Cumulative Primary Graft Patency 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.)

Long term results of polytetrafluoroethylene in above knee femoropopliteal bypass for critical ischaemia

Ninety-six consecutive above-knee femoropopliteal bypasses, using polytetrafluoroethylene (PTFE) preferentially, were performed for limb-threatening ischaemia. Cumulative primary graft patency was 68 per cent, 49 per cent and 36 per cent and limb salvage 93 per cent, 85 per cent and 75 per cent at 1, 3 and 5 yr respectively. As a result of poor long term survival (51 per cent at 5 yr), and the healing of remedial lesions before graft occlusion, 68 patients (72 per cent) required no further intervention. Eighteen secondary bypasses were undertaken, 12 using ipsilateral saphenous vein. In this group of elderly patients with poor life expectancy, where a limited operation is desirable, the use of PTFE provided excellent limb salvage with low morbidity. Although we can no longer justify our continued use of PTFE in every case of critical ischaemia because of its inferior patency to autogenous vein, we continue to use it preferentially in patients whose lifespan is likely to be short and in cases where a remedial lesion is present.

Glutaraldehyde-tanned bovine carotid artery graft for infrainguinal vascular reconstruction: 5-year follow-up

To assess the long-term patency of a modified biological conduit, the glutaraldehyde-tanned bovine carotid artery, in above-knee infrainguinal arterial reconstruction. Prospective follow-up of a cohort of 58 above-knee femoropopliteal grafts in 55 patients. Graft patency was assessed at yearly intervals with doppler ankle pressure measurements. The median follow-up period has been 67 months. Nine grafts occluded within 30 days of surgery and a further 19 graft closures have been observed in the follow-up period. The overall cumulative primary graft patency at 1, 3 and 5 years was 70%, 61% and 56%, respectively. If the 30-day graft failures are excluded, the primary graft patency rises to 83%, 74% and 68% at 1, 3 and 5 years, respectively. Six limbs have been amputated, four above the knee and two below the knee. There were no graft aneurysms and no graft infections. Results indicate that the modified bovine carotid artery graft with an above-knee anastomosis does not seem to be inferior to PTFE, but is inferior to reversed vein. Modified biological conduits offer a reasonable alternative to synthetic grafts for infrainguinal arterial reconstruction and appear to maintain acceptable long-term mechanical stability.

Re-do operation after failed multisegmental reconstructive arterial surgery for critical limb ischaemia

The purpose of this study was to investigate the long-term graft patency rates after multisegmental arterial reconstruction for treatment of chronic critical limb ischemia, and to evaluate the role of re-do surgery in treatment of graft failure. A total of 449 aortofemoropopliteal/tibial grafts carried out over a 10-year period were retrospectively reviewed. All patients were operated upon with chronic critical limb ischemia grade III and IV according to the Fontaine classification; 221 operations were performed in one stage (group A), and 228 in two stages (group B). Distribution of graft failures in the postoperative period, re-do operations and their impact on limb salvage were investigated using life-table methods. During follow up, 62 cases of inflow graft thrombosis were observed (23 in group A and 39 in group B). To correct the inflow graft failure, 59 re-do procedures were performed (27 in group A, 32 in group B). Inflow graft failures were most common during 24 months after primary surgery. During the same period, 92 cases of isolated outflow graft thrombosis were observed (45 in group A and 47 in group B). Outflow graft thromboses were most common after 24–36 months. For treatment of recurrent symptoms caused by outflow graft thrombosis, 68 re-do operations were performed. The 5 year cumulative primary graft patency, secondary graft patency and limb salvage rates were 43.2%, 71.8% and 79.9% in group A, and 23.8%, 54% and 67.5% in group B respectively. In conclusion the long term primary graft patency rate after multisegmental aortofemoropopliteal/tibial reconstructive surgery is low and significantly lower, when compared with single segment reconstructions. Re-do operations have a positive impact on secondary long-term graft patency and limb salvage.

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.

