Femoropopliteal Bypass Grafts Research Articles

Indobufen. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic efficacy in cerebral, peripheral and coronary vascular disease.

Indobufen is an inhibitor of platelet aggregation which acts by reversibly inhibiting the platelet cyclo-oxygenase enzyme. Improvements in walking distances and microcirculatory parameters have been achieved during therapy with indobufen in patients with peripheral vascular disease and intermittent claudication. Indobufen has been shown to be as effective as aspirin plus dipyridamole in preventing the reocclusion of coronary and femoro-popliteal artery bypass grafts and has been shown to significantly reduce platelet deposition on haemodialysis membranes. Initial studies have also indicated that indobufen may have a prophylactic effect on the incidence of secondary thrombotic events following transient ischaemic attack or mild stroke and may be effective in the prophylaxis of migraine. Indobufen is well tolerated following oral administration and has been associated with a low incidence of adverse effects rarely requiring withdrawal of treatment. Thus, available evidence indicates that indobufen may be an effective alternative to aspirin for the treatment of cerebral, peripheral and coronary vascular diseases with the advantage of a lower incidence of gastrointestinal effects compared to high dose aspirin, rendering indobufen more suitable for longer term therapy.

Ten-year Follow-up of Femoropopliteal Bypass Grafts: Comparative Review of Late Patency Rates of PTFE and Saphenous Vein Grafts for Lower Extremity Ischemia

Between January, 1987 and June 1988, 335 femoropopliteal bypass (FPBP) operations were performed on 308 patients who had limb ischemia caused by femoropopliteal occlusion. The greater saphenous vein graft (SVG) was used whenever possible (165) and polytetrafluoroethylene (PTFE) prosthesis was used in 165. In addition, 4 Dacron grafts and 1 umbilical vein graft were used in 5 operations but were excluded from comparison in this study. The two groups did not differ significantly regarding stage of peripheral ischemia, preoperative indication, distal popliteal anastomotic site, and number of patent runoff ves sels. Overall cumulative patency rates according to occlusive criteria alone were calculated by the life table method. Graft occlusion was determined by angiog raphy, Doppler assessment, loss of previously palpable pulses, or return of symp toms. Diabetes mellitus was associated with a significantly lower patency rate. It is concluded from this study that the saphenous vein is superior to PTFE as femoropopliteal bypass.

Successful thrombolysis of a chronically occluded femoropopliteal synthetic bypass graft via the popliteal approach: Case report

Thrombolysis of an occluded femoropopliteal synthetic bypass graft was performed via the popliteal artery approach for infusion catheter placement and urokinase delivery. Graft thrombolysis was achieved without complication. The proximal graft anastomosis could not be identified and prevented selective antegrade catheter placement and infusion. Because the distal graft anastomosis was visualized, the percutaneous popliteal approach was used. Subsequently, angioplasty was performed of an unmasked stenosis that presumably led to graft closure. We can conclude that selective thrombolysis via catheter placed from popliteal thrombolysis is an effective technique for recanalization of occluded femoropopliteal bypass grafts if the antegrade approach is not feasible.

Urokinase infusion of chronically occluded femoropopliteal gortex™ bypass grafts via the popliteal approach

Thrombolysis of two occluded above-knee femoropopliteal Gortex bypass grafts utilizing the popliteal approach for catheter placement was successfully performed without complication. In both cases, the proximal anastomoses of the graft could not be identified. A percutaneous popliteal approach was used for catheter placement and delivery of urokinase. Angioplasty was performed on the unveiled stenoses that, presumptively, led to graft closure. Selective thrombolysis via catheter placed from popliteal approach is a new technique for recanalization of occluded femoropopliteal bypass grafts and warrants further investigation.

Use of lower extremity deep veins as arterial substitutes: Functional status of the donor leg

Large veins (superior and inferior vena cava, portal vein) have been replaced successfully with lower extremity deep veins (superficial femoral-popliteal). Femoropopliteal bypass with superficial femoral-popliteal veins has been reported to give excellent long-term results. Nevertheless, this source of autogenous veins has not gained acceptance, in part because of the fear that deep vein removal will result in severe venous outflow restriction in the donor limb. To assess the clinical and functional effect of excising a deep vein, we compared a group of limbs in which the superficial femoral-popliteal vein was resected for use as a femoropopliteal bypass graft (25 legs) with a control group of 22 legs in which a saphenous vein or polytetrafluoroethylene graft was used for femoropopliteal bypass. No significant differences were found in age or sex distribution, time from surgery to the venous test, side of bypass, or the incidence of postoperative extremity swelling, either early or late. A mild but significant calf enlargement was observed in the deep vein group ( p < 0.05), and a pattern consistent with venous outflow obstruction was shown by plethysmography in 21 of 25 extremities (84%) in which a deep vein was used for femoropopliteal bypass but in only 11 of 22 (50%) control extremities ( p < 0.02). It is concluded that a lower extremity deep veins should be considered as a suitable replacement for a large vein or, when superficial vein is not available, as an infrainguinal arterial substitute.

