Bypass Vein Grafts in Patients with Distal Popliteal Artery Occlusion Robert C. Davis, MD, Boston, Massachusetts W. Tudor Davies, FRCS, Boston, Massachusetts John A. Mannick, MD, Boston, Massachusetts
Considerable clinical evidence suggests that the reversed autogenous saphenous vein bypass graft is currently the treatment of choice in patients with arteriosclerotic peripheral vascular disease of the femoral and popliteal arteries. In addition, our experience and that of others [l-4] have shown that the autogenous saphenous vein bypass graft makes successful reconstruction possible even when there is only fair or poor distal outflow or runoff. There are patients threatened with major amputation because of severe arteriosclerotic occlusive disease of the femoropopliteal system who are not candidates for conventional femoropopliteal bypass vein grafts because of distal popliteal occlusion. In these patients, the distal anastomosis of a vein graft could be placed in either an “isolated segment” of popliteal artery or a tibia1 vessel distal to the popliteal artery. The distribution of arteriosclerotic occlusions in a patient with an isolated popliteal artery segment is shown in Figure 1. An isolated popliteal artery segment occurs when there is complete occlusion of the superficial femoral artery and complete occlusion of either the distal popliteal artery or the popliteal artery bifurcation. This patent segment of popliteal artery fills and empties only through collateral vessels. Several vascular surgery groups have reported satisfactory late results with vein grafts to the tibial vessels distal to the popliteal artery [4-61. We have previously reported long-term success of vein grafts to isolated popliteal artery segments [I], and other groups of surgeons have indicated that vein bypass grafts to isolated popliteal artery segments have been successful [3,7-g]. A comparison From the Department of Surgery, Boston University Medical Center, Boston, Massachusetts. Reprint requests should be addressed to Robert C. Davis, MD, Boston University Medical Center, 80 East Concord Street, Boston, Massachusetts 02118. Presented at the Fifty-Fifth Annual Meeting of the New Engbnd Surgical Society, Waterville Valley, New Hampshire, September 26-28. 1974.
Volume 129, April 1975
of tibial vessel grafts and isolated popliteal artery segment grafts in the experience of the same group of surgeons has apparently never been made. We have, therefore, evaluated our results, over the same period of time, with vein grafts to isolated popliteal artery segments and with vein grafts to tibia1 vessels distal to the popliteal artery.
Material and Methods The fifty-five reversed autogenous saphenous vein bypass grafts in this study were performed at University Hospital, Boston University Medical Center. All patients underwent arterial surgery for purposes of limb salvage. Each of these patients had either an ulcer that would not heal, rest pain or other pregangrenous findings, or frank gangrene often with cellulitis or an abscess. As noted in Table I, the incidence of each of these indications was similar in the isolated popliteal segment and tibia1 vessel groups. As noted in Table II, the mean age and proportion of women were higher in the group with an isolated popliteal segment. The proportion of patients with insulin-treated diabetes was similar. The majority of patients had clinical and electrocardiograpic evidence of arteriosclerotic heart disease. About one quarter of the patients in each group had had previous myocardial infarctions. Equal proportions of patients in each group had hypertension, chronic renal disease, or chronic lung disease. About 10 per cent of patients in each group had had major amputations of the opposite limb when they presented with threatened amputation of the remaining limb. Each patient had the pulses determined by palpation. All patients had femoral pulses of good quality and no patient had a palpable pulse on the involved side below the femoral level prior to surgery. All patients had femoral arteriography performed before surgery. The patients were placed in the category of isolated popliteal artery segment or tibia1 vessel graft on the basis of preoperative arteriograms. In selecting patients for this series, we vigorously adhered to the definition of an isolated popliteal segment as one having a complete occlusion of the superficial
421
Davis, Davies,
and Mannick
ISOLATED POPLITEAL ARTERY
TIBIAL
VESSELS:
+-Vessels distal to the popliteal artery
F/gore 1. Drawing of the arterlas ot the leg in a patient with arterkscierotk occluskns of the superfklal femoral and distal popliteal arteries. M this patient were treated by an autogenous saphenous vein bypass graff, there wouid be a choke between the isolated popMeal artery segment and a tiblai vessel tor the site of dktai anastomask. TABLE
I
Indications
for Vascular
Number of lschemic Patients Ulcer
Grafts Tibia1 vessel grafts Isolated segment grafts
38 17
TABLE
Population
II
Patient
8 5
10 5
and Mortality
38 65 24 men, 14 women 7
Isolated Popliteal Artery Grafts 17 71 10 women 4
7 men,
Cl
z-5% 8
Late
soi-
8
t-l
days mm.
