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Management of the Failed Primary Infrainguinal Reconstruction: Treatment Options and Long-Term Outcome

Robert L. Hewitt, M.D.

Tulane Department of Surgery, New Orleans, Louisiana

Patients presenting with critical limb ischemia following failed infrainguinal grafts have been reported to have a significant amputation rate and reduced long-term survival. The authors reviewed their three-year experience with 33 patients with failed infrainguinal reconstruction. The median age was 63.1 years of age (range forty-three to eighty-seven years). There were 19 women and 14 men. Risk factors included the following: hypertension 31 (94%), diabetes 21 (64%), and tobacco use 30 (91%). All patients had limbthreatening ischemia,15.had gangrene (45.4%),8.had ulceration (24.2%), and 10 had rest pain 10 (30.3%). There had been 42 previous revascularizations (1.27 per patient, range 1 to 6). The authors performed 45 revascularization operations (1.36 per patient, range 1 to 4). Inflow was as follows: common femoral artery in 29 (64.4%), superficial femoral artery in 9 (20%), profunda femoris in 4 (8.9%), aortobifemoral graft limb in 2 (4.4%), and femoral-femoral bypass graft in 1 (2.2%). Outflow was as follows: posterior tibial artery 12 (26.7%), peroneal artery in 17 (37.8%), anterior tibial artery in 7 (15.6%), popliteal artery in 5 (11.1%), and tibioperoneal trunk in 4 (8.9%). The conduits were as follows: great saphenous vein (GSV) from the opposite lower limb in 8 (17.8%), GSV/lesser saphenous vein (LSV) composites in 8 (17.8%), expanded polytetrafluoroethylene in (ePTFE) 5 (11.1%), LSV composite in 10 (22.2%), ePTFE/GSV composite in 5 (11.1%), cadaveric vein in 2 (4.4%), superficial femoral vein/ePTFE composite in 2 (4.4%), endarterectomized superficial femoral artery/GSV composite in 1 (2.2%), GSV/upper limb vein composite in 1 (2.2%); and upper limb vein in 3 (6.7%). There was one perioperative death (2.2%). Six patients died during the follow-up period (74.1% survival). Limb salvage was obtained in 28 patients (83.1%). Cumulative secondary patency was 73.2% at three years. These results indicate that: (1) aggressive revascularization for failed infrainguinal grafts can result in significant limb salvage, and (2) long-term survival is common in this patient population.

Vascular and Endovascular Surgery, Vol. 30, No. 4, 281-288 (1996)
DOI: 10.1177/153857449603000403


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