The appropriate diameter for prosthetic heparin-bonded polytetrafluoroethylene femoropopliteal bypass grafts remains controversial

Abstract

Piffaretti et al1Piffaretti G. Dorigo W. Ottavi P. Pulli R. Castelli P. Pratesi C. PROPATEN Italian Registry GroupResults of infrainguinal revascularization with bypass surgery using a heparin-bonded graft for disabling intermittent claudication due to femoropopliteal occlusive disease.J Vasc Surg. 2019; 70: 166-174Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar have provided an excellent review of heparin-bonded polytetrafluoroethylene (PTFE) grafts used for infrainguinal disabling intermittent claudication. A take home message highlighted by the editors of the Journal was that smaller diameter grafts (6 mm) negatively affected outcome because 6-mm grafts were associated with a significantly higher rate of redo bypass in comparison to 8-mm grafts. The authors propose that this may rather reflect a worse condition of the outflow in terms of either diameter or vessel quality because there were more open surgical adjuncts at the distal anastomotic sites when 6-mm grafts were used. Although this may well be correct, a more likely explanation would be that 6-mm grafts were more likely used in the 54 tibial bypasses. It is well proven that nonautogenous tibial grafts do not perform as well as bypasses to the popliteal arteries. Even below-knee popliteal bypass grafts do not perform as well as above-knee bypass grafts. Although, as referenced, Green et al2Green R.M. Abbott W.M. Matsumoto T. Wheeler J.R. Miller N. Veith F.J. et al.Prosthetic above-knee femoropopliteal bypass grafting: five-year results of a randomized trial.J Vasc Surg. 2000; 31: 417-425Abstract Full Text Full Text PDF PubMed Scopus (149) Google Scholar suggested that 8-mm grafts perform better, theirs were Dacron grafts predominantly sewn to popliteal arteries. A negative experience with 8-mm grafts has prompted my group to use only 6-mm grafts for all infrainguinal bypass procedures. We noted that 8-mm standard wall PTFE grafts would often develop thrombus lining the walls, thus reducing lumen size. On occasion, the thrombus would not be laminar but rather heap up irregularly. This sometimes portended graft failure. Since then, we have used entirely 6-mm heparin-bonded expanded PTFE grafts (W. L. Gore & Associates, Flagstaff, Ariz) and have only rarely seen such laminar thrombus formation. I propose the authors re-evaluate the effect of graft size by excluding the tibial bypass grafts. It is probable that graft size will no longer be a variable associated with graft occlusion. Results of infrainguinal revascularization with bypass surgery using a heparin-bonded graft for disabling intermittent claudication due to femoropopliteal occlusive diseaseJournal of Vascular SurgeryVol. 70Issue 1PreviewThe purpose of this study was to analyze the results of infrainguinal revascularization for disabling intermittent claudication (IC) due to femoropopliteal occlusive disease using bypass graft (BPG) surgery with a heparin-bonded expanded polytetrafluoroethylene (HB-ePTFE) graft. Full-Text PDF Open ArchiveReplyJournal of Vascular SurgeryVol. 71Issue 1PreviewThe power is nothing without control. Full-Text PDF Open Archive