Femoropopliteal Bypass Grafts Research Articles

Postoperative predictive value of a new method of intraoperative angiographic assessment of runoff in femoropopliteal bypass grafting

In 96 consecutive patients undergoing primary femoropopliteal bypass grafting, the runoff was evaluated with a new grading system, based on findings at intraoperative postreconstruction serial angiography. This concept, which takes foot vessel involvement into account in patients with only one patent crural artery, is a modification of the traditional method of runoff assessment. Good runoff was defined as patency of two or three lower leg arteries to the foot or one patent, vessel continuous with intact anterior or posterior foot arch. In limbs with no patent vessel or one patent vessel with deficient or occluded foot arches, the runoff was classified as poor. The cumulative primary patency rates at 12 months in groups with good and poor runoff were 81% and 37%, respectively. The predictive value of the new method was superior to that of other comparable methods (traditional method, Society for Vascular Surgery and International Society for Cardiovascular Surgery criteria, and modified Society for Vascular Surgery and International Society for Cardiovascular Surgery criteria). This improved prediction can be ascribed to the optimal angiographic technique for visualizing distal vessels, selective evaluation of foot vessel runoff with a new concept, and the criteria used to define good and poor runoff.

Postoperative predictive value of a new method of intraoperative angiographic assessment of runoff in femoropopliteal bypass grafting

Postoperative predictive value of a new method of intraoperative angiographic assessment of runoff in femoropopliteal bypass grafting

Long-Term Results of Combined Iliac Balloon Angioplasty and Distal Surgical Revascularization

Long-term results of combined use of iliac artery percutaneous transluminal angioplasty (PTA) and distal surgical revascularization for the management of multilevel occlusive disease were evaluated over a 12-year period. A total of 79 combined procedures were performed in 75 patients. All patients had tandem occlusive disease, with the inflow lesion felt to preclude a distal revascularization procedure alone. Revascularization was performed for incapacitating claudication in 17 (22%) and limb salvage indications in 62 (78%) cases. A mean resting iliac artery pressure gradient of 29 +/- 11 mmHg pre-PTA was reduced to 0.9 +/- 0.4 post-PTA. Major complications of PTA occurred in five (6%) cases, but four were successfully corrected at the time of the distal surgical procedure without alteration of the operative plan. Infrainguinal operations included 55 femoropopliteal or tibial bypass grafts, 18 femorofemoral grafts, and 6 profundaplasties. Mean follow-up was 43 months. By life table analysis, the 5-year primary patency rate of the distal surgical procedures was 76%; a secondary patency of 88% at 5 years was achieved by various means of reintervention. Mean pretreatment ankle/brachial index of 0.31 +/- 0.14 increased to 0.80 +/- 0.16 after operation (p less than 0.0001). The 5-year limb salvage rate was 90%. There were no operative deaths. We conclude that in carefully selected patients, combined use of iliac PTA and distal surgical reconstruction is effective and durable, safely reducing the extent of surgical intervention while reliably increasing the comprehensiveness of revascularization.

Recanalization of total arterial occlusions with the Kensey dynamic angioplasty catheter.

The Kensey dynamic angioplasty catheter is a new device for recanalization of peripheral arterial occlusions. Twelve patients with segmental occlusions who were not considered candidates for conventional bypass surgery because of cardiovascular risk factors were studied. Four of the patients were treated in the operating room. Two had excellent primary results in limb salvage situations, and recanalization of an occluded femoropopliteal bypass graft was successful in another. Bilateral iliac recanalizations in the fourth patient were locally successful but did not prevent the patient's death from advanced ischemic disease. Eight patients were treated percutaneously. Initial recanalization was successful in seven. Four had early reocclusions and required amputation below the knee. One suffered distal embolization after recanalization of a 6-cm popliteal segment and underwent above-the-knee amputation. Long-term follow-up (7-18 months) in the other three patients with successful primary recanalizations has confirmed patency of the recanalized segments.

Femoro-popliteal versus femoro-distal bypass grafting for limb salvage in patients with an “Isolated” popliteal segment

In a prospective, multicentre trial, 59 patients with an ischaemic limb and an "isolated" popliteal segment on angiography were randomised to undergo infrainguinal bypass grafting to either the popliteal segment or to a reconstituted distal vessel lower in the calf. Limb salvage was attained with 88% of the femoro-popliteal grafts and 80% of the femoro-distal grafts. There was no difference in the one year graft patency rate between the femoro-popliteal group (79%) and the femoro-distal group (70%). Mean postoperative increase in ankle/brachial pressure index was similar in the two groups despite the presence of occluded or significantly diseased vessels distal to the popliteal anastomoses. Technical difficulties were encountered in 8% of the popliteal group and 24% of the distal group. Femoro-distal bypass grafting confers no apparent benefit over femoral bypass grafting into a patent popliteal segment, even though the popliteal run-off is impaired or occluded.

