Secondary femoropopliteal reconstruction

Retrospective analysis of the authors' experience with 109 primary femoropopliteal bypass vein grafts that failed allows description of three distinct modes of failure. Within 30 days of surgery, failure resulted primarily from technical or judgmental errors. The development of stenotic lesions within the vein graft caused a second group of failures during the first year after bypass. The third group most commonly failed due to progression of peripheral atherosclerosis a year or more following original bypass. No correlation was found, however, between the mode of failure and results of secondary femoropopliteal-tibial reconstruction, which yielded an overall 50% five-year cumulative limb salvage rate. The results indicate that this salvage rate can be anticipated regardless of the number of secondary operations required. The highest long-term patency rate was achieved when frequent postoperative follow-up examinations allowed recognition of graft failure prior to total occlusion. Under such circumstances a simple vein patch of stenotic lesions yielded an 85% five-year graft patency. Following actual thrombosis, however, the highest five-year patency rate was achieved when reconstruction was performed using a new vein graft; saphenous vein and arm vein were equally effective. When prosthetic material was used, no secondary graft remained patent beyond three years. Finally, when a proximal or distal portion of the original vein graft proved adequate in caliber following thrombectomy, it could be successfully incorporated in a secondary reconstruction with the expectation of a 50% five-year limb salvage rate. No statistically significant difference was found in salvage rates among each of the patient groups representing the three common modes of graft failure. This finding, coupled with an acceptable 2.5% operative mortality rate, provides justification for an aggressive approach toward secondary femoropopliteal reconstruction.