Long-term results of infragenicular bypasses with autogenous vein originating from the distal superficial femoral and popliteal arteries

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1 Long-term results of infragenicular bypasses with autogenous vein originating from the distal superficial femoral and popliteal arteries Mark S. Rosenbloom, M.D., James J. Walsh, M.D., James J. Schuler, M.D., Joseph P. Meyer, M.D., Thomas H. Schwarcz, M.D., Jens Eldrup.Jorgensen, M.D., Joseph R. Durham, M.D., and D. Preston Flanigan, M.D., Chicago, Ill. Forty-nine bypasses originating from the distal superficial femoral artery or popliteal artery in 46 patients were reviewed to examine late patency, limb salvage, and factors leading to graft failure. Operations were performed because of tissue loss in 86%, rest pain in 12%, and limiting claudication in 2% of limbs. Proximal anastomosis was from the distal superficial femoral artery in 12% and the popliteal artery in 88%. Distal anastomosis was to the below-knee popliteal artery or proximal tibial vessels in 2% and the distal tibial vessels in 8%. Life-table analysis showed a primary patency rate of 83%, 62%, and 41%, at 1, 3, and 5 years, respectively. The rate of limb salvage at 6 years for all grafts was 69%. Cox proportional hazards analysis determined that s tenosis of 2% or greater in the proximal superficial femoral artery before bypass was a significant risk factor for graft failure (p =.2) despite the presence of normal intra-arterial pressure at the site of the proximal anastomosis at the time of bypass. Long-term survival in these patients was low, with a 6-year survival rate of only 24%. Infragenicular bypasses originating from the distal superficial femoral artery or the popliteal artery can be performed with patency and limb salvage rates comparable to bypasses originating from the common femoral artery. These bypasses are more likely to fail when performed in the presence of a stenosis 2% or greater in the superficial femoral or popliteal artery proximal to the graft origin. (J VASC SURG 1988;7:691-6.) The common femoral artery is considered the preferred site of proximal anastomosis for infragenicular bypass grafting.1 Use of the superficial femoral artery or the popliteal artery as the source of inflow for distal bypasses has been criticized because of the belief that progression of atherosclerosis in the superficial femoral artery will subsequently lead to graft failure. 2-s Access to the common femoral artery as an inflow source may be precluded by infection or by scarring from previous operations in the groin. In addition, inadequate length of the vein available for bypass may not allow the use of the common femoral artery as the origin of distal bypass grafts. Use of the profunda femoris artery for bypass inflow has also been described. 6,7 Previous reports of infragenicular bypasses originating from the distal superficial femoral and popliteal arteries have shown patency rates From the Department of Surgery, Division of Vascular Surgery, University of Illinois College of Medicine at Chicago. Presented at the Eleventh Annual Meeting, Midwestern Vascular Surgical Society, Chicago, Ill., Sept , Reprint requests: D. Preston Flanigan, M.D., Chief, Division of Vascular Surgery (m/c 957), University of Illinois at Chicago, 174 West Taylor St., Suite 22, Chicago, IL of 7% to 8% and limb salvage rates of 7% to 9% at 3 to 6 years. 8~ This article examines the late patency and limb salvage for infragenicular bypasses pcrformed with autogenous vein grafts that originated from the distal superficial femoral or popliteal arteries and serves to update our earlier report on these bypasses. 9 In addition, the factors leading to graft failure, in particular progrcssion of superficial femoral artcry disease, will be assessed. MATERIAL AND METHODS All patients having infragenicular bypasses with autogenous vein grafts that originated from the distal superficial femoral or popliteal arteries at the University of Illinois, Cook County, and West Side Veterans Administration Hospitals between 1979 and 1986 were included in the study. Hospital charts, operative records, and noninvasive vascular laboratory charts from before and after operation were reviewed. Preoperative and operative arteriograms were studied so that ~he arterial runoff for each bypass could be determined as described by Rutherford et al. ~ Runoff scores ranged from 1, for widely patent vessels, to for blind segments. Preoperative 691

