What is the proper role of polytetrafluoroethylene grafts in infrainguinal reconstruction?

Abstract

Polytetrafluoroethylene grafts have been used extensively for infrainguinal vascular reconstruction either as the conduit of choice or as a substitute when saphenous vein is unavailable. Although numerous studies have shown satisfactory early patency rates, the long-term efficacy of these grafts in a large number of patients for specific indications and in various positions has been less well defined. From 1977 to 1987 we used four PTFE grafts from three different manufacturers to perform 300 infrainguinal reconstructions on 240 patients on our vascular service. The indications for surgery were disabling claudication in 28% and limb salvage in 72%. The 30-day operative mortality of 1% was not different from the 1.4% associated with infrainguinal autogenous vein grafting. The 5-year cumulative patency rate achieved with all infrainguinal polytetrafluoroethylene grafts was 35%, significantly higher for grafts placed for claudication (57%) than those placed for limb salvage (24%). There were no significant differences between the above-knee and below-knee locations for distal anastomoses regardless of indication, but femoropopliteal grafts provided significantly higher 5-year patency (37%) than infrapopliteal grafts (12%). Comparison of the 5-year patency rates among the three manufacturers of polytetrafluoroethylene grafts showed no significant differences. Fifty-four polytetrafluoroethylene grafts that failed underwent 67 revisions after catheter thrombectomy or thrombolysis, which resulted in a minimal 11% 5-year patency rate. Based on this experience, it is concluded that infrainguinal polytetrafluoroethylene prostheses provide significantly inferior results when compared with autogenous reconstruction.

Cryopreserved Saphenous Vein Allografts for Below-Knee Lower Extremity Revascularization

“…Over a period of more than 5 years, 1 15 cryopreserved vein allografts were implanted in 87 limbs to the distal popliteal (14) or tibial (101) arteries. The indication for surgery was rest pain in 56 procedures (49%), gangrene in 36 (31%), claudication in 21 (18%), and replacement of aneurysmal allografts in 2.…”

Recanalization of the Native Artery in Patients with Bypass Failure

“…Thrombectomy and revision of thrombosed grafts have resulted in patency rates of only 19% to 28% at the 5-year interval for failed vein grafts [7,8]. Long-term results after thrombectomy of polytetrafluoroethylene grafts have been even poorer, with patency rates of 32% at 2.5 years and 11% at 5 years [9,10]. Thrombolysis of occluded infrainguinal bypass grafts followed by graft revision has also resulted in the low patency rates of 0% to 37% 1 to 3 years after treatment for both prosthetic and vein conduits [11][12][13].…”

“…For patients who have severe ischemia at the time of graft failure, the available therapeutic options have offered suboptimal results. Restoration of long-term patency to thrombosed vein or prosthetic infrainguinal bypass grafts with either thrombectomy or thrombolytic therapy has proved difficult [7][8][9][10][11][12][13]. Given the inability to restore patency effectively to failed infrainguinal bypass grafts after graft thrombosis, it appears that replacement of the failed graft with an entirely new bypass (i.e., a secondary bypass) is the best therapeutic option.…”

Scaffolds and Cell-Based Tissue Engineering for Blood Vessel Therapy

“…Expanded polytetrafluoroethylene (ePTFE), Dacron and polyurethane are nondegradable conduit materials that have been used as large blood vessel substitutes for decades [McQuade et al, 2009;Tozzi et al, 2014]. Nevertheless, they are unsuitable for small-caliber vascular implantation due to thrombus formation and compliance mismatches [Thomson et al, 1989;Whittemore et al, 1989;Conte, 1998;Lu et al, 2013a]. Some clinical reports have shown that small-caliber ePTFE graft implantation had patency rates varying from 60% at 1 year to 14% at 3 years [McLarty et al, 1998].…”