

Femoro-femoral crossover bypass is a good alternative for revascularization in high risk patients for standard anatomic reconstructions due to comorbid conditions or local problems.

Extra-anatomical bypass grafting--a single surgeon's experience

INTRODUCTION

Extra-anatomical bypass grafting is a recognised method of lower limb re-vascularisation in high-risk patients who cannot tolerate aortic cross clamping, or in those with a hostile abdomen. We present a single surgeon series of such procedures and determine relevant outcomes.

PATIENTS AND METHODS

A retrospective review was performed on a prospectively maintained database of patients undergoing femoro-femoral or axillo-femoral bypass surgery between 1986 and 2004.

RESULTS

Patency rates for femoral (n = 28; 32%) versus axillary (n = 59; 68%) bypass procedures at 1 month, 1, 3 and 5 years were (92% vs 93%), (69% vs 85%), (60% vs 72%) and (55% vs 67%), respectively. Patient survival rates for the corresponding procedures and time intervals were (96% vs 90%), (96% vs 67%), (85% vs 45%) and (73% vs 38%) and revealed a significantly lower survival rate in those undergoing axillary procedures (P = 0.002). Limb salvage rates were calculated at (100% vs 91%), (96% vs 84%), (96% vs 81%) and (92% vs 81%) with no statistically significant difference found between the two groups (P = 0.124). Two-thirds of the patients who required major amputation died within 12 months of surgery.

CONCLUSIONS

Acceptable 30-day morbidity, long-term primary patency and survival rates are obtainable in patients suitable for extra-anatomical bypass surgery despite having significant co-morbidities. We have shown 5-year patency rates in those that survive axillary procedures to be as good as those undergoing femoral procedures. Furthermore, surviving patients who evade amputation within a year have an excellent chance of long-term limb salvage.

Derivação arterial extra-anatômica no segmento aorto-ilíaco: experiência de 15 anos

RESUMO CONTEXTO: As derivações extra-anatômicas, sendo procedimentos cirúrgicos alternativos à cirurgia clássica, têm como principal objetivo simplificar um procedimento de grande porte como a restauração aorto-femoral. OBJETIVOS: Analisar os resultados a longo prazo das derivações extra-anatômicas no segmento aorto-ilíaco. MÉTODOS: Estudo longitudinal retrospectivo envolvendo 79 derivações extra-anatômicas no segmento aorto-ilíaco, realizadas em 75 pacientes, no período de dezembro de 1991 a dezembro de 2006. RESULTADOS: Média de idade foi 64,2 anos, com predominância pelo gênero masculino (64%). A isquemia crítica foi a responsável pela maioria das indicações cirúrgicas (86,1%) e a derivação ilíaco-femoral cruzada representou 41,8% dos casos. Em cinco anos, as taxas de mortalidade geral, perviedade e salvamento do membro foram, respectivamente, de 28%; 70,3% e 67,6% em cinco anos. CONCLUSÕES: As derivações extra-anatômicas devem permanecer como cirurgias alternativas, pois apresentam taxas de perviedade inferiores aos procedimentos que seguem as vias anatômicas naturais além de morbimortalidade considerável. Entretanto, são procedimentos importantes nos casos em que a limitação de ordem clínica ou de natureza local torna difícil ou impede a revascularização por via anatômica. As derivações cruzadas apresentaram perviedade superior às derivações axilo-femorais e as ilíaco-femorais cruzadas revelaram a maior perviedade entre todas (77,3% em cinco anos).

A personal experience with direct reconstruction and extra-anatomic bypass for aortoiliofemoral occlusive disease

OBJECTIVE

This study was conducted to investigate factors influencing the outcome of all open operations for aortoiliofemoral (AIF) revascularization performed by a single surgeon at a tertiary referral center.

