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21.4 Dacron or PTFE for femoropopliteal bypass: Results of a prospective randomized trial
FemoropopiitealI C~~~&.&WZS: Postoperative outcome of arterial reconstruction in octogenarians with limb threatening &hernia and the diabetic patients with gangrenous foot was extremely poor, and criteria of surgical indication remain controversial. However, the results of reconstructive arterial surgery including tibia1 arterial bypass were acceptably good with regard to mortality and limb salvage rates in patients without these medical conditions.
21.4 Dacron or PTFE for Femoropopliteal Bypass: Results of a Prospective Randomized Trial J.I? FLETCHER and B.I. ROBINSON, Sydney, NSW, Australia A prospective randomized trial was performed to compare graft patency between expanded polytetrafluoroethylene (PTFE) and gelatin sealed knitted Dacron (GSKD) for femoropophteal bypass. There were 108 patients randomized to receive either a PTFE or GSKD prosthetic graft. Indications for surgery were severe claudication in 68 and critical limb ischaemia in 40. Distal anastomosis was above knee in 7.5 and below knee in 33. There were no significant differences between the PTFE and GSKD groups with respect to mean age, male:female ratio, cardiovascular risk factors, incidence of aortoihac disease, previous surgery in the same limb, adjunctive procedures, site of distal anastomosis and number of run-off vessels. Primary patency at 1, 2 and 3 years was 72%, 52% and 52% for PTFE and 70%, 56% and 47% for GSKD (P = 0.87). Secondary patency at 1,2 and 3 years was 74%, 54% and 54% for PTFE and 78%, 70% and 53% for GSKD (P = 0.39). The most significant predictors of early graft failure were poor vessel run-off and critical limb ischaemia. In conclusion, there was no difference in graft patency between PTFE and GSKD for femoropopliteal bypass.
21.5 Assessment of Crural VesselsUsing Duplex Prior to Distal Grafting YG. WILSON, J.K. GEORGE, D.C. WILKZNS and S. ASHLEY, Plymouth, UK Aims: Doppler insonation may inadequately predict the optimum run-off artery or fail altogether to detect patent vessels and preoperative arteriography (hitherto the “gold is often supplemented by on-table, standard” modality) prereconstruction arteriography. The aim of this study was to prospectively evaluate colour duplex versus preoperative arteriography in the assessment of distal run-off prior to femoro-crural reconstruction. Methods: Patients requiring distal bypasses underwent preoperative run-off assessments using dependent Doppler, arteriography and duplex by a vascular surgeon, radiologist and technologist, respectively, each blinded to the findings of the next during measurement. Preoperative findings were compared with intraoperative clinical findings and completion flow studies/arteriograms. Resnlts: Thirty-nine consecutive patients (30 male, nine female; mean age 71 years (range: 53-95); 26% diabetic) undergoing 40 femoro-crural reconstructions for limb salvage due to critical ischaemia were assessed. The 30 day primary cumulative patency for the series was 90%. Dependent
CARDIOVASCULAR
SURGERY
SEPTEMBER
1997
Doppler correctly predicted the optimum vessel in 43% of cases, but was indeterminate as to the optimum vessel in 9% and unrecordable in 48%. Arteriography correctly predicted the optimum vessel in 75% of cases, but was indeterminate in 12%, failed to demonstrate run-off in three cases (8%) and selected an inferior vessel in two cases (5%). Duplex correctly predicted the optimum vessel for all 40 grafts. Conclusions: Duplex is a superior modality to arteriography for preoperative assessment of distal run-off and may therefore obviate the need for on-table, prereconstruction arteriography during femoro-crural reconstruction.
