Long-term results of above the knee femoro-popliteal bypass depend on indication for surgery and graft-material

Abstract

Conclusions: Femoral popliteal bypass above the knee with saphenous vein provides good long-term results. Femoral popliteal bypass with expanded polytetrafluoroethylene (PTFE) to the above-knee popliteal artery for claudication cannot be recommended. Occlusion occurs often and frequently leads to critical limb ischemia. Summary: The study was designed to determine long-term results of above-knee femoropopliteal bypass with expanded PTFE vs autologous saphenous vein in a community surgical practice. Data were derived from the Swedish Vascular Registry and were reviewed retrospectively. The study used patients undergoing above-knee femoral popliteal bypass in 1996 and 1997. Results were assessed between 5 and 7 years later. Data were obtained from clinical follow-up and from review of case records. The end point used in this study was a composite end point of graft failure that included graft occlusion, death within 30 days, major amputation, extension of the graft to the below-knee popliteal position, and removal of an infected graft. Cox proportional hazard ratios and Kaplan-Meier curves were calculated. There were 499 patients who underwent above-knee femoral popliteal bypass for either critical limb ischemia (56%) or claudication (44%). Seventy-two percent of the grafts were expanded PTFE, and 28% were saphenous vein. Patient characteristics did not differ significantly between the patients with vein or PTFE grafts. Data analysis indicated that risk factors for graft failure were critical limb ischemia and a PTFE graft. With respect to the composite end point, patients treated for claudication and patients treated for critical limb ischemia with saphenous vein grafts had better long-term results than those treated with PTFE grafts (P < .03 and P < .003, respectively). Of the 220 patients who underwent surgery for claudication, graft failure occurred in 79. In 32 of these patients (41%), graft failure was associated with deterioration of symptoms compared with the preoperative status, and in 42% an urgent reoperation was required. All patients but one who had symptom aggravation with graft occlusion had PTFE grafts, and all urgent reoperations were performed in patients with PTFE grafts. Comment: This study used a unique end point in the evaluation of saphenous vein vs PTFE grafts. The composite end point described was used to include all graft-related events that may be considered procedural failures. The end point is unusual but perhaps better reflects the overall potential problems of infrainguinal bypass grafts than the usual patency end points. On the basis of the authors’ data, it is difficult to argue with their conclusion that saphenous vein grafts should be used for femoral popliteal bypass whenever possible.