METHODS

The series included 355 direct reconstructions and 181 extra-anatomic bypass (EAB) grafts in 339 men (63%) and 197 women, with median ages of 61 and 62 years, respectively. These procedures were done for claudication alone in 267 patients (50%), for advanced ischemia in 258 (48%), and to facilitate other interventions in 11 (2.0%). Simultaneous infrainguinal bypass was necessary in 36 patients (6.7%). Survival and patency analyses were performed using logistic regression, Kaplan-Meier estimations, and proportional hazards models.

RESULTS

Patients receiving EAB were older (P < .001) and were more likely to have advanced preoperative limb ischemia (P < .001), superficial femoral artery occlusions (P < .001), a history of previous lower extremity inflow operations (P < .001), elevated serum creatinine (P = .017), and clinically severe chronic obstructive pulmonary disease (P = .016). On multivariable analysis, EAB resulted in a higher incidence of postoperative death (8.8% vs 2.3%, P = .005) or graft thrombosis (8.8% vs 2.8%, P = .006) than direct reconstruction. Women were more likely to sustain graft thrombosis (P = .006) or require major amputation (P = .050), or both, during the early postoperative period. Overall late survival rates were 87% +/- 3% at 1 year, 64% +/- 5% at 5 years, 39% +/- 5% at 10 years, and 20% +/- 4% at 15 years. Late survival rates were significantly lower (P = .026) after EAB and also were unfavorably associated with advanced preoperative ischemia (P = .046) as well as with several medical comorbidities (P < .001). Primary limb-based patency rates were 95% +/- 2% at 1 year, 85% +/- 3% at 5 years, 77% +/- 5% at 10 years, and 69% +/- 7% at 15 years. Late occlusions occurred more frequently in patients who had undergone previous inflow procedures (P = .028) and were especially common after EAB (P < .001). Patients >65 years had higher early and late mortality rates than younger patients (P < .001), but younger patients had lower long-term patency rates (P < .001).

CONCLUSIONS

The worse operative mortality and late survival rates for EAB in this series largely were preordained by the frequent selection of EAB for patients who represented poor medical risks for direct AIF reconstruction. However, the durability of aortofemoral, aortoiliac, or iliofemoral bypass compared with either femorofemoral or axillofemoral bypass makes direct reconstruction clearly superior for average or low-risk patients. Direct reconstruction should be used preferentially in such cases, especially in women and for younger patients of either gender.

Fluoropolymer-coated Dacron Versus PTFE Grafts for Femorofemoral Crossover Bypass: Randomised Trial

OBJECTIVES

To investigate whether patency of a thin walled 8 mm fluoropassivated Dacron graft was similar to that of a standard 8mm PTFE graft for femorofemoral crossover bypass surgery.

DESIGN

A randomised multicentre clinical trial comparing two vascular grafts with participation of 10 departments of vascular surgery in Denmark, Sweden and Norway.

PATIENTS AND METHODS

198 patients were randomised to PTFE (n=107) or fluoropolymer-coated Dacron grafts (n=91), 63% underwent surgery for claudication, 27% for ischaemic rest pain and 10% for tissue loss. The median follow-up time was 24 months (IQR 19-26 months).

RESULTS

The primary patency rate of the two grafts was similar (log rank test: p=0.35). The primary patency rates (95% CI) for coated Dacron and PTFE grafts were 92% (86-98) and 94% (89-99) at 12 months and 87% (74-95) and 93% (87-99) at 24 months, respectively.

CONCLUSION

In patients with unilateral iliac artery disease not amenable to angioplasty, the femoral-femoral bypass is durable and effective. No difference in patency was found between the two graft materials (fluoropolymer coated Dacron and PTFE).

Factors Affecting the Long-term Patency of Crossover Femorofemoral Bypass Graft

OBJECTIVES

To determine the factors affecting long-term patency of crossover femorofemoral bypass (FFB) graft.

DESIGN

A retrospective clinical study of a prospectively registered database.

MATERIALS

Two hundred and sixteen FFBs performed for 192 patients with atherosclerotic iliac occlusive disease.

METHODS

The clinical and surgical variables influencing graft patency were assessed with log-rank test and Cox's proportional hazard analysis.

