Treatment of failed lower extremity bypass grafts with new autogenous vein bypass grafting James E. Edwards, MD, Lloyd M. Taylor, Jr., MD, and John M. Porter, MD, Portland, Ore. During the last 9 years w e performed 111 bypass procedures for lower extremity ischemia, which occurred after failed infrainguinal bypass grafting. An all autogenous reversed vein bypass was achieved in 103 of 111 operations (93%). Five-year primary and secondary patency of bypasses placed as treatment for one or more failed prior bypass(es) was 57% and 71%, respectively, as compared to 80% and 83%, respectively, for 5-year primary and secondary patency of simultaneously placed first time leg bypasses. Five-year limb salvage for bypass procedures performed as treatment for failed bypass was 90%, which was identical to that achieved for first time bypasses. (J VAsc StJRG 1990;11:136-45.)
The large number of leg bypasses placed annually in our aging population has inevitably led to the presence of an increasing number of patients with failed bypass grafts. All surgeons performing lower extremity bypass procedures are thus encountering a number of patients with limb ischemia associated with one or more failed prior bypasses in the same leg. In our experience this patient group comprises about one fifth of our total lower extremity bypass population. These patients are widely regarded to be at high risk for graft occlusion after repeat infrainguinal bypass surgery, and recent reports have documented that the results of repeat bypass surgery in these patients are indeed poor, with 3-year patency and limb salvage rates in the range of 30% to 40%. 16 Because of these poor results several authors have questioned whether repeat bypass surgery should be performed at all in these patients. 6 Most of the reports published to date include a large number of patients with reoperations on failed prosthetic bypasses or reoperations with the use of prosthetic conduits. We have remained committed to an all autogenous lower extremity vascular reconstruction policy. Our lower extremity bypass grafting results have been published and are clearly superior From the Division of Vascular Surgery, Oregon Health Sciences University. Supported by grant R000334, Clinical Research Center Branch, National Institutes of Health. Presented at the Thirty-seventh ScientificMeeting of the North American Chapter, International Society for Cardiovascular Surgery, New York, N.Y., June 19-20, 1989. Reprint requests: John M. Porter, MD, Division of Vascular Surgery, Oregon Health Sciences University, 3181 SW Sam Jackson Park Rd., Portland, OR 97201. 24/6/16621 136
Table I. Demographics of patient population undergoing repeat bypass surgery Characteristic
Diabetes Smokers Age (mean) Sex
32 (39%) 74 (90%) 68 yr 56 men/26 women
to those achieved with prosthetics. 7'8 To date, however, we have not specifically reviewed our experience with repeat autogenous bypass procedures in patients with failed prior ipsilateral bypass(es). In the past 9 years at the Oregon Health Sciences University 19.2% of all leg bypasses were placed in patients with one or more failed prior bypass(es) in the same ~,ib. The outcome of our reoperative experience with this patient group forms the basis for this report. MATERIAL AND METHODS Between Jan. 1, 1980, and Dec. 15, 1988, we treated 576 limbs in 444 patients with lower extremity ischemia. All patients tmderwent angiography. Eleven limbs in 11 patients were found to be unreconstructable and underwent primary amputation. We performed lower extremity bypass grafting in 565 limbs in 433 patients. Eighty-seven patients (111 limbs) undergoing lower extremity bypass surgery had one or more failed prior bypass(es) in the same limb. An autogenous reversed vein bypass graft was placed in 103 of these limbs. No autogenous vein could be found in eight limbs (five patients) and prosthetic bypasses were placed. These prosthetic b ~ pass grafts are not considered further in this article.
