Resurrection of the in situ saphenous vein bypass. 1000 cases later

Predictors of infrapopliteal vein bypass graft revision in patients with chronic limb-threatening ischemia

PURPOSE

Surgical revascularization is the standard treatment for chronic limb-threatening ischemia (CLTI). However, some patients may require reintervention. The Global Anatomic Staging System (GLASS), which evaluates the complexity of infrainguinal lesions, was proposed. This study aimed to identify predictors for graft revision and evaluate whether GLASS impacts vein graft revision.

METHODS

Between 2011 and 2018, CLTI patients who underwent de novo infrapopliteal bypass using autogenous veins were retrospectively analyzed. To assess anatomic complexity with GLASS, femoropopliteal, infrapopliteal, and inframalleolar/pedal (IM) disease grades were determined. The outcomes of patients with or without graft revision were compared. Cox regression analysis was performed.

RESULTS

Thirty-six of the 80 patients underwent reintervention for graft revision. Compared to the non-graft revision group, the graft revision group exhibited significantly higher rates of GLASS stage III (66% vs 81%, p = 0.046) and grade P2 IM disease (25% vs 58%, p = 0.009). Multivariate analysis revealed that IM grade P2 (hazard ratio [HR], 3.35; 95% confidence interval [CI], 1.66-6.75; p = 0.001) and spliced vein grafts (HR, 3.18; 95% CI, 1.43-7.06; p = 0.005) were significantly associated with graft revision.

CONCLUSIONS

This study demonstrated that IM grade P2 and spliced vein grafts were predictors of graft revision. The GLASS stratification of IM disease grade may be useful in optimizing treatment for CLTI.

Comparative analysis of patients undergoing lower extremity bypass using in-situ and reversed great saphenous vein graft techniques

OBJECTIVE

Autologous great saphenous vein (GSV) is considered the conduit of choice for lower extremity bypass (LEB). However, the optimal configuration remains the source of debate. We compared outcomes of patients undergoing LEB using in-situ and reversed techniques.

METHODS

The Vascular Quality Initiative database was queried for patients undergoing LEB with a single-segment GSV in in-situ (ISGSV) and reversed (RGSV) configurations for symptomatic occlusive disease from 2003 to 2021. Patient demographics, procedural detail, and in-hospital and follow-up outcomes were collected. The primary outcome measures included primary patency at discharge or 30 days and one year. Secondary outcomes were secondary patency, and reinterventions at discharge or 30 days and one year. Cox proportional hazards models were created to determine the association between bypass techniques and outcomes of interest.

RESULTS

Of 8234 patients undergoing LEBs, in-situ and reversed techniques were used in 3546 and 4688 patients, respectively. The indication for LEBs was similar between the two cohorts. ISGSV was performed more frequently from the common femoral artery and to more distal targets. RGSV bypass was associated with higher intraoperative blood loss and longer operative time. Perioperatively, ISGSV cohort had higher rates of reinterventions (13.2 vs 11.1%; p = 0.004), surgical site infection (4.2 vs 3%; p = 0.003), and lower primary patency (93.5 vs 95%; p = 0.004) but a comparable rate of secondary patency (99 vs 99.1%; p = 0.675). At 1 year, in-situ bypasses had a lower rate of reinterventions (19.4% vs 21.6%; p=0.02), with similar rates of primary (82.6 vs 81.8%; p = 0.237) and secondary patency (88.7 vs 88.9%; p = 0.625). After adjusting for significant baseline differences and potential confounders, in-situ bypass was independently associated with decreased risks of primary patency loss (HR 0.9; 95% CI, 0.82-0.98; p = 0.016) and reinterventions (HR 0.88; 95% CI, 0.8-0.97; p = 0.014) but a similar risk of secondary patency loss (HR 0.99; 95% CI, 0.86-1.16; p = 0.985) at follow-up, compared to reversed bypass. A subgroup analysis of bypasses to crural targets showed that in-situ and reversed bypasses had similar rates of primary patency loss and reinterventions at 1 year. Among patients with chronic limb-threatening ischemia, in-situ bypass was associated with a decreased risk of reinterventions but similar rates of primary and secondary patency and major amputations at 1 year.

CONCLUSIONS

In patients undergoing LEBs using the GSV, in-situ configuration was associated with more perioperative reinterventions and lower primary patency rate. However, this was offset by decreased risks of loss of primary patency and reinterventions at 1 year. A thorough intraoperative graft assessment with adjunctive imaging may be performed to detect abnormalities in patients undergoing in-situ bypasses to prevent early failures. Furthermore, closer surveillance of reversed bypass grafts is warranted given the higher rates of reinterventions.

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.

[Current Strategy in Endovascular Management for Below-the-Knee Arterial Lesions]

The below-the-knee arterial tree is the thinnest of all the leg vessels and is an important path for blood flow to the foot. Hence, lesions including stenosis, especially obstruction, may lead to critical limb ischemia which represents the most severe clinical manifestation of peripheral arterial disease. It is characterized by the presence of ischemic rest pain, ischemic lesions, or gangrene attributable to the objectively proven arterial occlusive disease. Typically, the atherosclerotic disease process involving the below-the-knee arterial tree is diffuse in the majority of patients. The cornerstone of therapy is vascular reconstruction and limb salvage. Revascularization should be attempted whenever technically possible, without delay, in patients presenting critical limb ischemia and when the clinical status is not hopelessly non-ambulatory. Therefore, endovascular treatment can become the gold standard for the full range of patients including below-the-knee, limiting the clinical role of the classically trained surgeons.

Prosthetic versus native artery inflow for infrainguinal bypass

BACKGROUND

Infrainguinal bypass performed after previous prosthetic inflow reconstruction offers a choice of where to perform the proximal anastomosis. The hood of a previous inflow bypass might be technically easier to isolate during reoperative surgery. However, the more distal native artery might offer better patency to the outflow revascularization. The purpose of the present study was to compare the outcomes of infrainguinal bypass using the hood of a previous inflow bypass vs the native artery as the inflow source.

METHODS

A single vascular group's database was queried for all cases of infrainguinal bypass performed after previous prosthetic inflow bypass to a femoral artery from January 2006 to December 2016. The demographics, indications, operative details, and long-term results were recorded and analyzed. Two groups were compared stratified by the location of the proximal anastomosis for the distal bypass. In one group, the inflow source for the distal bypass was from the hood of a previous inflow graft (prosthetic). In the second group, the distal native arterial tree was used as the inflow source. A subset analysis of the patency of the distal bypass was also performed between the two groups for those in which the previous inflow reconstruction had become occluded. Patency was calculated using the Kaplan-Meier method.