The Effect of Postoperative Smoking on Femoropopliteal Bypass Grafts

Effect of smoking habits on limb loss rates and cumulative patency rates of 136 arterial reconstructions performed for lower limb ischemia were analyzed in a five year follow-up retrospective study. Of 121 patients, 103 (85%) smoked before the operation and 43 of the smokers (42%) discontinued smoking postoperatively. Patients who continued to smoke more than 15 cigarettes per day (34 patients) increased the probability of losing their limb approximately five times at two years and three times at five years postoperatively, compared with nonsmokers and smokers of up to 15 cigarettes per day (87 patients) (p = 0.013). Cumulative patency rates of nonsmokers and smokers of up to five cigarettes per day (Group A, 66 patients) were not significantly influenced (p = 0.518) by preoperative symptoms (claudication versus limb salvage). However, for smokers of more than five cigarettes per day (Group B, 55 patients), at five years claudicants had a cumulative patency rate of 62.9% compared to 38.3% for limb salvage patients (p = 0.015). In group A at five years, autologous saphenous vein grafts had a cumulative patency rate of 74.2%, compared to 24% for prosthetic grafts (P = 0.013). In group B the CPR differences between autologous saphenous vein and prosthetic grafts were not significantly different (p = 0.394). Multiple interactions between smoking and variables like age, preoperative symptoms, and graft material demonstrate the complexity of the effects of smoking on cumulative patency rate and the need for sub-grouping and removal of confounding factors. In view of the adverse affects of continued smoking on postrevascularization prognosis, patients should be strongly advised to discontinue smoking.

The effect of postoperative smoking on femoropopliteal bypass grafts

The effect of postoperative smoking on femoropopliteal bypass grafts

The correlation of peroperative outflow resistance measurements with patency in 109 infrainguinal arterial reconstructions

The predictive value of outflow resistance measurements for the patency of femoro-popliteal and femoro-crural bypass grafts was analysed. Peroperative outflow resistance measurements were performed in 109 infrainguinal arterial reconstructions. Outflow resistance was significantly higher in occluded bypasses compared with those which remained open (P less than 0.01), but there was a considerable overlap of values in both groups. Statistical analysis of the correlation between outflow resistance and patency rates at 3 months revealed a marginal correlation in the femoro-popliteal bypass group (R = -0.25), which was not significant (P = 0.064). In the femorocrural bypass group there was again only a marginal correlation (R = -0.27) but this was statistically significant (P = 0.05). These data demonstrate that intraoperative outflow resistance measurements are only of limited value for predicting bypass patency in individual cases.

PLASMA FIBRINOGEN AND SMOKING LINKED TO VEIN-GRAFT OCCLUSION.

This prospective study assessed the effects of smoking and levels of plasma lipids, lipoproteins, apolipoproteins, and fibrinogen on the outcome of saphenous vein femoropopliteal bypass grafts. One year after bypass, 113 of 157 subjects had patent grafts; 44 grafts were …

Femoropopliteal reconstruction for claudication. The risk to life and limb.

The current study was undertaken to examine the results of femoropopliteal bypass grafting with intermittent claudication as the indication. Of 1173 infrainguinal reconstructions carried out on our service during the past decade, 249 (21%) consecutive femoropopliteal grafts were performed for disabling claudication in 191 patients. The primary five-year cumulative patency rates were 78% for autogenous vein and 52% for polytetrafluoroethylene grafts. There were two (0.8%) 30-day operative deaths and a subsequent five-year amputation rate of 2.4% for both groups. Femoropopliteal reconstruction for claudication may therefore be carried out with acceptably low operative mortality and a subsequent amputation rate comparable with that anticipated from the natural history of the disease. While the five-year patency rate is significantly higher utilizing autogenous vein grafts, symptomatic relief may be expected with prosthetic grafts in approximately half the patients without incurring a higher risk of limb loss.

Percutaneous transluminal angioplasty of infrapopliteal vessels: preliminary results and technical considerations.

Infrapopliteal balloon angioplasty was performed in 11 patients facing reconstructive surgery for limb salvage. Twelve separate sessions of angioplasty were performed, during which 15 of 16 diseased tibial runoff vessels were successfully dilated. Three complications occurred during percutaneous transluminal angioplasty (PTA). One was related to the concomitant use of a thrombolytic agent to open a femoropopliteal bypass graft and not related to the angioplasty itself. No limbs were lost as a result of complications. The procedure was a technical success in nine of 12 cases (75%) and an initial clinical success in eight of the nine that were technically successful (89%). Follow-up ranged from 1 to 22 months. Six of the nine cases (67%) remained clinically successful during this period. Preliminary results suggest that infrapopliteal PTA is a safe and effective alternative to surgical reconstruction in selected patients.