21.6 Composite Prosthetic/Vein Bypass Grafts to InfragenicuIate Vessels- A a 14 Year Experience I? EYERS, S. ASHLEY, M.J. DENNIS, D.C. WILKINS and B.I? BLISS, Piyymouth, UK Aim: The use of composite grafts comprising a proximal prosthetic graft anastomosed to a distal segment of vein is well described, but there is little in the way of literature to support or refute their efficacy. To assess the value of this conduit, we reviewed all such composite grafts performed over a I4 year period in Plymouth, UK. Methods: From 1978 to 1992,Sl compostte prosthetic/vein bypass grafts to infrageniculate vessels were performed in 48 patients (29 male, 19 female, mean age 66.5 years). The senior author performed 92% of reconstructions and the results have been analysed retrospectively. Results: There were 11 secondary and two tertiary reconstructions. Thirty grafts (59%) were performed for critical ischaemia, 18 (35%) for severe intermittent claudication and three (6%) for popliteal aneurysms. The outflow vessel was the distal popliteal artery in 40 cases (78%) and a tibia1 artery in 11 cases (22%). The prosthetic component was Dacron in 32 cases (63%) and PTFF in 19 (37%). The vein conduit was reversed long saphenous vein in the majority (84%). Followup was by clinical and Doppler examination, more recently supplemented by Duplex scanning. Early graft failure (within 30 days) occurred in nine cases (18%) of which four were distal bypasses. At 1 year, 26 grafts had failed (15 Dacron composites and 11 PTFE composites), of which 17 had been performed for limb salvage, eight for severe intermittent claudication and one for popliteal aneurysm. The cumulative patency rates at 3,6,9 and 12 months were 66%, 56% 46% and 40%, respectively. Fourteen grafts remained patent for more than 4 years, but five (36%) developed an aneurysm at the prosthetic/vein junction. Conclttsion: In conclusion, the patency of infrageniculate reconstructions using composite grafts is relatively poor and there is a high incidence of late aneurysm formation at the prosthetic/vein anastomosis.
21.7 DuDleX Surveillance of PTFE Grafts Worthwhile? R.T.A: CHALMERS, T.G. GILLIES, /e KELMAN, P.L. ALLAN and C.V. RUCKLEY, Edinhurgb, UK
Is
Following infrainguinal bypass with polytetrafluoroethylene (PTFE), patients were entered into a prospective graft surveillance programme using colour flow duplex ultrasound, anklebrachial pressure index measurement and clinical examination
107
21.4 Dacron or PTFE for Femoropopliteal Bypass: Results of a Prospective Randomized Trial J.I? FLETCHER and B.I. ROBINSON, Sydney, NSW, Australia A prospective randomized trial was performed to compare graft patency between expanded polytetrafluoroethylene (PTFE) and gelatin sealed knitted Dacron (GSKD) for femoropophteal bypass. There were 108 patients randomized to receive either a PTFE or GSKD prosthetic graft. Indications for surgery were severe claudication in 68 and critical limb ischaemia in 40. Distal anastomosis was above knee in 7.5 and below knee in 33. There were no significant differences between the PTFE and GSKD groups with respect to mean age, male:female ratio, cardiovascular risk factors, incidence of aortoihac disease, previous surgery in the same limb, adjunctive procedures, site of distal anastomosis and number of run-off vessels. Primary patency at 1, 2 and 3 years was 72%, 52% and 52% for PTFE and 70%, 56% and 47% for GSKD (P = 0.87). Secondary patency at 1,2 and 3 years was 74%, 54% and 54% for PTFE and 78%, 70% and 53% for GSKD (P = 0.39). The most significant predictors of early graft failure were poor vessel run-off and critical limb ischaemia. In conclusion, there was no difference in graft patency between PTFE and GSKD for femoropopliteal bypass.
