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Objective In the presence of long lesions, in patients with chronic limb threatening ischaemia, a femorodistal bypass is often the only option to avoid major amputation. This study investigated whether targeted bypass to the affected angiosome, according to the angiosome concept definition of direct (DR) and indirect revascularisation (IR), has an impact on wound healing, major amputation rate, and mortality. Methods A retrospective analysis was performed at Ghent University Hospital of 201 non-healing ischaemic wounds (Rutherford categories 5 and 6) requiring femorodistal bypass surgery in 177 patients (61% male, median age 69 years) with a follow up of 36 months. For every patient, the site of the ulcer, the type of bypass, and material were identified. Based on ulcer location and distal anastomosis, the legs were divided into DR and IR. Kaplan–Meier univariable analysis was used to estimate cumulative ulcer healing, leg salvage, survival, and patency. Results DR was performed in 103 legs (51%) and IR in 98 legs (49%), with no difference in comorbidity. The mean wound healing time was seven months. DR did not lead to a higher healing rate. The fastest healing rate was obtained when opting for a DR with an autologous greater saphenous vein (GSV; 90% at 12 months). Cryopreserved allografts also yielded good results, especially for wound healing after IR (85% at 12 months). Major amputation was performed in 28.5% after IR vs. 17.3% after DR (p = .071). There was no difference in mortality rate (36.8% [DR] vs. 41.3% [IR]) (p = .088). Autologous GSV had a longer primary patency, primary assisted patency, and secondary patency (26, 34, and 38 months, respectively) than cryopreserved GSV (12.5, 18, and 24 months, respectively) (p = .002, p = .003, and p = .018, respectively), with no difference between DR and IR. Conclusion Direct or indirect revascularisation performed according to the angiosome concept definition yields similar results with regard to healing rates, limb salvage, and mortality.

Below-knee femoropopliteal and femorodistal bypass with nonautologous material shows poor patency rates, especially in multiple occlusions of the tibioperoneal vessels. Twenty-four patients underwent arterial reconstruction for limb salvage using the deep leg veins because the great saphenous vein was not available owing to previous operations. A follow-up period of forty-two months revealed an average bypass patency rate of 75%. During the control period all patients were prospectively investigated concerning changes in the venous system. The authors found only little changes in the venous system and no significant signs of venous insufficiency. The deep leg veins seem to be a valuable addition to arterial reconstructive surgery for limb salvage.

Background: It has been shown that autogenous veins are associated with the best limb salvage rates for femorodistal bypass surgery. However, in emergency settings, when an autogenous vein is unavailable, use of synthetic graft material or amputation is a critical decision to make. Objective: To assess the appropriateness of femorodistal bypass grafts for acute limb ischemia in emergency settings. Methods: Patients who underwent emergent bypass and elective femorodistal bypass surgery between 1996 and 2006 were reviewed retrospectively in a single center. Results: There were 147 patients of which 84 had elective and 63 had emergent bypass. The graft patency rates for elective admissions were 44 and 25% vs. 25 and 23% for admissions for acute femorodistal graft surgery at 2 and 4 years, respectively (p < 0.004). Admissions for acute ischemia who were treated with prosthetic grafts had a primary patency of 24 vs. 27% for vein grafts at 2 years and 24 vs. 23% at 4 years (p = 0.33). In the acute femorodistal grafts group, primary patency at 2 years for vein and prosthetic grafts was 27 and 24% as compared to 42 and 32% for electives. These values for cumulative limb salvage rates for elective bypasses were 73 and 63% as compared to 52% at both time points in the acute femorodistal graft group (p < 0.004). In emergency settings, the limb salvage rate for acute femorodistal bypass with prosthetic grafts was 38%, and for vein grafts it was 62% at both time points (p = 0.08). Conclusion: The long term limb salvage rate of 38% suggests that emergent femorodistal revascularization is worthwhile. Contexto: Já foi mostrado que veias autógenas estão associadas às melhores taxas de salvamento de membros para a cirurgia de bypass femorodistal. No entanto, em cenários de emergência, quando não há uma veia autógena disponível, é crítica a decisão entre o uso de material de enxerto sintético ou a amputação. Objetivo: Avaliar a adequação de enxertos femorodistais para isquemia aguda de membros em cenários de emergência. Métodos: Pacientes submetidos a cirurgia de bypass de urgência e cirurgia de bypass femorodistal eletiva entre 1996 e 2006 foram retrospectivamente revisados em um único centro. Resultados: Havia 147 pacientes, dentre os quais 84 haviam sido submetidos à cirurgia de bypass eletiva e 63 à cirurgia de bypass de urgência. As taxas de patência dos enxertos para internações eletivas foram 44 e 25% versus 25 e 23% para internações para cirurgia aguda de enxerto femorodistal a dois e quatro anos, respectivamente (p < 0,004). Internações por isquemia aguda que foram tratadas com enxertos prostéticos tiveram patência primária de 24 versus 27% para enxertos venosos a 2 anos e 24 versus 23% a 4 anos (p = 0,33). No grupo de enxertos femorodistais agudos, patência primária a 2 anos para enxertos venosos e prostéticos foi de 27 e 24%, comparado a 42 e 32% para eletivas. Esses valores para taxas de salvamento de membros em bypasses eletivos foram 73 e 63%, comparadas a 52% em ambos pontos no tempo para o grupo de enxerto femorodistal agudo (p < 0,004). Em cenários de emergência, a taxa de salvamento de membros para bypass femorodistal com enxertos prostéticos foi de 38% e para enxertos venosos a taxa foi de 62% em ambos pontos no tempo (p = 0,08). Conclusão: A taxa de 38% para salvamento de membros a longo prazo indica que a revascularização femorodistal de urgência é vantajosa.

Objectives The purpose of this study was to assess limb salvage and functional outcome in patients who underwent distal reconstructions. Design Retrospective study. Materials and methods 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). Results 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. Conclusions 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.