Distal Anastomotic Hyperplasia in Superficial Femoral-Popliteal Vein Femoropopliteal Bypass Grafts

The incidence of distal anastomotic hyperplasia (DAH) in superficial femoral- popliteal veins (SF-PVs) used as femoropopliteal bypass (FPB) grafts was inves tigated, with particular reference to the form of distal anastomotic construction. Seventy-seven SF-PV grafts that met specific angiographic follow-up criteria quali fied as "studied" grafts. DAH was identified in 13 (17%). Cobra head anastomoses, 2 cm or less in length, were used in 21 grafts and yielded 6 in stances of DAH (29%). When 8 sharply tapered 3 cm (swordfish) anastomoses were constructed, 3 grafts (37.5%) developed DAH. With 3 cm moderately ta pered (fishmouth) anastomoses in 48 grafts, DAH was seen 4 times (8%). Be cause the distal 1 cm of the swordfish configuration was very narrow, the swordfish and cobra head constructions were functionally equivalent and were grouped together as "short" anastomoses. The difference in the incidence of DAH with long and short anastomoses, 8% vs 31%, was statistically significant (p = .016). In the 48 "studied" grafts with fishmouth anastomoses, the occurrence of all 4 DAHs among the 15 female diabetic limbs was also significant (p = .019). Constructing 3 cm moderately tapered anastomoses significantly reduced the incidence of DAH, the leading cause of graft failure, in SF-PV FPB grafts. The achievement of primary and assisted patency rates of 84% and 91% at both three and five years in the 93 SF-PVs placed as primary FPB grafts since October, 1982, was largely due to the reduction in DAH that resulted from anastomotic modification.

Femoro-popliteal vein bypass grafts studied by intravascular ultrasound

The usefulness of intra-operative intravascular ultrasound (30 MHz) was evaluated in three patients who underwent a femoropopliteal vein bypass. Intravascular echography analysis of the surgical procedure revealed a normal uneventful result in one patient. In two other patients obstructions in the vein grafts were identified either caused by internal obstruction or external compression. Angiography in these two patients provided equivocal data. We conclude that intravascular ultrasound imaging may be a useful adjunct to angiography and may offer important clinical data to facilitate the surgeons in analysing the results of the interventional procedures.

Aneurysm formation in distal saphenous vein bypass grafts as a cause of graft failure

Aneurysms of a reversed saphenous vein femoropopliteal bypass graft developed in two patients. In both patients, the aneurysm led to thrombosis and occlusion of the graft. One graft was reopened by intraarterial thrombolysis followed by local graft revision; the other required complete regrafting. This uncommon cause of graft occlusion should be considered before thrombolysis.

Femoral-Distal Bypass with In Situ Greater Saphenous Vein Long-term Results Using the Mills Valvulotome

During a 7-year period, 440 consecutive in situ saphenous vein grafts originating in the groin were performed in 371 patients, exposing the entire vein for valvulotomy with a modified Mills valvulotome. critical ischemia was the indication for bypass in 68%, and the distal anastomosis was to an infrapopliteal artery in 46%. Thirty-day operative mortality was 2.0%. Postoperative surveillance identified 18 stenotic grafts (4.1%), which were revised while still patent (primary revised patency); 36 grafts (8.2%) underwent revision after graft occlusion (secondary patency). Five-year life-table analysis showed overall primary revised patency of 78%, secondary patency of 83%, limb salvage of 88%, and patient survival of 66%. Femoroperoneal and inframalleolar bypasses fared well. The presence of diabetes did not diminish late graft patency. In contrast to reversed vein grafts, long infrapopliteal in situ grafts had long-term secondary patency similar to shorter femoropopliteal bypass grafts (p greater than 0.05). These results, coupled with the versatility and simplicity of the technique as used in the present series, suggest that in situ vein grafting is the procedure of choice for long infrapopliteal bypass.

