Femoro-Popliteal Bypass Above Knee with Saphenous Vein vs Synthetic Graft

Abstract

There is still debate whether sintethic graft (polytetrafluoroethylene or Dacron) is equivalent to vein as bypass graft material for the above-knee femoropopliteal bypass. Therefore, we performed prospective randomized trial to compare vein with polytetrafluoroethylene/dacron for femoropopliteal bypasses with the distal anastomosis above the knee. Between January 2000 and June 2003, 121 femoropopliteal bypasses were performed. The indications for operation were severe claudication in 96 cases, rest pain in 16 cases, and ulceration in 9 cases. After randomization, 60 reversed saphenous venous bypasses and 61 polytetrafluoroethylene/dacron bypasses were performed. No perioperative mortality was seen, and 5% of the patients had minor infections of the wound, not resulting in loss of the bypass, the limb, or life. After 5 years, 37% of the patients had died and 7% were lost to follow-up. Only once saphenous vein was necessary for coronary artery bypass grafting. Primary patency rates after 5 years were 76,6% for venous bypass grafts and 59,1% for polytetrafluoroethylene/dacron grafts (p=0,035). Secondary patency rates were 83,3% for vein and 69,2% for polytetrafluoroethylene/dacron bypasses (p = 0,036). In the venous group, 10 bypasses failed, leading to four new bypasses. In the polytetrafluoroethylene group, 22 bypasses failed, leading to 12 reinterventions. After 5 years of follow-up, we conclude that a bypass with saphenous vein has better patency rates at all intervals and needs fewer reoperations. Saphenous vein should be the graft material of choice for above-knee femoropopliteal bypasses and should not be preserved for reinterventions. Polytetrafluoroethylene/dacron is an acceptable alternative if the saphenous vein is not available.

Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: Analysis of amputation free and overall survival by treatment received

“…However, a review of the recent literature reveals a conflicting view of the role of prosthetic bypass for this condition. It is generally accepted that the results of prosthetic bypass are worse than those constructed with vein and that the difference in performance increases as the grafts become more distal, [31][32][33][34] but prosthetic grafts are still being widely promoted, and one presumes used, for patients with SLI/ CLI. 35,36 Various design modifications such as heparin bonding 37 and distal precuffing 36,38 are claimed to be effective in increasing graft patency to acceptable levels, even for tibial bypasses.…”

Trends and outcomes after surgical lower limb revascularization in England

“…The in‐hospital mortality rate of 6·7 per cent after femoropopliteal bypass was comparatively high despite a significant reduction over the 5 years. Perioperative rates of between 0 and 7 per cent have been published internationally18, 19, but the most comparable data are from the UK BASIL trial which reported a 30‐day mortality rate of 5·6 per cent. This suggests that the rate reported in the present population analysis was valid, but it was high compared with rates in other developed countries.…”

Current Status of Arterial Revascularization for the Treatment of Critical Limb Ischemia in Infrainguinal Atherosclerotic Disease

“…35 Generally, femoropopliteal bypass grafts to the above-knee popliteal artery target have the highest patency rates, and patency rate decreases when the distal target is the below-knee popliteal or tibial artery. 7,28,[35][36][37] Mortality and major morbidity of open surgical revascularization for CLI were documented well owing to the PRE-VENT III trial. According to this prospective randomized multicenter trial of 1404 CLI patients who were treated with vein bypass from 2001 to 2003, the rates of perioperative mortality, postoperative myocardial infarction, and early graft occlusion were 2.7%, 4.7% and 5.2%, respectively.…”