The greater saphenous vein is assessed as part of the workup for femorodistal bypass surgery in our unit. The aim of this study was to determine whether the minimum internal diameter (MID) of the vein predicted graft patency and limb salvage in femorodistal bypass surgery, independently of the quality of the runoff. A consecutive series of 67 infrainguinal vein bypass grafts were performed on 62 patients with critical lower limb ischemia. All were followed for at least 1 year. The MID of the greater saphenous vein was calculated from preoperative saphenograms, and all of the arteriograms were scored for their runoff using an ad hoc method approved by the Society for Vascular Surgery. The cumulative patency of all vein grafts at 3 years was 59 ± 7% (SE), and the limb salvage was 85 ± 5%. All femoropopliteal bypass grafts were patent at 3 years if the MID of the vein was greater than 3.0 mm. The crural bypass patency was 66 ± 12% for an MID greater than 3.0 mm and only 27 ± 12% for an MID less than 3.0 mm. Every extra point on the runoff score increased the hazard of bypass failure by 16% (95% CI 1.0–34; p < .05). Vein diameter and runoff score were independent of one another ( r2 = -.106). The MID of the greater saphenous vein is a major determinant of outcome in infrainguinal vein bypass surgery independent of the arterial runoff.

Purpose: To compare long-term patency and limb survival rates for the classical in situ surgical bypass procedure versus a minimally invasive technique for femorodistal revascularization. Methods: From May 1992 to June 1994, a prospective multicenter study was undertaken at 4 centers to evaluate the open versus closed technique for femorodistal bypass grafting. Of 97 patients enrolled in the trial, 73 patients (49 men; mean age 71 years) were assigned to the long-term follow-up protocol and prospectively randomized to the open (n = 38) or closed (n = 35) procedure. The classical open technique is characterized by a long incision over the length of the bypass graft, while the minimally invasive procedure involves only two short incisions over each anastomosis site (the side branches are closed with a coaxial embolization catheter system). Graft patency was evaluated with duplex imaging periodically throughout the 4-year observation period. Results: There was no statistically significant difference between the treatment groups with respect to age, sex, hypertension, ischemic heart disease, or smoking. However, the open group had a significantly greater incidence of diabetes (p = 0.037). Over a median 4.7-year follow-up (range 0.3–6.4), 9 (12%) patients (3 open and 6 closed) were lost to follow-up: 2 died and 7 refused the duplex examination. No significant differences in 4-year patency, limb salvage, or survival was demonstrated between the open versus closed treatment groups; 4-year secondary patency was 62% versus 64%, respectively, and limb salvage was 72% versus 86%. Conclusions: The closed technique for femorodistal in situ bypass procedures yields favorable long-term outcomes compared to the traditional open technique.

Femorodistal bypass using exclusively PTFE is known to have a poor prognosis, mostly because of the development of myointimal hyperplasia (MIH). Several vein patch techniques are established but the role of hemodynamics within the anastomotic site has only been explained insufficiently and is hardly considered clinically. In a prospective study, between 6/1992 and 7/1998 129 patients (89 m/40 f, mean age 65.2 +/- 10.0 years) with critical limb ischemia and no usable saphenous vein were included to undergo femorodistal ePTFE bypass grafting with a new, hemodynamically optimized distal end-to-side anastomosis. Patients were followed at 6-month intervals with clinical investigation and color-coded Doppler sonography. Primary and secondary graft patency (PPR, SPR), limb salvage, and patient survival were calculated according to Kaplan-Meier. With a median follow-up of 45 (range 6 to 72) months, PPR and SPR at 1, 3 and 5 years were 63.0, 35.7 and 27.6% and 74.5, 44.8%, and 37.6%, respectively. Limb salvage at 1, 3 and 5 years was 86.4%, 78.7% und 73.2%. There was no perioperative mortality. Graft infection occurred in 7 patients (5.2%). ePTFE bypass grafting represents a valuable option for infragenicular and crural reconstruction in the absence of autologous vein. The new anastomotic design was feasible and represents another adjunct to possibly improve patency of femorodistal bypass allografts.

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.

Objectives to analyse graft patency and limb salvage following femorodistal bypass with ePTFE using a new distal anastomotic technique. Design prospective non-randomised study. Material and methods one hundred and twenty-nine patients (M:F; 2.23:1; mean age 65.2±10.0 years) underwent 135 operations for severe limb ischaemia. The new anastomosis, constructed entirely from ePTFE, was attached to the popliteal (21), anterior (46) and posterior (52) tibial, and peroneal (16) arteries. Cumulative primary (PPR) and secondary patency rates (SPR), limb salvage and survival were analysed using the Kaplan–Meier method. Results median follow-up was 45 (range 6 to 72) months. There was no perioperative mortality. PPR and SPR at 1, 2, 3, 4, and 5 years were 63.0%, 44.9%, 35.7%, 33.1% and 27.6% and 74.5%, 55.2%, 44.8%, 43.0%, and 37.6%, respectively. Cumulative limb salvage was 86.4%, 78.7%, and 73.2% at 1, 3, and 5 years, respectively. Conclusions this new anastomotic design was feasible and resulted in acceptable long-term results.

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

Free flap transfer is a technically feasible adjunct to wound healing in tissue loss in vascular reconstructive surgery. The authors present the case of a 68-year-old diabetic who underwent successful femorodistal bypass and free flap transfer on both of his legs with successful bilateral limb salvage at 25 and 17 months, respectively.

Resumen Objetivo Analizar los resultados obtenidos a largo plazo (4 anos) de las derivaciones fe'moro-distales a tronco unico en la isquemia critica de la extremidad comparando permeabilidad y tasa de salvamento segun vaso receptor. Metodo Estudio de 102 derivaciones femoro-distales en 94 pacientes (66 varones, 28 mujeres), con una edad media de 70 anos (r=43-92). Criterios de inclusion: isquemia critica de la extremidad, anastomosis proximal en femoral comun, un unico vaso distal permeable (42 arteria peronea, 39 tibial anterior, 21 tibial posterior), y que el injerto utilizado fuera vena safena (82 casos valvulotomizada, 20 casos invertida). Se han realizado tablas de contingencia mediante x 2 o t de Student para comparar los grupos entre si. La permeabilidad y la tasa de salvamento se evaluaron mediante Kaplan-Meier (test de Log-Rank). Tambien se determino el numero de amputaciones menores asociadas a cada grupo. Resultados A 4 anos, la permeabilidad global de los injertos fue del 42% (45% tibial anterior, 44% tibial posterior, 41% peronea), sin existir diferencias significativas entre los 3 (Log rank=0,51). El salvamento global de la extremidad fue del 58% (55% tibial anterior, 54% tibial posterior, 59% peronea), sin diferencias significativas (Log rank= 0,5). El numero de amputaciones menores asociadas fue mayor cuando el vaso receptor era la arteria peronea (p=0,007) Conclusiones La arteria peronea como receptora de una derivacion femoro-distal es util en el salvamento de miembros inferiores. Existe un mayor numero de amputaciones menores asociadas cuando el vaso receptor es la arteria peronea.