RESULTS

The primary patency rates of all FFB grafts at 3 and 5 years were 73+/-4 and 65+/-5%, respectively. By multivariate analysis, hypertension (Odds ratio 2.8, P=0.002) and critical ischemia (Odds ratio 0.42, P=0.01) significantly (P<.05) influenced long-term patency of FFB grafts.

CONCLUSION

The long-term patency of FFB grafts was not affected by procedural modifications. Graft patency was inferior in patients with severe lower limb ischemia but superior in patients with hypertension. Further study is required to clarify the mechanism of an unexpected beneficial effect of hypertension on FFB graft patency.

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.

Long-term results of stenting for chronic iliac artery occlusion

PURPOSE

To evaluate the long-term results of stent placement for chronic occlusions of the iliac arteries.

METHODS

Between October 1992 and December 1997, 73 patients (40 men; median age 64 years, range 42-89) with 76 occluded iliac arteries (33 common, 34 external, and 9 both vessels) were treated with percutaneous recanalization and stenting using a variety of self-expanding and balloon-expandable devices. Median occlusion length was 7 cm (range 1-14). Follow-up consisted of clinical assessment, ankle-brachial index measurement, and arteriography or duplex ultrasound when indicated.

RESULTS

Anatomical success was achieved in 74 (97%) limbs. Seven (10%) patients experienced major complications: 2 distal embolizations, 2 arterial ruptures, 1 myocardial infarction, 1 groin hematoma requiring surgery, and 1 contrast-induced nephropathy. There was no 30-day mortality. Over a median follow-up of 27 months (range 1-75), there was 1 early occlusion (< or = 30 days) and 16 late recurrent lesions (11 occlusions and 5 stenoses) at a median 6.2 months (range 1.4-30). The recurrent lesions were treated with endovascular techniques in 8 limbs and surgery in 7 limbs (5 after failed endovascular procedures); 1 patient died before retreatment, and 1 patient refrained from further intervention. Primary and secondary patencies were 79% and 87% at 1 year and 69% and 81% at 3 years, respectively.

CONCLUSIONS

Stenting of chronic iliac occlusions is a safe and durable alternative to surgical treatment.

Is the preferential use of ePTFE grafts in femorofemoral bypass justified?

The choice of prosthetic graft material for cross-femoral bypass has been evolving in the past two decades. Expanded polytetrafluoroethylene (ePTFE) has become our preferred graft material since 1995. However, few studies have looked into the optimal graft material in this procedure. Justification for the preferential use of ePTFE graft in lower limb revascularization remains unknown. The aim of the present study was to compare the long-term outcomes of Dacron and ePTFE grafts in femorofemoral bypass. The records of 61 consecutive patients who underwent femorofemoral bypass at the University of Hong Kong Medical Center from 1981 to 1998 were retrospectively reviewed. Dacron grafts were used in 27 patients and 34 patients had ePTFE grafts. The demographic features, patency, and limb salvage rates of the two groups of patients were compared. The 3-year primary patency rates of Dacron and ePTFE grafts were 85% (SE = 9.5%) and 66% (SE = 14.5%), respectively. The difference was not statistically significant. The limb salvage rates of Dacron and ePTFE grafts were 91% and 83% at 3 years, respectively (p = 0.27). The long-term outcomes of Dacron and ePTFE grafts in femorofemoral bypass were equivalent. The preferential use of ePTFE graft in femorofemoral bypass is not evidence based. Selection of an appropriate prosthetic graft for femorofemoral bypass should be based on the cost and its handling characteristics.

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.

Crossover iliofemoral bypass grafting for treatment of unilateral iliac atherosclerotic disease

PURPOSE

In patients with unilateral iliac disease, a less invasive procedure than aortobifemoral bypass grafting may be desirable, especially in poor-risk patients or when sexual dysfunction is feared. In these cases, femorofemoral (FF) bypass grafting is often proposed. Compared with FF bypass grafting, iliofemoral (IF) bypass grafting avoids bilateral exposure of the groins, which may reduce the risk of infection. When the primitive iliac artery is occluded from its origin or heavily calcified, one may use the contralateral artery as inflow, after a small retroperitoneal exposure, to perform a crossover iliofemoral (CIF) bypass grafting procedure, through the Retzius space. Our 10-year experience with CIF bypass grafting in a select group of patients was studied.