Volume ii Number i January 1990
Treatment offailed lower extremity bypass 137
Table IIa. Primary patency of repeat autogenous vein limb bypass grafting Time 0 6 12 24 36 48 60
A t risk
Occluded
Withdrawn
Interval patency
Cumulative patency
SEM
103 96 63 47 32 13 8
4 13 2 4 3 1 0
3 20 14 11 16 4 4
0.96 0.85 0.96 0.90 0.88 0.91 1.0
0.96 0.82 0.79 0.71 0.62 0.57 0.57
0.019 0.041 0.044 0.054 0.067 0.081 0.081
Table IIb. Secondary patency of repeat autogenous vein limb bypass grafting Time 0 6 12 24 36 48 60
A t risk
Occluded
Withdrawn
Interval patency
Cumulative patency
SEM
92 89 59 44 31 12 8
0 10 1 2 3 0 0
3 20 14 11 16 4 4
1.0 0.87 0.98 0.95 0.87 1.0 1.0
1.0 0.87 0.86 0.81 0.71 0.71 0.71
0.0 0.038 0.040 0.049 0.071 0.071 0.071
The demographics of the patients with a failed prior bypass graft undergoing autogenous repeat grafting are shown in Table I. Three patients had bilateral repeat bypass operations. Twelve limbs required two operations, and three limbs required three operations. The indication for surgery was limb salvage in 93 limbs (90%, 72 patients) and short distance claudication in 10 limbs (10%, 10 patients). Limb salvage was defined as restpain and/or ischemic ulceration or gangrene and an ankle/brachial index (ABI) of less than 0.4. 9 All previously placed grafts had failed clinically as determined by an absence of palpable distal pulses, reversion of ABI to prebypass ranges, and/or low or undeterminable graft flow velocity.1°,11 At the time of angiography the bypass was not visualized in 97 limbs, and in these limbs a new bypass was constructed. The distal anastomosis of the repeat bypass was to the above-knee popliteal artery in 10 limbs, the below-knee popliteal artery in 26 limbs, the tibial arteries in 54 limbs, and the pedal arteries in seven limbs. In the remaining six limbs the graft was found to be patent with either outflow occlusion or highgrade stenosis, and a new bypass was constructed from the previously placed graft to a tibial artery in four limbs and a pedal artery in two limbs. Repeat grafts were constructed of ipsilateral greater saphenous vein (22), contralateral greater saphenous vein (32), portions of remaining ipsilateral greater saphenous vein (14), arm vein (31), lesser saphenous vein (17), or some combination of these Ceres. Venovenostomy was required in 31 bypass procedures. In 58 limbs the new graft originated from an inflow site distal to the common femoral
artery. Seventeen grafts originated from the superficial femoral artery, 13 from the deep femoral artery, 10 from the popliteal artery, two from tibial arteries, and 16 from previously placed grafts (proximal leg bypass graft in six, aorta-bifemoral limb in four, femoral-femoral graft in two, and patent proximal portion of occluded prior bypass graft in four). Bypass grafts were classified as patent if the limb maintained a palpable distal pulse after surgery where one had not been present before surgery, if the limb maintained an ABI ___ 0.1 from the maximum postoperative ABI, or if the graft was demonstrated to be patent on angiography. A limb was classified as salvaged if a portion of the foot was maintained. Patency and limb salvage figures were calculated by the life-table method. Life tables were compared with a log rank test. 12 RESULTS The mean foUow-up for all patients was 20.5 months. Eighteen patients were lost to fonow-up at a mean interval of 20 months. Fifty-nine patients died during follow-up at a mean interval of 26 months. Five-year primary and secondary patencies of these bypasses were 57% and 71%, respectively, and are shown in Table II and Fig. 1. Five-year limb salvage was 90% and is shown in Table III and Fig. 2. Patient survival at 5 years was 12% and is shown in Table IV and Fig. 3. For grafts to infrapopliteal arteries, the 5-year primary and secondary patencies were 59% and 74%, respectively. The patency results for bypass graftings to popliteal arteries are only reported to 2 years, because beyond 2 years the standard error of patency
138
loumal of VASCULAR
Edwards, Taylor, and Porter
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O
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SURGERY
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.
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10 0
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I
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0
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'
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N = 103 N=92 N=425 '
60
48
POST-OP
Fig. 1. Cumulative primary and secondary patency of repeat bypass surgery compared with cumulative primary patency of first time bypass surgery.