RESULTS

A total of 197 patients had undergone infrainguinal bypass after previous inflow bypass from 2006 to 2016. Of the 197 procedures, 59 (30%) had used the hood of the previous bypass as the inflow source (prosthetic group) and 138 (70%) had used the native artery distal to the hood of the inflow bypass as the inflow source (native group). The indications were similar between the two groups. The two groups had a similar proportion of men and a similar incidence of hypertension, hyperlipidemia, coronary artery disease, tobacco use, and renal disease. The previous inflow procedures were also similar between the two groups. The native artery used for the inflow source in the native group was the profunda femoris in 80 (58%), common femoral artery in 51 (37%), and superficial femoral artery in 7 (5.1%). Patency was significantly greater for the native group at 1 year (91% vs 75%; P = .0221). Also, the patency after inflow bypass occlusion significantly favored the native group at 1 year (87% vs 40%; P = .0035).

CONCLUSIONS

Infrainguinal bypass performed after previous ipsilateral inflow bypass offers the option of using the hood of the bypass or a native artery as the inflow source. The present study demonstrated greater patency rates when using the distal native artery as the inflow source. The native artery option also offered continued patency when the inflow bypass occluded.

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.

Determinants of Peroneal Artery Bypass Failure

Although the peroneal arteryyoften remains patent despite occlusion of other infrageniculate arteries, there is skepticism regarding its use for dista Jl bypass for salvage when a patent inframalleolar artery ispreent. The authors reviewed their experience with lower extremity arterial bypass for-occlusive disease to determine-predictors of peroneal artery bypass failure. The records of all patients undergoing bypass to the peroneal artery for atherosclerotic occlusive disease were reviewed. Patient demographics, operative indications, and the quality of peroneal runoff were evaluated for their contribution to bypass failure.

Between 1976 and 1996, 925 bypasses were performed to the peroneal artery. The indications for operation were limb salvage in 875 (95%). The graft patency rate was 89% and 77% and the limb salvage rate was 96% and 93% at 1 and 5 years, respectively. Bypass conduits included in situ vein (66%), excised vein (31%), and synthetic graft (3%). There were 139 bypass occlusions, of which 27 were revised. The causes of bypass occlusion were conduit failure (66%), inflow lesion (12%), and outflow lesion (22%). There were 18 hemodynamic failures. Thirteen (72%) of these were secondary to inadequate perfusion of the foot. However, 69% of these patients achieved salvage with a jump bypass to a patent more distal vessel. Revisions were performed equally for inflow disease, conduit stenosis, and hemodynamically significant arteriovenous fistulae. Patient demographics; operative indication, including the site of tissue loss; or quality of peroneal artery runoff did not predict bypass occlusion or hemodynamic failure.

The peroneal artery remains an excellent choice of infrageniculate arterial bypass for occlusive disease. The quality of the venous conduit rather than proximity of the distal anastomosis to an area of tissue ischemia should be the primary concern in deciding on distal bypass. No other variables correlated with bypass failure.

Video-Assisted Vein Harvest: A Single Institution's Experience of 103 Peripheral Bypass Cases

Traditional harvesting of the greater saphenous vein (GSV) has meant a long, continuous incision with the potential for increased morbidity, pain, and hospital stay. The authors have used a minimally invasive video-assisted technique in an attempt to reduce these complications. In this report, they retrospectively analyze a series of 103 cases of videoassisted saphenous vein harvests for vascular bypass procedures. All patients from September 1994 to May 1997 who underwent video-assisted saphenous vein harvest were reviewed for vein harvest time, hospital length of stay, surgical complications, graft patency, and clinical outcome. Operative technique used limited incisions, video-assisted dissection, and two different subcutaneous retractors-endoplastic (Type I) (Snowden Pencer, Tucker, GA) and endosaphenous (Type II) (Ethicon Endosurgery, Cincinnati, OH).

Ninety-six patients underwent 103 operations for lower and upper extremity vascular disease. For all patients, the average time of vein removal was 0.74 cm vein/minute operative time, for procedures with the Type I retractor 0.63 cm vein/minute, for procedures with the Type II retractor 1.07 cm vein/minute (p≤0.0001). Postoperative length of stay (LOS) averaged 7.7 days (median 5 days) for all patients and was longer between patients with rest pain (6.4 days) and tissue loss (10.1 days) vs claudicants (4.4 days) (p<0.05), between patients with tibioperoneal anastomoses (10.0 days) vs patients with popliteal anastomoses (6.0 days) (p<0.05), and between Type I patients (8.3 days) and Type II patients (6.9 days) (p=0.03). Nine wound complications occurred (8.7%), two of which (1.9%) were directly related to the video-assisted technique. Cumulative graft patency was 84% ±9% after 18 months. According to the International Society for Cardiovascular Surgery reporting standards for lower extremity occlusive disease, patient outcome averaged +2.03 for all patients, and was improved between patients with claudication (+2.82) vs patients with rest pain (+1.50) (p<0.05) and between Type II patients (+2.36) vs Type I patients (+1.64) (p=0.01).

Video-assisted saphenous vein harvest can be accomplished with low morbidity and provides a satisfactory conduit. The patients had a short postoperative LOS, a satisfactory wound complication rate, and a good operative outcome. The Type II saphenous vein retractor decreased operative time, shortened hospital LOS, and improved outcome.

Comparison of the Resistive Properties of Reversed and Nonreversed Saphenous Veins at Arterial Pressure and Flow: Implications for Optimal Graft Configuration

Clinicians continue to debate the hemodynamic advantages of reversed vs nonreversed vein grafts in infrainguinal arterial reconstructions. Vein grafts placed in the reversed configuration do not require valve lysis but have the theoretical drawback of being smaller in caliber at the inflow end than the outflow end. The purpose of this study was to objectively determine the effect of vein valve lysis and flow direction on vein graft hemodynamics by using physiologic levels of pulsatile flow (Q), pressure gradient (AP), outflow resistance (Ro), and longitudinal impedance (ZL).

Nine cryopreserved human greater saphenous veins (length=23 ±1 cm) were perfused via an in vitro circuit utilizing a variable pulsatile perfusion pump, Windkessel, and clamp resistor. Levels of Q and AP were chosen to simulate the known physiologic conditions of infrainguinal bypass grafting while holding Reynolds numbers <2,400. Veins were studied in the reversed configuration prior to valve lysis, after valve lysis by use of a catheter-directed valvulotome with 3 mm cutting head, and in the nonreversed configuration. Ultrasonic transit-time flow and proximal and distal intraluminal pressure were continuously recorded while Ro and pump rate were varied. Waveforms were digitally stored at 200 Hz at pump rates of 60, 100, 140, and 180 beats per minute at a Q of 154 ± 1 and 253 ± 1 mL/min while Pprox was maintained at 100 mmHg. Veins were perfusion fixed at 100 mmHg, sectioned at 2 cm intervals, and analyzed morphometrically. Inner diameter (id) and outer diameter (od) were determined by light microscopy after correction for shrinkage artifact by comparing to outer diameter measured by digital calipers at 2 cm intervals at the time of perfusion. Percent vein taper was calculated as (idmax7idmin)/idmax and wall thickness (t) as (od-id)/2. After Fourier transformation, ZL was calculated as AP/Q at each harmonic and the curves compared by use of Wilcoxon signed-ranks test.

