The value of donor iliac artery pressure gradients in predicting the outcome of femorofemoral bypass

Abstract

This study tests the clinical value of femoral artery pressure measurements by analysis of the relationship between iliac artery pressure gradients (PGs) and both femorofemoral bypass graft patency and the hemodynamic changes produced in the donor and recipient limbs. Systemic and donor femoral artery systolic and mean pressures were measured during surgery at rest and during papaverine-induced hyperemia before 94 femorofemoral bypasses. Ankle/brachial (A/B) pressure ratios and pulse volume recordings (PVRs) were measured before and early after surgery. Donor iliac artery stenosis was 25% +/- 23% (mean +/- 1 SD). Follow-up was 23+/- 20 months. Eight bypasses failed at 21 +/- 20 months. Patients with failed bypasses had a resting systolic and mean PG of 23 +/- 22 mm Hg and 5 +/- 7 mm Hg, respectively, compared with 10 +/- 11 mm Hg (p = 0.007) and 1 +/- 2 mm Hg (p = 0.001) for the 86 patent bypasses. Donor limb A/B ratios and PVRs decreased 9% +/- 5% and 15% +/- 14%, respectively, had a linear regression slope less than 0 (p < 0.05) with resting and hyperemic PGs, and correlated best with resting PGs (p < 0.05). Recipient limb A/B ratios and PVRs increased 86% +/- 48% and 191% +/- 111%, respectively, had a linear regression slope greater than 0 (p < 0.05) with all resting and hyperemic PGs, and correlated best with hyperemic systolic PGs (p < 0.05). However, all regressions had a large SD, wide 95% confidence limit, and a low correlation coefficient. Sensitivity-specificity receiver-operating characteristic curves for optimal PG criteria for both graft failure and donor limb hemodynamic impairment are weak, with an accuracy of 50% to 75%. Recommended criteria for not performing a femorofemoral bypass are a resting systolic PG of 28 mm Hg or greater or a resting mean PG of 6 mm Hg or greater. Although iliac artery PGs correlate with graft failure and both the degree of donor limb hemodynamic impairment and recipient limb improvement, the large variability in PGs between patients with similar outcomes and the low accuracy of optimal PG criteria indicate that they have limited clinical value in decision making.