Prospective, randomized comparison of ringed and nonringed polytetrafluoroethylene femoropopliteal bypass grafts: A preliminary report

Kinking and compression with knee flexion are thought to be one cause of failure of below-knee polytetrafluoroethylene femoropopliteal bypass. To prevent this problem polytetrafluoroethylene grafts externally supported with rigid rings have been developed. The present randomized, prospective study compared ringed and nonringed polytetrafluoroethylene grafts in 122 patients who underwent femoropopliteal bypass for severe limb ischemia. Patients were well matched for surgical indications and risk factors. There was no significant difference in the 3-year graft patency rate of ringed versus nonringed polytetrafluoroethylene femoropopliteal bypasses (74% vs 68%, p = 0.5). Similarly, no significant differences were found in the 3-year graft patency rates of ringed versus non-ringed above-knee (82% vs 74%, p = 0.5) or below-knee polytetrafluoroethylene femoropopliteal bypasses (68% vs 59%, p = 0.5). The 3-year graft patency rate of all above-knee polytetrafluoroethylene femoropopliteal bypasses was slightly greater than that of below-knee polytetrafluoroethylene femoropopliteal bypasses (76% vs 62%), but this difference was not statistically significant (p = 0.25). The 3-year limb salvage rate with ringed polytetrafluoroethylene grafts was 92% compared with 79% for nonringed polytetrafluoroethylene grafts, but this difference was not statistically significant (p = 0.25). Data to date from this study fail to support the recommendation that ringed polytetrafluoroethylene grafts be used preferentially over conventional polytetrafluoroethylene grafts in patients who require femoropopliteal bypass with a synthetic graft.

Deep leg veins as femoropopliteal bypass grafts

Deep leg veins as femoropopliteal bypass grafts

Deep leg veins as femoropopliteal bypass grafts

ConclusionOur extensive experience indicates that resection of normal superficial femoral and popliteal veins is free of significant late morbidity. Adequate evidence to the contrary has never been presented. Our 5‐year patency rates using deep leg veins equal or surpass the best results ever reported with saphenous veins. Erroneous presentation of our work, as exemplified by the comments of Bergan and associates, tends to delay the acceptance of a major arterial graft source. Deep leg vein grafts represent an important advance in arterial reconstructive surgery, and we are confident that future reports by other groups will confirm the high patency rates and lack of significant late morbidity in our reports [36, 37, 43] and that of Noppeney [1].

Significance and management of inflow gradients unexpectedly generated after femorofemoral, femoropopliteal, and femoroinfrapopliteal bypass grafting

With multilevel arteriosclerosis, some patients undergoing infrainguinal bypass grafting will develop femoral/brachial pressure gradients only after the bypass is performed. We therefore evaluated arteriographically alternate inflow sites and measured the femoral/brachial pressure gradients before and after placement of 87 femorofemoral and 510 femoropopliteal/infrapopliteal bypasses. No prebypass femoral/brachial pressure gradients were present with and without intraarterial papaverine. However, femoral/brachial pressure gradients ≥15 mm Hg were observed after the bypass placement in 16 femorofemoral patients and 43 femoropopliteal/infrapopliteal patients. Gradients averaged 28 ± 8 (SD) (range, 15 to 50) mm Hg. The post femorofemoral bypass gradients were treated by immediate supplementary inflow extension to the aorta (three patients) or an axillary artery (three patients); by postoperative iliac percutaneous transluminal angioplasty (four patients) or by no treatment (six patients with femoral/brachial pressure gradients of 15 to 35 [23 ± 5] mm Hg). The 43 postfemoropopliteal/infrapopliteal bypass gradients were treated by immediate supplementary inflow extension to the contralateral femoral artery (15 patients), the aorta (8 patients), or an axillary artery (3 patients); by postoperative iliac percutaneous transluminal angioplasty (5 patients) or by no treatment (12 patients with femoral/brachial pressure gradients of 15 to 30 [21 ± 4] mm Hg). No thrombosis occurred in the 10 femorofemoral bypasses with postbypass femoral/brachial pressure gradients that were treated. One of the six femorofemoral patients with untreated gradients required a subsequent aortic extension, and one thrombosed after 2 years. Of the 12 untreated patients with femoropopliteal/infrapopliteal bypasses one graft occluded early, and two late failures occurred 12 and 18 months later. These data underscore the importance of measuring femoral/brachial pressure gradients after placement of bypasses from the femoral artery and show that 10% of femorofemoral and femoropopliteal/infrapopliteal bypasses will produce unanticipated inflow pressure gradients. Strategies for managing such gradients depend on appropriate preoperative arteriographic evaluation and preparation to anticipate this problem. In selected circumstances, inflow gradients up to 35 mm Hg may be accepted without negatively influencing long-term patency of femorofemoral and femoropopliteal/infrapopliteal bypasses.

Angiographic criteria for prediction of early graft failure of secondary infrainguinal bypass surgery

Complete intraoperative postreconstruction angiograms were obtained during 93 reoperations after failed femoropopliteal and femorodistal bypass grafts to evaluate the predictive value of a new method of angiographic runoff assessment. Good runoff was defined as patency of two or three lower leg arteries to the foot, or one patent vessel continuous with an intact anterior or posterior foot arch in femoropopliteal and proximal femorodistal bypasses, and integrity of both arches in low femorodistal bypasses. All other outflow patterns were considered poor. The cumulative 1-year patency rate was 61% with a 79% limb salvage rate after reoperations performed in limbs with good runoff. In reoperations with poor runoff, the patency rate was only 5% with a 22% limb salvage rate. In reoperations with good runoff, an 85% patency rate of vein grafts compared to 43% of prosthetic grafts clearly demonstrated the importance of graft material on early outcome. The improved prediction of early outcome with this new method of angiographic runoff evaluation might allow more rational management of patients with failed infrainguinal grafts.