2 692 Rosenbloom et al.,yournat of VASCULAR SURGERY 9 BO?O , Og, \ I MONTHS Fig. 1. Life-table plot of primary patency for 49 infragenicular bypasses that originated from the distal superficial femoral or popliteal arteries. Number of patent grafts remaining at each interval is shown over the standard error for each interval. arteriograms were also reviewed to determine the presence of stenotic atherosclerotic disease proximal to the origin of the bypass graft. The degree of diameter reduction as measured in one plane was used to determine the amount of stenosis present. Follow-up information was obtained from recent clinic visits. Graft patency was determined by the presence of a palpable pulse in the graft on physical examination or by Doppler-derived pressure measurements in the bypassed limb. Patients without recent follow-up were contacted for reexamination. When examination was not possible, follow-up information regarding death, cause of death, and limb salvage was obtained from referring physicians, the patient, or the patient's family. In cases where recent follow-up was not possible, patency was determined at the time of the most recent examination. Primary patency, secondary patency, and limb salvage were defined according to the standards for reports of lower extremity ischemia suggested by Rutherford et al. ~I Primary patency was defined as any graft having continued function without procedures performed on the graft to maintain its function. Secondary patency was defined as any graft that required additional operations to maintain patency. Limb salvage was defined as the presence of a viable foot for walking even if a toe or transmetatarsal amputation was performed. Revision was defined as any operation to restore patency to a graft or to prevent eventual failure of a graft. Reoperation was any operation that resulted in replacement of most or all of the original graft. Data were stored on an IBM 381 mainframe computer. Statistical analysis was performed by one of us (M. S. R.), with software from Statistical Analysis Systems and consisted of X 2, life-table methods, and Cox proportional hazards linear regression. RESULTS The study group consisted of 46 patients who underwent 49 operations. The mean age of the patients was 64 years (range 6 to 79 years). Seventysix percent were men, 65 % were black, and 35% were white or Hispanic. Significant cardiovascular risk factors were prevalent, including diabetes in 76%, smoking in 62%, and hypertension in 69%. Symptomatic cardiac disease was present in 46% of patients and 23% of patients had a previous myocardial infarction. The indication for operation was claudication in one limb (2%), ischemic rest pain in six limbs (12%), and tissue loss in 42 limbs (86%). The operations included one above-knee popliteal-below-knee popliteal artery bypass, six distal superficial femoral artery-tibial artery bypasses, and 42 popliteal-tibial artery bypasses. Autogenous vein grafts included one reversed arm vein, five in situ saphenous veins, two composite leg vein grafts, and 41 reversed saphenous vein grafts. Bypass grafts originated from the distal superficial femoral artery in six cases (12%), the above-knee popliteal artery in 19 cases (39%), and the belowknee popliteal artery in 24 cases (49%). All patients had direct arterial pressure measurements at opera-

3 8 7 O 5 4 5O 2 Distal superficial femoral and popliteal to infragenicular bypass 693 \ oo 2o \.11 4, I ~ 72 MONIHS Fig. 2. Life-table plot of secondary patency for 49 infragenicular bypasses that originated from the distal superficial femoral or popliteal arteries. Number of patent grafts remaining at each interval is shown over the standard error for each interval. tion documenting normal inflow at the site of the proximal anastomosis. Distal anastomosis was performed to the below-knee popliteal artery in one case (2%), proximal tibial vessels in nine cases (18%), and distal tibial vessels in 39 cases (8%), including 18 bypasses to the dorsalis pedis artery. Runoff scores as calculated from preoperative arteriograms and operative prereconstruction arteriograms were 1. to 3.5 in 4% and 8.5 to in 6% of cases. There were no operative deaths. Twelve bypasses required intraoperatne revision, which