Table III. Limb salvage in patients with repeat autogenous vein limb bypass surgery Time 0 6 12 24 36 48 60
At r i s k
Amputated
Withdrawn
90 83 55 42 29 11 6
0 4 0 0 1 0 0
7 24 13 13 17 5 2
exceeded 10%. 9 At 2 years the primary and secondary patencies were 84% and 84%, respectively, which were 20% and 4% greater than the corresponding values for infrapopliteal bypasses. These differences were not significant and are shown in Tables V and VI and Figs. 4 and 5. These results were compared with the 425 first time bypasses placed concurrently by our group./3 The 5-year primary and secondary patency rates in the first time bypass group were 80% and 83%, respectively, and the limb salvage rate at 5 years was 90%. The primary patency rate of the repeat bypasses is significantly lower than the first time bypasses (p < 0.05), whereas the limb salvage rate is identical. The secondary patency rate of the repeat bypasses is
Interval salvage 1.0 0.94 1.0 1.0 0.95 1.0 1.0
Cumulative salvage
SEM
1.0 0.94 0.94 0.94 0.90 0.90 0.90
0.0 0.027 0.027 0.027 0.052 0.052 0.052
not significantly different from that of first time bypasses (p > 0.05). DISCUSSION
The vascular surgeon treating a patient with severe lower extremity ischemia after a failed leg bypass clearly has a number of therapeutic choices. The available interventions include amputation if vascular reconstruction is deemed impossible or unlikely to succeed, graft thrombolysis and revision, graft thrombectomy and revision, and repeat bypass surgery with either a prosthetic or autogenous vein conduit. Thrombolytic therapy of occluded grafts followed by graft revision has reported patencies only in the range of 20% to 60% at 1 year. 14'~s In the
Volume 11 Number 1 January 1990
Treatment of failed lower extremity bypass 1 3 9
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0
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48
60
MONTHS POST-OP Fig. 2. Cumulative limb salvage of repeat and first time bypass procedures.
Table IV. Survival in patients with repeat autogenous vein limb bypass grafting Time 0 6 12 24 36 48 60
A t risk
Died
82 76 53 42 31 16 10
3 17 8 10 12 3 4
:
Withdrawn
Interval survival
Cumulative survival
SEM
3 6 3 1 3 3 2
0.96 0.77 0.85 0.76 0.59 0.79 0.56
0.96 0.74 0.62 0.47 0.28 0.22 0.12
0.021 0.050 0.057 0.060 0.056 0.053 0.047
patients in whom no reason for graft failure could be found, the i-year patency was 37%? s Catheter thrombectomy and revision has also resulted in poor long-term patency. Reported patencies have ranged from 65% at 3 years for above-knee grafts to 12% at 3 years for below-knee pophteal and tibia[ grafts when polytetrafluoroethylene (PTFE) was used as a conduit 16and 14% at 1 year in a mixed series of vein (45%) and PTFE (55%) leg bypass grafts? 4 The results of repeat leg bypass surgery over the years have been poor. In 1968 Sautot 17reviewed his experience with bypass grafting for failed reconstructions. He achieved a 1-year limb salvage of only 50% and concluded that reoperation for a failed infrainguinal bypass graft should only be performed in pa-
tients with limb-threatening ischemia because of the poor results. Craver et al. 18 in 1973 reported 98 infrainguinal grafts that occluded within 30 days after operation, 66 of whom underwent reoperation (28% with prosthetic grafts). Life-table graft patency was 65% at 30 days, 28% at 1 year, and 23% at 3 years. Szilagyi et al.19 in 1974 reviewed their experience with 169 secondary operations for lower extremity ischemia after infrainguinal bypass grafting. 19 Although the data presented in the article do not allow calculation of life-table patencies, the authors comment that their results were less satisfactory than the results of secondary aortoiliac reconstruction. In 1978 Painton et al. 2° reviewed the effectiveness of reoperation after late failure of infrainguinal by-