Since a significant number of patients do not have suitable autologous saphenous vein for femorodistal bypass, the search for alternative graft material continues. The most commonly used prosthetic material is Polytetrafluoroethylene, however because of the poor patency of these grafts in the below knee position, a variety of techniques have been tried to improve their patency. A series of studies utilizing venous cuffs at the distal anastomosis have showed improved patency of PTFE grafts. We have reviewed the biological basis for graft failure and the literature for possible mechanical explanations.

Arterial variations of distal parts of lower extremities are well-documented and can be demonstrated with the help of Doppler ultrasound or by arteriography. However, absence or variation of posterior tibial artery is considered a rare finding. We present a case of hypoplastic posterior tibial artery that terminated by supplying soleus muscle. The variant arterial supply to the sole was provided by the enlarged peroneal artery that continued as the lateral plantar artery. The awareness of these variations is important to vascular surgeons while performing arterial reconstructions in femorodistal bypass graft procedures, and also to orthopedists during surgical clubfoot release. Variações arteriais de partes distais dos membros inferiores estão bem documentadas e podem ser demonstradas com o auxílio de ultra-sonografia Doppler ou por arteriografia. Entretanto, a ausência ou variação da artéria tibial posterior é um raro achado. Apresentamos um caso de artéria tibial posterior hipoplásica que terminava suprindo o músculo solear. Esse suprimento arterial variante foi fornecido pela artéria peroneal aumentada que continuava como artéria plantar lateral. Estar consciente dessas variações é importante para cirurgiões vasculares ao realizarem reconstruções arteriais em procedimentos de derivação femorodistal, bem como para ortopedistas durante correção cirúrgica do pé torto.

Objectiveto investigate the relationship between bypass patency, limb survival and clinical symptoms after femorodistal bypass procedures.Designmulticentre, prospectively planned 12-month postoperative follow-up.Patients and methodsfive 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.Resultscomplete 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.Conclusionsthere 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.

The authors present a retrospective study on 30 patients with prosthetic graft infection. Included are 25 patients with aortic graft infection, three with infection of a femorodistal bypass and two with infected axillofemoral grafts. There were 23 isolated primary prosthetic graft infections and seven aorto-enteric fistulas. Treatment consisted of graft excision and replacement with cryopreserved arterial homografts, harvested from brain-death multi-organ donors. The in situ technique was used in 27 cases. Eight patients died postoperatively and two deaths were from allograft related complications. The operative mortality rate was 11% for isolated aortic graft sepsis and the early limb salvage rate was 100%. Persistent or recurrent infection was noted in two cases. The mean follow-up of the series was 24.5 months and occlusive complications occurred in five patients (23%), which resulted in two major amputations. Serial CT scans showed abnormalities in six of the 22 survivors, all of them related to the aortic segment of the allograft. It is concluded that in situ reconstruction with cryopreserved arterial allografts represents an acceptable alternative, especially in the treatment of isolated aortic graft sepsis. Continued follow-up towards late deterioration and/or occlusive complications remains mandatory.

Objective: To determine whether infrainguinal bypass surgery is worthwhile in patients with critical limb ischaemia (CLI) and chronic renal failure. Design: Longitudinal observational study. Materials and Methods: Twenty-two patients with moderate renal failure indicated by serum creatinine level above 150 μmol/l, 10 patients with end-stage renal disease requiring dialysis, and three patients with functioning kidney transplant, underwent 39 bypass procedures for critical limb ischaemia. Results: Six femoropopliteal, 14 femorocrural and 19 femoropedal bypasses were performed. The immediate, 1-month, and 1-year primary patency rates were 97%, 84%, and 70%, respectively. The limb salvage was 93% at 1-month and 72% at 1-year follow-up. One-year patency and leg salvage rates were 81% and 79% in non-dialysis patients, and 47% and 37% in dialysis patients. At 1-year follow-up, 55% of surviving patients had salvaged limbs. None of the patients in dialysis was alive with salvaged legs 4 months after revascularisation. Among preoperative risk factors, only serum creatinine showed a statistical significance in predicting leg salvage and survival. Conclusions: As the outcome of patients on dialysis is very poor after infrainguinal bypass grafting, revascularisation is seldom indicated. On the contrary, leg salvage can achieve good results in patients not requiring dialysis.

The purpose of this prospective randomized multicenter study is to compare patency for a new carbon-impregnated polytetrafluoroethylene (PTFE) graft and standard PTFE grafts. One hundred and sixty patients presenting severe chronic ischemia of the lower extremity were recruited at 17 centers of the French Association Universitaire de Recherche en Chirurgie. Eighty-one carbon-impregnated graft and 79 standard grafts were implanted. The procedure consisted of below-knee femoropopliteal bypass in 83 cases and femorodistal bypass in 77 cases. The minimum duration of the follow-up period was 2 years. Twenty-four patients died during the study. The actuarial primary patency rate, actuarial secondary patency rate, and limb salvage rate were 45%, 53%, and 57% respectively in the carbon-impregnated PTFE group and 35%, 36%, and 47% respectively in the standard PTFE group. The carbon-impregnated graft appeared to achieve better patency than the standard graft but the difference was not statistically significant. Since there was no difference up to 12 months, the study will be continued to determine if further follow-up confirms these findings. In this study we also assessed factors contributing to patency of below-knee prosthetic bypass grafts. Only two factors had a significant influence on patency, i.e., ankle/arm pressure difference greater than 0.25 as opposed to ankle/ arm pressure difference less than 0.25 (p < 0.01) and below-knee femoropopliteal bypass as opposed to femorodistal bypass (p < 0.001). (Ann Vasc Surg 1997; 11:596-603.)