Localized Necrosis
Prenecrosis 20 7
Tibia1 Vessel Grafts Number Age, mean (yr) Sex Diabetes Deaths Thirty days
Reconstruction
YEARS
9
Figure 2. Bypass graft patency rates by the life table method.
422
femoral artery proximally and complete occlusion of the distal popliteal artery or popliteal artery bifurcation, the patency of the popliteal artery being completely dependent on collateral flow. Several patients were excluded from the group of isolated popliteal artery segments at the time of this report because short segments of either the anterior tibia1 or tibial-peroneal artery were patent even though these vessels were occluded in the proximal calf. Our technic for performing saphenous vein bypass grafts has previously been described [IO]. All grafts in this series were reversed grafts and we employed the Kunlin [II] technic for producing a broad, shallow end to side anastomosis. The suture material used was 5-O Tycron@ for the isolated popliteal segment grafts and 6-O Tycron or 6-O Prolene@ for the distal anastomosis of the tibia1 vessel grafts. Occasionally, a localized endarterectomy was carried out at the site of the proximal anastomosis; this often included endarterectomy of the origin of the profunda femoris artery. Endarterectomy at the site of the distal anastomosis was avoided. Saphenous veins that were less than 3.5 mm in diameter after saline dilatation, veins with thick walls that did not distend well, and veins with rough intimal surfaces were not used. When the saphenous vein in the involved leg was not suitable, the saphenous vein of the opposite leg was employed. When the opposite saphenous vein was not available, a vein from the arm was employed. If the available vein was too short, the proximal vein was anastomosed to the superficial femoral artery, if patent. The superficial femoral artery was used for the proximal anastomosis in two of seventeen isolated popiiteal artery segment grafts. The distal popliteal artery was employed for the distal anastomosis unless the proximal popliteal artery appeared relatively uninvolved by arteriosclerosis on arteriography. There were four anastomoses to the proximal popliteal artery. The superficial femoral artery was used for the proximal anastomosis in ten of thirty-eight tibia1 vessel grafts. One proximal anastomosis was performed in the profunda femoris and three at the level of the popliteal artery. Of the thirty-eight tibia1 grafts, the distal anastomosis was made to the posterior tibia1 artery in fifteen, the anterior tibia1 artery in ten, the peroneal artery in nine, tibial-peroneal trunk in three, and the dorsalis pedis in one patient.
The fifty-five patients in these series were operated on from six months to nine years prior to the preparation of this report. There were no operative deaths in the patients in the isolated popliteal segment group. There were two operative deaths in the patients having grafts to the tibia1 vessels. A seventy-six year old man with hypertension and arteriosclerotic heart disease died of myocardial infarction in the immediate postoperative period.