METHODS

Between 1986 and 1996, 36 patients underwent CIF bypass grafting for symptomatic unilateral iliac occlusion or stenosis. All patients were examined by means of Doppler ultrasound scanning and underwent bilateral multiplane angiography. Patients were considered for this procedure when the ipsilateral common iliac artery was occluded from its origin or was diffusely and heavily calcified. The decision to perform a CIF bypass grafting procedure was made when no significant disease of the contralateral common iliac artery was seen, and patients who had features of contralateral iliac disease were excluded. The main outcomes were perioperative mortality and morbidity, long-term primary and secondary patency rates, and limb salvage rate.

RESULTS

The study included 31 men and five women, with a mean age of 58.8 years. Indications for bypass grafting were disabling claudication (26 of 36 patients, 72%) and limb-threatening ischemia (10 of 26 patients, 28%). Twelve procedures were performed simultaneously: endarterectomy of the recipient common femoral artery (n = 3), femoropopliteal bypass grafting (n = 4, 11.1%), profundoplasty (n = 4, 11%), and right internal carotid endarterectomy (n = 1). New postoperative erectile dysfunction did not develop in any of the patients. The survival rate was 97.3% at 1 year and 68.5% at 5 years. The primary and secondary patency rates were 94% and 100%, respectively, at 1 year and 76.7% and 95%, respectively, at 5 years. The limb salvage rate was 100% at 1 year and 87% at 3 years.

CONCLUSION

The operative mortality associated with CIF is low. The long-term primary and secondary patency rates are satisfactory, and they are lower than those reported for aortobifemoral bypass grafting. This procedure does not preclude a later performance of an aortobifemoral bypass grafting procedure. CIF bypass grafting is not only suitable for poor-risk patients with a limited life expectancy who have the appropriate arterial anatomy, but also may be warranted for young patients in whom erectile dysfunction is feared.

Current controversies in the management of aortoiliac occlusive disease

The numerous options currently available for treatment of aortoiliac occlusive disease have led to considerable controversy in regard to the optimal method of revascularization in such patients. Differences of opinion exist not only with respect to certain technical aspects of direct anatomic aortic reconstruction, which has traditionally been regarded as the "gold standard" treatment, but even more importantly as to whether alternative methods including a variety of catheter-based endoluminal therapies and extraanatomic grafts may offer nearly equivalent results with less risk and possible cost advantages. Although little truly definitive data is available, a review of published information can help clarify many of these management dilemmas. In the final analysis, the various methods may not be as competitive with one another as first seems apparent. Each has its own specific advantages and disadvantages and when used, in appropriate circumstances can provide excellent results. Indeed, it is this broad spectrum of options that can be matched to each patient's own unique anatomic and risk characteristics that make treatment of aortoiliac disease one of the most successful areas of contemporary vascular surgery practice.

The crossover femoropopliteal bypass: a useful option for unilaterial iliofemoral occlusive disease

OBJECTIVE

To study the outcome of treating critical limb ischaemia due to concurrent, unilateral iliac and femoral arterial occlusive disease by the placement of a crossover femoropopliteal bypass graft.

DESIGN

Retrospective study of 10 patients unfit for aortic reconstruction whose disease was not amenable to endovascular therapy who were treated with this graft.

MATERIALS

Seven grafts originated from the common femoral artery, two from aortobifemoral graft limbs and one from the common iliac artery. There was not direct revascularisation of the profunda femoris artery. The distal anastomosis was to the above-knee popliteal artery in nine cases and to the below-knee popliteal artery in one.

OUTCOME MEASURES

Follow-up after discharge from hospital consisted of regular ankle-brachial index measurement and Duplex ultrasound scan assessment to record graft patency and limb salvage.

