Cumulative Primary Graft Patency Rates Research Articles

Long-term outcomes of Omniflow II biosynthetic vascular graft in lower extremity arterial revascularization.

This study aims to evaluate the patency rates and long-term outcomes of femoro-popliteal bypass procedures with Omniflow II biosynthetic vascular grafts in patients with occlusive vascular disease. This retrospective, observational, clinical study included a total of 93 patients (61 males, 32 females; mean age 56.9±7.4 years; range, 43 to 83 years) who underwent femoro-popliteal bypass in which Omniflow II biosynthetic vascular grafts were used due to peripheral arterial disease. The patients were divided into two groups: 62 patients undergoing femoro-popliteal above-knee bypass and 31 patients undergoing the femoro-popliteal belowknee bypass. We evaluated preoperative clinical characteristics, postoperative graft patency rates, and other clinical results. The mean follow-up was 44.9±18.8 months in the femoropopliteal above-knee bypass group and 47.3±22.3 months in the femoro-popliteal below-knee bypass group (p=0.302). The cumulative primary graft patency rates of the femoro-popliteal above-knee bypass and femoro-popliteal below-knee bypass groups at three, four, and five years were 98%, 95% and 78% and 86%, 75% and 45%, respectively (log-rank; p=0.312). The cumulative assisted graft patency rates of the femoro-popliteal above-knee bypass and femoro-popliteal below-knee bypass groups at five years were 87.9% and 65.3%, respectively (log-rank; p=0.530). The Omniflow II biosynthetic vascular graft is suitable for above- and below-knee femoro-popliteal bypass procedures. These grafts may be prefered due to high patency rates, low incidence of aneursym formations, and infections.

Systematic review of preservation methods and clinical outcome of infrainguinal vascular allografts

We systematically reviewed clinical studies on the use of venous and arterial allografts for infrainguinal revascularization. We attempted to find evidence for the best infrainguinal vascular allograft by a systematic review of the available literature. An electronic search of the MEDLINE, EMBASE, and Cochrane databases was used to determine key articles from studies on the different types of vascular allografts used in infrainguinal reconstruction from 1966 to 2004. Articles were independently reviewed by using previously defined inclusion and exclusion criteria. Study results were gathered with cumulative primary patency as the primary end point. Secondary end points were major complications, graft disintegration, and major limb loss. Quantitative analysis was performed on the prospective randomized trials, and linear regression analysis was performed on cumulative primary patency. Fontaine's classification system was applied. No systematic review of randomized controlled trials was found. Five randomized controlled trials, 3 prospective cohort or case series, and 15 retrospective case series with 3,837 vascular allografts were found. Methods of allograft preservation were cryopreservation (5 studies), cold storage (3 studies), and glutaraldehyde preservation of human umbilical veins (15 studies). One-year cumulative primary patency rates were 13% to 79% for cryopreservation, 63% to 80% for cold storage, and 40% to 91% for glutaraldehyde. The weighted mean 1-year cumulative primary graft patency rate was 41% for cryopreservation, 71% for cold storage, and 70% for glutaraldehyde allografts. Four randomized trials on femoropopliteal bypasses demonstrated higher patency rates of glutaraldehyde-preserved human umbilical veins than polytetrafluoroethylene grafts. Statistical heterogeneity between studies (I(2) = 91.4%) was too high to perform a formal meta-analysis. The rate of major limb loss was 20% to 58% for cryopreservation, 10% to 69% for cold storage, and 0% to 65% for glutaraldehyde, and the percentage of graft disintegration was 2% to 6% for cryopreservation, 4% to 15% for cold storage, and 0% to 11% for glutaraldehyde. A firm conclusion could not be made because there were no studies available in which direct comparison was performed between different preservation methods of vascular allografts. In addition, heterogeneity of the individual studies hampered direct comparison of different types of vascular allografts. However, the overall graft performance of glutaraldehyde-preserved human umbilical vein allografts may be superior to that of other vascular allografts.

