N. J. Gargiulo1, F. J. Veith3, E. C. Lipsitz4, N. S. Cayne3, G. S. Landis2 1The Brookdale Hospital And Medical Center,Vascular Surgery,New York, NY, USA 2Northwell Health System,New Hyde Park, NY, USA 3New York University,Surgery,New York, NY, USA 4Montefiore Medical Center,Surgery,Bronx, NY, USA
Introduction: Polytetrafluoroethylene (PTFE) tibial and peroneal arterial bypasses without vein cuffs, patches or arteriovenous fistulas have been advocated for critical limb ischemia in circumstances when autologous saphenous vein is not available. This reviews a 30-year experience.
Methods: A retrospective analysis was performed on a group of 377 patients with critical limb ischemia facing immediate amputation requiring revascularization between July 1977 and June 2011. These 377 patients had no autologous vein on duplex examination and operative exploration and underwent 411 PTFE bypasses to a tibial or peroneal artery (the only patent outflow vessels) without any adjunctive procedure. The majority of these patients had two or more prior ipsilateral infrainguinal bypasses. Tourniquet control of the tibial or peroneal was used in the majority of cases (85%). Cumulative life table primary and secondary patency and limb salvage rates were calculated for these bypasses. These results were compared to those infrapopliteal bypasses performed with alternate autologous vein conduits or PTFE in conjunction with an adjunctive procedure (i.e. cuff, patch or av fistula).
Results: The 5- and 10-year cumulative primary graft patency rates for tibial and peroneal arterial PTFE bypasses were 39% +/- and 28% +/-, respectively. Secondary graft patency rates were 55% and 51% at 5 and 10 years, respectively. Limb salvage rates were 71 % at 5 years and 66% at 10 years. Several effective surgical strategies employed over the last 3 decades included meticulous attention to the distal anastomosis, mandatory completion arteriography, initial pharmacologic treatment of distal anastomotic or runoff pseudodefects, thrombectomy and/or graft extension for those defects that failed to resolve, and postoperative anticoagulation.
Conclusions: PTFE bypasses without adjunctive procedures to infrapopliteal arteries is an acceptable alternative option for those patients without autologous vein facing imminent amputation in this small cohort of patients. Several important perioperative strategies may help improve PTFE graft patency and overall limb salvage.