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Abstract

We appreciate our colleagues' interest in our study and welcome their call to attention to the availability and potential of femoropopliteal veins (FPVs) for below the knee popliteal (BKP) bypasses. Thirty years ago, Shulman and Badhey1Schulman M.L. Badhey M.R. Late results and angiographic evaluation of arm veins as long bypass grafts.Surgery. 1982; 96: 1032-1041Google Scholar were among the first to question the use of arm veins because their results suggested that, when used as infrainguinal bypass grafts, they have distinct limitations and might be inferior to other conduits. This is in agreement with our findings.2Avgerinos E. Sachdev U. Naddaf A. Doucet D. Mohapatra A. Leers S. et al.Autologous alternative veins may not provide better outcomes than prosthetic conduits for below-knee bypass when great saphenous vein is unavailable.J Vasc Surg. 2015; 62: 385-391Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar Although we do not disagree with the selective use of FPVs for BKP bypasses, more data are still needed, particularly in today's practice. The need for extensive surgical dissection, need for preoperative venography, need for fasciotomy (∼10%), risk of subsequent tibial-popliteal venous thrombosis (∼10%), and being less familiar with the technique and the criteria for optimal patient-vein selection are all associated to the low popularity of peripheral bypasses using FPVs.3Chung J. Clagett G.P. Neoaortoiliac system (NAIS) procedure for the treatment of the infected aortic graft.Semin Vasc Surg. 2012; 24: 220-226Abstract Full Text Full Text PDF Scopus (60) Google Scholar, 4Dorweiler B. Neufang A. Chaban R. Reinstadler J. Duenschede F. Vahl C.F. Use and durability of femoral vein for autologous reconstruction with infection of the aortoiliofemoral axis.J Vasc Surg. 2014; 59: 675-683Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar Available preliminary results on use of FPVs may be encouraging, but we lack comparative studies, with the exception of the randomized trial by Shulman et al5Schulman M.L. Badhey M.R. Yatco R. Superficial femoral-popliteal veins and reversed saphenous veins as primary femoropopliteal bypass grafts: a randomized comparative study.J Vasc Surg. 1987; 6: 1-10Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar comparing saphenous vein against FPVs for primary popliteal bypasses. They concluded that both conduits have similar patency and minimal morbidity. Regarding morbidity, these results may not be surprising given that most patients who received a FPV bypass retained a patent saphenous vein and that 8% were claudicants.5Schulman M.L. Badhey M.R. Yatco R. Superficial femoral-popliteal veins and reversed saphenous veins as primary femoropopliteal bypass grafts: a randomized comparative study.J Vasc Surg. 1987; 6: 1-10Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar Others later showed that the risk of fasciotomy is 10-fold higher in concurrent ipsilateral saphenous vein harvesting (76% required fasciotomy) and 60-fold higher when the ankle-brachial index is very low (<0.4).6Modrall J.G. Sadjadi J. Ali A.T. Anthony T. Welborn 3rd, M.B. Valentine R.J. et al.Deep vein harvest: predicting need for fasciotomy.J Vasc Surg. 2004; 39: 387-394Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar Concurrent ipsilateral saphenous vein harvesting was also a predictor of long-term venous insufficiency with persisting edema.7Modrall J.G. Hocking J.A. Timaran C.H. Rosero E.B. Arko 3rd, F.R. Valentine R.J. et al.Late incidence of chronic venous insufficiency after deep vein harvest.J Vasc Surg. 2007; 46: 520-525Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar Although this does not necessarily extrapolate to patients who have history of prior harvested saphenous veins, we would be hesitant to use FPV in the absence of saphenous vein given the reported complications. In a patient population with critical limb ischemia—in need of a bypass to a popliteal target—multiple comorbidities, and questionable life expectancy, the use of a heparin-bonded graft or selectively of good single segment arm vein seems to be a safer alternative. We would welcome a contemporary study comparing FPVs vs alternative superficial autologous veins or prosthetic grafts. Regarding “Autologous alternative veins may not provide better outcomes than prosthetic conduits for below-knee bypass when great saphenous vein is unavailable”Journal of Vascular SurgeryVol. 63Issue 4PreviewWe read the report on autologous alternative veins1 for below-knee (B-K) bypass with great admiration and a healthy serving of nostalgia. Full-Text PDF Open Archive