RESULTS

The median duration of secondary patency was 52.5 months (range 14-84). During follow-up, there were four occlusive events. One graft had its patency restored, but in the other three patients, graft occlusion was associated with limb loss (at 18, 51 and 83 months respectively). In one of this latter group, surveillance had identified a failing graft and a jump graft prolonged patency for a further 34 months.

CONCLUSION

This experience demonstrates that the crossover femoropopliteal bypass achieves satisfactory limb salvage in patients with extensive iliofemoral occlusive disease who are not suitable for major aortic reconstruction.

Benefits of arterial reconstruction in claudication

We conducted a midterm follow-up of 150 claudicants who underwent surgical reconstruction by assessing cumulative patency, survival, and palliation (graft patency in live patients) rates. Eighty-nine claudicants (group I) underwent direct (in situ) proximal revascularization, 33 (group II) had indirect (ex situ) proximal revascularization, while 28 (group III) had distal revascularization. The secondary patency rates at 3 years were 97.5% in group I, 97.0% in group II, and 75.0% in group III, respectively. Only one patient with limb graft thrombosis required below-knee amputation. There were 3 perioperative deaths (2 in group I and 1 in group II). The survival rates at 3 years were 86.0% in group I, 69.5% in group II, and 95.8% in group III, respectively. The palliation rates at 3 years were 84.8% in group I, 70.0% in group II, and 77.9% in group III, respectively. These findings indicate the midterm benefits of supra- and infrainguinal arterial reconstructions, and also suggest that the preoperative assessment of risks in individual patients, the selection of the appropriate operative procedure and graft material, and intensive postoperative follow-up and management of any associated disease are all important aspects in the treatment of claudicants.

Extra-anatomic reconstruction

Extra-anatomic bypass grafts have proven to be effective in bypassing infected regions, in avoiding hostile abdomens, and in patients with limited life expectancy. The extra-anatomic bypass graft can be used as a temporizing conduit while infected fields are definitively treated. The recommendation to expand the role of extra-anatomic bypass grafts over more direct revascularization with an aortobifemoral artery bypass graft must be critically evaluated. With advances in anesthesia and critical care management, the postoperative mortality for aortobifemoral bypass is 3% to 5%, with an incidence of myocardial infarction of 2%. Long-term primary patency of the aortofemoral bypass graft is 80% to 92% at 5 years. The 5-year primary patency rate for the axillofemoral bypass graft of 50% to 73% does not strongly support the expanded role of extra-anatomic bypass in otherwise healthy patients undergoing aortoiliac bypass. Yet the extra-anatomic bypasses have a vital role in the management of selected patients and should be in the armamentarium of all vascular surgeons.

Autogenous vein grafts for femorofemoral revascularization in contaminated or infected fields

PURPOSE

The purpose of this study was to determine the indications and the long-term results for femorofemoral revascularization with autogenous vein grafts (AVG) rather than conventional synthetic materials.

METHODS

A consecutive series of 13 men and 12 women (mean age 64 years) receiving femorofemoral AVG was collected during a retrospective review of our experience from 1979 to 1992. Sixteen of these 25 patients required revascularization for acute ischemia in the presence of potential groin contamination (group 1), and the remaining nine had frank infections involving previous synthetic grafts (group 2). New grafts were constructed with the greater saphenous vein in 23 patients (92%) and with the cephalic vein in two.

RESULTS

One patient in each group (8%) died after operation with patent grafts. Preoperative and postoperative ankle/brachial indexes (ABI) were available for 12 patients in group 1 and for seven patients in group 2. There was significant improvement in the ABI among 11 patients with ischemia in group 1 (mean 0.33 +/- 0.13; p = 0.0001), whereas no change in the ABI occurred in conjunction with the replacement of patent infected grafts among six patients in group 2 (mean 0.04 +/- 0.17; p = NS). One patient from each group sustained a reduction in postoperative ABI for the recipient limb despite a patent AVG. Cumulative 3-year survival and primary patency estimates for all 23 operative survivors were 63% and 75%, respectively. Late results seemed to be comparable in group 1 and group 2, but each contained too few patients for adequate analysis.