Objectives: There is continued controversy over whether a failed distal bypass influences the level of amputation. This issue is important as the number of arterial bypass grafts undertaken for critical ischaemia is increasing, followed by an increasing number of failed grafts. Setting: Teaching hospital. Study design and materials: A prospective analysis of 109 consecutive femorocrural/pedal bypass grafts performed between June 1991 and January 1995 on patients presenting with severe critical lower limb ischaemia (CLI) to a single vascular unit. A further 43 amputations for non-reconstructible distal disease were also analysed. Chief outcome measures: Mortality, amputation, rehabilitation, survival and knee salvage rates. The Kaplan-Meier method was used for comparison of factors associated with knee preservation. Results: Primary amputees had a higher in-hospital mortality (18% vs. 10%) but similar 3 year survival rates (30%) compared with secondary amputees (36.6%). Patients with successful grafts showed a trend towards better survival (61.9% at 3 years) compared to amputees (38.6% at 42 months, p = 0.061). Below- to above-knee amputation ratio was similar in the two groups (0.85 in secondary vs. 0.95 in primary amputees). Factors significantly associated with knee salvage at 3 years were shown to be: the condition of the inflow (81.9% for good vs. 43.1% for impaired, p = 0.000) the state of the profunda femoris artery (good 93%, impaired 71%, occluded 37% p = 0.0001) and the graft material (vein 81.8% vs. PTFE 59.8%, p = 0.033). The presence of tissue loss ( p = 0.0523) and secondary procedures ( p = 0.0879) showed a trend to become significant. Multivariate and Cox regression analysis showed that the most important factors were the inflow ( p = 0.001), the state of the profunda ( p = 0.001), the graft material ( p = 0.034) and previous revascularisation attempts ( p = 0.019). Conclusions: The factors which determine knee loss are a compromised inflow state, the presence of an inadequate profunda femoris, previous revascularisation attempts and the use of synthetic graft material. Most of these factors (with the exception of infection related to revascularisation) are present before reconstructive arterial surgery is performed and this study shows that failure of a distal graft does not affect the final amputation level.

Objective:To determine the effect that revascularising chronic critically ischaemic legs has no neutrophil activation and adhesion.Design:Prospective clinical study.Setting:University Hospital.Materials:Twenty-five patients, 16 men and nine women undergoing femorodistal surgery.Chief outcome measures:Venous blood assays for neutrophils expression of CD11b, neutrophil adhesion, and the plasma concentration of the shed endothelial adhesion receptor, soluble intracellular adhesion molecule 1 (sICAM-1). Urinary microalbuminaemia was measured and expressed as an albumin/creatinine ratio (ACR), as a marker of vascular permeability and plasma neutrophil elastase as evidence of neutrophil activation. Venous blood was taken preoperatively, during surgery and for the first 7 days postoperatively.Main results:Neutrophil CD11b expression fell following reperfusion of the limb (21.4 mcf to 9.7 mcf, p

Input impedance describes the relationship between pressure and flow in a vascular system and, hence, characterizes the outflow bed. The purpose of this investigation was to measure input impedance spectra in vascular reconstructions of skeletal muscle, renal, and mesenteric beds. Input impedance was measured in 107 vascular reconstructions in 96 patients. Reconstructions were performed at the aortofemoral/aortoiliac (AF, n = 20), femoropopliteal (FP, n=18), femorodistal (FD, n=41), infrapopliteal-inframalleolar (IM, n = 6), renal (REN, n = 16), or mesenteric (MES, n= 6) level. Grafts were constructed from autologous vein in all cases except AF bypasses in which bifurcated woven Dacron grafts were employed. Input impedance was measured intraoperatively after reperfusion. For impedance calculation, simultaneously acquired intraluminal pressure (transducer-tipped pressure catheter) and blood flow (electromagnetic probe) waveforms of ten-second duration were digitized at 200 Hz and subjected to Fourier transformation in near real-time. AF grafts exhibited the highest blood flow (443 ± 72.8 mL/minute) followed by MES (300 ± 30.4), REN (172 ± 43.9), FP (91.6 ± 20.0), FD (59.3 ± 5.09), and IM grafts (22.4 ± 5.44 mL/minute). A similar (inverse) trend was observed with respect to resistance (Rin), ie, MES≈AF3 dyne•s•cm-5). As expected, AF grafts exhibited the lowest characteristic impedance (Z0 3.5 ± 0.8 x 103 dyne•s•cm-5). However, the Z0 of REN (20.2 ± 3.7 x 103 dyne•s•cm-5) grafts exceeded that of FP and MES grafts (10.5 ± 1.1 and 12.4 ± 4.0 x103 dyne•s•cm-5) and more closely approximated that of FD (22.2 ± 2.2 x 103 dyne•s•cm-5). The highest Z0 was seen in IM grafts (42.1 ± 15.8 x 103 dyne•s•cm-5). Therefore, the highest ratios of Z0/Rin were observed with MES (0.75 ± 0.23) and REN (0.33 ± 0.04) grafts as compared with the other groups (AF 0.23 ± 0.03, FP 0.12 ± 0.13, FD 0.19 ± 0.02, IM 0.16 ± 0.06). As expected, Rin of vascular reconstructions follows the general trend of MES ≈ AF < REN < < FP < FD < < IM. However, examination of the high-frequency components of the impedance spectra reveals that Z0 follows a different pattern, AF < FP MES < FD ≈ REN < < IM and the ratio of ZO/Rin is highest in REN and MES vascular beds compared with skeletal muscle beds. Thus, although the REN and MES beds are “privileged” (ie, maximally dilatated with low arteriolar tone), the intrinsic properties of the graft and larger blood vessels are no different than those of a femorodistal bypass.

The quality of distal run-off is one of the most important factors in determining outcome of femorodistal bypass. Accurate evaluation is important. Preoperative intra-arterial digital subtraction angiography and Doppler evaluation with pulse-generated augmentation of 90 patients who underwent femorodistal reconstruction were compared with postoperative angiography. Underestimation of distal run-off of the calf vessels occurred in 33% of cases by preoperative intra-arterial digital subtraction angiography. A below-knee pulse-generated run-off score of 3 or less was associated with a 12-month cumulative patency of 73% compared with 85% with a below-knee pulse-generated run-off score of 4 or more (P=0.079, log rank test; P =0.060, Wilcoxon signed rank test). The 12-month cumulative patency for grafts with a complete, incomplete and occluded arch as defined by pulse-generated run-off was 78, 90 and 38% respectively (P

Aims: To objectively assess the quality of life after femorodistal bypass and compare this to quality of life achieved following primary limb amputation. Design: Retrospective review. Setting: Leicester Royal Infirmary, U.K., 1988–1993. Methods: A self-assessment postal questionnaire containing scales measuring emotional disorder, social functioning and mobility was sent to 112 patients who had previously undergone femorodistal bypass (n = 86) or primary limb amputation (n = 26). Results: Further analysis demonstrated that a secondary procedure (PTA or graft revision) to maintain graft patency did not adversely affect quality of life. Additionally, patients undergoing secondary amputation after graft failure had an identical quality of life to those undergoing primary amputation. Conclusions: These data illustrate that the quality of life after successful femorodistal bypass is higher than after primary or secondary amputation. To attain the maximum quality of life in patients with critical ischaemia, femorodistal bypass should be performed wherever feasible.

