Elsevier

Annals of Vascular Surgery

Volume 27, Issue 2, February 2013, Pages 208-217
Annals of Vascular Surgery

Clinical Research
Mid- and Long-Term Results of the Treatment of Infrainguinal Arterial Occlusive Disease With Precuffed Expanded Polytetrafluoroethylene Grafts Compared With Vein Grafts

https://doi.org/10.1016/j.avsg.2012.04.018Get rights and content

Background

Prosthetic grafts for lower-extremity bypass have limited patency compared with autologous vein grafts. Precuffed expanded polytetrafluoroethylene (ePTFE) grafts alter the geometry of the distal hood to improve patency. This study reports the authors’ long-term results on the use of precuffed ePTFE grafts for infrainguinal bypasses in patients with arterial occlusive disease and compares these with results of reversed great saphenous vein grafts (rSVG).

Methods

A retrospective review of billing codes identified 101 polytetrafluoroethylene (PTFE) and 47 rSVG bypasses performed over a 6-year period. Femoral to below-knee popliteal and femoral to tibial bypasses were analyzed. Data collected consisted of risk factors, Rutherford classification, bypass inflow and outflow, runoff vessels, patency, amputation, and death. Primary end points consisted of primary, assisted-primary, and secondary patency along with limb salvage.

Results

Mean age of the patients was 76 years in the PTFE group and 69.8 years in the rSVG group. For femoral to below-knee popliteal bypasses, primary patency at 1, 3, and 5 years in the PTFE group was 76.9%, 48.7%, and 43.3%, respectively, compared with 77.1%, 77.1%, and 77.1%, respectively, in the rSVG group (P = 0.225). Secondary patency was 89.2%, 70.9%, and 50.6% in the PTFE group compared with 84.4%, 84.4%, and 84.4% in the rSVG group (P = 0.269). Limb salvage was similar in the PTFE compared with the rSVG group (97.7%, 90.5%, and 79.4% vs. 83.3%, 83.3%, and 83.3%; P = 0.653). For femoral to tibial bypasses, primary patency in the PTFE group at 1, 3, and 5 years was 57.1%, 40.4%, and 22.1%, respectively, compared with 67.4%, 67.4%, and 50.6%, respectively, for the rSVG group (P = 0.246). Secondary patency was 75.5%, 44.9%, and 22.7% in the PTFE group compared with 91.8%, 91.8%, and 52.5% in the rSVG group (P = 0.022). Limb salvage at 1, 3, and 5 years was 79.2%, 55.7%, and 55.7%, respectively, in the PTFE group compared with 96.4%, 96.4%, and 64.3%, respectively, in the rSVG group (P = 0.046).

Conclusions

Precuffed ePTFE grafts demonstrate similar 1-year patency to that of rSVG. However, mid- and long-term patency is reduced compared with saphenous vein grafts (SVG), especially to tibial targets. PTFE grafts to the popliteal demonstrate limb salvage rates similar to those of SVG. In the tibial vessels, limb salvage rates for PTFE grafts are significantly worse compared with SVG.

Introduction

Lower-extremity bypass constitutes one of the foundations for the treatment of symptomatic peripheral arterial disease. Despite advances in surgical technique, bypass graft occlusion still remains the primary problem in infrainguinal bypass grafts, especially to targets below the knee. Autologous saphenous vein remains the conduit of choice and the gold standard for long-term patency.1, 2, 3 Unfortunately, saphenous vein is desirable as a conduit for a number of surgical procedures and often has been harvested for cardiac or previous vascular procedures. Expanded polytetrafluoroethylene (PTFE) conduits offer an acceptable alternative for patients without suitable autologous conduit.2, 3, 4, 5, 6 However, although patency of PTFE grafts is reasonable to above-knee popliteal targets, below-knee (BK) popliteal and tibial artery targets have poorer patency rates.3, 4

Studies into the flow dynamics of prosthetic bypass grafts have shown that altered hemodynamic flow patterns at the distal anastomosis may contribute to decreased sheer stress and, as a result, accelerated restenosis.7, 8, 9, 10 Adjunctive procedures, such as vein cuffs, may act as a bridge at the distal anastomosis, thus altering the flow dynamics to more closely mimic the natural state and improve patency.11, 12, 13 However, vein cuffs add significantly to the bypass complexity and operative time. Based on these flow dynamic studies, precuffed expanded PTFE grafts incorporate a large hood at the distal anastomosis in an attempt to alter the hemodynamic flow, eliminating areas of low flow and reducing restenosis.14 The Bard Distaflo (Bard, Tempe, AZ) graft incorporates such a cuff and has demonstrated improved flow dynamics and reduced levels of intimal hyperplasia at the distal anastomosis in premarket studies.14, 15

Studies analyzing early patency results of the Distaflo graft demonstrated acceptable patency.15 However, long-term patency results are lacking. This study seeks to evaluate the long-term patency of the Distaflo graft and compares these with those of reversed saphenous vein grafts (rSVG).

Section snippets

Methods

A retrospective search of all infrainguinal bypasses performed at a single institution from June 2003 to December 2009 was performed. All patients undergoing revascularization to BK targets with either Distaflo grafts or rSVG were selected for analysis. The choice of conduit was solely at the discretion of the operating surgeon, and although an effort was made to use a saphenous vein if present, the operating surgeons could elect to use a prosthetic if they deemed the saphenous vein

Patient Characteristics

Review of infrainguinal bypasses identified 101 Distaflo and 47 SVG bypasses to targets below the knee. BK popliteal targets accounted for 52 (51.5%) bypasses in the Distaflo group and 16 (34%) bypasses in the SVG group. Tibial targets accounted for 49 (48.5%) bypasses in the Distaflo group and 31 (66%) bypasses in the SVG group. Both groups were similar in age, with the SVG group having a significantly higher percentage of male subjects. The most common comorbidities were hypertension,

Discussion

Autologous great saphenous vein (GSV) remains the gold standard conduit for lower-extremity bypasses, especially to targets below the knee, with superior patency rates.1, 2 However, the GSV is a highly prized conduit for any operation requiring vascular reconstruction, especially coronary bypass and previous lower-extremity bypass. Thus, the GSV has been used for other procedures in up to 40% of patients requiring lower-extremity bypass, with an additional 12% of patients having a GSV that is

Conclusion

In the BK popliteal position, Distaflo grafts offer early patency comparable with rSVG but have significantly poorer mid- and long-term patency. Secondary interventions can improve midterm patency, with overall comparable limb salvage rates at all time points. Patency and limb salvage rates of the Distaflo bypasses are similar to those of standard PTFE bypasses reported historically. In the tibial position, Distaflo graft performed significantly worse compared with vein grafts at all time

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