CONCLUSIONS

Despite their infrequent use, AVG seem to represent a reasonable alternative to synthetic bypass for femorofemoral revascularization in patients having either contaminated wounds or established graft infections.

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

PURPOSE

Aortofemoral bypass (AFB) is a durable reconstruction; however, graft limb occlusion occurs in 10% to 20% of patients and results in limb ischemia. Treatment of AFB limb occlusion has been debated, but many recommended femorofemoral bypass (FFB). FFB grafts have had excellent patency rates. The durability of FFB specifically for AFB limb occlusion has not been reported. This study retrospectively examined a 10-year experience with FFB for AFB limb occlusion to determine FFB performance.

METHODS

Between 1982 and 1992, FFB was performed on occluded AFB limbs in 22 patients (14 men and 8 women). Reoperation was performed for disabling claudication in five cases, but the remaining 17 patients (77%) had critical limb ischemia. FFB originated from the contralateral patent AFB limb in all cases. Distal anastomosis was to the common femoral artery (n = 8) or the profunda femoris (n = 14). FFB graft patency was confirmed by direct Doppler arterial examination over a mean follow-up of 47 months.

RESULTS

The cumulative life-table primary patency rate of FFB was 54% at 5 years. Reoperative procedures performed in nine cases resulted in a secondary patency rate of 84% at 5 years. The limb salvage rate was also 84% at 5 years, reflecting the impact of successful reoperation. Major amputations (two below-knee, one above-knee) were necessary in only three cases. There were no perioperative deaths after FFB, and the cumulative 5-year survival rate was 77%.

CONCLUSION

Aortic graft limb occlusion occurs less frequently than failure of infrainguinal grafts making the success of specific reoperative strategies difficult to document reliably. This study suggests that FFB is a safe and durable alternative for AFB limb failure. An aggressive policy of reoperation has resulted in successful extension of FFB graft function and an excellent rate of limb salvage.

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.

Donor iliac angioplasty and crossover femorofemoral bypass

We reviewed our experience with 99 patients who had 111 femorofemoral bypass grafts placed over a 10-year period. Mean follow-up was 36 +/- 28 months (range: 1 to 120 months). Bypass alone was performed in 89 cases (group 1). Preoperative donor iliac angioplasty was utilized in 22 cases (group 2). Overall graft failure was 21 of 89 in group 1 and 2 of 22 in group 2 (difference was not significant by chi 2: p greater than 0.05). Clinical success as calculated by life-table analysis was 95%, 83%, 75%, and 67% at 1, 3, 5, and 7 years, respectively, for group 1. Clinical success was 100% and 91% at 1 and 3 years, respectively, and 91% at 42 months for group 2. The success rates were not different for the two groups when analyzed by the log-rank test at 42 months (p greater than 0.30). We conclude that donor iliac angioplasty and femorofemoral bypass is an excellent option for patients with severe occlusive disease of one iliac artery and contralateral disease amenable to angioplasty.

Options for percutaneous coronary and peripheral revascularization

Angioplasty has become an established treatment for both coronary and peripheral atherosclerosis, and a number of new techniques and devices promise to improve the results of percutaneous intervention during the coming decades. It is likely that balloon angioplasty will remain the percutaneous treatment of choice for both coronary and peripheral intervention; however, we look with hope toward the development of new devices that will expand the role of percutaneous angioplasty and improve the long-term success of these procedures. As technical expertise grows with the new procedures, prospective randomized trials comparing them with standard PTCA will be required to enable physicians to judge their clinical utility.

