Tibial Bypass Research Articles

COMPOSITE SEQUENTIAL BYPASSES FOR MULUTI-SEGMENTAL ARTERIOSCLEROSIS OBLITERANS

A sequential arterial bypass has been recommended as the surgical treatment for severe lower limb ischemia in patients with complex multi-segmental arterial occlusion. To evaluate this alternative technique clinically, sequential grafting was performed on 14 limbs; 14 patients with the manifestations of intermittent claudication (2), rest pain (8) and nonhealing ulcers (4). Sequential aortofemoro-popliteal bypass grafting was performed on 7 limbs, ilio-femoro-popliteral bypass grafting on 3 limbs and femore-femoral crossover-popliteal bypass grafting and femoro-popliteral-posterior tibial bypass grafting on 2 limbs each. Among the 14 patients, one died in the perioperative period from cardicac arrest and another succumbed to renal failure 57 months after surgery. A total graft occlusion of the sequential graft occurred in two patients during the 57 month follow-up period. One patient (22 months after a sequential bypass) showed a symptomatic remission while undergoing a conservative therapy, but the another (7 months after operation) required an amputation below the knee. Measurement of the segmental Doppler arterial pressure revealed a significant increase in the ankle brachial index from 0.31±0.22 before the operation to 0.83±0.17 three weeks after the operation. Ten limbs showed a remission in the clinical symptoms, while 2 limbs showed no change during the 57 month follow-up period. Sequential bypass grafting is considered to be a useful alternative method for limb preservation.

Wound complications after in situ bypass

In situ saphenous vein bypass presents unique problems in wound management. A retrospective analysis of wound complications occurring after in situ bypass was undertaken in 93 patients who had 98 operations. For purposes of statistical analysis, only the first procedure was considered in patients having bilateral bypass. Fifty-nine percent of patients were male, the average age was 69 years. Medical risk factors surveyed included diabetes (64%), hypertension (52%), and smoking (53%). Ninety-one percent of the procedures were done for limb salvage; the mean ankle-brachial index was 0.43. Sixty percent of bypasses were infrapopliteal, and the mean duration of surgery was 4.6 hours. Continuous incision was used to expose the vein in 59% of cases. Skin closure was effected with staples in 44% and with sutures or both in the remainder. The mean postoperative hospital stay was 27 days. Wound problems developed in 31 cases; 11 of which were major. The thigh was the most common location. There was a significant association between continuous incision and anterior tibial bypass and wound complications. Anterior tibial bypass and staple closure were found to be independent predictors of wound problems with the use of stepwise logistic regression. Postoperative hospital stay was significantly prolonged; two bypasses failed and three lower extremities were amputated because of incisional complications. A discussion of the technical aspects of wound management is presented.

Wound complications after in situ bypass.

In situ saphenous vein bypass presents unique problems in wound management. A retrospective analysis of wound complications occurring after in situ bypass was undertaken in 93 patients who had 98 operations. For purposes of statistical analysis, only the first procedure was considered in patients having bilateral bypass. Fifty-nine percent of patients were male; the average age was 69 years. Medical risk factors surveyed included diabetes (64%), hypertension (52%), and smoking (53%). Ninety-one percent of the procedures were done for limb salvage; the mean ankle-brachial index was 0.43. Sixty percent of bypasses were infrapopliteal, and the mean duration of surgery was 4.6 hours. Continuous incision was used to expose the vein in 59% of cases. Skin closure was effected with staples in 44% and with sutures or both in the remainder. The mean postoperative hospital stay was 27 days. Wound problems developed in 31 cases, 11 of which were major. The thigh was the most common location. There was a significant association between continuous incision and anterior tibial bypass and wound complications. Anterior tibial bypass and staple closure were found to be independent predictors of wound problems with the use of stepwise logistic regression. Postoperative hospital stay was significantly prolonged; two bypasses failed and three lower extremities were amputated because of incisional complications. A discussion of the technical aspects of wound management is presented.