Very distal bypass for salvage of the severely ischemic extremity

Forty-six bypass grafts to tibial arteries distal to the ankle were performed in 35 patients for salvage of extremities threatened by gangrene or nonhealing ulcers (grade III, category 5) or ischemic rest pain (grade II, category 4). Most patients (80%) were diabetic, with severely calcified arteries, whom previously we would have considered as candidates for primary amputation. All reconstructions were performed with autologous saphenous vein. Inflow was from the common femoral artery in 5 (11%), the popliteal artery in 25 (54%), or the mid-tibial arteries in 16 (35%). Life-table analysis was used to calculate primary patency and limb salvage. Results were analyzed according to origin of inflow, outflow, or configuration of the conduit (in situ saphenous vein, n = 29 [63%], reversed saphenous vein, n = 11 [24%], or nonreversed saphenous vein, n = 6 [13%]). Overall cumulative primary graft patency at 2 years for all grafts was 72%, and the cumulative limb salvage rate was 89% for the same interval. No significant differences were seen in comparing grafts originating from the femoral or popliteal level with those arising from the tibial arteries. No significant differences were noted in graft patency or limb salvage among grafts with a posterior tibial, dorsalis pedis, or plantar artery outflow. No significant difference was noted between in situ saphenous vein grafts and reversed saphenous vein grafts. A significant decreased primary patency was noted for grafts performed with nonreversed, translocated saphenous vein. We conclude that bypass grafts to the ankle or foot vessels are beneficial and should be considered for limb salvage in extremities with gangrene, ischemic ulceration, or ischemic rest pain. In our experience, in situ saphenous vein grafts or reversed saphenous vein grafts performed similarly, whereas nonreversed saphenous vein grafts have a poorer prognosis. Vessel wall calcification requires a modification in technique for performance of these grafts but did not affect long-term performance or limb salvage, and thus should not be considered a contraindication to vascular reconstruction. The operative microscope was used in 61% (28 of 46) of these cases and found useful in creating these delicate anastomoses. Additional follow-up is needed to document the long-term results of these very distal reconstructions.

A Prospective Study of 100 Gelatin-Sealed Aortic Grafts

A gelatin-sealed knitted Dacron graft has been developed which has zero porosity at implantation and does not require preclotting. Its patency rate up to 57 months and effectiveness at saving blood loss have been studied. Gelatin-sealed aortic grafts were implanted into 100 consecutive patients--77 men, 23 women. Surgery was performed for aneurysm in 36 patients (including four with rupture), intermittent claudication in 44, rest pain in 17, and gangrene in three, over an 18 month period. The patients were followed up prospectively for 57 months. Perioperative mortality was 1%. Cumulative primary graft patency was 99%. There was no measurable blood loss at implantation. Forty-seven patients required blood transfusion: mean volume transfused was 430 ml. There were no problems related to the sealant.

Combined Percutaneous Transluminal Angioplasty and Extraanatomic Bypass for Symptomatic Unilateral iliac Artery Occlusion with Contralateral iliac Artery Stenosis

We have reviewed our experience with percutaneous transluminal angioplasty of contralateral iliac stenosis and extraanatomic bypass of the occluded iliac artery. Twenty-two men and nine women with a mean age of 65 years (range 46 to 84) presented with symptomatic iliac occlusive disease. Twenty-four (77%) had disabling claudication, four (13%) rest pain, and three (10%) ischemic tissue loss. Six (19%) had undergone previous vascular reconstructive procedures. All had an occluded iliac artery on the symptomatic side and greater than 50% stenosis of the contralateral iliac artery. Percutaneous transluminal angioplasty of the iliac stenosis was done prior to extraanatomic bypass, using polytetrafluoroethylene. There were six late deaths after discharge. The only significant complication was a femoral artery thrombosis which was corrected when the bypass graft was performed. Cumulative primary graft patency was 89% at one year and 81% at three years. The crossover graft occluded in six patients, five within 48 months of surgery, and one after nine years. One of these occluded grafts was salvaged by thrombectomy, for a secondary patency rate of 85% at three years. Two patients required aortobifemoral bypass, one an iliobifemoral bypass and one an ilioprofunda bypass. One patient operated upon for rest pain came to below-knee amputation. Mean resting ankle/brachial systolic pressure index increased significantly on the side of the iliac occlusion from 0.35 +/- 0.21 to 0.70 +/- 0.20 (p less than 0.05, paired t test) after the combined procedure. There was no significant difference in the mean resting ankle/brachial systolic pressure index on the contralateral side (0.60 +/- 0.22 to 0.65 +/- 0.27, ns).(ABSTRACT TRUNCATED AT 250 WORDS)

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.