A nine-year experience with crossover femoro-femoro-popliteal sequential bypass

Multisegmental arterial occlusive disease may require a combined inflow and outflow procedure for optimal treatment of limb ischemia. Twenty-one patients with unilateral iliac artery stenosis or occlusion and ipsilateral superficial femoral artery occlusion underwent crossover femoro-femoro-popliteal sequential bypass during a 9-year period. Seventeen operations were for limb salvage. Patency rates were determined separately for each segment of the bypass. Primary patency rates for the femoro-femoral segment were 89%, 83%, and 57% at 1, 2, and 5 years, respectively. Primary patency rates for the femoro-popliteal segments were 68%, 62%, and 40% at 1, 2, and 5 years, respectively. Limb salvage rates were 100%, 90%, and 77% at 1, 2, and 5 years, respectively. This experience indicates that femoro-femoro-popliteal bypass is an effective treatment in selected patients with severe ischemia due to combined iliac artery and superficial femoral artery disease.

Combined percutaneous transluminal angioplasty and extraanatomic bypass for symptomatic unilateral iliac artery occlusion with contralateral iliac artery stenosis

We have reviewed our experience with percutaneous transluminal angioplasty of contralateral iliac stenosis and extraanatomic bypass of the occluded iliac artery. Twenty-two men and nine women with a mean age of 65 years (range 46 to 84) presented with symptomatic iliac occlusive disease. Twenty-four (77%) had disabling claudication, four (13%) rest pain, and three (10%) ischemic tissue loss. Six (19%) had undergone previous vascular reconstructive procedures. All had an occluded iliac artery on the symptomatic side and greater than 50% stenosis of the contralateral iliac artery. Percutaneous transluminal angioplasty of the iliac stenosis was done prior to extraanatomic bypass, using polytetrafluoroethylene. There were six late deaths after discharge. The only significant complication was a femoral artery thrombosis which was corrected when the bypass graft was performed. Cumulative primary graft patency was 89% at one year and 81% at three years. The crossover graft occluded in six patients, five within 48 months of surgery, and one after nine years. One of these occluded grafts was salvaged by thrombectomy, for a secondary patency rate of 85% at three years. Two patients required aortobifemoral bypass, one an iliobifemoral bypass and one an ilioprofunda bypass. One patient operated upon for rest pain came to below-knee amputation. Mean resting ankle/brachial systolic pressure index increased significantly on the side of the iliac occlusion from 0.35 +/- 0.21 to 0.70 +/- 0.20 (p less than 0.05, paired t test) after the combined procedure. There was no significant difference in the mean resting ankle/brachial systolic pressure index on the contralateral side (0.60 +/- 0.22 to 0.65 +/- 0.27, ns).(ABSTRACT TRUNCATED AT 250 WORDS)

Femoro-femoral or ilio-femoral bypass for unilateral inflow reconstruction?

Femoro-femoral and ilio-femoral bypass are two popular options for unilateral inflow reconstruction. In order to evaluate these alternative approaches, the records of 70 consecutive patients who underwent either femoro-femoral (n = 50) or ilio-femoral (n = 22) grafts were retrospectively reviewed. There were 46 men and 24 women, ranging in age from 27 to 84 years (mean: 66 years). Operative mortality was 10% for all femoro-femoral procedures, including 50% for emergent, 14% for synchronous, and 0% for solitary procedures; mortality was 9% for all ilio-femoral grafts including 20% for synchronous and 6% for solitary procedures. Among the elective solitary procedures, there was no significant difference with respect to operative time, blood loss, fluid requirement, time until resuming an oral diet, or duration of postoperative course for the two procedures. Five-year patency was 93% for all ilio-femoral and 57% for all femoro-femoral grafts. Although femoro-femoral bypass has been the more popular option for unilateral inflow reconstruction in this and other institutions, these findings justify the more widespread use of ilio-femoral bypass.