Avoiding Early Failure of Tibial Prosthetic Bypass Grafts

In a series of 97 tibial reconstructions using PTFE bypass grafts the value of perioperative anticoagulation was studied. Acetylsalicylic acid as well as low-dose heparin treatment resulted in a high graft failure rate during the first postoperative days (42%). Patency could be restored in half of the cases by simple thrombectomy. When heparin was given at a dose of 1000 I.U. per hour for two days the graft failure rate was 14%. Only one out of eight thrombosed grafts could be re-opened by thrombectomy. Long-term patency, however, was similar in both groups. We conclude that perioperative heparin treatment is a suitable method to avoid unnecessary thrombectomies of long prosthetic bypass grafts.

Effect of inflow and outflow sites on the results of tibioperoneal vein grafts

We have reviewed our experience with the tibial vessel bypass operation and have found the overall patency and limb salvage rates to be acceptable. Patients were divided into two groups based on the site of the proximal anastomosis. In Group I, the proximal anastomosis was at the common femoral artery and in Group II, the proximal anastomosis was at the distal superficial femoral artery or the popliteal artery. The patients in the the two groups were similar with regard to indications for operation, age, and sex. However, in Group I, 35 percent of the patients were diabetic and in Group II, 74 percent of the patients were diabetic. In the Group I patients, the 72 month graft patency rate was 65 percent with a limb salvage rate of 75 percent. In the Group II patients, the 72 month patency rate was 81 percent with a limb salvage rate of 89 percent. Some possible explanations for this slightly better result in Group II patients are discussed. All tibial bypasses were divided into three groups based on the recipient tibial artery. Analysis revealed that the 72 month patency rates were as follows: the anterior tibial artery 63 percent, the posterior tibial artery 81 percent, and the peroneal artery 80 percent. These differences were not significant but indicate, as others have recently pointed out, that the peroneal artery is indeed an acceptable recipient artery for tibial bypass surgery.

Factors affecting length of hospital stay for femoropopliteal bypass. Implications of the DRGs.

We compared the length of hospitalization of 329 patients undergoing femoropopliteal bypass during 1982 with that allowed under Medicare's diagnosis-related groups (DRGs) for major reconstructive vascular surgery (DRGs 110 and 111). The mean length of stay was found to be related to the patients' age, increasing at a rate of about 1 percent per year. The site of distal anastomosis, a factor not considered in establishing the criteria for these DRGs, was also important. The lengths of stay for above-the-knee popliteal, below-the-knee popliteal, and tibioperoneal anastomoses were significantly different (F = 3.31; P less than 0.05), with lengths of stay increasing for more distal anastomoses. More distal anastomoses were also associated with increased rates of postoperative morbidity, reoperation, and mortality. Significant differences were noted among the patients treated by different surgeons, with respect to their age, the percentage with previous ipsilateral surgery, the frequency of tibial bypass, and the rates of morbidity, reoperation, and mortality. The most highly qualified surgeons dealt with the sickest patients. We conclude that the DRG system does not take account of important variables influencing the length of hospitalization for femoropopliteal bypass, that it favors younger patients undergoing proximal bypass, and that it is biased against distal bypass for limb salvage.