Pseudoaneurysm of the posterior tibial artery as an early complication after fogarty catheter thrombectomy

After angioplasty of the superficial femoral artery at Hunter's canal in a 65-year-old woman thrombosis developed and femoropopliteal bypass grafting was necessary. Four weeks later the graft occluded, successful thrombectomy was performed with a Fogarty catheter and the patient heparinised. Three days later a pseudoaneurysm developed on the posterior tibial artery which was excised and the artery which was longitudinally torn repaired with a vein graft giving good functional results. Complications after Fogarty balloon catheter thrombectomy are relatively rare but Pseudoaneurysms can occur after perforation or rupture of smaller vessels.

Femoro-popliteal versus femoro-distal bypass grafting for limb salvage in patients with an “isolated” popliteal segment: Darke S, Lamont P, Chant A, et al. Eur J Vasc Surg 1989;3:203–207

Femoro-popliteal versus femoro-distal bypass grafting for limb salvage in patients with an “isolated” popliteal segment: Darke S, Lamont P, Chant A, et al. Eur J Vasc Surg 1989;3:203–207

The influence of smoking and plasma factors on prosthetic graft patency

The effects of smoking and plasma risk factors on the patency of prosthetic femoro-popliteal bypass grafts were investigated in 93 patients entered into a multicentre trial of prosthetic graft materials (70 patients had patent grafts and 23 patients had occluded grafts 2 years after surgery). The smoking markers thiocyanate and fibrinogen were significantly higher in patients with occluded grafts, whereas LDL-cholesterol was significantly higher in patients with patent grafts 2 years after bypass. Based on smoking markers, graft patency in smokers was 57% at 2 years by life table, compared to 78% in non-smokers. P less than 0.05. Fibrinogen was an important variable, predicting graft occlusion with graft patency in patients with below median fibrinogen levels, being 84% at 2 years by life table compared to 51% in those with above median fibrinogen levels, P less than 0.025. Although increased levels of LDL-cholesterol have been associated with accelerated atherosclerosis, patients with above median levels of LDL-cholesterol had improved graft patency (83%) at 2 years compared to patency in patients with below median LDL-cholesterol (60%), P less than 0.05. The plasma risk factors associated with the failure of prosthetic grafts are similar to those associated with the failure of saphenous vein grafts, indicating that higher fibrinogen levels and smoking may contribute to an hypercoagulable state. Greater efforts are needed to stop patients smoking after vascular reconstruction.

Flavimonas Oryzihabitans Infection of a surgical wound

An unusual case of a post operative wound infection involving Flavimonas oryzihabitans is described. This organism is rarely isolated from human sources. It can cause infections in patients having continuous ambulatory peritoneal dialysis. Our patient developed a wound infection 2 months after femoro-popliteal bypass grafting. The source of the organism was unknown.

Combined Therapy for Arterial Stenosis with Angioscopy and Transluminal Balloon Angioplasty After PTFE Grafting— A Case Report

Stenosis of the distal right popliteal artery after femoropopliteal bypass grafting was visualized by angioscopy and successfully treated by transluminal balloon angioplasty (TBA) through polytetrafluoroethylene (PTFE) graft. This approach is an attractive alternative to surgical angioplasty and/or graft revi sion, especially in patients with peripheral anastomotic stenosis of distal arterial stenosis after bypass grafting.

Reoperation for complications of stabilized human umbilical vein grafts

Among 211 femoropopliteal bypass grafts constructed with stabilized human umbilical vein performed between 1977 and 1986, 3 major complications were seen: graft thrombosis, aneurysm formation, and infection. Early thrombosis (within 30 days of operation) was successfully treated in 14 of 17 patients (82 percent) with either graft thrombectomy (13 of 17 patients) or graft replacement (1 patient). Late graft closure (2 to 55 months after operation) was successfully treated with thrombectomy in 17 of 28 patients (61 percent) or graft revision or replacement in 4 patients (14 percent). Aneurysms and graft infections were each seen in 3 percent of the grafts at risk. The former were successfully reconstructed in six of seven instances, whereas the latter eventuated in amputation in six of seven patients. An aggressive approach to graft closure in stabilized human umbilical vein grafts is recommended as this conduit is amenable to thrombectomy or revision if closure occurs.