Objectives: To examine the changing relationship between general and vascular surgical workload on a vascular “firm”, over a 6-year period. Design: Retrospective review. Setting: Leicester Royal Infirmary and Professorial Surgical Unit, U.K. 1987–1992. Method: Analysis of audit of all surgical admissions. Relation of vascular surgery to general surgery. Results: There has been a slight decrease (5%) in the number of general surgical elective admissions. Overall, the number of general surgical admissions, both elective and emergency, show a slight increase of about 3%. In contrast the number of vascular admissions increased by 42%. Of the general surgical procedures carried out 75.9% were either minor or intermediate, whereas 92.5% of vascular procedures were coded as major or higher. There has been a three times increase in the number of carotid endarterectomies, a similar increase in the number of the femorodistal bypass grafts and a halving of the number of major amputations. There has also been a five times increase in the number of angioplasties carried out. Conclusions: Our figures show the progressive, rapid increase in vascular surgical workload, compared to general surgery, and the need for the continued expansion of vascular surgery as a speciality.

Routing a bypass through a bony structure in a transverse direction during femorodistal bypass procedures has been previously reported. This paper describes a patient who needed a crural revascularisation, but a normal passage through a deep or superficial route was not possible because of the circumferential ossification of the lower left leg muscles as a result of trauma 7 years earlier. The long saphenous vein in the left leg had been used for an earlier reconstruction, ruling out an in-situ graft. A limb saving bypass to the distal posterior tibial artery was performed through an intra-medullary tibial route.

Calf vessel continuity with an intact pedal arch is an important factor in femorodistal (FD) bypass for critical ischaemia. Pulse generated runoff (PGR) was used in combination with the pedal arch patency test of Roedersheimer to determine preoperatively calf vessel and pedal arch patency. Three pedal arch groups were identified; complete (two calf vessels in continuity), incomplete (one vessel) and occluded (no vessels). One hundred non-reversed FD grafts were performed for critical ischaemia (63 men and 37 women), median age 72 (range 43-89 years). Sixteen grafts were to the above knee popliteal artery, 36 to the distal popliteal, three to the tibioperoneal trunk and 45 to a single calf vessel. There were 25 complete, 64 incomplete and 11 occluded pedal arches. The overall primary patency rate was 73%, nine grafts were successfully revised giving a secondary patency rate of 83.5%. The secondary graft patency rates for the above knee popliteal, below knee popliteal, tibioperoneal and single calf vessel grafts were 100, 92, 66 and 66% respectively. The 1 year graft patency rates for grafts to a complete, incomplete and occluded pedal arch were 88, 75 and 9% respectively (Lee-Desu p0.01). Similar results were obtained for limb salvage; 100, 84 and 24% respectively (p0.01). These results confirm the value of PGR in the preoperative assessment of patients with critical ischaemia. In reconstructions to the popliteal artery, PGR derived pedal arch status does not appear to influence the outcome. By contrast PGR derived pedal arch status in an excellent predictor of success following reconstructions to a single calf vessel.(ABSTRACT TRUNCATED AT 250 WORDS)

The aim of this study was to assess intraoperative transit-time volume flow measurements (VFMs) as a tool for intraoperative evaluation of lower extremity arterial bypass grafts and to predict their patency. We analyzed 273 consecutive patients who had an infrainguinal bypass procedure using the great saphenous vein from 1998 until 2008; 103 had an intraoperative VFM. All intraoperative revisions were recorded and analyzed. Patency and revision rates were compared between those receiving and those not receiving intraoperative VFM. Cox regression was used for analysis of predictors of patency. Primary patency at 1 and 2 years was 75 and 67%, respectively, in patients receiving intraoperative VFM versus 72 and 69% in those without VFM ( p = .79). In the VFM group, 12% had an immediate revision versus 6% without VFM ( p = .06). In the VFM group, 4% underwent revision to salvage the bypass within the first postoperative 30 days versus 6% without VFM ( p = .32). Patency was not associated with the use of VFM. Receiver operating characteristic curve was significant for occlusion at 30 days postoperatively but with a low predictive value ( p = .019,area under the curve 0.648). VFM may be helpful in selecting bypasses requiring immediate revision to prevent postoperative occlusion. The use of VFM is not significantly associated with patency.

To enable early detection and treatment of vascular defects leading to early graft failure, intraoperative flow waveform analyses were carried out during lower extremity arterial reconstructions in 226 patients undergoing 102 aortoiliac/femoral and 124 femorodistal bypass grafts. Flow waveform types III or IV indicated early graft failure. These were noted in seven grafts (6.9%) in the aortoiliac/femoral position and in eight grafts (6.5%) in the femorodistal position. The main cause of the abnormal flow waveform pattern was misinterpretation of preoperative arteriographic findings in aortoiliac/femoral reconstructions and technical errors in anastomoses in femorodistal reconstructions. Of 15 grafts with an abnormal flow waveform pattern, 13 were effectively repaired with patch angioplasty, graft extension, or replacement with thrombectomy. In two grafts, the repair failed and amputation had to be done. Thus, intraoperative flow waveform analysis is a simple, useful, and safe method to detect vascular defects leading to early graft failure. Unless assessment of preoperative arteriographic findings in aortoiliac/femoral reconstructions are accurate and anastomotic techniques in femorodistal reconstructions are refined, early graft failure may occur.

Although balloon angioplasty for the management of failing bypass grafts has been well documented, little mention has been made of its use in treating the occlusive lesion within the native artery after a failed bypass graft. We report our experience with five patients in whom successful balloon angioplasty was carried out subsequent to failure of a femoral popliteal bypass graft. Increasingly aggressive percutaneous therapy of arterial occlusive disease may now be expanded to include a unique group of patients with chronically failed bypass grafts and occlusive disease within the native artery conducive to percutaneous transluminal angioplasty. This group of patients would previously have been relegated to repeat bypass grafts with its inherently inferior patency and recognized added technical demands. Percutaneous balloon angioplasty appears to be a plausible alternative in selected cases for repeat lower extremity revascularization.