Popliteal and Tibial Artery Bypasses for Limb Salvage

This is a report on personal experiences with 549 cases of popliteal and tibial artery revascularization. There were 204 cases of femoral-popliteal artery by pass procedures utilizing vein grafts. In 193 cases, this procedure was done with autogenous greater saphenous vein grafts. The remainder of the cases consisted of arm veins, bank veins and superficial femoral veins. There were 149 femoral- tibial or popliteal-tibial artery bypasses utilizing vein grafts or composite grafts. In 83 cases, tibial artery bypasses were done with autogenous greater saphenous vein grafts. In 30 cases, popliteal-tibial artery bypasses were done with autoge nous greater saphenous vein grafts. In 25 cases, femoral-popliteal-tibial artery sequential bypasses were done with autogenous greater saphenous vein grafts. The remainder were arm veins and composite grafts with arm vein, leg vein and graft materials. In 178 cases, femoral-popliteal or tibial artery bypasses were done with PTFE grafts. Of these cases, 157 femoral-popliteal bypasses were done with PTFE. Femoral-tibial artery bypasses were done with PTFE in 21 cases. In 18 cases, femoral-popliteal artery bypasses were done with biografts, utilizing human umbilical vein grafts. The sexual ratio in the total number of cases was 62% male to 38% female. The total number of cases was further divided into different groups. The cumulative patency rate of femoral-popliteal artery bypass, utilizing PTFE graft with distal anastomosis at above-knee level, was 90% at the third year. The femoral-popliteal artery bypass with autogenous greater saphenous vein graft had a patency rate of 84% at the fifth year. The patency rate of femoral-tibial artery bypass with autogenous greater saphenous vein graft was 68% at the fifth year. The femoral-popliteal-tibial artery sequen tial bypass, with autogenous greater saphenous vein graft, had a third-year patency rate of 80%. The popliteal-distal-tibial artery bypass, with autogenous greater saphenous vein graft, had a patency rate of 70% at the third year. These patients had been faced with major limb loss due to extremely poor distal run- off, and had been offered major amputation at one time. The patency rate of femoral-popliteal artery bypass, utilizing PTFE, combining both above and be low-knee level of distal anastomosis, was 85% at the third year. However, the femoral-tibial artery bypass utilizing PTFE graft had an extremely poor pat ency rate. At the third year, the patency rate was around 20%. The five year patency rate of femoral-popliteal artery bypass with PTFE graft was 75%, if the distal anastomosis was made at the above-knee level. The same graft, at the below-knee level, was 60%. The patency rate in five years was extremely poor for femoral-tibial artery bypass with PTFE graft. The five-year patency rate of femoral-popliteal-tibial artery sequential bypass, with autogenous greater saphenous vein graft, was 70%. The popliteal-distal tibial artery bypass graft, with autogenous greater saphenous vein graft, had a patency rate of 65% at the fifth year. The femoral-popliteal artery bypass with autogenous greater saphe nous vein graft had a patency rate of 70% at the eighth year. The femoral-tibial artery bypass with autogenous greater saphenous vein graft had a patency rate of 60% at the eighth year.

The need for arteriography in diabetic patients with gangrene and palpable foot pulses.

A group of five diabetic patients had gangrene or failed limited amputations and palpable foot pulses in a total of seven limbs. Because a failure to heal persisted and gangrene progressed, arteriography was performed and disclosed occlusion of all three infrapopliteal arteries. Tibial bypass grafting resulted in complete healing in four of the five patients. The fifth patient refused surgery and died with progressive sepsis. The incidence of this unusual syndrome is unknown, but presumably it is rare. The mechanism of pulse formation in the foot, despite occlusion of the infrapopliteal vessels, is dependent on good flow to the popliteal artery, collateral flow to the rigid distal tibial-peroneal vessels, compliant ankle arteries, and highly resistive distal foot vessels. Although healing of limited amputations is usual in diabetic patients with foot pulses, it is not universal. We recommend that arteriography be performed routinely if gangrene is present and the foot is salvageable, irrespective of pedal pulse status.

Gore-Tex autogenous vein composite grafts for tibial reconstruction.