There were one to four valves per vein (idmean=3.6 ±0.3 mm; range 2.3-6.2) with an average taper of -8 + 12% (range: -46-36%) and mean wall thickness of 0.51 ±0.03 mm (range 0.42-0.68 mm). ZL curves were smooth and reproducible over the measured frequency range. Neither valve lysis nor flow direction had an effect on ZL at any level of Q or Ro, even in veins with a taper >25%. Mean wall thickness correlated with ZL (r2=0.43; p=0.05).

In this in vitro system, saphenous vein graft impedance (ZL) was independent of valve lysis, flow direction, and the degree of vein taper but was weakly dependent on wall thickness. In veins of adequate size, hemodynamic considerations should not influence the decision to use the reversed vs nonreversed configuration.

Long-Term Results of Infrapopliteal Bypass Using Polytetrafluoroethylene and Taylor Vein Patch for Critical Lower Extremity Ischemia

Although distal anastomotic vein patch and cuff techniques have been advocated to improve the patency of lower extremity bypass grafts with polytetrafluoroethylene (PTFE), use of this approach in the infrapopliteal position remains unproven. The purpose of this study is to evaluate the results of infrapopliteal bypass grafting using PTFE and Taylor vein patch for critical lower extremity ischemia. All patients undergoing infrapopliteal bypass grafting with PTFE and Taylor vein patch for ischemic rest pain or tissue loss were identified from the vascular surgery registry. This report describes results for surgical morbidity and mortality, patency, limb salvage, and survival for procedures performed from 1993 through 1998. Forty-two infrapopliteal bypass grafts with PTFE and Taylor vein patch were placed for critical lower extremity ischemia during the 6-year period. Surgical indications were rest pain in 25 (60%) patients and ischemic tissue loss in 17 (40%). Distal arterial anastomosis included 17 (40%) anterior tibial, 10 (24%) peroneal, eight (19%) posterior tibial, and seven (17%) tibioperoneal arteries. Follow-up ranged from 1 to 52 months (mean 17 months). Life-table primary patency, secondary patency, limb salvage, and survival at 3 years were 25%, 31%, 44%, and 66%, respectively. Infrapopliteal bypass with PTFE and Taylor vein patch for critical lower extremity ischemia has poor long-term results that are comparable to those reported for PTFE without Taylor vein patch.

Infrainguinal Bypass Conduit: Autogenous or Synthetic - A National Perspective

Numerous studies have compared autogenous versus synthetic grafts for infrainguinal bypasses. Synthetic grafts are associated with shorter operating times, comparable reimbursement, and despite inferior patency rates, remain in frequent use. Therefore, this study was undertaken in an effort to characterize, from a national perspective, the practice patterns and the drivers of practice variation in the use of synthetic grafts for infrainguinal bypass. Two data sets were obtained: 1) Medicare billings of infrainguinal bypasses in 49 states, years 1995 through 1997 (number of procedures, 254,677). Procedures were defined by nine CPT billing codes. 2) Hospitals over 150 beds in six states (CA, CO, CT, IA, MN, MS) were asked for volume statistics on the same CPT codes. Data were received from 27 institutions, comprising 1,063 procedures. Variations in graft use were analyzed by hospital type (teaching versus nonteaching) and correlated with the prevalence of diabetes mellitus and smoking. Nationwide, 41% of infrainguinal bypasses in 1997 were performed using synthetic grafts. Interstate synthetic conduit use ranged from 27% to 80%. These differences were similar for bypasses to popliteal or infrapopliteal vessels. Admission to a teaching hospital was associated with a lower use of synthetic grafts (21% vs 51%, odds ratio 0.26, p<0.0001). No correlation was seen between the prevalence of diabetes mellitus or smoking, and synthetic graft use. Synthetic graft use was significantly lower at teaching hospitals, and there was substantial interstate and intrastate variations. These findings suggest that there is wide variation in practice patterns. Further studies appear warranted to define the role of patient demographics and physician preference in explaining these differences.

Relationship Between Preoperative Duplex Vein Mapping and Intraoperative Longitudinal Impedance in Infrainguinal Vein Grafts

The importance of favorable vein size, resistance, and impedance for the sustained success of infrainguinal vein grafting procedures has repeatedly been demonstrated. Estimating these properties preoperatively, however, has been problematic. Ultrasonic vein mapping is a reliable technique for measuring vein diameters at venous pressures, but it is unknown whether these data accurately assess the resistive potential of the conduit in the arterial circulation. The purpose of this study was to compare vein diameter measured preoperatively with vein graft longitudinal impedance measured intraoperatively.

Patients who had undergone both preoperative vein mapping and intraoperative impedance studies at the time of infrainguinal bypass were included (December 1995-April 1999). Vein mapping was performed using B-mode ultrasound with a 10 MHz probe. The dimensions of the specific vein segment used for reconstruction were tabulated and its mean diameter (D̄) was calculated. At the time of operation, following reconstruction, transgraft blood pressure gradient (δP) and blood flow (Q) waveforms were recorded by using digital data acquisition. Longitudinal impedance (ZL) was calculated as δP/Q at each harmonic following Fourier transformation and the area under the curve from 0 to 4 Hz designated as ∫ZL.

Twenty-three bypasses in 22 patients were studied (D̄ = 3.5 ±0.2 mm, range 1.6-5.5 mm; ∫ZL= 37 ±4 x 103 dyne cm-5, range 13-95 X 103 dyne cm-5). D̄ significantly correlated with ∫ZL (slope = -0.454, p < 0.05), albeit with a fairly low correlation coefficient ( r2 = 0.23). D̄ > 3.6 mm was predictive of graft patency at 12 months (D̄ > 3.6 mm 100% vs D̄ < 3.6 mm 57 ±20%; p = 0.02).

Larger veins identified by preoperative mapping have, in general, more favorable intraoperative resistive characteristics as defined by a lower JZL. However, some veins thought to have small diameters (< 3.6 mm) may still demonstrate sufficiently low ∫ZL when grafted to remain patent.

Preliminary Report of a New Approach to Sparing the Greater Saphenous Vein for Grafting: Valvuloplasty Combined with Axial Transposition of a Competent Tributary Vein

Purpose:

To compare a new vessel-sparing technique combining valvuloplasty with axial transposition of a competent tributary vein versus single valvuloplasty for the treatment of greater saphenous vein (GSV) incompetence.

Methods:

In 55 patients with GSV incompetence, 29 of 57 limbs were treated by angioscopic valvuloplasty of the subterminal valve alone, whereas the remaining 28 limbs underwent angioscopic valvuloplasty combined with axial transposition of a competent tributary vein identified preoperatively by duplex scanning. After angioscopic valvuloplasty in the latter group, the competent tributary vein was exposed and cut 1.5 cm distal to its insertion point on the GSV. The transected vein was anastomosed end to side to the GSV, which was ligated between the tributary insertion site and the anastomosis. Changes in venous hemodynamics, including venous filling index (VFI), ejection fraction (EF), and residual volume fraction (RVF), were analyzed by use of air plethysmography.