The measurement of peripheral resistance (PR) is a useful technique for predicting the outcome of femorodistal bypass. In an attempt, non-invasively, to predict PR, Pulse Generated Runoff (PGR) was used to assess 35 consecutive patients undergoing femorodistal non-reversed vein bypass for critical ischaemia. The PGR subscores (anterior tibial, posterior tibial, peroneal, pedal arch status were correlated against the measured PR. Using multiple linear regression three resistance values were derived for runoff at different levels: (1) a single calf vessel (R1); (2) distal popliteal artery (R3); (3) irrespective of the level (R0). There was good agreement between the predicted resistances RO, R1 and R3 and the measured PR. In the single calf vessel group (R1) the limits of agreement (−0·41 to +0·39) and 95 per cent confidence interval (−0·16 to +0·14) with the measured PR were better than in the R0 and R3 groups. These levels of agreement are small enough to replace the measured PR with the predicted PR method. Using the appropriate resistance equation in a further prospective series of 14 cases, there was agreement between the predicted and measured PR (limits of agreement −0·67 to +0·41; 95 per cent confidence interval −0·26 to +0·15). These results confirm the value of PGR in the assessment of critically ischaemic limbs particularly with a single calf vessel. Calf vessel continuity with the pedal arch appears to be a major determinant of PR, particularly in the isolated calf vessel group. A non-invasive resistance value can be derived which will predict the intraoperative peripheral resistance and should help predict subsequent graft outcome.

Objective The aim of the present study was to assess the effect of an adjuvant av-fistula on prosthetic bypass grafting and whether intraoperative flow measurements could predict patency and adverse events of cuffed femorocrural PTFE bypass with or without an av-fistula. Methods A total of 50 patients in need of vascular reconstruction for critical limb ischaemia (CLI) but with no suitable venous conduit were included. Results The flow values in patients with av-fistula were significantly higher (p=0.009) than in the group without the fistula but the higher flow values did not result in improved patency. The maximum flow velocity (Vmax) in the av-fistula group was significantly higher in the immediate postoperative period (p=0.04), but there was no difference in patency. When a flow value of 50 ml/min was used as a cut-off point, patients with a higher flow had significantly better immediate patency (p=0.025). Conclusion The adjuvant av-fistula neither caused any adverse effects nor had any effect on patency.

Although the femoral artery bifurcation can usually be dissected out for the purposes of constructing a femorodistal bypass without technical difficulty, wound complications that may lead to graft complications are relatively common. Here, we report what is believed to be the first case of in situ lower extremity bypass performed in association with a videoscopic approach to the femoral bifurcation.

Introduction: the rationale behind the Distaflo graft is inhibition of myointimal hyperplasia through optimisation of haemodynamic forces at the distal anastomosis. This prospective study reports our early clinical results. Method: patients with critical limb ischaemia, but no autologous vein, underwent infrainguinal bypass using Distaflo. Clinical and Duplex assessment provided prospective data from which one year cumulative patency, limb salvage and survival rates were calculated using Kaplan–Meier analysis. Log rank test enabled comparison with an historical control group of Miller cuff grafts. Results: fifty Distaflo were inserted over 29 months into 46 patients, median age 68.5 years, 27 male (59%), of which 27 (54%) were re-do procedures. Proximal anastomoses were to common femoral arteries in 40 cases (80%); distal anastomoses were to popliteal vessels in 20 (40%), and tibial vessels in 30 (60%). The Distaflo graft had patency, limb salvage and survival rates of 39, 50 and 82% respectively compared to 49, 56 and 85% respectively in the control group, with no statistical difference ( p = 0.39; 0.65; 0.67 respectively; log rank). Conclusion: in this non-randomised study, the Distaflo has similar one year patency, limb salvage and survival rates to the Miller cuff, potentially justifying its use an alternative in distal prosthetic arterial reconstruction for critical limb ischaemia. Eur J Vasc Endovasc Surg 25, 235–239 (2003)

Objectives: femorodistal bypass operation is one of three index procedures for vascular training in the U.K. Our aim is to determine the suitability of femorodistal bypass to be considered as an index procedure in the era of increasing utilisation of percutaneous transluminal angioplasty (PTA). Design: a retrospective analysis of prospectively collected data. Patients and Methods: a total of 526 patients with 608 chronic critically ischaemic limbs admitted to the vascular unit, at the Royal United Hospital, Bath, between January 1994 and December 1999 was included in the study. Results: revascularisation either by PTA, bypass surgery or a combination of both was attempted in 524 limbs (86%). Crural procedures were carried out on 71 limbs (14% of revascularised limbs). Primary crural procedures included 34 PTAs as a sole treatment (48%), and 37 femorodistal bypass operations (52%). Conclusions: during a 6-year period only 37 primary femorodistal bypass operations were performed in a unit which aggressively treats CLI. PTA is the initial step and increasingly the sole treatment for critical limb ischaemia (CLI), including distal lesions. We question the rationale of including an uncommon operation as a vascular training index procedure. Eur J Vasc Endovasc Surg 25, 135–138 (2003)

