The multiple sequential distal bypass graft: Seven-year follow-up (original) (raw)
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The efficacy of salvage interventions on threatened distal bypass grafts
Journal of vascular surgery, 2015
Infrapopliteal bypass is an established and effective method for limb salvage in patients with critical limb ischemia. Secondary interventions maybe required to maintain graft patency. The aim of this study was to look at the frequency and outcomes of such interventions. Consecutive patients undergoing bypasses onto the infrapopliteal vessels for critical limb ischemia (Rutherford 4-6) at a single institution were analyzed between 2009 and 2013. The primary end points were graft patency, amputation-free survival (AFS), and freedom from reintervention at 12 months by Kaplan-Meier analysis. A total of 114 infrapopliteal bypasses were performed in 102 patients. Distal anastomosis was on to the anterior tibial (n = 31), posterior tibial (n = 27), peroneal (n = 24), tibioperoneal trunk (n = 23), or dorsalis pedis artery (n = 9). Primary patency, assisted primary patency, and secondary patency was 57%, 76%, and 82%, respectively, at 12 months and 44%, 70%, and 80%, respectively, at 36 mon...
Popliteal-to-Distal Bypass for Limb Salvage
Annals of Vascular Surgery, 2004
A retrospective study was carried out to examine the patency and limb salvage rates of poplitealto-distal bypass and compare the results of diabetic to those of nondiabetic patients and elective versus emergency procedures. From January 1990 to December 2001, 71 popliteal-to-distal bypasses were performed. Indications for surgery were rest pain, tissue loss, and acute ischemia, including extensive post-traumatic tibial lesions. Survival, graft patency, and limb salvage rates were determined according to the life-table method. The log-rank test was used to compare diabetic versus nondiabetic patients, elective versus emergency procedures, and saphenous vein bypass versus PTFE bypass. Postoperative primary patency, secondary patency, and limb salvage rates at 30 days were 88.7%, 91.4%, and 87%, respectively. Postoperative mortality was 2.8%, with one case of acute myocardial ischemia and one multiorgan failure. Lifetable analysis showed primary and secondary patency rates of 57% and 61%, respectively, a limb salvage rate of 64%, and survival of 77% at 5 years Log-rank testing showed no statistical difference between diabetic and nondiabetic patients, whereas a statistical difference was observed in elective versus emergency procedures (p < 0.005) and great saphenous vein versus PTFE graf (p < 0.05). These results show that popliteal-to-distal bypass is a safe and effective procedure with good long-term patency and limb salvage rates in selected cases.
Limb salvage after infrainguinal bypass graft failure
Journal of Vascular Surgery, 2004
The purpose of this study was to examine the outcome of patients in whom an infrainguinal bypass graft failed. Methods: This was a retrospective analysis of consecutive patients undergoing infrainguinal bypass grafting in a single institution over 8 years. Results: Six hundred thirty-one infrainguinal bypass grafts were placed in 578 limbs in 503 patients during the study period. The indication for surgery was limb-threatening ischemia in 533 patients (85%); nonautologous conduits were used in 259 patients (41%), and 144 (23%) were repeat operations. After a mean follow-up of 28 ؎ 1 months (median, 23 months; range, 0-99 months), 167 grafts (26%) had failed secondarily. The rate of limb salvage in patients with graft failure was poor, only 50% ؎ 5% at 2 years after failure. The 2-year limb salvage rate depended on the initial indication for bypass grafting: 100% in patients with claudication (n ؍ 16), 55% ؎ 8% in patients with rest pain (n ؍ 49), and 34% ؎ 6% in patients with tissue loss (n ؍ 73; P < .001). The prospect for limb salvage also depended on the duration that the graft remained patent. Early graft failure (<30 days; n ؍ 25) carried a poor prognosis, with 2-year limb salvage of only 25% ؎ 10%; limb salvage was 53% ؎ 5% after intermediate graft failure (<2 years, n ؍ 110) and 79% ؎ 10% after late failure (>2 years, n ؍ 15; P ؍ .04). Multivariate analysis revealed shorter patency interval before failure (P ؍ .006), use of warfarin sodium (Coumadin) postoperatively (P ؍ .006), and infrapopliteal distal anastomosis (P ؍ .01) as significant predictors for ultimate limb loss. Conclusion: The overall prognosis for limb salvage in patients with failed infrainguinal bypass grafts is poor, particularly in patients with grafts placed because of tissue loss and those with early graft failure.