Long-term outcome after surgical treatment of arterial lesions in Behçet disease

Surgical treatment of arterial lesions associated with Behçet disease (BD) is often complicated by graft occlusion and recurrence of aneurysms. The purpose of this study was to clarify the long-term outcome of surgical intervention for arterial involvement in BD. Ten patients with BD (9 men, 1 woman) who underwent surgical treatment for arterial aneurysms between 1980 and 2004 were included in the study. The age of patients at the first operation ranged from 36 to 69 years (mean, 50.4 +/- 9.0 years). The mean period between the onset of BD and that of arterial manifestations was 8.0 +/- 5.0 years. We retrospectively reviewed their postoperative courses, including survival, graft occlusion, formation of anastomotic false aneurysms, and the development of aneurysms at different sites. The Kaplan-Meier method was used to calculate the chronologic incidence of complications after surgery. The mean follow-up period was 133 +/- 92 months, ranging from 5 to 285 months. One patient died of rupture of a dissecting aortic aneurysm after undergoing several surgical interventions for multiple aneurysms. There were five graft occlusions among 21 grafts. The cumulative primary graft patency rate in the infrainguinal region was 83.9% at 3 years. Five anastomotic false aneurysms formed among 49 anastomoses between grafts and host arteries. The overall cumulative incidence of formation of anastomotic pseudoaneurysm was 12.9% at 5 and 10 years. All of them formed within 18 months after surgery. Development of new aneurysms in different arteries was observed in two patients. Early occurrence of anastomotic false aneurysm is characteristic of BD. Further investigation is necessary to establish effective postoperative treatment.

Pedal Branch Arterial Bypass for Limb Salvage

In patients with critical lower extremity ischemia and occlusion of the distal tibial and pedal arteries bypasses to pedal artery branches may offer the only alternative to primary amputation. The results of 22 pedal branch arterial bypasses are reported, and a review of the literature is offered. The charts of 22 patients undergoing pedal branch arterial bypass during a 12-year period were retrospectively reviewed. The results of six additional reports of this technique were also evaluated. In the present series the cumulative primary graft patency rate was 72 per cent after 2 years. The cumulative limb salvage rate during this interval was 82 per cent. Similar graft patency and limb salvage rates were obtained with the approximately 200 other bypasses of this nature as reported in six other series. Pedal branch arterial bypass offers limb salvage results that are comparable to perimalleolar and pedal artery bypasses. In patients with critical limb ischemia and occlusion of distal tibial and pedal arteries, pedal artery branches should be sought as potential outflow sites. Bypasses to these arteries result in good long-term limb salvage, improved survival, and good functional ability for amputation. Pedal artery branch bypasses are a superior alternative to primary amputation.

Usefulness of autogenous bypass grafts originating distal to the groin

Purpose: Infrainguinal bypass grafting with a proximal anastomosis distal to the groin has been used increasingly to conserve available conduit and reduce wound morbidity and recovery time. The usefulness of the liberalized use of distal origin grafts (DOGs) is unknown. Methods: Consecutive autogenous DOG procedures that were performed between 1978 and 2000 were reviewed retrospectively with a computerized registry. Procedures performed as revisions to earlier infrainguinal bypass grafting procedures and for popliteal aneurysm were excluded Results: In the 22-year study period, 249 autogenous DOG procedures were performed in 217 patients. Comparison of the 159 DOGs in patients with diabetes mellitus (+DM) with the 90 grafts in patients without diabetes mellitus (–DM) revealed more associated renal disease (33% vs 9%), preoperative foot necrosis (80% vs 52%), distal popliteal artery graft origins (49% vs 37%), and non–greater saphenous conduits used (30% vs 19%) among the +DM subgroup than the –DM subgroup (P <.05). The operative mortality rate was 2.0%, the major morbidity rate was 8.8%, the early graft failure rate was 6.4%, and the early amputation rate was 2.4%, with no differences related to diabetes mellitus. Follow-up was complete in 92% of patients in a mean interval of 27 months. At 5 years, cumulative primary graft patency rates were 62% overall, 73% for the +DM subgroup, and 45% for the –DM subgroup (P <.001). The overall limb salvage rate after DOG procedures for critical ischemia was 79%, and it was 84% for the +DM subgroup and 69% for the –DM subgroup (P <.04). The overall patient survival rate was 45%, with no difference related to diabetes mellitus Conclusion: Outcome after autogenous DOG revascularization is satisfactory overall. Graft patency and limb salvage after DOG for critical ischemia are significantly better among patients with diabetes mellitus than patients without diabetes mellitus, despite significantly more bypass grafting procedures performed for foot necrosis. DOG revascularization appears to be an appropriate preference for patients with diabetes mellitus with good inflow below the groin; it should be used less liberally among patients without diabetes mellitus. (J Vasc Surg 2002;35:48-55.)