The American Journal of Surgery
Distal Popliteal Artery Occlusion
Another patient died from a femoral aneurysm after discharge from the hospital. The patency rates of the grafts in both groups of patients are presented in life table style in Figure 2. There was only one occlusion within the first postoperative month after seventeen isolated segment grafts. There were four occlusions in the first month after thirty-eight grafts to tibia1 vessels. Within the first six months there were no additional occlusions in the group with isolated popliteal segments, but there were six additional occlusions in the group with tibia1 vessel grafts during this time. At one year there were again no additional occlusions in the isolated popliteal artery segment group whereas there was one additional occlusion in the tibia1 vessel graft group. The difference in graft patency between the two groups at six months (p
Considerable clinical evidence suggests that the reversed autogenous saphenous vein bypass graft is currently the treatment of choice in patients with arteriosclerotic peripheral vascular disease of the femoral and popliteal arteries. In addition, our experience and that of others [l-4] have shown that the autogenous saphenous vein bypass graft makes successful reconstruction possible even when there is only fair or poor distal outflow or runoff. There are patients threatened with major amputation because of severe arteriosclerotic occlusive disease of the femoropopliteal system who are not candidates for conventional femoropopliteal bypass vein grafts because of distal popliteal occlusion. In these patients, the distal anastomosis of a vein graft could be placed in either an “isolated segment” of popliteal artery or a tibia1 vessel distal to the popliteal artery. The distribution of arteriosclerotic occlusions in a patient with an isolated popliteal artery segment is shown in Figure 1. An isolated popliteal artery segment occurs when there is complete occlusion of the superficial femoral artery and complete occlusion of either the distal popliteal artery or the popliteal artery bifurcation. This patent segment of popliteal artery fills and empties only through collateral vessels. Several vascular surgery groups have reported satisfactory late results with vein grafts to the tibial vessels distal to the popliteal artery [4-61. We have previously reported long-term success of vein grafts to isolated popliteal artery segments [I], and other groups of surgeons have indicated that vein bypass grafts to isolated popliteal artery segments have been successful [3,7-g]. A comparison From the Department of Surgery, Boston University Medical Center, Boston, Massachusetts. Reprint requests should be addressed to Robert C. Davis, MD, Boston University Medical Center, 80 East Concord Street, Boston, Massachusetts 02118. Presented at the Fifty-Fifth Annual Meeting of the New Engbnd Surgical Society, Waterville Valley, New Hampshire, September 26-28. 1974.
Volume 129, April 1975
of tibial vessel grafts and isolated popliteal artery segment grafts in the experience of the same group of surgeons has apparently never been made. We have, therefore, evaluated our results, over the same period of time, with vein grafts to isolated popliteal artery segments and with vein grafts to tibia1 vessels distal to the popliteal artery.
Material and Methods The fifty-five reversed autogenous saphenous vein bypass grafts in this study were performed at University Hospital, Boston University Medical Center. All patients underwent arterial surgery for purposes of limb salvage. Each of these patients had either an ulcer that would not heal, rest pain or other pregangrenous findings, or frank gangrene often with cellulitis or an abscess. As noted in Table I, the incidence of each of these indications was similar in the isolated popliteal segment and tibia1 vessel groups. As noted in Table II, the mean age and proportion of women were higher in the group with an isolated popliteal segment. The proportion of patients with insulin-treated diabetes was similar. The majority of patients had clinical and electrocardiograpic evidence of arteriosclerotic heart disease. About one quarter of the patients in each group had had previous myocardial infarctions. Equal proportions of patients in each group had hypertension, chronic renal disease, or chronic lung disease. About 10 per cent of patients in each group had had major amputations of the opposite limb when they presented with threatened amputation of the remaining limb. Each patient had the pulses determined by palpation. All patients had femoral pulses of good quality and no patient had a palpable pulse on the involved side below the femoral level prior to surgery. All patients had femoral arteriography performed before surgery. The patients were placed in the category of isolated popliteal artery segment or tibia1 vessel graft on the basis of preoperative arteriograms. In selecting patients for this series, we vigorously adhered to the definition of an isolated popliteal segment as one having a complete occlusion of the superficial
421
Davis, Davies,
and Mannick
ISOLATED POPLITEAL ARTERY
TIBIAL
VESSELS:
+-Vessels distal to the popliteal artery
F/gore 1. Drawing of the arterlas ot the leg in a patient with arterkscierotk occluskns of the superfklal femoral and distal popliteal arteries. M this patient were treated by an autogenous saphenous vein bypass graff, there wouid be a choke between the isolated popMeal artery segment and a tiblai vessel tor the site of dktai anastomask. TABLE
I
Indications
for Vascular
Number of lschemic Patients Ulcer
Grafts Tibia1 vessel grafts Isolated segment grafts
38 17
TABLE
Population
II
Patient
8 5
10 5
and Mortality
38 65 24 men, 14 women 7
Isolated Popliteal Artery Grafts 17 71 10 women 4
7 men,
Cl
z-5% 8
Late
soi-
8
t-l
days mm.