Runoff resistance and early graft failure in infrainguinal bypass surgery.

Recent reports suggest that intraoperatively measured runoff resistance can identify patients destined for early graft failure. We measured runoff resistance in 80 consecutive patients who had undergone infrainguinal bypass surgery, and periodically assessed graft patency. There were 57 femoropopliteal bypass grafts and 23 infrapopliteal bypasses. After 3, 6, or 12 months, there was no significant difference in mean resistance between those grafts remaining patent and those that failed. Moreover, among patients with very high resistance (greater than 1.2 mm Hg/mL/min), 12 bypass grafts remained patent for more than one year. These results demonstrate that even patients with relatively high runoff resistance can undergo successful bypass grafting. Consequently, patients with measured or angiographic evidence of poor runoff should not be denied vascular reconstruction on this basis alone. We believe that graft failure is a multifactorial process in which the nature of the graft material, location of the distal anastomosis, runoff resistance, and a number of other factors are likely to play a role.

Comparison of transcutaneous oximetry, vascular hemodynamic measurements, angiography, and clinical findings to predict the success of peripheral vascular reconstruction

The present study examined prospectively the prognostic value of preoperative clinical findings, angiography, and conventional vascular hemodynamic and transcutaneous oximetry measurements in a consecutive series of patients undergoing lower extremity vascular reconstruction. A total of 25 variables were independently evaluated in each limb. Follow-up at least 6 months after operation was carried out in all patients. The postocclusive transcutaneous oxygen recovery time was found to be the most accurate predictor of short-term femoropopliteal bypass graft success. Preoperative foot transcutaneous oxygen recovery time values were significantly worse in patients whose femoropopliteal bypass grafts failed than in those in whom the outcome was successful (p less than 0.03). Transcutaneous oxygen recovery time values were also valuable in patients who underwent aortofemoral bypass; patients with isolated aortoiliac disease had significantly better foot transcutaneous oxygen recovery time values than those with combined aortoiliac and femoropopliteal disease (p less than 0.05). Foot transcutaneous oxygen recovery time values were also found to correlate well with the severity of symptoms (p less than 0.01), as did ankle-brachial Doppler pressure indices. Although the other variables analyzed provided useful diagnostic information, none were as accurate as the postocclusive transcutaneous oxygen recovery time in predicting the outcome of peripheral vascular reconstruction. As a means of more accurately classifying patients with peripheral vascular disease, we recommend the complimentary use of clinical findings, angiography, and hemodynamic and transcutaneous oximetry measurements. Because transcutaneous oxygen tension reflects the balance between local oxygen supply and demand, it may help to better define risk factors preoperatively in physiologic terms.

Four years' results of a prospective, randomized clinical trial comparing polytetrafluoroethylene and modified human umbilical vein for below-knee femoropopliteal bypass

Polytetrafluoroethylene (PTFE) (Gore-Tex) and human umbilical vein (Biograft) arterial grafts were compared for below-knee femoropopliteal bypass grafting in a prospective randomized clinical trial. One hundred five patients (105 limbs) entered the trial. Seventy-six percent suffered from rest pain, ulceration, or gangrene. The median postoperative ankle-arm blood pressure index was 0.36. Twenty-three limbs had three patent tibial arteries, 46 limbs had two tibial arteries, 31 limbs had one patent artery, and five limbs had isolated popliteal segments. Thirty-four percent were repeat operations. Fifty-five patients were allocated to receive PTFE grafts and 50 to receive human umbilical vein grafts. The two groups were comparable as to preoperative risk factors and operative and postoperative treatment. During the first 4 years (maximum 1609 days) 40 PTFE graft and 24 umbilical veins occluded. At 1 year the PTFE patency rate was 53% and at 4 years was 22%. For umbilical vein the corresponding figures were 74% and 42% (p = 0.005, Gehan test). During follow-up the incidence of PTFE failure was on the average 2.1 times higher than that of umbilical vein failure (95% confidence limits 1.2 to 3.4).

Traumatic Pseudoaneurysm in an In-Situ Femoro-Popliteal Bypass Graft — A Case Report

Anastomotic false aneurysm is a commonly reported complication of bypass surgery, but blunt trauma has been a rare etiologic mechanism. An unusual case of a traumatic false aneurysm arising in the distal anastomosis of an in-situ femoro-popliteal bypass graft is presented and the pathophysiology of the entity is discussed.