Usefulness of autogenous bypass grafts originating distal to the groin

Purpose: Infrainguinal bypass grafting with a proximal anastomosis distal to the groin has been used increasingly to conserve available conduit and reduce wound morbidity and recovery time. The usefulness of the liberalized use of distal origin grafts (DOGs) is unknown. Methods: Consecutive autogenous DOG procedures that were performed between 1978 and 2000 were reviewed retrospectively with a computerized registry. Procedures performed as revisions to earlier infrainguinal bypass grafting procedures and for popliteal aneurysm were excluded Results: In the 22-year study period, 249 autogenous DOG procedures were performed in 217 patients. Comparison of the 159 DOGs in patients with diabetes mellitus (+DM) with the 90 grafts in patients without diabetes mellitus (–DM) revealed more associated renal disease (33% vs 9%), preoperative foot necrosis (80% vs 52%), distal popliteal artery graft origins (49% vs 37%), and non–greater saphenous conduits used (30% vs 19%) among the +DM subgroup than the –DM subgroup (P <.05). The operative mortality rate was 2.0%, the major morbidity rate was 8.8%, the early graft failure rate was 6.4%, and the early amputation rate was 2.4%, with no differences related to diabetes mellitus. Follow-up was complete in 92% of patients in a mean interval of 27 months. At 5 years, cumulative primary graft patency rates were 62% overall, 73% for the +DM subgroup, and 45% for the –DM subgroup (P <.001). The overall limb salvage rate after DOG procedures for critical ischemia was 79%, and it was 84% for the +DM subgroup and 69% for the –DM subgroup (P <.04). The overall patient survival rate was 45%, with no difference related to diabetes mellitus Conclusion: Outcome after autogenous DOG revascularization is satisfactory overall. Graft patency and limb salvage after DOG for critical ischemia are significantly better among patients with diabetes mellitus than patients without diabetes mellitus, despite significantly more bypass grafting procedures performed for foot necrosis. DOG revascularization appears to be an appropriate preference for patients with diabetes mellitus with good inflow below the groin; it should be used less liberally among patients without diabetes mellitus. (J Vasc Surg 2002;35:48-55.)

Polytetrafluoroethylene bypasses to infrapopliteal arteries without cuffs or patches: A better option than amputation in patients without autologous vein

This study was undertaken to evaluate our results of polytetrafluoroethylene (PTFE) tibial and peroneal artery bypasses done for limb salvage. Within a group of patients undergoing infrainguinal limb salvage bypasses at our institution between January 1986 and May 1995, 63 patients faced an immediate amputation, had no autologous vein on duplex examination and operative exploration, and had only a tibial or peroneal artery as an outflow vessel for bypass. Most of these patients (82%) had two or more prior ipsilateral infrainguinal bypasses. These 63 patients underwent 66 PTFE bypasses to a tibial or peroneal artery without a distal anastomotic vein cuff or an adjunctive arteriovenous fistula. Our results were then compared with those reported from infrapopliteal (crural) bypasses performed with alternate autologous vein sources or PTFE in conjunction with various recommended adjuncts. The 3- and 5-year cumulative primary graft patency rates for our PTFE infrapopliteal bypasses were 39%+/-7% and 28%+/-9%, respectively. Secondary graft patency rates were 55%+/-8% and 43%+/-10% at 3 and 5 years, respectively. Limb salvage rates were 71%+/-7% at 3 years and 66%+/-8% at 5 years. Two-year actuarial patient survival rate was only 67%+/-7%. These results indicate that a PTFE bypass to an infrapopliteal artery remains a worthwhile option in patients without usable autologous vein. The secondary patency and limb salvage rates were acceptable in this setting and were not significantly different from the best results reported with prosthetic tibial/peroneal bypasses with distal vein cuffs or patches (74% at 1 year; 58% at 3 years), arteriovenous fistulas (71% at 1 year) or composite arm vein grafts (39% and 29% at 3 and 5 years, respectively).