140
Journal of VASCULAR SURGERY
Edwards, Taylor, and Porter
100
'
°
°
"
r'
90 80 hi > ..J
The large number of leg bypasses placed annually in our aging population has inevitably led to the presence of an increasing number of patients with failed bypass grafts. All surgeons performing lower extremity bypass procedures are thus encountering a number of patients with limb ischemia associated with one or more failed prior bypasses in the same leg. In our experience this patient group comprises about one fifth of our total lower extremity bypass population. These patients are widely regarded to be at high risk for graft occlusion after repeat infrainguinal bypass surgery, and recent reports have documented that the results of repeat bypass surgery in these patients are indeed poor, with 3-year patency and limb salvage rates in the range of 30% to 40%. 16 Because of these poor results several authors have questioned whether repeat bypass surgery should be performed at all in these patients. 6 Most of the reports published to date include a large number of patients with reoperations on failed prosthetic bypasses or reoperations with the use of prosthetic conduits. We have remained committed to an all autogenous lower extremity vascular reconstruction policy. Our lower extremity bypass grafting results have been published and are clearly superior From the Division of Vascular Surgery, Oregon Health Sciences University. Supported by grant R000334, Clinical Research Center Branch, National Institutes of Health. Presented at the Thirty-seventh ScientificMeeting of the North American Chapter, International Society for Cardiovascular Surgery, New York, N.Y., June 19-20, 1989. Reprint requests: John M. Porter, MD, Division of Vascular Surgery, Oregon Health Sciences University, 3181 SW Sam Jackson Park Rd., Portland, OR 97201. 24/6/16621 136
Table I. Demographics of patient population undergoing repeat bypass surgery Characteristic
Diabetes Smokers Age (mean) Sex
32 (39%) 74 (90%) 68 yr 56 men/26 women
to those achieved with prosthetics. 7'8 To date, however, we have not specifically reviewed our experience with repeat autogenous bypass procedures in patients with failed prior ipsilateral bypass(es). In the past 9 years at the Oregon Health Sciences University 19.2% of all leg bypasses were placed in patients with one or more failed prior bypass(es) in the same ~,ib. The outcome of our reoperative experience with this patient group forms the basis for this report. MATERIAL AND METHODS Between Jan. 1, 1980, and Dec. 15, 1988, we treated 576 limbs in 444 patients with lower extremity ischemia. All patients tmderwent angiography. Eleven limbs in 11 patients were found to be unreconstructable and underwent primary amputation. We performed lower extremity bypass grafting in 565 limbs in 433 patients. Eighty-seven patients (111 limbs) undergoing lower extremity bypass surgery had one or more failed prior bypass(es) in the same limb. An autogenous reversed vein bypass graft was placed in 103 of these limbs. No autogenous vein could be found in eight limbs (five patients) and prosthetic bypasses were placed. These prosthetic b ~ pass grafts are not considered further in this article.