Four years' results of a prospective, randomized clinical trial comparing polytetrafluoroethylene and modified human umbilical vein for below-knee femoropopliteal bypass

Polytetrafluoroethylene (PTFE) (Gore-Tex) and human umbilical vein (Biograft) arterial grafts were compared for below-knee femoropopliteal bypass grafting in a prospective randomized clinical trial. One hundred five patients (105 limbs) entered the trial. Seventy-six percent suffered from rest pain, ulceration, or gangrene. The median postoperative ankle-arm blood pressure index was 0.36. Twenty-three limbs had three patent tibial arteries, 46 limbs had two tibial arteries, 31 limbs had one patent artery, and five limbs had isolated popliteal segments. Thirty-four percent were repeat operations. Fifty-five patients were allocated to receive PTFE grafts and 50 to receive human umbilical vein grafts. The two groups were comparable as to preoperative risk factors and operative and postoperative treatment. During the first 4 years (maximum 1609 days) 40 PTFE grafts and 24 umbilical veins occluded. At 1 year the PTFE patency rate was 53% and at 4 years was 22%. For umbilical vein the corresponding figures were 74% and 42% (p = 0.005, Gehan test). During follow-up the incidence of PTFE failure was on the average 2.1 times higher than that of umbilical vein failure (95% confidence limits 1.2 to 3.4).

Early experience with synchronous aorto-bifemoral and femoropopliteal bypass grafts

Over a three-year-period 51 concomitant aorto-bifemoral and femoro-popliteal reconstructions, using prosthetic materials below the inguinal ligament, were carried out in 39 patients, with both aorto-iliac and femoro-popliteal disease, presenting with severe lower limb ischaemia. Thirteen grafts were inserted for rest pain and/or gangrene, while 38 were performed for disabling claudication. There was no perioperative mortality. Cummulative patency for all femoro-popliteal grafts was 53% at 2 years. Limb salvage rates of 84.6% at 2 years were achieved in patients with critical ischaemia. These results suggest that synchronous aorto-bifemoral and femoro-popliteal reconstructions with prosthetic materials can be performed safely in selected patients with acceptable early patency and limb salvage rates.

SURGICAL TREATMENT FOR ARTERIOSCLEROTIC CARDIOVASCULAR DISEASES WITH MALIGNANT TUMOR

Cases of complication of arteriosclerotic cardiovascular disease and malignant tumor are increasing with the prolongation of patients' age and the progression of treatment for malignant tumor. From May 1985 to April 1986, we experienced seven patients with these lesions, all of when were male. Four patients had gastric cancer, two others had prostatic cancer and one had renal cancer. We have done total of ten surgical treatments in these patients: A-C bypass grafting (1 case), abdominal aortic aneurysmectomy (2 cases), thoracic aortic aneurysmectomy (1 case), aorto-femoral bypass grafting (4 cases) and femoro-popliteal bypass grafting (2 cases). All cases showed improvement, and there were no early or late deaths. To prolong life and improve its quality in these patients, surgical treatment should be done actively for arteriosclerotic cardiovascular disease as well as in cases in which a malignant tumor is present and is not in the terminal stage.

Sciatic artery aneurysms: Report of three cases and review of the literature

Sciatic artery aneurysms (SAAs) develop in a persistent sciatic artery, which is a congenital anomalous continuation of the internal iliac artery and may be the major blood supply to the lower extremity. SAAs may appear clinically with rupture, thrombosis, distal embolization, or compression of the sciatic nerve. We have reviewed our three cases and the literature to delineate those factors that permit correct preoperative diagnosis and appropriate surgical intervention. Our three patients (aged 54 to 82 years) appeared with severe ischemia that resulted in above-knee amputations. The literature reveals 21 patients ranging in age from 35 to 84 years (58% were women). Twenty of those patients had operations, one of which resulted in death, and five in above-knee amputations. Unexplained sciatic or buttock pain, or a palpable “pulsating” buttock mass, suggests an SAA. The diagnosis is confirmed by angiography. The recommended treatment is femoropopliteal bypass grafting followed by ligature or percutaneous endovascular thrombosis of the aneurysm. Early diagnosis and correct surgical therapy are the keys to successful management of SAA.

A saphenous alternative: Preferential use of superficial femoral and popliteal veins as femoropopliteal bypass grafts

Our experience with 100 superficial femoral and popliteal veins over a 12 year period has established a firm basis for their preferential use as femoropopliteal bypass grafts. Deep leg veins are currently used in two thirds of primary femoropopliteal bypass candidates. Groups identifiable preoperatively in whom results have been inferior include patients with excessively large grafts, black patients, and those with extremely poor runoff. Patients who will develop distal anastomotic hyperplasia, a fourth problem group, cannot be detected preoperatively but can be diagnosed and managed effectively. Disadvantages of superficial femoral and popliteal vein use include longer and more traumatic operations, increased early limb swelling, and the need for preoperative venography and postoperative arteriography to achieve optimum results. The most important advantage of preferential deep leg vein use is the high patency rate at 2 years with the expectation, already being realized, of significantly reduced intrinsic graft failures in the later years. Saphenous vein preservation constitutes a major additonal bonus.