Prevention of Anastomotic Intimal Hyperplasia in Infrainguinal PTFE Bypass Grafts with Distal Arterial Segment Interposition

Abstract

Anastomotic intimal hyperplasia (AIH) is a common cause of graft failure after femoropopliteal polytetrafluoroethylene (PTFE) bypass. Compliance mismatch between the PTFE graft and the native artery may be a significant factor causing AIH. This study examines whether reduction of compliance mismatch by interposition at the distal anastomosis of a segment of superficial femoral artery after eversion endarterectomy could reduce or eliminate AIH and improve graft patency. Between July 1989 and June 1996, PTFE grafts with a distal arterial segment (AS) were used to revascularize 51 limbs in 45 patients (12 men and 33 women). Twenty-five grafts were above-knee (AK) and 26 below-knee (BK). Disabling claudication was the indication in 32 limbs (AK 20, BK 12) and limb-threatening ischemia in 19 (AK 5, BK 14). Physical examination, measurement of ankle-brachial index, and duplex scanning were used to follow up patients at regular intervals. For those patients who had recurrent symptoms and/or reduction of ankle/brachial index (ABI), arteriography was performed. Follow-up ranged from 1-54 months (mean 20 months) for AK grafts and 1-76 months (mean 19 months) for BK grafts. The overall primary patency rate at 4.5 years was 57.2%. There appears to be no significant difference between AK and BK primary patency survival distributions (64.8% vs 48.5%). The primary patency failure distributions for the two ischemic conditions are statistically significant (69.8% vs 31.9%). The limb salvage rate at 4.5 years was 80%. Of the 51 grafts, the causes of the 19 failures included progression of disease in eight, thromboembolus in three, stenosis of the AS in three, poor runoff in one, AIH at the proximal anastomosis in one, and unknown in three. This pilot study suggests that the femoropopliteal PTFE bypass with distal AS interposition provides improved graft patency and limb salvage rates when compared with those published in the literature for PTFE bypass without the AS. Further evaluation is warranted.