From April 1981 to April 1985, 128 limbs in 120 patients who had primary femoropopliteal bypasses were entered in a randomized comparative study. Grafts used were 56 randomized and five obligatory reversed saphenous veins (RSVs), 41 randomized and 24 obligatory superficial femoral-popliteal veins (SF-PVs), and two obligatory prosthetic grafts. The primary patency rates of randomized SF-PVs (64% at 3 years) and RSVs (60% at 3 years) were not significantly different. Similarly, there was no statistically significant difference in the secondary patency rates of 68% for SF-PVs and 63% for RSVs at 3 years. Combinations of obesity, hypertension, and poor medical condition mandated obligatory RSV use. Obligatory SF-PV use was necessitated by absence (eight cases) or inadequacy (16 cases) of the saphenous vein. Indications for bypass were critical ischemia (RSVs, 93% and SF-PVs, 92%) and claudication (RSVs, 7% and SF-PVs, 8%). Diabetes was present in 69% of patients with SF-PV bypass and 49% of those with RSV bypass. Limb retention, operative mortality, and patient survival rates were not significantly different with each graft. Continuation of the study as originally structured, with nonselective SF-PV use, became ethically untenable when it was appreciated that results in black patients and patients with excessively large grafts were markedly inferior and that construction of 3 cm moderately tapered anastomoses significantly reduced the incidence of distal anastomotic hyperplasia. These results, obtained during a period when important lessons about SF-PV use were being learned, indicate that during the first three years of observation after primary femoropopliteal bypass, the differences in cumulative primary and secondary patency rates of SF-PVs and RSVs were not statistically significant. Results in the most recent 76 SF-PV grafts, with primary and secondary patency rates of 82% and 89% at 3 years, provide a more realistic picture of the effectiveness of SF-PVs as primary femoropopliteal bypass grafts.

Actuarial Analysis↗

PubMed1986

An 11-year experience with deep leg veins as femoropopliteal bypass grafts.

Since 1974, 82 primary femoropopliteal bypasses were performed using superficial femoral, popliteal, and deep femoral veins exclusively. Saphenous nonavailability dictated usage in 20 cases, and 62 grafts were placed as part of a randomized comparative study with saphenous veins. Cumulative life table patency rates at 1, 2, 3, 4, and 5 years were 89%, 87%, 70%, 60%, and 60%. Surgical indications were critical ischemia (n = 77) and claudication (n = 5). Late stasis changes and ulceration did not occur and six-month ankle swellings were only 0.58 cm greater than in patients with saphenous vein grafts. Routine periodic postoperative angiography (256 studies in 74 patients) allowed informed evaluation of most late graft failures. Occlusions in the first two years, which were mainly associated with advanced distal disease, were predominantly not graft related. Most later occlusions were intrinsic; they were caused by distal anastomotic hyperplasia or, in those patients with the largest grafts, the embolization of graft mural thrombi. Revised anastomotic technique and rejection of the largest grafts may ameliorate these problems.

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PubMed1986

A saphenous alternative: preferential use of superficial femoral and popliteal veins as femoropopliteal bypass grafts.

Our experience with 100 superficial femoral and popliteal veins over a 12 year period has established a firm basis for their preferential use as femoropopliteal bypass grafts. Deep leg veins are currently used in two thirds of primary femoropopliteal bypass candidates. Groups identifiable preoperatively in whom results have been inferior include patients with excessively large grafts, black patients, and those with extremely poor runoff. Patients who will develop distal anastomotic hyperplasia, a fourth problem group, cannot be detected preoperatively but can be diagnosed and managed effectively. Disadvantages of superficial femoral and popliteal vein use include longer and more traumatic operations, increased early limb swelling, and the need for preoperative venography and postoperative arteriography to achieve optimum results. The most important advantage of preferential deep leg vein use is the high patency rate at 2 years with the expectation, already being realized, of significantly reduced intrinsic graft failures in the later years. Saphenous vein preservation constitutes a major additional bonus.

Actuarial Analysis↗

PubMed1986

Orthodontic economic index--1986.

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Costs and Cost Analysis↗

PubMed1985

Percutaneous transluminal angioplasty of stenotic deep vein arterial bypass grafts.

Successful percutaneous transluminal angioplasty was performed in six patients with lower-extremity vein-graft stenosis. In all patients we used autogenous, superficial femoral veins as the vein-graft material because the greater saphenous veins were too small or had been harvested for previous surgery. Angioplasty was performed on three men and three women (average age, 73 years). Stenosis of the vein graft was suspected in the presence of recurrent symptoms and physical signs of vascular insufficiency; additionally, Doppler pulse volume recordings of the ankle aided in the identification of patients with falling grafts. Angiography confirmed the presence of superficial femoral vein stenosis in all patients prior to balloon catheter dilation. On an average, angioplasty was performed approximately seven months following surgery; successful dilation was demonstrated by an increased luminal diameter seen arteriographically. Two of the six patients underwent a second angioplasty six months after the first procedure. Graft patency has been maintained in all six patients, as measured by clinical follow-up and Doppler pulse volume recordings. Arteriography was performed in the presence of recurrent symptoms or physical signs of diminished flow to the extremity. The oldest surviving grafts in this group of patients are 24 and 26 months, respectively.

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PubMed1985