Die subendotheliale myointimale Hyperplasie (MIH) stellt eine der Hauptursachen für die Ausbildung von Stenosen und Verschlüssen im Bereich von Anastomosen dar. Besondere Bedeutung hat die MIH in termino-lateralen Anastomosen. An der Entstehung der MIH sind hämodynamische Faktoren entscheidend beteiligt. Ausgehend von der Annahme, daß eine Veränderung der Anastomosenform die Hämodynamik beeinflussen kann, wurde in der vorliegenden Arbeit eine neue Anastomosenform, die femorocrurale Patchprothese (FCPP), entwickelt mit dem Ziel einer Optimierung der Strömungsverhältnisse im Anastomosenbereich. In einem hydrodynamischen Kreislaufmodell wurden elastische, transparente Silikonmodelle von termino-lateralen Anastomosen mit einem blutanalogen Newtonschen Fluid (Glycerol-Wasser-Gemisch) unter Simulation der femorocruralen Druckkurve pulsatil bei Variation der Strömungsbedingungen perfundiert. Die konventionellen und klinisch erprobten Anastomosenformen (termino-laterale Anastomose, Composite Bypass, Linton Patch, Miller Collar, Taylor Patch) wurden in vitro mit der FCPP-Anastomose und zwei Modifikation dieser Anastomosenform verglichen. Die Visualisierung des Strömungsfeldes wurde mit drei verschiedenen Methoden erreicht. Bei der farboptischen Methode wurde die Verteilung und Bewegung von Farbteilchen im Anastomosenbereich nach Injektion in das strömende Fluid mittels Video aufgezeichnet. Für die Ultraschalluntersuchung mittels hochauflösender farbcodierter Dopplersonographie (FKDS) wurde das Fluid mit Sephadex-Partikeln dotiert. Sämtliche Ultraschalluntersuchungen wurden ebenfalls mittels Video aufgezeichnet. Die Dopplerspektren korrespondierender Punkte in den Randzonen der Anastomosen wurden off-line der Fast Fourier Analyse (FFT) unterzogen und diese dreidimensional dargestellt. Die semiquantitative Analyse anhand der farboptischen Methode zeigte eine signifikante Verringerung bis Elimination MIH-assoziierter Strömungsphänomene in der FCPP-Anastomose und deren Modifikationen. Die Ausprägung der einzelnen Strömungsphänomene war abhängig von der Reynolds-Zahl und von dem Verhältnis von proximalem und distalem Stromzeitvolumen. Als Vorteil der FCPP erwies sich die Möglichkeit der Anpassung ihrer Form an die entsprechende Flußsituation durch Modifikation der Gabelform mit annähernd laminarer Strömung im gesamten Anastomosenbereich. Die FKDS bestätigte die Ergebnisse der farboptischen Methode. In der Peak-Systole und am Beginn der Diastole waren Rezirkulationszonen und Zonen niedriger Strömungsgeschwindigkeit in der FCPP am geringsten ausgeprägt oder nicht mehr nachweisbar (modifizierte FCPP). Der Vergleich der 3D-Darstellungen der FFT der Dopplerspektren zeigte niedrige Frequenzen und damit Flußgeschwindigkeiten und partiell eine Strömungsumkehr nahezu konstant in allen Anastomosenformen außer der FCPP und deren Modifikationen. In einer prospektiven Studie zum klinischen Einsatz der FCPP Anastomose wurden im Zeitraum von 6 / 1992 bis 7 / 1998 135 PTFE-Prothesenbypass-Rekonstruktionen mit distaler FCPP Anastomose bei 129 Patienten im klinischen Stadium III und IV der paVK analysiert. Die kumulativen primären und sekundären 1-, 2-, 3-, 4-, und 5-Jahres-Offenheitsraten nach Kaplan / Meier betrugen jeweils 63,0%, 44,9%, 35,7%, 33,1% und 27,6% bzw. 74,5%, 55,2%, 44,8%, 43,0% und 37,6%. Die kumulativen 1-, 3-, und 5-Jahres-Wahrscheinlichkeiten für den Erhalt der Extremität betrugen jeweils 86,8%, 79,2% und 77,5%. Eine Optimierung des Strömungsverhaltens innerhalb der Anastomosenregion ist in der FCPP derart möglich, daß der Anteil der für die Pathogenese der MIH ursächlichen Strömungsmuster minimiert wird. Diese Anastomose ist klinisch anwendbar und führt bei ausschließlicher Verwendung von ePTFE als Bypassmaterial im femorodistalen Bereich zu akzeptablen Langzeitergebnissen, die denen bei Anwendung von alternativ möglichen Venenpatchplastiken nicht nur vergleichbar, sondern teilweise überlegen sind., The subendothelial myointimal hyperplasia (MIH) represents one of the main etiological factors in the formation of stenoses and occlusions of vascular anastomoses. MIH plays a role especially in termino-lateral anastomoses. Hemodynamic factors have a decisive impact on the development of MIH. Assuming that changes in the morphology of the anastomoses influence the hemodynamics, a novel anastomosis form, the femorocrural patch prosthesis (FCPP), was developed with the goal of optimizing the blood flow-dynamics within the anastomotic site. In a hydrodynamic circulation model, various elastic, transparent silicon phantoms of termino-lateral anastomoses were perfused with a Newton fluid blood analog (glycerol-water mixture) while simulating the femorocrural pressure curve in a pulsatile manner under variation of the flow conditions. The conventional and clinically tested anastomosis forms (termino-lateral anastomosis, composite bypass, Linton patch, Millar collar, Taylor patch) were compared with the FCPP-anastomosis and two modifications of the FCPP in vitro. The visualization of the flow velocity field was achieved using three different methods. By means of the color-optic method, the distribution and motion of color elements in the anastomotic area were video-recorded following injection in the flowing liquid. For the ultrasound examination with high resolution, color-coded Doppler sonography, the fluid was marked with Sephadex particles. All ultrasound examinations were also recorded on video. The corresponding doppler spektrum points in the marginal zones of the anastomosis were subjected to the Fast Fourier Transform (FFT) analysis off-line and then displayed three-dimensionally. The semiquantitative analysis using the color-optic method showed a significant decrease or elimination of MIH-associated current phenomena in the FCPP-anastomosis and its corresponding modifications. The intensity of singular flow phenomena was dependent upon the Reynolds-number and upon the relation of proximal to distal flow volume over time. The possibility to adapt the FCPP to the flow phenomena by modifying the bifurcated form and thereby achieving almost laminar flow in the complete anastomotic area proved to be advantageous. The color-coded Doppler sonography confirmed the results of the color-optic method. During peak systole and at the beginning of the diastole, recirculation zones and zones with low flow velocity were least intense in the FCPP or not detectable at all (in the modified FCPPs). The comparison between the FFT 3D-reconstructions from the Doppler spektrum showed low frequencies and thus flow velocities and a partial flow reversal almost constantly in all anastomosis forms except the FCPP and its modifications. In a prospective study on the clinical application of the FCPP anastomosis during the period of June 1992 to July 1998, 135 ePTFE prosthetic bypass reconstructions with distal FCPP anastomosis were analyzed in 129 patients suffering from peripheral arterial occlusive disease stages III and IV. The cumulative primary and secondary 1-, 2-, 3-, 4-, and 5-year patency rates calculated with the Kaplan / Meier method were 63.0%, 44.9%, 35.7%, 33.1%, and 27.6%, and 75.5%, 55.2%, 44.8%, 43.0% and 37.6%, respectively. The cumulative 1-, 3-, and 5-year probabilities for limb salvage were 86.8%, 79.2% and 77.5%, respectively. As a result of anastomotic engineering, FCPP optimizes the flow properties within the anastomosis region to such an extent that the pathogenetic role of flow disturbances is minimized. This anastomosis is clinically employable when using ePTFE as bypass material in femoro-distal vascular reconstruction and leads to acceptable long-term results that are not only comparable but sometimes superior to the results obtained when using alternative vein cuff techniques.

