Sequential femoro-popliteal-tibial bypass grafting: operative technique and results

Sequential femoro-popliteal-tibial saphenous vein grafts were constructed in 25 patients for limb salvage. Angiographically, these patients had an isolated popliteal artery segment and at least one distal tibial or peroneal artery patent. In each case, two distal anastomoses were made: one side-to-side to the isolated popliteal segment and the other end-to-side to a tibial or peroneal artery. Twenty-three of 25 grafts were successful; there was an immediate increase in ankle/brachial pressure index and limb salvage. Patency rates calculated by life table analysis were 90.2% at six months, 83.8% at one year, and a stable interval patency thereafter. For comparison, 65 standard femoro-tibial or peroneal vein grafts performed during the same time interval by the same surgeons were analyzed. Each graft had one distal anastomosis to a tibial or peroneal artery. Graft patency was 75% at six months, 72.6% at one year, 54.5% at two years, and 49.7% at three years. The superior patency rate of the sequential grafts was statistically significant (p less than .03). We conclude that the sequential vein graft technique may result in more complete extremity revascularization and increased graft flow, thereby improving patency rates. In selected patients with an isolated popliteal segment and a patent distal tibial or peroneal artery, the sequential graft technique should be considered.