Results:

In the 1-year follow-up, no venous thrombosis was detected in either group. In the valvuloplasty-only group, 22 (75.9%) limbs exhibited reflux in the proximal GSV; recurrent varicose veins were detected in 5 (17.2%) limbs. In contrast, only 2 (7.1%) limbs showed reflux in the valvuloplasty + transposition group. There were no significant differences in EF and RVF between the groups before or after the operation, although a significant difference was seen in VFI at 1 year (p = 0.005, Wilcoxon rank sum test).

Conclusions:

Valvuloplasty combined with tributary vein transposition gives a better result than valvuloplasty alone at 1 year. This new treatment option may be useful for both reducing the rate of varicose veins and sparing the GSV for grafting.

Popliteal-to-Dorsalis Pedis In-Situ Small Saphenous Vein Bypass under Planning with Mapping Using Computed Tomography Volume Rendering Technique

The small saphenous vein (SSV) is an important graft in limb salvage surgery. It is frequently translocated for bypass surgery. Sometimes, the use of the SSV as an in-situ graft for posterior tibial artery or peroneal artery reconstruction offers the advantages of reduced vein graft injury and improved patency. Recently, saphenous vein mapping through computed tomography (CT) volume rendering technique offers a great quality view to the surgeon. We experienced a patient in whom a CT image with volume rendering technique revealed an aberrant SSV connected with the great saphenous vein at the medial malleolus level. This case indicates that an aberrant SSV may be successfully used as an in-situ conduit for bypass to the dorsalis pedis artery. Here, we present the case of a popliteal-to-dorsalis pedis in-situ vein bypass using a LeMaitre valvulotome (LeMaitre Vascular Inc., USA) under mapping of the aberrant SSV by CT volume rendering technique.

Endovascular recanalization of native chronic total occlusions in patients with failed lower-extremity bypass grafts

PURPOSE

To investigate the feasibility, safety, and outcome of endovascular recanalization of native chronic total occlusions (CTOs) in patients with failed lower-extremity bypass grafts.

MATERIALS AND METHODS

Retrospective review of 19 limbs in 18 patients with failed lower-extremity bypass grafts that underwent recanalization of native arterial occlusions between February 2009 and April 2013 was performed. Nine of the limbs presented with acute ischemia and 10 presented with chronic ischemia, including eight with critical limb ischemia and two with disabling claudication.

RESULTS

The mean patency of the failed bypass grafts (63% venous) was 27 months. All limbs had Transatlantic Inter-Society Consensus class D lesions involving the native circulation. Technical success of the endovascular recanalization procedure was achieved in all but one limb (95%). The mean ankle brachial indices before and after treatment were 0.34 and 0.73, respectively. There were no major complications or emergency amputations. Mean patient follow-up was 64 weeks, and two patients were lost to follow-up. Primary patency rates at 3, 6, and 12 months were 87%, 48%, and 16%, respectively. Successful secondary procedures were performed in seven patients, with secondary patency rates at 3, 6, and 12 months of 88%, 73%, and 44%, respectively. Limb salvage rates at 12 and 24 months were 94% and 65%, and amputation-free survival rates at 12 and 24 months were 87% and 60%, respectively.

CONCLUSIONS

Endovascular recanalization of native CTOs in patients with failed lower-extremity bypass grafts is technically feasible and safe and results in acceptable limb salvage.

Vein graft failure

After the creation of an autogenous lower extremity bypass graft, the vein must undergo a series of dynamic structural changes to stabilize the arterial hemodynamic forces. These changes, which are commonly referred to as remodeling, include an inflammatory response, the development of a neointima, matrix turnover, and cellular proliferation and apoptosis. The sum total of these processes results in dramatic alterations in the physical and biomechanical attributes of the arterialized vein. The most clinically obvious and easily measured of these is lumen remodeling of the graft. However, although somewhat less precise, wall thickness, matrix composition, and endothelial changes can be measured in vivo within the healing vein graft. Recent translational work has demonstrated the clinical relevance of remodeling as it relates to vein graft patency and the systemic factors influencing it. By correlating histologic and molecular changes in the vein, insights into potential therapeutic strategies to prevent bypass failure and areas for future investigation are explored.

Cyclic adenosine monophosphate response-element binding protein activation by mitogen-activated protein kinase-activated protein kinase 3 and four-and-a-half LIM domains 5 plays a key role for vein graft intimal hyperplasia

OBJECTIVE

Intimal hyperplasia (IH) is the main cause of vein graft stenosis or failure after bypass surgery. Basic investigations are proceeding in an animal model of mechanically desquamated arteries, and numerous molecules for potential IH treatments have been identified; however, neither insights into the mechanism of IH nor substantially effective treatments for its suppression have been developed. The goals of the present study are to use human vein graft samples to identify therapeutic target genes that control IH and to investigate the therapeutic efficacy of these candidate molecules in animal models.

METHODS

Using microarray analysis of human vein graft samples, we identified two previously unrecognized IH-related genes, mitogen-activated protein kinase-activated protein kinase 3 (MAPKAPK3) and four-and-a-half LIM domains 5 (FHL5).

RESULTS

Transfer of either candidate gene resulted in significantly elevated vascular smooth muscle cell (VSMC) proliferation and migration. Interestingly, cotransfection of both genes increased VSMC proliferation in an additive manner. These genes activated cyclic adenosine monophosphate response-element (CRE) binding protein (CREB), but their mechanisms of activation were different. MAPKAPK3 phosphorylated CREB, but FHL5 bound directly to CREB. A CREB dominant-negative protein, KCREB, which blocks its ability to bind CRE, repressed VSMC proliferation and migration. In a wire-injury mouse model, gene transfer of KCREB plasmid significantly repressed IH. In this vessel tissue, CRE-activated gene expression was repressed. Furthermore, we confirmed the changes in MAPKAPK3 and FHL5 expression using vein graft samples from eight patients.

CONCLUSIONS

We successively identified two previously unrecognized IH activators, MAPKAPK3 and FHL5, using human vein graft samples. Gene transfer of KCREB repressed IH in an animal model. Inhibition of CREB function is a promising gene therapy strategy for IH.

Hemodynamic effects of closure of residual arteriovenous fistulae during in situ graft procedures

The objective was to study the intraoperative hemodynamic effects of closure of residual arteriovenous fistulae during in situ saphenous vein graft procedures. Data on 60 residual arteriovenous fistulae in nine patients (five men) with a median age of 74 years (range 64-83 years) with critical lower limb ischemia were obtained. Direct measurements of proximal and distal blood pressures in the graft were taken and simultaneous determinations of volume blood flow proximally and distally in the graft with ultrasound transit time technique before and after closure of residual fistulae were made. Closure of a fistula with blood flow around or below 100 mL/min did not increase distal outflow, whereas closure of fistulae with higher blood flow resulted in unpredictable changes in distal outflow. Only fistulae with a blood flow above approximately 100 mL/min may be of hemodynamic significance.