included revision of the distal anastomosis, patch angioplasty, and graft thrombectomy. Follow-up extended to 72 months with a mean follow-up of 24 months. During this period, 2 patients died and were lost to follow-up. There were seven early (less than 3 days) and six late graft failures. Six grafts that failed early underwent thrombectomy and only two of these patients left the hospital with patent grafts. In addition to six late graft failures, two patent grafts had to be ligated for infection and two grafts were revised because of progressive inflow disease. The two patients who required inflow revision had patent grafts with evident progression ofstenosis in the superficial femoral artery as determined by noninvasive studies. One of these patients was lost to follow-up and one has a patent graft after revision. Life-table analysis showed a primary patency rate of 83% at 1 year, 62% at 3 years, and 41% at 5 years (Fig. 1). The secondary patency rate was 84% at 1 year, 62% at 3 years, and 42% at 5 years (Fig. 2). Cumulative limb salvage as calculated by life table was 69% at 6 years (Fig. 3). Cox proportional hazards linear regression analysis found that stenosis of 2% or more in the proximal superficial femoral artery, even with normal inflow pressure, was a significant risk factor for graft failure (p =.2), as was the severity of the runoff vessel disease (p =.4). Also tested in the proportional hazards model and found to be not significant were sex (p =.74), race (p =.8), diabetes (p =.35), smoking (p =.43), number of intraoperative revisions (p =.75), location of proximal anastomosis (p =.9), and location of distal anastomosis (p =.17). Life-table survival analysis revealed that only 24% of these patients were still alive at the end of 6 years (Fig. 4). Myocardial in:farction and stroke accounted for 35% and 15% of the deaths, respectively. DISCUSSION The early reports of infragenicular arterial reconstruction considered distal bypasses originating from the superficial femoral or popliteal arteries to have a higher risk of failure. 1'2,12aa However, these reports did not selectively evaluate the results of bypasses performed from vessels other than the common femoral artery. It was thought that these bypasses would fail because of progression of superficial femoral artery disease. 2 This belief was based on natural history studies that used serial arteriography to evaluate the progression of arterial disease in patients with claudication, a-s In particular, the likelihood of progression of superficial femoral artery disease as assessed by serial arteriogranas was found

4 694 Rosenbloom et al. Journal of VASCULAR SURGERY 8O 7O, I I.6, OO, MONTHS Fig. 3. Life-table plot of limb salvage for 48 limbs that underwent infragenicular bypasses originating from the distal superficial femoral or popliteal arteries. Number of limbs remaining at each interval is shown over the standard error for each interval. to be directly related to the degree of stenosis present on the first arteriogram2 Veith et al.8 compared the results of 419 popliteal and tibial bypasses originating from the common femoral artery with the results of 139 popliteal and tibial bypasses originating from the distal superficial femoral artery or popliteal artery. Similar secondary patency rates were achieved for bypasses that originated from the common femoral artery compared with those that originated from the distal superficial femoral artery or popliteal artery. The 6-year secondary patency rate for vein grafts to the popliteal artery was 89% for bypasses that originated from the distal superficial femoral artery or popliteal artery and 75% for bypasses that originated from the common femoral artery. Vein grafts to the infragenicular vessels had a 6-year secondary patency rate of 69% when originating from the superficial femoral and popliteal arteries. The 6-year secondary patency rate was 71% for infragenicular bypasses that originated from the common femoral artery. None of the 32 failures in 139 bypasses originating from the distal superficial femoral artery or popliteal artery was thought to be due to progression of stenosis in the superficial femoral artery. Our first report on this subject reported the results of 23 patients who had below-knee popliteal and tibial artery bypasses that originated from the distal superficial femoral artery or popliteal artery. 