International Journal of Surgery Open, 2019
Background: Peripheral occlusive arterial disease (POAD) is a steadily increasing global epidemic. Femoropopliteal bypass (FPB) is the traditional therapeutic option whenever endovascular treatments failed or not indicated. We present our experience in lower limb revascularization. Patients and methods: Prospective observational cohort single center study included 158 patients with intermittent claudication (IC) or critical limb ischemia (CLI). The patients were placed in 7 Rutherford categories & their angiographic findings were graded according to Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) criteria. The ipsilateral great saphenous vein was used for revascularization. Results: male patients were 113 (71.5%); female were 45 (28.5%). Age ranged from 39 to 77 years, with a mean of 60.7 ± 7.8 years. About 79.1% of patients were in the 6th & 7th decades. Only 26 patients (16.5%) had severe IC & 83.5% had CLI. Almost all patients with Rutherford category 3e6 had an ankle brachial index (ABI) less than 0.70. Most Femoropopliteal lesions (n ¼ 115, 72.8%)near half infrapopliteal lesions (n ¼ 74, 46.8%) were of TASC II B & C types. Majority of patients received a vein graft. Distally, 100 grafts (66.7%) were sutured below the knees whereas the remainder were either behind (n ¼ 31) or above the knees (n ¼ 8). The follow up ranged from 1 month to 11 years. One & 5 year patency rates of vein grafts were 88.7% & 70.2% respectively. Conclusions: FPB using saphenous graft yield a very good graft patency, low rates of amputation, morbidity and mortality. Long-term patency is excellent.
Long-term outcome of revised lower-extremity bypass grafts*1
Journal of Vascular Surgery, 2002
Purpose: Reversed lower-extremity vein grafts (LEVGs) frequently require operative revisions to maintain patency. Identifying grafts that are at risk, however, requires an intensive duplex scanning-based surveillance program. Excellent 5-year graft patency and limb-salvage rates have previously been reported in patients undergoing graft revisions, but results beyond 5 years are essentially unknown, a factor that is of importance in an increasingly aging population. This study was performed to determine the results of surgical revisions of LEVGs after a follow-up as long as 10 years. Methods: All patients undergoing placement of a LEVG were observed in a program of duplex scanning-based surveillance as long as the patient remained a candidate for graft revision. Grafts were considered for revision on the basis of the presence of focal areas of increased velocity, a prestenotic to intrastenotic velocity ratio more than 3.0, or uniformly low velocities throughout the graft. All lesions were confirmed with preoperative arteriography before revision. Assisted primary patency, limb-salvage, and survival rates were determined by means of Kaplan-Meier analysis in all patients who underwent LEVG revision from January 1990 to December 2000. Results: A total of 1498 LEVG procedures were performed during the study period. A total of 330 surgical graft revisions were performed on 259 extremities in 245 patients. The median follow-up period was 38 months. The assisted primary patency rate of all grafts, the limb-salvage rate for patients undergoing surgery for limb-salvage indications, and the survival rate of all patients were 87.4%, 88.7%, and 72.4%, respectively, 5 years after the original bypass grafting procedure, 85.7%, 83.4%, and 67.8%, respectively, 7 years after the original bypass grafting procedure, and 80.4%, 75.4%, and 53.4%, respectively, 10 years after the original bypass grafting procedure. A total of 180 revisions (55%) were performed during the first year, 110 (33%) between the first year and the fifth year, and 40 revisions (12%) were performed on grafts older than 5 years. LEVGs revised within the first year after bypass grafting had lesions within the graft in 78%, in the native arterial inflow in 10%, and in the native arterial outflow in 12%. This differed significantly from the location of lesions in revisions performed between 1 and 5 years and after 5 years (graft, 63% and 62%; inflow, 20% and 19%; outflow, 17% and 19%; P > .05, Chi-square). Conclusion: Excellent assisted primary patency and limb-salvage rates can be achieved for as long as 10 years in LEVGs that require revision, with only a 7% drop in overall patency and limb-salvage rates between the fifth and 10th years. Although most revisions were required within the first year, 34% were performed between the first year and the fifth year, and 11% after 5 years. These data support the growing body of evidence that favors an aggressive regimen of duplex scanning surveillance of LEVGs for the life of the graft. Revised grafts have excellent patency through 10 years.