To allow and facilitate complete endoluminal vein preparation under angioscopic guidance for in situ femorodistal bypass grafting, a novel instrument was constructed. In experiments in cadavers we developed the occluder valvulotome, consisting of a modified Mills' valvulotome containing a laterally-ending working channel, a retrograde cutting blade and an advanceable Teflon® tube within the working channel. Using this instrument in combination with commercially available wire coils, we successfully performed five femorocrural in situ reconstructions with endoluminal valvulotomy and embolization of a total of ten thigh tributaries. The technique allows angioscope-assisted valvulotomy and simultaneous endoluminal tributary occlusion, making long skin incisions and extensive vein dissection obsolete.

Many questions have been raised which factors play a role in early occlusion of infra-inguinal bypasses. To answer the question, whether the peripheral resistance plays a role in this matter, we have investigated 54 consecutive patients, who received a femoropopliteal or femorodistal bypass at our institution during the first half year of 1994. The bypass material was saphenous vein in most cases, or ePTFE: (Gore Tex®) or composed of these two materials (composite bypass).

Objectives: To investigate the socioeconomic aspects and the outcome of femorodistal bypass grafting operations in terms of general health state. Design: Prospective open clinical study. Material: 168 operations in 153 patients. Methods: A structured questionnaire was used to assess quality of life, and each patient was classified into a health state group defined by levels of disability and distress. Results: Before operation 23 patients were actively employed, 96 were old age pensioners, 29 received invalidity pension, and five were long term sick, 80% were living in their own home without any help. Only 19 patients were actively employed at follow up, 12 of these had been working before the operation, and seven other patients had taken up paid work. About three-quarters of the patients could manage daily life without help after the operation, and 82% had no or only mild distress. There were significant changes with respect to physical mobility in all groups and emotional status in one group. In all other cases a significant change could not be shown. The median Quality of Life score at follow up was 0.986 ( n = 102, variance 0.022). The immediate costs were £1.5 million. Conclusions: The classification into disability and distress groups was informative, but the methods for assessment of the results of vascular surgery on quality of life, evaluation of patients satisfaction and of patients' expectations must be further developed.

A case of bilateral persistent sciatic artery (PSA) aneurysms with thromboembolic complications is presented along with a review of the 167 cases of PSA reported in the world literature. Its embryology, anatomy, clinical features, diagnosis, and treatment are reviewed and provide the following findings: The incidence of PSA is estimated to be from 0.025% to 0.04%, based on angiographic studies. Ages range from 6 months to 89 years, with a mean of 54 years. There is no gender predilection. A PSA was present on the right side in 32%, on the left side in 29%, bilaterally in 22%, and on either side in 18%. The "complete" type of PSA was 69%. Aneurysmal change was present in 46% of all PSAs. Overall, 59% had symptoms, including ischemia in 31% (acute in 14% and chronic in 17%), a gluteal mass in 26% (painful in 10%, painless in 6%, and pulsatile in 13%), gluteal pain in 2%, and ischialgia in 5%. Exclusion of the aneurysm or PSA by surgical or interventional techniques, with a femorodistal bypass as required for the resultant ischemia is currently the treatment of choice.

Various vein factors affect the outcome of femorodistal bypass using vein in the treatment of lower limb ischaemia. In this review, the effect of factors such as vein size, compliance and morphology are discussed.

When polytetrafluoroethylene (PTFE) became available many surgeons turned to the ‘graft on the shelf’ from the more demanding vein harvesting techniques. For many years there were proponents for both extended PTFE grafts and vein but there is now conclusive evidence that vein grafts have a better patency rate when the distal anastomosis is below the knee. In fact, prosthetic grafts perform so poorly in the infrapopliteal segment (10–60% 12-month patency, average 40%1) that many surgeons believe these operations should probably not be attempted in the absence of vein2. Unfortunately, patients requiring bypass grafts may have already lost the long saphenous vein during previous coronary or peripheral arterial surgery. Many authorities have emphasized the fact that there is now good evidence to suggest that arm and short saphenous veins are useful alternatives to the long saphenous vein3. Indeed, some claim that with such a policy it is never necessary to insert a prosthetic graft to the infrapopliteal arteries. There are, however, many surgeons who are unable to find sufficient lengths of vein to perform a femorocrural graft in some of these patients with end stage arterial disease and multiple previous reconstructions. In patients with critical ischaemia the current primary amputation rate at the author’s hospital is 3% and one-third of reconstructions are to the crural arteries; 20% of the patients no longer have adequate lengths of autologous vein. There is therefore a great need to develop techniques that might improve the results of femorocrural grafts with extended PTFE.

Infected lower extremity bypass grafts have been associated with high rates of limb loss. Traditionally treatment has included graft excision. To compare aggressive local treatment, without graft removal, with more conventional graft excision, we reviewed 38 consecutive patients with 39 infected lower extremity bypasses treated during the last 10 years. The grafts used were prosthetic in 33 cases, vein in 4, and composite in 2. Median follow-up was 2.7 years. Twenty-eight infected grafts were treated with either complete (14) or partial (14) graft removal. Nine new grafts were placed. Recurrent infection developed in five cases, and two patients died of complications of graft infection. Ten of 20 limbs at risk were lost. Eleven patients with patent bypasses (4 vein, 2 composite, 5 prosthetic) were treated without graft excision. Treatment of five patients in this group included muscle transposition. Five patients were treated with incision and drainage of abscesses, and one had excision of a persistent sinus tract. One patient underwent major amputation 6.3 years after treatment of graft infection. Limb salvage was significantly higher ( p = 0.012, log-rank test) than in patients treated with graft excision. One patient died, and no recurrent infections developed; these were not significant differences compared with those having graft excision. We conclude that aggressive local treatment of infected lower extremity bypass grafts, including drainage, debridement, and muscle transposition may treat infection in selected patients without the need for graft removal and with rates of limb salvage superior to those obtained with excisional therapy. (J Vasc Surg 1992;15:295–305.)