9 The secondary patency rate at 31 months was 84% with a limb salvage rate of 7%. There were ~w o cases of graft thrombosis, neither of which were related to the progression of stenosis in the superficial femoral artery. This report recommended the use of the superficial femoral artery or popliteal artery as the inflow source for infragenicular bypasses in patients having normal inflow to the popliteal artery and inadequate vein for a bypass from the common femoral artery. Cantelmo et al. 1 reported 1- and 3-year patency rates of 79% for distally based infragenicular bypasses. This report showed limb salvage rates of 89% at 1 year and 82% at 3 years. Feldman et al. 14 reported 11 bypasses from the below-knee popliteal artery to the distal tibial vessels. Two bypasses were immediate failures and nine remained patent for 2 to 48 months. These reports of grafts originating from the distal superficial femoral or popliteal arteries show that these bypasses can be performed with satisfactory patency and limb salvage. These reports cast doubt on the commonly held belief that progression of superficial femoral artery disease is inevitable and that such progression would lead to graft failure. In addition, there has been further evidence to suggest that shorter grafts may perform better than longer ones) sa6 The results of bypasses originating from the distal superficial femoral and popliteal arteries should be compared with the results of reversed saphenous vein bypasses and in situ saphenous vein bypasses origi-

5 Volume 7 Number 5 May 1988 Distal superficial femoral and popliteai to infragenicular bypass 695 8O 8.og MONTHS Fig. 4. Life-table plot of survival for 46 patients who underwent infragenicular bypasses originating from the distal superficial femoral and popliteal arteries. nating from the common femoral artery. Five-year patency and limb salvage rates with reversed saphenous vein bypass to the infragenicular vessels were respectively 55% and 73% as reported by Mannick, 17 46% and 6% as reported by Kacoyanis et al.,18 and 47% as reported by Reichle et al.19 Taylor et al.2.21 reported on the results of reversed vein bypasses including 38 bypasses to the tibial arteries that originated from the common femoral artery with a primary patency rate of 89% at 1 and 3 years. With the in situ saphenous vein technique, Corson et al. 22 reported 7% 3-year primary patency in 37 bypasses to ankle, foot, or discontinuous tibial vessels. Bandyk et al.23 reported 58% primary patency and 8% secondary patency for 128 femorotibial in situ saphenous vein grafts at 3 years. Fogle et al.24 compared in situ saphenous vein with reversed saphenous vein bypasses and found a 3-year patency rate of 87% for in situ saphenous vein grafts and 62% patency for reversed saphenous vein grafts. The early results of the present series are comparable to the results of both in situ and reversed saphenous vein bypasses. Although long-term patency is not so good as that found in other studies, the 5-year limb salvage rate was 69%. Significant risk factors for graft failure were stenosis in the superficial femoral artery of 2% or more at the time of bypass (p =.2) and the severity of disease in distal runoff vessels as measured by the runoff index (p =.4). The significance of 2% or more stenosis in the superficial femoral artery combined with documenta- tion of hemodynamically normal inflow at the proximal anastomsis of these bypasses at the time of operation leads us to speculate that progression of disease in the superficial femoral artery may occasionally result in graft: failure. An interesting finding was the high mortality rate in this group of patients, particularly from cardiovascular disease. This finding is in agreement with previous reports of patients having a distal pattern of atherosclerotic disease.25,26 The high mortality rate may have also adversely affected the patency rates for these bypasses in the life-table calculation. Infragenicular bypasses that originate from the distal superficial femoral or the popliteal artery can be performed with satisfactory pateney and limb salvage rates. Distally based bypasses provide a good alternative when the length of vein to be used for bypass is inadequate for anastomosis to the common femoral artery. Despite the apparent increased risk, we would still recommend that when there is not enough vein available to perform a long bypass, a distally based bypass should bc performed even in the presence of disease in the superficial femoral artery, provided the arterial pressure at the proximal anastomosis is systemic. Such a bypass, with autogenous vein used as a conduit, can be expected to have better patency and provide a higher limb salvage rate than longer prosthetic bypasses from the common femoral artery. This study cannot assess whether the common femoral or the popliteal artery used for graft origin is preferable when there is sufficient vein to