Journal of Vascular Surgery, 2002
Background: To evaluate the efficacy of a modification of the composite sequential femorocrural bypass graft that we adopted in 1985, a retrospective case-note study was undertaken. The grafts combined a prosthetic femoropopliteal section with a popliteal to crural section with autologous vein, linked via a common intermediate anastomosis sited on the above-knee popliteal artery. Patients and methods: Between 1985 and 2000, 68 grafts of this type were constructed in 65 patients with critical ischemia of the lower limb and insufficient autologous vein for construction of an all venous bypass. Reasons for insufficient long saphenous vein included previous lower limb bypass in 33 cases, phlebitis in 16 cases, venous hypoplasia in eight cases, and previous varicose vein surgery in seven cases. Distal anastomoses were carried out to the peroneal artery in 26 cases, the anterior tibial artery in 17 cases, the posterior tibial artery in 17 cases, and the pedal arteries in eight cases. Sources of vein included the long saphenous vein in 26 cases, the arm vein in 38 cases, and the short saphenous vein in two cases. In 22 limbs (32%), angiography had shown an occluded segment of above-knee popliteal artery, and in these cases, local popliteal disobliteration was performed to receive the composite anastomosis and to provide additional outflow. Results: The 2-year cumulative primary patency, secondary patency, and limb salvage rates were 68%, 73%, and 75%, respectively. Localized popliteal disobliteration did not compromise graft patency (P ؍ .07, with log-rank test). Conclusion: In the absence of sufficient autologous vein, patients needing bypass to crural arteries can be offered reconstruction with composite sequential grafting with satisfactory results. Furthermore, an occluded above-knee popliteal segment is not a contraindication for composite sequential bypass reconstruction. (J Vasc Surg 2002;36:
Functional Outcome of Distal Bypasses for Lower Limb Ischemia
European Journal of Vascular and Endovascular Surgery, 2006
The purpose of this study was to assess limb salvage and functional outcome in patients who underwent distal reconstructions. Retrospective study. Fifty-nine consecutive patients underwent 63 femorodistal bypass operations during 1998-2002 at a university hospital. Late functional outcome was assessed using a questionnaire (mean 27 months after the primary operation). At the end of the study, 81% (30/37) of the surviving patients were alive with a viable limb. In all, 90% (27/30) of patients were living in their own homes and 3% (1/30) in a nursing home. Sixty percent (18/30) were able to walk independently. The walking distance was unlimited in 42% (13/31) and limited in 42% (13/31) of the operated limbs. In 16% (5/31) of cases, the treated limbs served only as a support. According to our results, the functional outcome of distal bypasses seems to be favourable. It is recommended that these operations should be performed even in elderly patients to avoid major amputations and to maintain the independence of the patient.
Meta-analysis of femoropopliteal bypass grafts for lower extremity arterial insufficiency
Journal of Vascular Surgery, 2006
Background: In femoropopliteal bypass surgery, the use of saphenous vein grafts is preferable, but synthetic grafts are widely used above the knee. The objective of this meta-analysis was to assess the long-term patency of femoropopliteal bypass grafts classified as above-knee polytetrafluoroethylene, above-knee saphenous vein, or below-knee saphenous vein. Methods: Studies published from 1986 through 2004 were identified from electronic databases and reference lists; 73 articles contributed 1 or more series that used survival analysis, assessed femoropopliteal bypasses in one of the foregoing configurations, reported a 1-year graft patency rate, and included at least 30 bypasses. The series with a predominance of claudicant patients were included in meta-analysis C, and the series in which critical ischemia predominated were included in meta-analysis CI. Pooled survival curves of graft patency were constructed. Results: In meta-analysis C, the pooled primary graft patency was 57.4% for above-knee polytetrafluoroethylene, 77.2% for above-knee vein, and 64.8% for below-knee vein at 5 years; there was a significant difference between above-knee grafts at 3, 4, and 5 years (P < .05). The corresponding pooled secondary graft patency was 73.2%, 80.1%, and 79.7%, respectively (P > .05). In meta-analysis CI, the pooled primary graft patency was 48.3% for above-knee polytetrafluoroethylene, 69.4% for above-knee vein, and 68.9% for below-knee vein at 5 years; there was a significant difference between above-knee grafts until 4 years (P < .05). The corresponding pooled secondary graft patency was 54.0%, 71.9%, and 77.8%, respectively, with a significant difference between above-knee grafts at 2, 3, and 4 years (P < .05).