Autologous saphenous vein popliteal-tibial artery bypass for limb-threatening ischemia: A reassessment

The purpose of this review was to ascertain the cumulative primary and secondary graft patency rates, the cumulative limb salvage rate, and the frequency of atherosclerotic disease progression proximal to the graft origin, in patients with autologous saphenous vein popliteal-tibial artery bypass grafts whose operative indication was limb-threatening ischemia. Forty-three short autologous saphenous vein grafts originating from the popliteal artery were retrospectively reviewed. The life-table method was used to determine primary and secondary graft patency and limb salvage rates. Atherosclerotic disease progression proximal to the graft origin was assessed via follow-up arteriography, segmental limb pressures, or pulse-volume recordings. All other data were compared by chi-square analysis. The cumulative primary graft patency rate at 1, 3, and 5 years (86%, 66%, 58%) was similar to the cumulative secondary patency rate (90%, 70%, 62%) and the cumulative limb salvage rate (80%, 55%, 55%). No patient developed hemo-dynamically significant atherosclerotic disease proximal to the graft origin during the follow-up period. The similarity of the life-table data suggests graft-dependent, poorly collateralized limbs; it is therefore not uncommon for these patients to require major amputations shortly after bypass failure. There was no evidence of critical proximal disease progression that might warrant a more proximal graft origin. Poplitealtibial artery bypass grafts are durable, with acceptable graft patency and limb salvage rates.

Infrainguinal bypass in patients with end-stage renal disease

This study was undertaken to evaluate the outcome of infrainguinal arterial reconstruction in a high-risk subset of patients with end-stage renal disease. We reviewed the medical records of 44 patients requiring maintenance dialysis and undergoing 57 infrainguinal bypass procedures for limb salvage from 1986 to 1992. These included 16 (28%) femoropopliteal and 41 (72%) tibial or pedal bypasses with autogenous (82%), prosthetic (12%), or composite (6%) graft materials. The principal indications for operation were ischemic ulceration or gangrene (79%) and rest pain (21%). Angiographic evaluation most frequently showed single-vessel runoff (56%). Risk factors included age (mean, 63 years), diabetes (75%), hypertension (93%), coronary artery disease (52%), smoking (39%), previous myocardial infarction (20%), and contralateral amputation (18%). Infection was present in 22 limbs (39%). Early (30-day) surgical morbidity rate was 39%, including wound breakdown (19%), graft thrombosis (9%), and major amputation (4%). Perioperative mortality rate was 9%. Cumulative primary graft patency rates were 71% and 63%, secondary patency rates were 80% and 66%, and limb salvage rates were 70% and 52% at 1 and 2 years, respectively. Limb loss correlated most highly with the presence of preoperative infection (p = 0.036; log-rank method). Patient survival rate was 52% at 2 years. Life-table analysis confirms a poor life expectancy for this population but indicates that an acceptable level of limb salvage may be achieved with arterial reconstruction in properly selected patients.