Femorofemoral crossover bypass for noninfective complications of aortoiliac surgery

Between 1973 and 1989, 39 femorofemoral crossover bypasses were performed to treat unilateral noninfective complications of aortoiliac surgery. The initial revascularization procedure, performed an average of 79.5 months previously, was an aortobifemoral bypass in 29 cases, an aorto- or iliofemoral bypass in six cases, an inlay graft for abdominal aortic aneurysm and aortoiliac endarterectomy in two cases each. The indications for femorofemoral crossover bypass included prosthetic occlusion in 35 cases, thrombosed false aneurysm in two, and further degradation after endarterectomy (iliac stenosis and occlusion in one case each). There was no operative mortality. One patient with acute ischemia upon admission and another with distal gangrene required below-knee and forefoot amputations, respectively. No amputations were required during the rest of the follow-up period. Three repeat aortobifemoral bypasses were performed because of occurrence of aortic or inflow vessel lesions. Primary and secondary actuarial five year patency rates for femorofemoral crossover bypasses were 59.7% and 78.4%, respectively. Femorofemoral crossover bypass can extend the benefits derived from direct aortoiliac surgery with low mortality and morbidity in the absence of associated aortic pathology (false aneurysm at the aortic implantation site or severe obstructive lesions).

Combined transluminal angioplasty and infrainguinal reconstruction in multilevel atherosclerotic disease

Patients with multilevel atherosclerotic disease represent a difficult surgical challenge. This report is a retrospective review of 46 patients who were treated using a combination of iliac transluminal angioplasty and infrainguinal reconstruction. There were 42 male and 4 female patients with an average age of 62 years (range: 40 to 74 years). Follow-up ranged from 1 month to 10 years (mean: 27.3 months). These patients had multiple health problems typical of patients with peripheral vascular disease, including coronary artery disease (67%), hypertension (61%), and diabetes mellitus (42%); 80% of the patients were smokers. Forty-one patients were treated for rest pain and/or tissue loss, while five were treated for incapacitating claudication. Forty-three patients had a combination of angioplasty and distal bypass, while 3 patients had a form of femoral endarterectomy. Iliac artery pressure gradients were reduced from 35.4 +/- 4 mm Hg preangioplasty to 0.6 +/- 0.3 mm Hg postangioplasty. The procedures were well tolerated with no mortality and four serious complications. Vascular laboratory studies showed an improvement in the mean ankle-brachial index from 0.35 +/- 0.03 preoperatively to 0.71 +/- 0.04 postoperatively (p less than 0.05). Life-table analysis revealed a 72% 5-year primary patency rate, with a 93% 5-year limb salvage. Eight patients required a secondary procedure to maintain limb salvage. Five patients underwent amputation, three due to early graft thrombosis and two due to late graft failure. We conclude that combined iliac angioplasty and infrainguinal reconstruction is a safe and effective method for managing the patient with severe multilevel atherosclerotic disease.

Femorofemoral bypass in unilateral iliac artery occlusion

Between January 1973 and January 1988, 188 patients with unilateral iliac artery occlusion were treated at The Middlesex and University College Hospitals, 185 for primary disease and three for blockage of a previous aortobifemoral graft. In the early part of the series, a variety of operations, including aortofemoral and iliofemoral bypass, and endarteriectomy, was used. Femorofemoral bypass was at first reserved for patients who were considered unfit for major surgery, but the results seemed so good that it was adopted as the procedure of choice. Latterly, percutaneous transluminal angioplasty became available, and the role of this is discussed. Over the 15-year period, 150 patients underwent femorofemoral bypass (all but two receiving a prosthetic graft). Of these, 90 per cent had disabling claudication and 8 per cent had critical ischaemia. There were six early deaths (within 30 days of operation) and five late deaths, and two surviving amputees; nine patients could not be traced. The remaining 128 patients have been assessed at intervals of from 3 to 92 months, both clinically and with Doppler studies. The cumulative patency was 86 per cent at 13 years, and all of these patients experienced subjective and haemodynamic improvement in the recipient limb. Eight grafts occluded in the early postoperative phase. In five patients there was deterioration in the donor limb; it is postulated that the effect was due to causes other than the operation. There were two serious postoperative complications due to technical error, one of which led to early above-knee amputation. These are presented in detail. In the light of this experience, the advantages and indications for femorofemoral bypass and the results to be expected from it have become clarified, and the technique standardized so that errors can be avoided. We suggest that femorofemoral bypass is now the operation of choice for unilateral iliac artery occlusion.