Volume ii Number i January 1990
Treatment offailed lower extremity bypass 137
Table IIa. Primary patency of repeat autogenous vein limb bypass grafting Time 0 6 12 24 36 48 60
A t risk
Occluded
Withdrawn
Interval patency
Cumulative patency
SEM
103 96 63 47 32 13 8
4 13 2 4 3 1 0
3 20 14 11 16 4 4
0.96 0.85 0.96 0.90 0.88 0.91 1.0
0.96 0.82 0.79 0.71 0.62 0.57 0.57
0.019 0.041 0.044 0.054 0.067 0.081 0.081
Table IIb. Secondary patency of repeat autogenous vein limb bypass grafting Time 0 6 12 24 36 48 60
A t risk
Occluded
Withdrawn
Interval patency
Cumulative patency
SEM
92 89 59 44 31 12 8
0 10 1 2 3 0 0
3 20 14 11 16 4 4
1.0 0.87 0.98 0.95 0.87 1.0 1.0
1.0 0.87 0.86 0.81 0.71 0.71 0.71
0.0 0.038 0.040 0.049 0.071 0.071 0.071
The demographics of the patients with a failed prior bypass graft undergoing autogenous repeat grafting are shown in Table I. Three patients had bilateral repeat bypass operations. Twelve limbs required two operations, and three limbs required three operations. The indication for surgery was limb salvage in 93 limbs (90%, 72 patients) and short distance claudication in 10 limbs (10%, 10 patients). Limb salvage was defined as restpain and/or ischemic ulceration or gangrene and an ankle/brachial index (ABI) of less than 0.4. 9 All previously placed grafts had failed clinically as determined by an absence of palpable distal pulses, reversion of ABI to prebypass ranges, and/or low or undeterminable graft flow velocity.1°,11 At the time of angiography the bypass was not visualized in 97 limbs, and in these limbs a new bypass was constructed. The distal anastomosis of the repeat bypass was to the above-knee popliteal artery in 10 limbs, the below-knee popliteal artery in 26 limbs, the tibial arteries in 54 limbs, and the pedal arteries in seven limbs. In the remaining six limbs the graft was found to be patent with either outflow occlusion or highgrade stenosis, and a new bypass was constructed from the previously placed graft to a tibial artery in four limbs and a pedal artery in two limbs. Repeat grafts were constructed of ipsilateral greater saphenous vein (22), contralateral greater saphenous vein (32), portions of remaining ipsilateral greater saphenous vein (14), arm vein (31), lesser saphenous vein (17), or some combination of these Ceres. Venovenostomy was required in 31 bypass procedures. In 58 limbs the new graft originated from an inflow site distal to the common femoral
artery. Seventeen grafts originated from the superficial femoral artery, 13 from the deep femoral artery, 10 from the popliteal artery, two from tibial arteries, and 16 from previously placed grafts (proximal leg bypass graft in six, aorta-bifemoral limb in four, femoral-femoral graft in two, and patent proximal portion of occluded prior bypass graft in four). Bypass grafts were classified as patent if the limb maintained a palpable distal pulse after surgery where one had not been present before surgery, if the limb maintained an ABI ___ 0.1 from the maximum postoperative ABI, or if the graft was demonstrated to be patent on angiography. A limb was classified as salvaged if a portion of the foot was maintained. Patency and limb salvage figures were calculated by the life-table method. Life tables were compared with a log rank test. 12 RESULTS The mean foUow-up for all patients was 20.5 months. Eighteen patients were lost to fonow-up at a mean interval of 20 months. Fifty-nine patients died during follow-up at a mean interval of 26 months. Five-year primary and secondary patencies of these bypasses were 57% and 71%, respectively, and are shown in Table II and Fig. 1. Five-year limb salvage was 90% and is shown in Table III and Fig. 2. Patient survival at 5 years was 12% and is shown in Table IV and Fig. 3. For grafts to infrapopliteal arteries, the 5-year primary and secondary patencies were 59% and 74%, respectively. The patency results for bypass graftings to popliteal arteries are only reported to 2 years, because beyond 2 years the standard error of patency
138
loumal of VASCULAR
Edwards, Taylor, and Porter
O
O
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~
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SURGERY
-
.
.
.
.
.
.
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.
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Prev Bypass 1 °Patency Prev Bypass 2°Patency • • • No P r e v B y p a s s 1 ° P o t e n c y -
10 0
,
I
,
I
12
0
24 MONTHS
'
I
36
'
-
I
N = 103 N=92 N=425 '
60
48
POST-OP
Fig. 1. Cumulative primary and secondary patency of repeat bypass surgery compared with cumulative primary patency of first time bypass surgery.
