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An argument against all-autogenous tissue for vascular bypasses below the inguinal ligament
W S Moore1, W J Quiñones-Baldrich
1UCLA School of Medicine.
Insights
Femoropopliteal bypasses often fail, necessitating secondary repairs. Using polytetrafluoroethylene (PTFE) grafts initially preserves saphenous vein for better secondary repair outcomes, improving limb salvage.
Area of Science:
- Vascular Surgery
- Reconstructive Surgery
Background:
- Femoropopliteal bypass grafts have a significant 5-year failure rate.
- Most patients experiencing initial reconstruction failure require subsequent repair procedures.
Purpose of the Study:
- To advocate for a long-term planning strategy in managing femoropopliteal reconstruction patients.
- To determine the optimal conduit strategy for initial and secondary femoropopliteal bypass procedures to maximize long-term patency and limb salvage.
Main Methods:
- Comparative analysis of secondary repair patency rates based on initial conduit choice (PTFE vs. autogenous saphenous vein).
- Evaluation of conduit availability for secondary repairs based on initial graft material.
Main Results:
- Secondary femoropopliteal repairs demonstrate superior patency rates when utilizing autogenous saphenous vein compared to expanded polytetrafluoroethylene (ePTFE) grafts.
- Initial reconstruction with ePTFE preserves autogenous saphenous vein for potential secondary repairs, unlike initial saphenous vein use which limits options.
Conclusions:
- Preferential use of ePTFE for primary femoropopliteal bypass provides the best long-term palliation and limb salvage.
- A staged approach, using ePTFE initially and autogenous saphenous vein for secondary repairs if needed, optimizes outcomes for lower extremity arterial occlusive disease.
Abstract:
1. Femoropopliteal bypass, regardless of the conduit used, has a 5-year failure rate. 2. The majority of patients with initial reconstruction failure will require secondary repair. 3. Recognition of the ultimate need for secondary repair justifies a long range planning approach for the management of patients who require femoropopliteal reconstruction. 4. Secondary repairs have a dramatically higher patency rate when performed with autogenous saphenous vein than they do with PTFE grafts. 5. Patients who had the initial operation performed with PTFE will have autogenous saphenous vein available for secondary repair, in contrast to the patients who had saphenous vein used in the initial operation; they must rely upon second-best choices including amputation. 6. The greatest and longest term of effective palliation, relief from disabling claudication, or limb salvage will be achieved when PTFE is used preferentially for the first femoropopliteal reconstruction. In the majority of patients, this will be the only operation necessary; they will have had a simple operation, requiring a short period of time, and probably reduced hospitalization. For those who require secondary repair, autogenous saphenous vein is available for that purpose and will yield the best long-term results in comparison to the other alternatives including amputation. Thus, the concept of staged infrainguinal repair using first PTFE and, if necessary, saphenous vein for the secondary repairs provides the longest term palliation for patients with lower extremity arterial occlusive disease.