Femoropopliteal Above-Knee Bypass: The True Results

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Femoropopliteal Above-Knee Bypass: The True Results Lise Pyndt Jørgensen, Camilla Rasmussen & Torben V Schroeder Rigshospitalet and University of Copenhagen, DENMARK

Treatment options in the femoropopliteal segment BMT + Stop smoking and keep walking Bypass surgery Vein in situ, reversed, arm vein etc. Umbilical vein Prosthetic graft PTFE, dacron, Heparin bonded prostetic graft Endovascular options in the SFA segment

DeRubertis et al. Ann Surg 2007;246: 415 424 Percutaneous infra-inguinal revascularization carries a low risk of morbidity and mortality, is well accepted by patients, does not prevent ultimate surgical revascularization if necessary and consequently should be considered the first-line therapy for chronic lower extremity ischemia.

Factors influencing indication for treating SFA lesions Claudication that interferes with the patient s life Rest pain Ulceration, gangraene

Factors influencing choice of treatment Severity of disease Clinical : Claudication vs CLI Anatomical: Lesion length; degree of obstruction; inflow/outflow; TASC TASC II 2007 Increasingly complex disease can be managed using endovascular techniques TASC A: endovascular treatment TASC B & C: can be treated using either TASC D: surgery, owing to endovascular treatment s prohibitive failure rate

Factors influencing choice of treatment Severity of disease Clinical : Claudication vs CLI Anatomical: Lesion length; degree of obstruction; inflow/outflow; TASC Risk factors and comorbidities Age, Gender, Smoking, DM, CAD, Lungs, Renal Availability of vein Autologous vein : Always first choice if available Prosthetic grafts The secondary choice above as well as below the knee

The immediate answer to The true Fem-Pop results is to look at which graft type produces the best results Searched relevant databases for results of fempop AK from published RCTs on Vein grafts In situ Reversed GSV Prosthetic grafts Human umbilical vein PTFE Dacron Trials on adjuvant procedures left for JB 13 trials were identified 1987-99: 7-2000-09: 6-2010 or newer: 0

In-situ graft technique vs. reversed greater saphenous vein (GSV) 2 RCT + Cochrane Database Syst Review (Twine et al 2010) Conclusion: no convincing difference

Vein (GSV) vs. Prosthetic graft 4 RCT + Cochrane Database Syst Review (Twine et al 2010) Conclusion: Vein better than prosthetic (PTFE) graft

Prosthetic graft (PTFE) vs. Human umbilical vein (HUV) 3 RCT : Conclusion: Human umbilical vein better than PTFE

Prosthetic grafts: PTFE vs. Dacron 4 RCT + Cochrane Database Syst Review (Twine et al 2010) Conclusion: Dacron is better than PTFE (at 24 and 60 months)

The graft material hierachy in the fempop AK position: GSV ~ in situ vein? Human umbilical vein Dacron PTFE

Factors influencing choice of treatment Severity of disease Clinical : Claudication vs CLI Anatomical: Lesion length; degree of obstruction; inflow/outflow; TASC I-IV Risk factors and comorbidities Age, Gender, Smoking, DM, CAD, Lungs, Renal Availability of vein Patients perception of disease severity Preference of the patient Preference of the phycisian Availability of endovascular technichnues Ongoing research projects

Factors influencing choice of treatment Severity of disease Clinical : Claudication vs CLI Anatomical: Lesion length; degree of obstruction; inflow/outflow; TASC I-IV Risk factors and comorbidities Age, Gender, Smoking, DM, CAD, Lungs, Renal Availability of vein Patients perception of disease severity Preference of the patient Preference of the phycisian Availability of endovascular technichnues Ongoing research projects MIP = Mild Industrial Pressure Economy

Which parameters/endpoints are most relevant to compare results obtained with different methods? Seen from the perspective of The patient The physician The society The medical company

Which parameters/endpoints are most relevant to compare results obtained with different methods? Seen from the perspective of The patient The physician The society The medical company Patency (pp, sp ) Haemodynamics (flow, ABI, TcPO2 ) Restenosis rate Complications (m&m, stent fractures ) Survival (life, limb, wound) Physical performance (walking distance ) Quality of Life (generic or disease specific ) Economy (patient, society, physician, company )

Remember Risk factor modification for every patient. Stop Smoking, Decrease lipid levels, Reduce blood pressure Loose weight, Daily exercise, Better regulation of Diabetes Patients (%) Relative 5-year PAD mortality rates versus other common pathologies 100 90 80 70 60 50 40 30 20 10 0 15 Breast cancer 1 18 28 38 50 86 Hodgkin's PAD 2 Colon and CLI Lung cancer 1 disease 1 rectal cancer 1 Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) L. Norgren et al. Eur J Vasc Endovasc Surg Vol 33, Supplement 1, 2007 American Cancer Society. Cancer Facts and Figures 1997. Kampozinski RF, Bernhard VM. In: Vascular Surgery (Rutherford RB, ed). WB Saunders: 1989;chap 53.

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