The results of in situ saphenous vein bypass for infrainguinal arterial reconstruction: Comparison between two types of valvulotomes

PURPOSE

To evaluate the authors' experiences with in situ saphenous vein bypasses that were performed using two types of valvulotomes and to respectively compare their efficacy on the basis of the operative outcomes.

METHODS

Between June 1993 and December 2008, 103 constructive in situ saphenous vein bypasses were performed, of which 53 were performed between 1993 and 2000 using an Insitucat valvulotome (B Braun Melsungen AG, Germany), and 50 were performed between 2000 and 2008 using a LeMaitre valvulotome (LeMaitre Vascular Inc, USA).

RESULTS

There were no statistical differences with regard to age, sex and bypass procedures between the two groups. Critical limb ischemia (P=0.021) and diabetes (P=0.005) were more frequent in the LeMaitre group than the Insitucat group. Intraoperative graft revisions (P=0.079) and graft spasms (P=0.638) were less frequent in the LeMaitre group. Graft failures in the perioperative period or within the first year were less frequent in the LeMaitre group. The five-year cumulative primary patency rates were 63.2% and 59.8% in the LeMaitre and Insitucat groups, respectively (χ(2)=0.390, not significant). The five-year cumulative secondary patency rates were 91.9% and 81.7% in the LeMaitre and Insitucat groups, respectively (χ(2)=2.690, not significant).

CONCLUSIONS

The results suggested that there were no significant differences in the outcome and adverse effects between the two types of valvulotomes for in situ saphenous vein bypass.

Adaptive changes in autogenous vein grafts for arterial reconstruction: clinical implications

For patients with the most severe manifestations of lower extremity arterial occlusive disease, bypass surgery using autogenous vein has been the most durable reconstruction. However, the incidence of bypass graft stenosis and graft failure remains substantial and wholesale improvements in patency are lacking. One potential explanation is that stenosis arises not only from over exuberant intimal hyperplasia, but also due to insufficient adaptation or remodeling of the vein to the arterial environment. Although in vivo human studies are difficult to conduct, recent advances in imaging technology have made possible a more comprehensive structural examination of vein bypass maturation. This review summarizes recent translational efforts to understand the structural and functional properties of human vein grafts and places it within the context of the rich existing literature of vein graft failure.

Lower extremity vein graft failure: a translational approach

Abstract

Patients with the most severe manifestations of lower extremity arterial occlusive disease often require peripheral bypass surgery for limb salvage and preservation of function. Although good quality saphenous vein offers the most durable conduit for reconstruction, 5-year failure rates are 30–50% and have remained largely unchanged for the past two decades. The majority of these failures occur within the first year of implantation, which is regarded as the most biologically active time during which the vein graft adapts to the arterial environment. Although intimal hyperplasia is generally regarded as the primary culprit of vein graft failure, geometric remodeling of the healing vein graft has recently emerged as a potentially significant contributing factor. While hemodynamic forces, including an increase in shear stress and wall tension, are undoubtedly central to the magnitude and direction of vein graft remodeling, we have determined that these forces alone cannot account for the extent of variability noted in early remodeling patterns. Therefore, we hypothesize that circulating factors, such as mediators of inflammation, may modulate the vein graft response to mechanical forces. This article reviews the definition and diagnosis of vein graft failure and summarizes our current efforts to understand the mechanisms of normal and abnormal vein graft adaptation to the arterial environment.

The Influence of Subintimal Angioplasty on Level of Amputation and Limb Salvage Rates in Lower Limb Critical Ischaemia: A 15-year Experience

OBJECTIVES

The aim of this study is to assess the influence of subintimal angioplasty (SIA) on lower limb amputation rate and level in critically ischaemic limbs.

METHODS

Between January 1989 and March 2004, 1268 patients were admitted for treatment of lower limb critical ischaemia. Eight hundred and twenty-nine patients underwent revascularisation (bypass 671 and angioplasty 158), while 439 patients had primary amputations. A retrospective analysis of a prospectively maintained vascular registry was performed. Patients were divided into two groups, those who were admitted prior to the availability of subintimal angioplasty and those treated post-introduction of angioplasty. The two groups were compared with regards to age, sex, diabetes mellitus, ASA grade, Rutherford classification and level of disease. Outcome was assessed by the limb salvage rate, 30-day morbidity and mortality, and length of hospital stay.

RESULTS

The average number of revascularisation increased with the introduction of subintimal angioplasty, from 53 to 96 per year (p<0.001). The overall limb salvage rate increased significantly from 42 to 70% (p<0.001). The cumulative limb salvage rate following revascularisation rose from 72 to 86% (p<0.001). The level of amputation (AKA:BKA) did not vary significantly. Thirty-day morbidity, mortality and length of hospital stay were significantly lower in the post-angioplasty group.

CONCLUSIONS

Technical advances have resulted in a steadying of amputation numbers despite an ageing population.

Wound infection after infrainguinal bypass operations: multivariate analysis of putative risk factors

Reported wound infection rates for infrainguinal bypass operations range from 17% to 44%, but there is limited appreciation of which characteristics of patients or operations are reliable markers of increased wound infection risk. The purpose of the present study was to analyze all wound infections observed after infrainguinal bypass operations during 20 years of practice in a large teaching institution. Independent risk factors for wound infection development were identified. During the 20-year period ending 31 December, 1997, 978 male patients underwent infrainguinal bypass operations at the Minneapolis Department of Veterans Affairs Medical Center. Wound infections complicated the recovery of 129 of these patients during a 30-day postoperative surveillance interval. Multivariate logistic regression analysis was used to test the association between wound infection occurrence and putative risk factors that were either features of patients or characteristics of the operations. The following variables were examined: obesity, prosthetic graft placement, diabetes mellitus, steroid use, anticoagulation use, length of preoperative hospital stay, development of incisional hematoma, duration of operation, and the preoperative presence of a non-healing wound in the extremity being revascularized. The overall wound infection rate was 13.2% (129/978). In a final logistic regression model, obesity was a significant and independent predictor of wound infection (Relative Risk 2.6, 95% confidence interval, 1.35-4.90), as was development of a post-operative incisional hematoma (Relative Risk 6.44, 95% confidence interval, 2.95-14.08). No other explanatory variable was significantly associated with wound infection development.

Replacement of in situ saphenous venous aneurysms with arterial autografts

BACKGROUND

Aneurysm formation in arterialized autologous saphenous veins is an unusual complication of in situ femoral popliteal bypass procedures.