The concept of composite grafts for revascularization of the ischemic lower extremity has been reported on numerous occasions. We have utilized this technique for approximately 8 years as an alternative for those patients who do not have an adequate length of autogenous vein for bypass grafting. We have studied composites utilizing Gore-Tex and umbilical vein for the prosthetic portion with autogenous saphenous vein, cephalic vein, or endarterectomized superficial femoral artery. Subsequent evaluation has led us to discontinue the use ofendarterectomized superficial femoral artery, as we believe that this is not a satisfactory autogenous component. Whenever possible, satisfactory angiograms are obtained prior to tibial bypass surgery; when this is not possible, intraoperative angiograms are utilized to demonstrate distal tibial circulation and to determine the site of distal anastomosis. Two, and sometimes three, operating teams are employed to minimize operating time, with one team constructing the prosthetic autogenous vein anastomosis on a separate table. Improved magnification, such as 21/2 • power magnification, is used in all cases. For the composite anastomosis and all tibial anastomoses, meticulous technique utilizing fine sutures in the form of 6-0 and 7-0 Prolene is stressed. The tibial vessels are handled in an atraumatic fashion using either vessel loops or intraluminal occluders and avoiding the use of clamps. We have stressed technique in harvesting the autogenous vein, utilizing atraumatic dissection, and irrigation of the graft with gradual distention not to exceed 100 mm Hg with a solution of heparinized autogenous whole blood containing papaverine. After harvesting, the grafts are stored in the same solution at 4 ° C. Following completion of the distal tibia] anastomosis, angiograms are performed in each case. No effort has been made to procure sufficient length of autogenous material to cover the crossing of the joint surface, as this has not proved a

Intraarterial streptokinase infusion for acute popliteal and tibial artery occlusion

Eight consecutive patients with acute thrombotic or embolic occlusion of the popliteal or tibial artery were treated with low-dose intraarterial streptokinase followed by arterial reconstructive surgery where appropriate. Three patients had acute thrombosis of a popliteal aneurysm with limbthreatening ischemia. All three were relieved of their acute ischemia by streptokinase infusion accompanied by lysis of clots in the popliteal artery outflow tract. Each patient then underwent elective popliteal aneurysm bypass. Four patients had acute embolic popliteal or tibial artery occlusion. Each was relieved of ischemic symptoms. One required surgery to remove residual clot. One patient with thrombosis of the tibioperoneal trunk did not have a decrease in symptoms with streptokinase infusion, but did experience sufficient outflow tract thrombolysis to permit construction of a tibial bypass with resultant restoration of normal circulation. Low-dose intraarterial streptokinase may be the treatment of choice for selected patients who present with thrombosis of a popliteal aneurysm with tibial vessel involvement or with embolic popliteal or tibial artery occlusion.

Objective analysis of factors contributing to failure of tibial bypass grafts

AbstractA retrospective study of 204 femoro‐tibial bypass procedures performed from 1979 through 1982 is reported. The effect of various parameters—patient age, graft material, type of bypass, bypass outflow, presence or absence of pedal arterial arches, and degree of preoperative ischemia as judged by the ankle—brachial index‐on tibial bypass patency was examined. The only obvious factor in graft failure was the type of graft material utilized, with autogenous saphenous vein grafts faring much better than the polytetrafluoroethylene (PTFE) grafts.

Distal tibial vein grafts for limb salvage.

Bypasses below the tibial peroneal trunk, which are not commonly performed, are an effective method of limb salvage. We have done long-term follow-up of all 148 consecutive grafts done during the past 19 years. By careful patient selection, detailed arteriograms, utilization of veins from all extremities, meticulous operating technique, and noninvasive follow-up, we have achieved a limb salvage rate of 75% and a cumulative five-year patency rate of 62%. Diabetics made up 53% of the series and did not affect the results. Seventy-one percent of all failures occurred in the first six months. Considering the charges for hospitalization, amputation, prostheses, and rehabilitation, distal tibial bypass procedures are cost-effective.

Femoropopliteal tibial bypass: What price failure?

