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The preferred management of superficial femoral artery occlusive disease remains unresolved. The oldest technique for restoring vascular continuity, endarterectomy, has been largely replaced by bypass operations and percutaneous transluminal angioplasty. We have continued to perform semi-closed endarterectomy in selected cases and review here a series of 231 consecutive cases in 197 patients treated during the last 10 years. The indication for the endarterectomy was disabling claudication in 186 operations (80%), rest pain in 21 (9%) and gangrene in 24 (11%). The superficial femoral artery abnormality consisted of 1-10 cm occlusion in 52 cases (23%), > 10 cm occlusion in 96 (41%), single stenosis in 21 (9%), multiple stenoses in 28 (12%) and it was unknown in 34 cases (15%). Postoperative mortality was 0.8% with a complication rate of 10%. Five year cumulative primary patency was 71% overall, 75% in patients with disabling claudication, 61% in those with rest pain and 46% in those with gangrene. Eight year patency was 55% (S.E. 5.4%). No difference in 5-year cumulative patency was seen between treatment for stenosis or occlusion (74 and 70%, respectively). The results of earlier studies and the current study raise the question of whether endarterectomy should be the first treatment of choice in obstructive lesions of the superficial femoral artery. The results of endarterectomy are better than can be achieved with angioplasty and compare well with the results of femoropopliteal bypass. Endarterectomy has specific advantages above femoro-popliteal bypass: the autologous saphenous vein is spared for future use and in case of failure of the endarterectomy, femoro-popliteal bypass remains possible.(ABSTRACT TRUNCATED AT 250 WORDS)

There still is a need for an alternative to autologous vein especially for infra-inguinal vascular reconstructions. Since 1984 we have used a denatured venous homograft in patients in whom the saphenous vein was either absent or unsuitable. One hundred and five homografts were implanted in the femoro-popliteal and 51 in the femoro-infrapopliteal position. The results obtained were satisfactory, with a 5-year cumulative patency (life-table method) of 53% overall, 68.4% in patients with disabling claudication, and 42% in those with critical ischaemia. The cumulative aneurysm rate was rather high, at 18% after 3 years and 58% after 5 years. An excellent limb salvage rate of 85% was achieved in patients with critical ischaemia. The management of graft aneurysms and the indications for reconstructive surgery with a denatured venous homograft are discussed.

In order to evaluate the repercussions of failure of femoro-popliteal reconstruction undertaken for claudication the records of 219 patients with 251 femoro-popliteal conduits were reviewed. Autogenous Saphenous Vein graft (SV) was used in 109 limbs, Polytetrafluoroethylene graft (PTFE) in 101 and human umbilical vein graft (HUV) in 41. Primary patency rates after 3 years of follow-up of 72% for all grafts, 81% for SV-grafts, 84% for HUV-grafts and 59% for PTFE-grafts were calculated: the difference between SV-grafts and PTFE-grafts is statistically significant (P = 0.0047). Accordingly the authors advise against the use of PTFE-grafts in femoro-popliteal reconstruction. Including reinterventions secondary patency rates after 3 years of follow-up of 88% for all grafts, 86% for SV-grafts, 94% for HUV-grafts and 79% for PTFE-grafts were found: these differences were statistically not significant. Further analysis of the occluded grafts showed that in case of graft failure one or two re-operations are justified. The 12-months patency rate of reinterventions was 58%. Considering the life-expectancy and the natural history for the next five years of a patient with claudication the authors have become conservative towards femoro-popliteal reconstruction for claudication.