METHODS

In a personal series of 207 in situ saphenous femoral popliteal bypass operations, three nonanastomatic venous aneurysms occurred. All three venous aneurysms occurred in male patients who had no adequate autologous vein available as an interposition graft. The use of eversion endarterectomized superficial femoral artery is reported as a substitute interposition graft with long-term results.

RESULTS

In the 3 male patients in this series, nonanastomatic aneurysms developed in their in situ saphenous femoral popliteal bypass grafts. The venous aneurysms developed between 5 and 8 years after the original surgical procedure. No adequate vein was available as a replacement for the excised venous aneurysm. Prosthetic conduit was not used owing to the remote possibility of a subclinical infection. A segment of eversion thromboendarectomized superficial femoral artery removed from the same leg was used as a replacement interposition graft in each patient. The in situ venous graft with the autologous interposition thromboendarterectomized superficial femoral artery remained patent until each patient's death 4 to 7 years after the venous aneurysm replacement.

CONCLUSIONS

A short segment of endarectomized superficial femoral artery has been found to be a novel solution for the treatment of isolated saphenous vein graft aneurysms when no suitable vein is available. These patients should be maintained on lifelong aspirin therapy owing to the thrombogenic potential of endarectomized artery.

Limb salvage after infrainguinal bypass graft failure

OBJECTIVE

The purpose of this study was to examine the outcome of patients in whom an infrainguinal bypass graft failed.

METHODS

This was a retrospective analysis of consecutive patients undergoing infrainguinal bypass grafting in a single institution over 8 years.

RESULTS

Six hundred thirty-one infrainguinal bypass grafts were placed in 578 limbs in 503 patients during the study period. The indication for surgery was limb-threatening ischemia in 533 patients (85%); nonautologous conduits were used in 259 patients (41%), and 144 (23%) were repeat operations. After a mean follow-up of 28 +/- 1 months (median, 23 months; range, 0-99 months), 167 grafts (26%) had failed secondarily. The rate of limb salvage in patients with graft failure was poor, only 50% +/- 5% at 2 years after failure. The 2-year limb salvage rate depended on the initial indication for bypass grafting: 100% in patients with claudication (n = 16), 55% +/- 8% in patients with rest pain (n = 49), and 34% +/- 6% in patients with tissue loss (n = 73; P <.001). The prospect for limb salvage also depended on the duration that the graft remained patent. Early graft failure (<30 days; n = 25) carried a poor prognosis, with 2-year limb salvage of only 25% +/- 10%; limb salvage was 53% +/- 5% after intermediate graft failure (<2 years, n = 110) and 79% +/- 10% after late failure (>2 years, n = 15; P =.04). Multivariate analysis revealed shorter patency interval before failure (P =.006), use of warfarin sodium (Coumadin) postoperatively (P =.006), and infrapopliteal distal anastomosis (P =.01) as significant predictors for ultimate limb loss.

CONCLUSION

The overall prognosis for limb salvage in patients with failed infrainguinal bypass grafts is poor, particularly in patients with grafts placed because of tissue loss and those with early graft failure.

Patency and Limb Salvage after Distal Prosthetic Bypass Associated with Vein Cuff and Arteriovenous Fistula

OBJECTIVE

To assess the usefulness of vein cuff with or without arteriovenous fistula interposition as adjuvant techniques for improving patency and limb salvage in patients undergoing femorodistal bypass surgery using prosthetic grafts.

METHOD

We undertook a retrospective study of 65 consecutive patients treated over a 5-year period with 67 prosthetic femorodistal bypasses with vein cuff, in whom an arteriovenous fistula was constructed at the distal anastomosis in 35. Patients were followed for a median time period of 23 months.

RESULTS

Primary patency rates were 68, 53 and 44% at 1, 2 and 3 years, respectively. The corresponding figures for secondary patency, limb survival and patients' survival were 73, 64 and 58% for 1 year, 78, 76 and 73% for 2 years and 72, 66 and 63% for 3 years. None of the criteria analyzed influenced patency or limb salvage on prosthetic bypasses using adjuvant techniques. No statistical differences were found between patency and limb salvage rates in patients for whom the vein cuff was constructed with or without an arteriovenous fistula. But patients who managed with a supplementary arteriovenous fistula had significantly fewer distal residual arteries in the limb (p=0.001).

CONCLUSION

Although results in patients treated with adjunctive techniques differed little from those in patients treated with direct prosthetic bypasses procedures, those who eventually had an adjunctive procedure had inferior runoff. This indicates that an arteriovenous fistula might be a valuable supplement in patients with poor runoff who have distal revascularisation using a prosthetic graft.

Lower Limb Amputations in Southern Finland in 2000 and Trends up to 2001

OBJECTIVES

To assess the current incidence of major lower limb amputations in Southern Finland and epidemiological trends during the last 17 years.

MATERIALS AND METHODS

In a retrospective survey for the year 2000 patient data was gathered from hospital records in the eight surgical hospitals in the area studied. Follow-up was 1 year. Amputation data for years 1984-1995 was gathered from reports done before at the same area and amputation figures for years 1990-2001 also from the National Research and Development Centre for Welfare and Health.

RESULTS

In year 2000, the incidence of major amputations was 154/million inhabitants. The reason for major amputation was chronic critical lower limb ischaemia in 71.8% and acute ischaemia in 16.5% of the cases. The below-knee (BK)/above-knee (AK) ratio was 0.76. After 1 year only 48% of the patients were alive. From 1984 to 2000 amputation incidence showed a decrease of 41%. The decline in age-adjusted amputation incidence from 1990 to 2000 was 30% and by 2001 as much as 40%. There was a significant inverse correlation both between incidence of infrainguinal bypass and amputation (r=-0.682, p=0.021) and between infrapopliteal bypass and amputation (r=-0.682, p=0.021).

CONCLUSIONS

There was a reduction in the number of amputations in Southern Finland during the past 17 years. This occurred synchronously with the increase in vascular reconstructions. Our data suggests that vascular surgery saves patients from BK-amputations and therefore relative amount of AK-amputations inevitably rises.

Infrapopliteal bypass reduces amputation incidence in elderly patients: a population-based study

OBJECTIVE

To examine the association between the incidences of infrapopliteal bypass for critical limb ischaemia (CLI) and major amputation in Finns aged >or=70 years.

METHODS

Patients undergoing infrapopliteal bypass or major amputation for CLI during 1997 were retrospectively analysed. The incidence of major amputation in a group of hospitals performing infrapopliteal bypass "actively" was compared to that in a group performing such surgery "passively".

RESULTS

The incidence of major amputations in the active (978 bypasses per million inhabitants) and passive (57 per million) groups was 1976 and 3177 per million, respectively (p = 0.016). There was a significant (p = 0.012) inverse relationship between the incidence of the two procedures in patients aged >or=80, but not <80 years.

CONCLUSIONS

These results suggest that infrapopliteal bypass is effective in reducing the requirement for major amputation in patients aged >or=80 years.