Table III. Limb salvage in patients with repeat autogenous vein limb bypass surgery Time 0 6 12 24 36 48 60
At r i s k
Amputated
Withdrawn
90 83 55 42 29 11 6
0 4 0 0 1 0 0
7 24 13 13 17 5 2
exceeded 10%. 9 At 2 years the primary and secondary patencies were 84% and 84%, respectively, which were 20% and 4% greater than the corresponding values for infrapopliteal bypasses. These differences were not significant and are shown in Tables V and VI and Figs. 4 and 5. These results were compared with the 425 first time bypasses placed concurrently by our group./3 The 5-year primary and secondary patency rates in the first time bypass group were 80% and 83%, respectively, and the limb salvage rate at 5 years was 90%. The primary patency rate of the repeat bypasses is significantly lower than the first time bypasses (p < 0.05), whereas the limb salvage rate is identical. The secondary patency rate of the repeat bypasses is
Interval salvage 1.0 0.94 1.0 1.0 0.95 1.0 1.0
Cumulative salvage
SEM
1.0 0.94 0.94 0.94 0.90 0.90 0.90
0.0 0.027 0.027 0.027 0.052 0.052 0.052
not significantly different from that of first time bypasses (p > 0.05). DISCUSSION
The vascular surgeon treating a patient with severe lower extremity ischemia after a failed leg bypass clearly has a number of therapeutic choices. The available interventions include amputation if vascular reconstruction is deemed impossible or unlikely to succeed, graft thrombolysis and revision, graft thrombectomy and revision, and repeat bypass surgery with either a prosthetic or autogenous vein conduit. Thrombolytic therapy of occluded grafts followed by graft revision has reported patencies only in the range of 20% to 60% at 1 year. 14'~s In the
Volume 11 Number 1 January 1990
Treatment of failed lower extremity bypass 1 3 9
100 "''''l
90, ¢:3 LIJ
>, I-Z laJ (.) I.iJ ¢L
J" . . . . .
T 55
T421:~o
J" .211 ..........
J:
I9529
. . . . . . . . . . . .
:-'- ........
I' 55 1'1
25'
80706050 40 30 20 No Prey Bypass -. • N=319 Prev Bypass , , N=90
10 0
'
I
0
'
I
12
'
I
24
'
I
36
'
48
60
MONTHS POST-OP Fig. 2. Cumulative limb salvage of repeat and first time bypass procedures.
Table IV. Survival in patients with repeat autogenous vein limb bypass grafting Time 0 6 12 24 36 48 60
A t risk
Died
82 76 53 42 31 16 10
3 17 8 10 12 3 4
:
Withdrawn
Interval survival
Cumulative survival
SEM
3 6 3 1 3 3 2
0.96 0.77 0.85 0.76 0.59 0.79 0.56
0.96 0.74 0.62 0.47 0.28 0.22 0.12
0.021 0.050 0.057 0.060 0.056 0.053 0.047
patients in whom no reason for graft failure could be found, the i-year patency was 37%? s Catheter thrombectomy and revision has also resulted in poor long-term patency. Reported patencies have ranged from 65% at 3 years for above-knee grafts to 12% at 3 years for below-knee pophteal and tibia[ grafts when polytetrafluoroethylene (PTFE) was used as a conduit 16and 14% at 1 year in a mixed series of vein (45%) and PTFE (55%) leg bypass grafts? 4 The results of repeat leg bypass surgery over the years have been poor. In 1968 Sautot 17reviewed his experience with bypass grafting for failed reconstructions. He achieved a 1-year limb salvage of only 50% and concluded that reoperation for a failed infrainguinal bypass graft should only be performed in pa-
tients with limb-threatening ischemia because of the poor results. Craver et al. 18 in 1973 reported 98 infrainguinal grafts that occluded within 30 days after operation, 66 of whom underwent reoperation (28% with prosthetic grafts). Life-table graft patency was 65% at 30 days, 28% at 1 year, and 23% at 3 years. Szilagyi et al.19 in 1974 reviewed their experience with 169 secondary operations for lower extremity ischemia after infrainguinal bypass grafting. 19 Although the data presented in the article do not allow calculation of life-table patencies, the authors comment that their results were less satisfactory than the results of secondary aortoiliac reconstruction. In 1978 Painton et al. 2° reviewed the effectiveness of reoperation after late failure of infrainguinal by-
140
Journal of VASCULAR SURGERY
Edwards, Taylor, and Porter
100
'
°
°
"
r'
90 80 hi > ..J