6 696 Rosenbloom et al perform either and there is less than 2% stenosis in the superficial femoral artery. REFERENCES 1. Garrett HE, Kotch PI, Green MT, Diethrich EB, DeBakey ME. Distal tibial artery bypass with autogenous vein grafts: an analysis of 56 cases. Surgery 1968;63:9. 2. Auer AL, Hershey FB. Bypass vein grafts to distal tibial or dorsalis pedis arteries. Mo Med 1973;7: Warren R, Gomez ILL, Marston JAP, Cox JST. Femoropopliteal arteriosclerosis obliterans: arteriographic patterns and rates of progression. Surgery 1964;55: Coran AG, Warren R. Arteriographic changes in femoropopliteal arteriosclerosis obliterans. N Engl J Med 1966; 274: Kuthan F, Burkhalter A, Baitsch R, Ludin H, Widmer LK. Development of occlusive arterial disease in lower limbs. Arch Surg 1971;3: Stabile BE, Wilson SE. The profunda femoris-popliteal artery bypass. Arch Surg 1977;112: Buxton B, Reeves L, Roberts AK. Distal profunda femoris to popliteal artery bypass for patients with a short length of long saphenous vein. Surgery 1978;83: Veith FJ, Gupta SK, Samson RH, Flores SW, Janko G, Scher LA. Superficial femoral and popliteal arteries as inflow sites for distal bypasses. Surgery 1981;9: Schuler JJ, Flanigan DP, Williams LR, Ryan TJ, Castronnovo JJ. Early experience with popliteal to infragenicular bypass for limb salvage. Arch Surg 1983;118:472.. Cantelmo NL, Snow JR, Menzoian J'O, LoGerfo FW. Successful vein bypass in patients with an ischemic limb and a palpable popliteal pulse. Arch Surg 1986;121: Rutherford RB, Flanigan DP, Gupta SK, et al. Suggested standards for reports dealing with lower extremity ischemia. J Vase SURG 1986;4: Garrett HE, De Bakey ME. Distal posterior tibia] artery bypass with autogenous vein graft: a report of three cases. Surgery 1966;6: Shieber W, Parks C. Dorsalis pedis artery in bypass grafting. Am J Surg 1974;128: Feldm_an AJ, Nevonen M, Berguer R. Experience with popliteai-inftapopliteal bypass grafting. Surg Gynecol Obstet 1982;154: Veith FJ, Ascer E, Gupta SK, et al Tibiotibial vein bypass grafts: a new operation for limb salvage. J Vase SURG 1985;2: Ascer E, Veith FJ, Gupta SK, White SA, Bakal CW, Wengetter K, Sprayregen S. Short vein grafts: a superior option for arterial reconstructions to poor or compromised outflow tracts' J VASC SURG 1988;7: Mannick JA. Femoro-popliteal and femoro-tibial reconstructions. Surg Clin North Am 1979;59: Kacoyanis GP, Whittemore AD, Couch NP, Mannick JA. Femorotibial and femoroperoneal bypass vein grafts. Arch Surg 1981;116: Reichle FA, Rankin KP, Tyson RR, Finestone AJ, Shuman C. Long,term results of 474 arterial reconstructions for severely ischemic limbs: a fourteen-year follow-up. Surgery, 1979;85: Taylor LM, Phinney ES, Porter IM. Present status of reversed vein bypass for lower extremity revascularization. J Vase SURG 1986;3: Taylor LM, Edwards JM, Phinney ES, Porter JM. Reversed vein bypass to infrapopliteal arteries. Ann Surg 1987;25: Corson ID~ Karmody AM, Shah DM, Naraynsingh V, Young HL, Leather RP. In situ vein bypasses to distal tibial and limited outflow tracts for limb salvage. Surgery 1984;96: Bandyk DF, Kaebnick HW, Stewart GW, Towne lb. Durability of the in sire saphenous vein arterial bypass: a comparison of primary and secondary patency. J VAse SUP,6 1987;5: Fogle/VIA, Whittemore AD, Couch NP, Mannick JA. A comparison of in situ and reversed saphenous vein grafts for infrainguinal reconstruction. J VASe SURG 1987;5: Martinez BD, Hertzer NR, Beven EG. Influence of distal arterial occlusive disease on prognosis following aortobifemoral bypass. Surgery 198;88: Kallero KS, Bergqvist D, Cederholm C, Jonsson K, Olsson PO, Takolander R. Arteriosclerosis in popliteal artery trifurcation as a predictor for myocardial infarction after arterial reconstructive operation. Surg Gynecol Obstet 1984;159: 133.