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Objective: To determine the long-term outcome of surgical repair of popliteal artery aneurysms (PAA)., Methods: A retrospective review of consecutive patients who underwent surgical PAA repair in two vascular surgery units between 1988 and 2006 was performed. Primary and secondary graft patency, limb salvage and patient survival rates were determined using Kaplan-Meier methods., Results: 48 patients underwent repair of 63 PAAs (ligation and bypass=45, interposition grafting=18). The 5-year primary graft patency, secondary graft patency, limb salvage and patient survival rates were 75%, 95%, 98% and 81%, respectively. The 10-year primary graft patency rates were significantly lower for emergency cases (59%) compared with elective cases (66%) (p=0.0023). Thirteen patients (16 PAAs) required a total of 20 late re-interventions. Duplex ultrasound was available in 33 of 45 PAAs treated by ligation and bypass. Five (15%) PAAs demonstrated perfusion of the aneurysm sac at median (range) follow up of 75 (1-246) months after primary repair and two of these required emergency re-operation., Conclusions: These data demonstrate that surgical PAA repair is associated with excellent long-term durability and provide an important benchmark with which to compare results of endovascular PAA repair. Patients treated using the ligation and bypass technique should be enrolled in an aneurysm sac surveillance program.

Aim: Infrainguinal bypass is an effective treatment for critical lower limb ischemia but up to 1/3 of these grafts will occlude within the 1st year. The aim of this audit was to evaluate the efficacy of aspirin in maintaining graft patency and also improving patient survival., Methods: In a single audited year (1997) 125 bypasses were carried out. Seventy-nine were on aspirin, 34 on no treatment and 12 were on other agents and hence excluded from analysis. The indication for surgery was critical ischaemia in 101 and disabling claudication in 12. Autologous vein was used in 104 and prosthetic grafts in 9., Results: The overall 2-year primary graft patency, secondary graft patency and limb salvage were 50%, 71% and 83%, respectively. The 2-year secondary patency in patients with or without aspirin was 73% and 64%, respectively (p<0.12-log rank test). The corresponding patient survival from vascular death in the 2 groups was 73% and 70% (p<0.67-log rank test). Crural/ pedal bypass (51/75 on aspirin) and smoking (51/61 on aspirin) were independent risk factors for graft failure and vascular death respectively whilst those with a previous myocardial infarct (21/28 on aspirin) reached significance in univariate analysis only (p< 0.03)., Conclusion: Aspirin was not a significant factor in preventing graft failure or vascular death in patients undergoing bypass for critical limb ischemia. Dual therapy with other antiplatelet agents needs to be considered in such patients particularly those undergoing crural/pedal bypass, smokers and those with a history of previous myocardial infarction.

Objectives: To establish the incidence of graft stenosis in a large population of patients undergoing femorodistal bypass procedures and to investigate the differences in incidence between individual surgical centres and other subpopulations., Patients and Methods: A total of 277 patients with femorodistal bypasses underwent duplex scanning of vein grafts for 12 months for the detection of graft stenoses. A standard definition of a significant stenosis was used in all twenty participating centres., Results: Overall stenosis rate was 27%. Stenoses were more common in composite vein grafts (43%) than in single segment vein grafts (25%) p=0.05. Stenoses were more common in female patients (38%) than males (22%) p=0.02. Stenosis rates in individual centres entering more than 20 patients varied from 9% to 56%. In a multiple regression analysis only aspirin use, sex and centre were significant factors predicting the likelihood of graft stenosis., Conclusion: Female patients, those taking aspirin and patients with composite vein grafts appear to be more at risk of graft stenosis, but this does not fully explain wide variations in the incidence of stenoses reported by individual centres., (Copyright 2000 Harcourt Publishers Ltd.)

Objective: There is evidence for superior patency in infra-inguinal bypass procedures in men compared to women. A large, prospectively planned series was investigated in order to confirm this finding and to determine the origin of this difference in outcome., Methods: Patients underwent femorodistal bypass surgery and a prospectively planned 12-month follow-up. Outcomes in male and female patients were compared and investigated for associations with characteristics of the patients and the surgical procedures., Results: A total of 517 patients received femorodistal bypass grafts, including 424 vein grafts and 93 prosthetic and vein-prosthetic composite grafts. Patency was confirmed to be higher in male than in female patients (56% vs. 42%, p=0.005). Fewer male patients received prosthetic or composite grafts (21% vs. 33%, p=0.005), but the difference in patency was evident only in patients receiving vein grafts. Female patients were smaller, included fewer smokers (p<0.001) and had worse symptoms (p=0.03), but none of these characteristics explained the difference in outcome. Patency in vein grafts was associated with graft diameter (p=0.004), but graft diameter was not significantly associated with sex (p=0.09) or with body size., Conclusions: It was confirmed that patency of femorodistal bypasses is significantly higher in males than females. None of the factors investigated here explain this difference, but the greater use of prosthetic and composite grafts in female patients suggests that poorer vein quality should be investigated as a possible source of the inferior outcome in female patients., (Copyright 2000 Harcourt Publishers Ltd.)

Objective: To investigate the relationship between bypass patency, limb survival and clinical symptoms after femorodistal bypass procedures., Design: Multicentre, prospectively planned 12-month postoperative follow-up., Patients and Methods: Five hundred and seventeen patients undergoing femorodistal bypass surgery for severe ischaemia. Clinical symptoms, bypass patency were recorded at regular intervals up to 12 months postoperatively., Results: Complete follow-up data was obtained on 498 patients (96%). Fifty-six (17%) of the 341 patients with patent bypasses had either rest pain or ulcers or had undergone major amputation at 12 months. Of the 167 patients with an occluded bypass, 22 patients (13%) had improved clinical symptoms and a total of 59 patients (35%) had avoided major amputation at 12 months. The clinical outcome for patients classified preoperatively as Fontaine stage IV was significantly worse than for those in stage III preoperatively despite similar bypass patency rates., Conclusions: There is a fair correlation between technical and clinical outcome after femorodistal bypass surgery at 12 months, but there are significant numbers of patients with occluded bypasses who have a good clinical outcome and of patients with patent bypasses who have a poor clinical outcome. The reporting of symptoms in addition to bypass patency would aid the interpretation of surgical results.

A double-blind, randomised, placebo-controlled trial was conducted to study the effect of the stable prostacyclin analogue iloprost on femoro-distal graft blood flow. After completing femoro-distal reconstruction, 3000 ng of iloprost or placebo was injected into the graft over 2 min. Graft blood flow, measured by electromagnetic flowmetry, increased by a mean (range) of 94% (12 to 192%) in patients receiving iloprost (n = 15) compared to 6% (-34 to 53%) in controls (n = 16; p less than 0.0001, t-test). Increased graft flow, measured by duplex ultrasound, was maintained in the iloprost group over a 7 day period postoperatively (F = 5.2, p = 0.03; analysis of variance) and remained higher at 7 days (p = 0.007, t-test). Iloprost produces an immediate, sustained increase in graft blood flow after femoro-distal reconstruction and may therefore be of benefit in reducing the incidence of early graft failure.