Localized Necrosis
Prenecrosis 20 7
Tibia1 Vessel Grafts Number Age, mean (yr) Sex Diabetes Deaths Thirty days
Reconstruction
YEARS
9
Figure 2. Bypass graft patency rates by the life table method.
422
femoral artery proximally and complete occlusion of the distal popliteal artery or popliteal artery bifurcation, the patency of the popliteal artery being completely dependent on collateral flow. Several patients were excluded from the group of isolated popliteal artery segments at the time of this report because short segments of either the anterior tibia1 or tibial-peroneal artery were patent even though these vessels were occluded in the proximal calf. Our technic for performing saphenous vein bypass grafts has previously been described [IO]. All grafts in this series were reversed grafts and we employed the Kunlin [II] technic for producing a broad, shallow end to side anastomosis. The suture material used was 5-O Tycron@ for the isolated popliteal segment grafts and 6-O Tycron or 6-O Prolene@ for the distal anastomosis of the tibia1 vessel grafts. Occasionally, a localized endarterectomy was carried out at the site of the proximal anastomosis; this often included endarterectomy of the origin of the profunda femoris artery. Endarterectomy at the site of the distal anastomosis was avoided. Saphenous veins that were less than 3.5 mm in diameter after saline dilatation, veins with thick walls that did not distend well, and veins with rough intimal surfaces were not used. When the saphenous vein in the involved leg was not suitable, the saphenous vein of the opposite leg was employed. When the opposite saphenous vein was not available, a vein from the arm was employed. If the available vein was too short, the proximal vein was anastomosed to the superficial femoral artery, if patent. The superficial femoral artery was used for the proximal anastomosis in two of seventeen isolated popiiteal artery segment grafts. The distal popliteal artery was employed for the distal anastomosis unless the proximal popliteal artery appeared relatively uninvolved by arteriosclerosis on arteriography. There were four anastomoses to the proximal popliteal artery. The superficial femoral artery was used for the proximal anastomosis in ten of thirty-eight tibia1 vessel grafts. One proximal anastomosis was performed in the profunda femoris and three at the level of the popliteal artery. Of the thirty-eight tibia1 grafts, the distal anastomosis was made to the posterior tibia1 artery in fifteen, the anterior tibia1 artery in ten, the peroneal artery in nine, tibial-peroneal trunk in three, and the dorsalis pedis in one patient.
The fifty-five patients in these series were operated on from six months to nine years prior to the preparation of this report. There were no operative deaths in the patients in the isolated popliteal segment group. There were two operative deaths in the patients having grafts to the tibia1 vessels. A seventy-six year old man with hypertension and arteriosclerotic heart disease died of myocardial infarction in the immediate postoperative period.
The American Journal of Surgery
Distal Popliteal Artery Occlusion
Another patient died from a femoral aneurysm after discharge from the hospital. The patency rates of the grafts in both groups of patients are presented in life table style in Figure 2. There was only one occlusion within the first postoperative month after seventeen isolated segment grafts. There were four occlusions in the first month after thirty-eight grafts to tibia1 vessels. Within the first six months there were no additional occlusions in the group with isolated popliteal segments, but there were six additional occlusions in the group with tibia1 vessel grafts during this time. At one year there were again no additional occlusions in the isolated popliteal artery segment group whereas there was one additional occlusion in the tibia1 vessel graft group. The difference in graft patency between the two groups at six months (p