The consequences of failure in 235 femoropopliteal and femorotibial operations are reviewed and compared with the benefits of success so that an accurate perspective of risk-benefit analysis can be achieved. In 72 operations performed for claudication, 10 grafts thrombosed early. The cost included nine reoperations to achieve eight patent grafts and a 12 day average increase in hospital stay. There were no deaths. The benefit obtained was 70 of 72 (97 percent) asymptomatic limbs. In 163 grafts placed for limb salvage, there were 58 initial thromboses. Reoperation in 28 produced an additional 14 patent grafts. The cost of thrombosis was an increase in mortality from 5.6 to 10.7 percent, a 12 day average increase in hospital stay, and raising of preoperative predicted amputation level from below to above the knee in 11 patients with thrombosed grafts whose distal anastomoses were below the knee. This contrasted with a 73 percent limb salvage rate in 104 patients whose preoperative predicted amputation level was below the knee, and a 54 percent limb salvage rate and a 12 percent lowering of amputation level in 39 patients whose preoperative amputation level was above the knee. Of patients with patent grafts, 89 percent achieved limb salvage. We conclude that the benefits of success in attempted vascular reconstruction for threatened limb loss far outweigh the risks of failure and that the combined results were far superior to the expected outcome in comparable patients undergoing primary amputation.

Further experience with the saphenous vein used in situ for arterial bypass

Ongoing experience with use of the saphenous vein in situ as an infrainguinal arterial bypass is presented. One hundred eighty-three bypasses were performed for limb-threatening ischemia, 92 of which were to the popliteal artery, either isolated or in continuity with one or more tibial vessels, and 91 bypasses were carried to single tibial vessels below the termination of the popliteal artery. The results were analyzed by the life table method and show an overall patency rate of 89.8 percent at 3 to 4 years. Separate life table analysis of the tibial bypass group showed a patency rate of 83 percent at 3 to 4 years. Special emphasis is placed on the ability to use veins less than 4 mm in diameter, which comprise 40 percent of those used in these procedures. The superior results provided by the in situ method are explained in part by experimental observations which show that endothelial stability is completely preserved by this method but is severely disturbed during the process of vein removal and reversal.

The use of arm veins in femoral-popliteal bypass grafts.

In view of the increasing debate as to the best alternative to saphenous vein for femoral popliteal bypass grafts, we present our experience with the use of arm vein grafts. Though there are many anecdotal reports, only one series has been previously published. Arm veins were used when saphenous vein was unavailable in 18 femoral popliteal or femoral tibial bypass grafts. Eighty-three per cent of the patients were diabetic. Ninety-four per cent of the patients were operated on for limb salvage, and in 67% the arteriograms showed only fair to poor run-off. Despite this, the one year patency rate was 82%, which is significantly better than the sixty-nine per cent one year patency rate reported by the senior author in an earlier series using cloth grafts. In view of these good results, we believe that autogenous vein remains the material of choice in femoral popliteal bypass grafts. We do not feel that expanded polytetrafluoroethylene grafts or umbilical vein grafts have yet been shown to be superior. We emphasize also the special techniques that are required when using arm veins.

Spontaneously Thrombosing Congenital Crural Arteriovenous Fistulas: Report of a Case

A report of spontaneously thrombosing arteriovenous fistulas in the popliteal and crural region jeopardizing the peripheral circulation is presented. A favourable effect was achieved with a femoral-posterior tibial bypass utilising a great saphenous graft.

Femoral tibial bypass grafts.

The results of 53 femoral to tibial artery bypass grafts have been reviewed. All were carried out in an attempt to salvage severely ischemic extremities which resulted from arteriosclerotic occlusive disease involving the femoral, popliteal, and tibial arterial systems as demonstrated by arteriography. Most grafts were done with autogenous vein; however, composite grafts comprised of a Dacron prosthesis and an autogenous vein and homologous veins were used in several patients. The initial salvage rate in these pregangrenous extremities was 74%. Fifty-two percent of the grafts remain patent at this writing, a period of 56 months in some instances. This study indicates that most patients with a severely ischemic extremity are candidates for revascularization and should have angiographic studies before amputation is considered.

Femorotibial bypass in patients with popliteal aneurysms

The application of distal tibial bypass grafting in patients with popliteal aneurysm and obliteration of the proximal vessels is presented. Success in these patients suggests that this procedure should be considered under these circumstances.