Return to well-being and function after infrainguinal revascularization

The purpose of this study was to assess functional status, well-being, and symptom relief of patients after infrainguinal revascularization for severe peripheral vascular disease. Two questionnaires were used to assess symptoms, functional status, and well-being before operation and 6 months after operation. Sociodemographics, comorbidities, indications for surgery, graft location, and morbidity, mortality, patency, and limb salvage rates were obtained via vascular registry. Of 318 patients who underwent revascularization over a 1-year period, 276 patients were asked to complete the questionnaires. Of the 156 patients who completed both questionnaires, mean age was 66 years, 67% were men, 84% had diabetes mellitus, and 83% had various heart-related conditions. Mean length of stay was 15.3 days. Distal graft sites were popliteal (29%), tibial/peroneal (40%), and pedal/plantar (31%). The operative morbidity rate was 21%, the cumulative primary graft patency rate was 93%, the cumulative secondary graft patency rate was 95%, and the limb salvage rate was 97% at 6 months. At follow-up, improved functioning of instrumental activities of daily living, mental well-being, and vitality were reported. Symptoms of calf cramping and toe or foot pain when walking and at rest were also improved. Sores or ulcers improved, but leg swelling did not. The only independent predictor of improved function and well-being was the patients' perception of their status at baseline: those patients who functioned better before operation reported improved function and well-being at 6 months. Only 45% of patients reported feeling "back to normal" at 6 months. Reported health status at baseline was a predictor of improved function, mental well-being, and resolution of symptoms after infrainguinal revascularization. Expected return to "normal" may take longer than 6 months.

Serial noninvasive studies do not herald postoperative failure of femoropopliteal or femorotibial bypass grafts.

We performed a 5-year retrospective case-control study of 232 patients undergoing femoropopliteal (n = 188) or femorotibial (n = 44) bypass to determine if serial noninvasive studies herald postoperative graft failure. We correlated serial ankle/arm pressure indices (API) with graft patency. An interval drop in API of greater than or equal to 0.20 was considered hemodynamically significant, but interventional therapy was carried out only for clinically symptomatic graft failure and an API less than 0.20 above the preoperative value. The cumulative 5-year limb salvage rate was 82% and the patient survival was 63%. A significant drop in API did not correlate with cumulative 5-year graft patency. The 5-year cumulative primary graft patency rates were 60% and 62% in patients with stable and interval drops in API, respectively (Z = 0.15, p = N.S.) These results suggest that a significant drop in postoperative API does not predict patients with impending femoropopliteal or femorotibial graft failure. We believe that routine noninvasive surveillance and prophylactic intervention on detected asymptomatic lesions in leg bypass grafts may not be justified.

Axillopopliteal bypass grafting: Indications, late results, and determinants of long-term patency

In the last 12 years we have performed 55 axillopopliteal bypass graftings with 6 mm polytetrafluoroethylene grafts for limb salvage in 50 patients who were at high risk for limb loss. Indications for this procedure were (1) severe atherosclerotic disease of the common, superficial, and deep femoral arteries (33 cases); (2) failed aortofemoral bypass grafting with sufficient fibrosis or disease progression in the deep femoral artery (five cases); (3) insufficient hemodynamic and clinical improvement after axillofemoral bypass grafting (10 cases); and (4) sepsis in the groin from a previously infected graft (seven cases). The 30-day operative mortality rate was 8%, and the 5-year cumulative patient survival rate was 40%. Overall 1-, 3-, and 5-year cumulative primary graft patency rates were 58%, 45%, and 40%, respectively. Comparable limb salvage rates were 83%, 68%, and 58%. Repeat operations increased 5-year patency rates from 40% to 59% (p < 0.05). Three-year patency rate for grafts placed in the presence of poor angiographic runoff in one vessel was 62% and for good angiographic runoff (two to three vessels) it was 57% (NS). Grafts to the above-knee popliteal artery had a patency rate of 67% at 3 years, whereas for grafts that crossed the knee joint it was 51% (NS). Three-year patency rate for 24 straight axillopopliteal grafts was 42%, and for 31 sequential axillofemoralpopliteal grafts it was 74% (p < 0.05). These results show that axillopopliteal bypass grafting is justified when other standard operations are not possible in patients who are in imminent danger of limb loss, and that every possible effort should be made to use the common or deep femoral artery as part of a sequential axillofemoral-popliteal procedure.