21.5 Assessment of Crural VesselsUsing Duplex Prior to Distal Grafting YG. WILSON, J.K. GEORGE, D.C. WILKZNS and S. ASHLEY, Plymouth, UK Aims: Doppler insonation may inadequately predict the optimum run-off artery or fail altogether to detect patent vessels and preoperative arteriography (hitherto the “gold is often supplemented by on-table, standard” modality) prereconstruction arteriography. The aim of this study was to prospectively evaluate colour duplex versus preoperative arteriography in the assessment of distal run-off prior to femoro-crural reconstruction. Methods: Patients requiring distal bypasses underwent preoperative run-off assessments using dependent Doppler, arteriography and duplex by a vascular surgeon, radiologist and technologist, respectively, each blinded to the findings of the next during measurement. Preoperative findings were compared with intraoperative clinical findings and completion flow studies/arteriograms. Resnlts: Thirty-nine consecutive patients (30 male, nine female; mean age 71 years (range: 53-95); 26% diabetic) undergoing 40 femoro-crural reconstructions for limb salvage due to critical ischaemia were assessed. The 30 day primary cumulative patency for the series was 90%. Dependent
CARDIOVASCULAR
SURGERY
SEPTEMBER
1997
Doppler correctly predicted the optimum vessel in 43% of cases, but was indeterminate as to the optimum vessel in 9% and unrecordable in 48%. Arteriography correctly predicted the optimum vessel in 75% of cases, but was indeterminate in 12%, failed to demonstrate run-off in three cases (8%) and selected an inferior vessel in two cases (5%). Duplex correctly predicted the optimum vessel for all 40 grafts. Conclusions: Duplex is a superior modality to arteriography for preoperative assessment of distal run-off and may therefore obviate the need for on-table, prereconstruction arteriography during femoro-crural reconstruction.
21.6 Composite Prosthetic/Vein Bypass Grafts to InfragenicuIate Vessels- A a 14 Year Experience I? EYERS, S. ASHLEY, M.J. DENNIS, D.C. WILKINS and B.I? BLISS, Piyymouth, UK Aim: The use of composite grafts comprising a proximal prosthetic graft anastomosed to a distal segment of vein is well described, but there is little in the way of literature to support or refute their efficacy. To assess the value of this conduit, we reviewed all such composite grafts performed over a I4 year period in Plymouth, UK. Methods: From 1978 to 1992,Sl compostte prosthetic/vein bypass grafts to infrageniculate vessels were performed in 48 patients (29 male, 19 female, mean age 66.5 years). The senior author performed 92% of reconstructions and the results have been analysed retrospectively. Results: There were 11 secondary and two tertiary reconstructions. Thirty grafts (59%) were performed for critical ischaemia, 18 (35%) for severe intermittent claudication and three (6%) for popliteal aneurysms. The outflow vessel was the distal popliteal artery in 40 cases (78%) and a tibia1 artery in 11 cases (22%). The prosthetic component was Dacron in 32 cases (63%) and PTFF in 19 (37%). The vein conduit was reversed long saphenous vein in the majority (84%). Followup was by clinical and Doppler examination, more recently supplemented by Duplex scanning. Early graft failure (within 30 days) occurred in nine cases (18%) of which four were distal bypasses. At 1 year, 26 grafts had failed (15 Dacron composites and 11 PTFE composites), of which 17 had been performed for limb salvage, eight for severe intermittent claudication and one for popliteal aneurysm. The cumulative patency rates at 3,6,9 and 12 months were 66%, 56% 46% and 40%, respectively. Fourteen grafts remained patent for more than 4 years, but five (36%) developed an aneurysm at the prosthetic/vein junction. Conclttsion: In conclusion, the patency of infrageniculate reconstructions using composite grafts is relatively poor and there is a high incidence of late aneurysm formation at the prosthetic/vein anastomosis.
21.7 DuDleX Surveillance of PTFE Grafts Worthwhile? R.T.A: CHALMERS, T.G. GILLIES, /e KELMAN, P.L. ALLAN and C.V. RUCKLEY, Edinhurgb, UK
Is
Following infrainguinal bypass with polytetrafluoroethylene (PTFE), patients were entered into a prospective graft surveillance programme using colour flow duplex ultrasound, anklebrachial pressure index measurement and clinical examination
107