Complication registration in patients after peripheral arterial bypass surgery

The objective of this study was to describe the kinds of complications and their incidence after peripheral vascular surgery of the lower limb, coding for causes and effect on the patient. In this prospective study, a standardized complication registration system was used at the Red Cross Hospital, The Hague. All patients (n = 373) receiving an infrainguinal bypass graft during the period January 1, 1996 to December 31, 1999 were included. All postoperative complications occurring during admission were coded. In 29% of the patients 153 complications were coded. Early occlusions of the graft occurred 36 times, wound infections 21 times and postoperative hemorrhages 20 times. Postoperative retention of urine was seen most frequently of all nonspecific complications (n = 22). In 43 cases the patient needed medication or a blood transfusion for his complication. In 42 cases a re-intervention was necessary. Complications led to a prolonged stay in the hospital in 20 cases. Six patients died during admittance (mortality 1.6%). An error in surgical therapy and error in nonsurgical therapy were the cause of the complication in 108 cases (out of 153). The advantage of this complication registration is that it describes all complications, not just the specific ones. Furthermore, by categorizing all complications we force ourselves to look for errors in nonsurgical therapy and surgical technique and to describe the effect of the complication.

Remote superficial femoral artery endarterectomy and distal vein bypass for limb salvage: initial experience

PURPOSE

To examine the results of remote superficial femoral artery endarterectomy (RSFAE) performed through a small groin incision in conjunction with distal saphenous vein (SV) bypass for limb salvage.

METHODS

A retrospective study was conducted of 21 patients (14 men; mean age 68.5 years, range 47-78) who underwent RSFAE and distal SV bypass between May 1998 and September 2001 for limb salvage. Thirteen had gangrene and 8 had rest pain. RSFAE was performed with the MollRing Cutter device through a femoral arteriotomy; the distal atheromatous plaque was "tacked up" with a stent. Distal SV bypass from the proximal popliteal artery was performed in situ in 7, from a transposed harvested vein in 8, or from a reversed graft in 6. All patients underwent follow-up examination with serial color-flow ultrasound scans.

RESULTS

The mean length of the endarterectomized SFA was 26.5 cm (range 12-40). There were no deaths, only 2 wound complications, and the mean hospital length of stay was 3.1+/-0.6 days. The primary cumulative patency rate by life-table analysis was 71.4% with follow-up extending to an average of 12.4 months (range 1-18). There were 2 amputations for gangrene and 6 percutaneous procedures in 4 (19.1%) patients to maintain bypass patency, producing an assisted primary patency rate of 81.5%. The locations of the restenoses were evenly distributed along the endarterectomized SFA and SV graft.

CONCLUSIONS

When adequate SV is not available, RSFAE with residual SV bypass is a safe and moderately durable procedure that may prove to be a useful adjunct for limb salvage, especially in the presence of foot infection, where an autogenous tissue bypass is preferred.

Pedicled or skeletonized? A review of the internal thoracic artery graft

The internal thoracic artery is the gold-standard conduit for coronary artery bypass surgery. Until recently, it was used almost exclusively as a pedicle, with construction of 1 distal anastomosis. Skeletonization of the internal thoracic artery has recently been advocated in order to increase the number of arterial anastomoses and decrease the occurrence of sternal wound infections. When skeletonized, the vessel loses its "milieu" which raises the question of whether this technique sacrifices the superior longevity of the conduit. The current status of research on the effects of skeletonization (depriving the internal thoracic artery of vasa vasorum, innervation, and lymphatic and venous drainage, together with creating an imbalance between vasoconstricting and vasodilating substances) appears to support the superiority of the pedicled graft. Long-term patency studies of the skeletonized ITA, with meticulous follow-up and confirmation by angiography, are not currently available. Theoretically, skeletonization of the ITA might adversely affect its long-term resistance to atherosclerosis. More data are needed before this technique can be universally recommended. If the skeletonized ITA has decreased long-term patency, bypass surgery may be at a disadvantage when compared with the new generation of drug-eluting stents.

Repeat surgery without preoperative angiography in limbs with patent infrainguinal bypass grafts

The aim of this study was to assess the feasibility and results of repeat surgery without preoperative angiography in limbs with patent infrainguinal bypass grafts. Between January 1995 and December 1999, 73 surgical interventions were performed for correction of inflow, graft, or runoff-related lesions in limbs with patent infrainguinal bypass grafts. Fifty-six of the 73 cases were operated on based on the findings obtained from duplex scanning alone. There were 53 vein and 3 prosthetic grafts in the series. The indications for intervention without angiography were stenotic or occlusive lesions in 35, graft aneurysm in 7, and arteriovenous fistulae in 14. There were no deviations from the preoperatively planned surgical strategy in patients undergoing surgery without preoperative angiography. Cumulative life table primary, (stenosis free) and primary-assisted patency rates, at 12 months following graft revisions (excluding arteriovenous fistulae ligatures) without preoperative angiography, were 64% and 85%, respectively. The corresponding figures for revisions performed with preoperative angiography were 58% and 84%, respectively. There were no significant differences between patients undergoing surgery with or without preoperative diagnostic angiography with regard to patency rates. Surgical interventions for correction of infrainguinal graft-related stenotic or aneurysmal lesions can be safely performed based on findings obtained from duplex scanning.

Non-Greater Saphenous Vein Grafting for Infrageniculate Bypass

Infrainguinal bypass grafting with greater saphenous vein has proven to be a highly effective procedure with primary 5-year patency and limb salvage rates exceeding 80 per cent. However, because of prior usage or intrinsic venous disease the greater saphenous vein is often not available as a conduit. Numerous studies have shown that patency rates for prosthetic bypass grafting to the infrageniculate vessels are clearly inferior to that reported for greater saphenous vein bypass. In this report we summarize our experience with the use of alternate autogenous vein grafting to the infrageniculate vessels. The records of all patients undergoing autogenous bypass grafting to the infrageniculate vessels using a conduit other than the greater saphenous vein between 1992 and 1999 were reviewed. Graft survival curves were plotted using the Kaplan-Meier method and results are reported using the Society for Vascular Surgery/International Society for Cardiovascular Surgery guidelines. Forty-eight patients underwent a total of 51 infrageniculate bypass procedures using non-greater saphenous autogenous conduits. Thirty-nine patients had reconstructions performed with single segments of arm vein, two had their operations performed with lesser saphenous vein, and ten had grafts created with two segments of non-greater saphenous autogenous vein. Twenty-one grafts were performed to the infrageniculate popliteal artery and 30 were performed to the tibial vessels. Primary and primary assisted patency rates at 30 months were 49 and 75 per cent. Limb salvage was 87 per cent. Infrainguinal bypass grafting using non-greater saphenous autogenous conduits can yield quite satisfactory intermediate limb salvage and patency rates. However, close graft surveillance and prompt intervention are required to avoid graft failure.