Femoropopliteal tibial bypass: What price failure?
The American Journal of Surgery, 1982
The benefits of successful femoropopliteal or tibia1 bypass graft operation performed for limb salvage, incapacitating claudication, or popliteal aneurysm are well documented [I-9]. The objectives of this stcdy were to determine the impact of early graft thrombosis on perioperative mortality, length of hospitalization, and overall morbidity. Our particular concern was the possible worsening of preexisting lin: b ischemia by graft thrombosis to the extent that the potential prebypass amputation level would be raised as a consequence of a failed attempt at vascular reconstruction. Clinical Material All femoropopliteal and femorotibial bypass graft operations performed at UCLA Hospital during the decade from January 1970 to August 1980 were identified from the operating room log, which revealed that 235 operations were performed in 206 patients. Among these, 29 (14 percent) underwent nonconcurrent bilateral operation. The foll:)w-up rate was 100 percent at l'month and 96 percent 3 months after operation. 1:ldications for operation were limb-threatening ischemia, incapacitating claudication, and asymptomatic popliteal aneurysm. In order t.o establish homogeneous populations for analysis, the patients were separated int.o two primary groups based on whether or not the operation was performed for limb salvage. Those operated on for popliteal aneurysm were grouped with those operated on for claudica tion, inasmuch as their risk factors were similar. There were three categories of bypass graft operations based on the location of distal anastomosis: femoropopliteal (su
Long-Term Results of Distal-Origin Bypass After Prior Femoro-Popliteal Angioplasty
Annals of Vascular Surgery, 2010
Background: To investigate whether prior staged percutaneous transluminal angioplasty of the femoro-popliteal segment influences long-term results of distal bypass grafts. Methods: Between October 1987 and January 2009, 261 distal origin grafts for critical limb ischemia were performed at a single institution. A total of 223 grafts had angiographic no inflow lesions (ÀPA-group). Additionally, 38 grafts were performed staged within 30 days after percutaneous femoro-popliteal angioplasty (+PA-group) because of 28 TASC A (73%) and 10 TASC B (27%) lesions. Postoperative graft surveillance was performed at 3, 6, 12, and 18 months, then annually thereafter. Treatment groups were compared with KaplaneMeier analysis. Results: Follow-up ranged from 1 to 198 months (median, 34 months). The 5-year primary patency was 73% for the +PA-group and 62% for the ÀPA-group (p ¼ 0.20). Assisted primary patency for the +PA-group at 5 years was 80% and for the ÀPA-group was 70% (p ¼ 0.17). The corresponding secondary patency at 5 years was 84% for the +PA-group and 71% for the ÀPAgroup (p ¼ 0.12), respectively. Limb salvage and amputation free survival at 5 years were 84% and 46% for the +PA-group, and 81% and 37% for the ÀPA-group, respectively (p ¼ 0.57, 0.92). Bypass-threatening stenosis of the inflow-vessel was detected for four (10.5%) cases in the +PA-group and for 21 (8%) in the ÀPA-group. Conclusion: Long-term results of distal origin grafts performed after femoro-popliteal angioplasty because of TASC A and B lesions are comparable with those observed in distal origin grafts without proximal stenosis. Distal origin bypass grafting is not compromised by prior endovascular treatment of the inflow-vessel.