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Axillopopliteal bypass grafting: indications, late results, and determinants of long-term patency
1Division of Vascular Surgery, Montefiore Medical Center-Albert ff1stein College of Medicine, New York, NY 10467.
Insights
Axillopopliteal bypass grafting using polytetrafluoroethylene grafts effectively salvages limbs in high-risk patients. Sequential grafts demonstrate superior patency, justifying their use when standard procedures fail.
Area of Science:
- Vascular Surgery
- Reconstructive Surgery
- Peripheral Artery Disease
Background:
- Limb salvage is critical for patients with severe peripheral artery disease.
- Axillopopliteal bypass grafting is an alternative for high-risk patients unsuitable for standard revascularization.
- Polytetrafluoroethylene (PTFE) grafts are utilized in these complex cases.
Purpose of the Study:
- To evaluate the efficacy and outcomes of axillopopliteal bypass grafting for limb salvage.
- To identify factors influencing graft patency and patient survival.
- To compare different surgical approaches within axillopopliteal bypass.
Main Methods:
- Retrospective analysis of 55 axillopopliteal bypass graftings in 50 high-risk patients over 12 years.
- Use of 6 mm polytetrafluoroethylene grafts.
- Indications included severe atherosclerotic disease, failed prior bypasses, and graft infections.
Main Results:
- The 5-year cumulative patient survival rate was 40%, with a 30-day operative mortality of 8%.
- Overall 5-year primary graft patency was 40%, and limb salvage rates were 58%.
- Sequential axillofemoral-popliteal grafts showed significantly higher 3-year patency (74%) compared to straight axillopopliteal grafts (42%).
Conclusions:
- Axillopopliteal bypass grafting is a viable option for limb salvage when standard procedures are not feasible.
- Sequential bypasses incorporating the common or deep femoral artery improve long-term graft patency.
- Careful patient selection and surgical technique are crucial for successful outcomes.
Abstract:
In the last 12 years we have performed 55 axillopopliteal bypass graftings with 6 mm polytetrafluoroethylene grafts for limb salvage in 50 patients who were at high risk for limb loss. Indications for this procedure were (1) severe atherosclerotic disease of the common, superficial, and deep femoral arteries (33 cases); (2) failed aortofemoral bypass grafting with sufficient fibrosis or disease progression in the deep femoral artery (five cases); (3) insufficient hemodynamic and clinical improvement after axillofemoral bypass grafting (10 cases); and (4) sepsis in the groin from a previously infected graft (seven cases). The 30-day operative mortality rate was 8%, and the 5-year cumulative patient survival rate was 40%. Overall 1-, 3-, and 5-year cumulative primary graft patency rates were 58%, 45%, and 40%, respectively. Comparable limb salvage rates were 83%, 68%, and 58%. Repeat operations increased 5-year patency rates from 40% to 59% (p less than 0.05). Three-year patency rate for grafts placed in the presence of poor angiographic runoff in one vessel was 62% and for good angiographic runoff (two to three vessels) it was 57% (NS). Grafts to the above-knee popliteal artery had a patency rate of 67% at 3 years, whereas for grafts that crossed the knee joint it was 51% (NS). Three-year patency rate for 24 straight axillopopliteal grafts was 42%, and for 31 sequential axillofemoral-popliteal grafts it was 74% (p less than 0.05). These results show that axillopopliteal bypass grafting is justified when other standard operations are not possible in patients who are in imminent danger of limb loss, and that every possible effort should be made to use the common or deep femoral artery as part of a sequential axillofemoral-popliteal procedure.