Alternative greater saphenous vein-sparing surgery: valvuloplasty combined with axial transposition of a competent tributary vein for the treatment of primary valvular incompetence---18-month follow-up

BACKGROUND

The greater saphenous vein (GSV) is one of the best grafts for vascular reconstruction, and a variety of sparing methods in patients with primary varicose veins have been performed. Of these, valvuloplasty of the subterminal valve is useful, but reflux in the proximal GSV via a competent tributary vein still remains. To minimize the subsequent reflux, we propose a new method, "valvuloplasty combined with axial transposition of a competent tributary vein" for the treatment of GSV incompetence.

OBJECTIVE

To compare this new method with single valvuloplasty.

METHODS

Seventy-eight limbs in 65 patients with GSV incompetence were included. Of these limbs, 38 underwent angioscopic valvuloplasty of the subterminal valve alone (V group). The remaining 40 were treated by angioscopic valvuloplasty combined with axial transposition of a competent tributary vein (V + T group). A competent tributary vein was identified by duplex scan in the thigh before surgery. After angioscopic valvuloplasty had been done, a competent tributary vein was exposed, and was cut 1.5 cm distal to its insertion. The distal cut end of the vein was then transposed to the GSV and end-to-side anastomosis was performed using 8-0 nylon under magnification. The incompetent GSV was ligated between the insertion and the anastomosed region. Venous hemodynamic changes were analyzed using air plethysmography (APG). Values obtained by9 APG included venous volume (VV), venous filling index (VFI), ejection fraction (EF), and residual venous function (RVF). The follow-up period was 18 months. Intergroup differences were analyzed with the Wilcoxon ranked sum test for nonparametric distribution.

RESULTS

There were no statistical differences in age, gender, or clinical presentation between the two groups. In the V group, 27 limbs had reflux in the proximal GSV (67.4%). On the other hand, only 6 limbs (13.3%) showed minor reflux in the V + T group. A significant difference was seen in VFI at 1 year, and a continuous increase was observed in the V group during the follow-up examinations (P =.0035, VFI = 2.50 plus minus 1.21, 1.14 plus minus 0.42 at 18 months, respectively).

CONCLUSION

Valvuloplasty combined with axial transposition of a competent tributary vein gives a better result than valvuloplasty alone at the 18-month follow-up. A competent valve in this location can be expected to improve VFI to a normal range.

Tibial bypass using complex autologous conduit: patency and limb salvage

Over an 8-year period, we performed 93 lower extremity bypasses using complex autologous conduits, which included (1) contralateral greater saphenous vein (GSV), (2) composite GSV, (3) superficial femoral vein, (4) lesser saphenous vein, (5) cephalic or basilic veins, and (6) composite-sequential (PTFE and vein) grafts. These grafts represented 16% of all infrainguinal bypasses during this period, and all grafts were performed to treat limb-threatening ischemia. Survival, patency, and limb salvage were examined by the life-table method. Primary graft patency was 46 and 38% at 3 and 5 years. Assisted-primary patency was 62 and 59%, and secondary graft patency rates were 68 and 64% at 3 and 5 years. Twenty-nine bypasses (31%) required revision to restore or maintain patency. The 3-year limb salvage rate was significantly better when revision was performed for graft stenosis than for graft thrombosis (90% vs. 46%, p < 0.05). Overall limb salvage rate was 73% at 5 years. The mortality rate was 5.4% and the 5-year survival was 51%. Complex autologous tibial bypasses provided acceptable long-term limb salvage in patients with severe ischemia and inadequate ipsilateral GSV. The increased operating time and complexity required did not produce prohibitive operative risks. Postoperative graft surveillance in these complex vein bypasses allowed revision in many cases before graft occlusion occurred and significantly improved long-term limb salvage.

Endoscopically assisted in situ lower extremity bypass graft: a preliminary report of a new minimally invasive technique

OBJECTIVE

Lower extremity arterial reconstructions with in situ greater saphenous vein (GSV) are an important component of limb salvage surgery. Initially, the procedure was performed through continuous skin incisions for side branch occlusion and valve lysis with a wound complication rate of 5% to 25%. To decrease these complications, we used endoscopic GSV harvest equipment in 25 in situ vein bypass grafts in 25 patients performed over 24 months.

METHODS

The procedures were performed with three skin incisions: two for arterial access and a 2-cm incision above the knee to insert the Endopath device (Ethicon) to locate and clip the GSV side branches. After completion of the proximal anastomosis, the valves were lysed through the distal end of the vein with a flexible valvulotome. Completion cineangiography was performed to confirm side branch occlusion and evaluate the entire reconstruction. The results of this technique were compared with our last 25 in situ bypass grafts done with standard long incisions.

RESULTS

In the endoscopic group there was one (4%) minor wound complication (cellulitis). No postoperative arteriovenous fistulas were detected by means of duplex examination, and the average hospital stay was 6.2 +/- 1 days. One graft closed at 9 months as a result of distal vein hyperplasia, but the other grafts have remained patent, with follow-up from 6 to 30 months (mean, 18 months). Patients with the standard in situ bypass grafts had significantly (P < .05) more wound complications (20%) and longer average hospital stay (9.2 +/- 2 days) than the endoscopic group. Patency rates were comparable for both groups.

CONCLUSION

These results show that less invasive endoscopic in situ bypass grafting minimizes wound complications and reduces the need for hospitalization without decreasing patency or increasing operative time.

The case for an in situ lesser saphenous vein bypass

In situ lesser saphenous vein (LSV) graft has been advocated in cases where the greater saphenous vein is not available and the target arteries are confined to the lower leg. This is often the case of diabetic patients, whose occlusive disease pattern typically affects the tibioperoneal vessels, sparing the femoropopliteal segment. The in situ technique offers the potential advantages of decreasing surgical trauma to the vein and its vasa vasorum, better size-matching between vein and artery at the anastomoses, and improving hemodynamics. The authors reviewed the use of in situ LSV graft with attention to its indications and technical requirements. A 73- and a 76-year-old man presented with critical limb ischemia. Both had a history of diabetes, chronic renal failure, and previous use of the greater saphenous veins for coronary or peripheral bypasses. Both had good femoropopliteal inflow and tibioperoneal disease with single runoff through the distal peroneal and common plantar arteries, respectively. Venous mapping showed diminutive veins, with exception of an adequate ipsilateral lesser saphenous vein. The patients were placed in prone position for a posterior approach. The lesser saphenous veins were exposed through a longitudinal incision. Proximal anastomosis was based on the popliteal artery, exposed through the same incision. A successful in situ lesser saphenous vein bypass was performed by using the common plantar and the distal peroneal artery as target vessels. Both bypasses were patent at 24 and 18-months' follow-up, respectively. Selection criteria for in situ LSV bypass are patent femoral arteries; accessible target vessels in prone position through a medial, posterior, or lateral approach; and adequate LSV in diameter and length. In the authors' experience, in situ LSV bypass is a safe and simple option that offers successful distal revascularization.