Results of 100 Consecutive Femoropopliteal Vein Grafts for Limb Salvage ALI NAJI, M.D., JENNIFER CHU, M.D., PETER R. MCCOMBS, M.D., CLYDE F. BARKER, M.D., HENRY D. BERKOWITZ, M.D., BROOKE ROBERTS, M.D.
One hundred consecutive patients with femoropopliteal autogenous vein grafts for lImb salvage were reviewed five years later. In this group 40% died and 30% of the limbs had been lost at the end of five years. Limb survival correlated best with adequacy of distal run-off, but not with the presence or absence of diabetes. Forty-seven per cent of the grafts were still patent among surviving patients, and when combined with the limbs that were viable despite failure of the orinal graft, 70% of the limbs were salvaged among the survivors at five years. Temporary graft patency was effective in preserving ischemic tissue by facilitating healing of ulcers or limited amputations. Femoral-popliteal bypass grafting in the presence of advanced ischemia is capable of improving the quality of life for many of these patients. E HAVE RECENTLY COMPLETED a review of our
63. These patients were generally older than those on whom we operated for claudication. The ratio of men to women in this series (7:3) did not demonstrate as high a predominance of males as was seen among the claudicators (6:1). Fifteen of the patients were black and 77 were white.
Associated Disease The incidence of associated disease was greater in this group (Table 2) than among the claudicators. Given the more advanced degree of peripheral vascular disease, this was not surprising. Forty-four per cent of these operations were done in diabetic patients, and many patients had more than one associated disease. Most of these were arteriosclerotic in etiology.
results of autogenous femoropopliteal grafts, beginning in 1963 and followed for a minimum of five years postoperatively. Those patients operated upon for relief of claudication alone are being reported separately.14 This series, similarly based on 100 consecutive operations, includes only patients thought to be imminently threatened with loss of limb because of severe ischemia, manifested by rest pain in the foot, frank gangrene of one or more toes, or ischemic ulcers which failed to heal under conservative management.
Smoking Data on the smoking habits of these patients was incomplete in this retrospective study. Of 69 patients for whom such information was recorded, all gave a history of smoking. In 23 charts the information was lacking.
Clinical Material The 100 operations were carried out on 92 patients, eight of whom had bilateral operations. None of these bilateral procedures were performed simultaneously. This series represents the work of both resident and staff surgeons on private and service patients at the Hospital of the University of Pennsylvania. During the period of both studies, 70% of all femoropopliteal grafts were carried out to salvage threatened limbs and 30% were done to relieve intermittent claudication. Age and Sex Over 90% of the patients were in the sixth, seventh and eighth decades of life (Table 1), the mean age being Submitted for publication: December 1, 1977.
From the Harrison Department of Surgical Research and the Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
Arteriography Femoral arteriography was used routinely in the selection of patients for these operations. Run-off was deemed good or excellent if the popliteal artery was drained by two or three of its normal major branches in continuity, even though they were often diseased. If one or none of these vessels was open, run-off was called fair or poor. On this basis, 68% of the. operations were done on patients having good or excellent run-off, and 32% on those classified as fair to poor.
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RESULTS OF VEIN GRAFTS
TABLE 1. One Hundred Consecutive Femoropopliteal Grafts for Limb Salvage; Age and Distribution
Age Years
No. of Operations
Male
Female
40-49 50-59 60-69 70-79 80-89
4 36 37 19 4
3 27 23 15 2
1 9 14 4 2
100
70
30
Total
Indications for Surgery Many of the patients in this series had several signs of limb-threatening disease. In the entire group, 62 had rest pain, 26 had frank gangrene of one or more toes, and 32 had nonhealing ischemic ulcers. Of these 100 vein grafts, the great majority originated from the common femoral artery. Seventy-eight of the distal anastomoses were placed in the popliteal artery above the level of the knee joint. The remaining 22 were carried to the popliteal below the knee.
Follow-up Eighteen patients were lost to follow-up within the five year period. Of these, only one patient's graft was known to have occluded prior to his being lost. We have surmised that many of these patients died outside of the hospital, but we cannot substantiate this. They are excluded from our analysis of mortality, graft patency and limb loss. Results Mortality Three operative deaths occurred, two as a result of myocardial infarction and one following a cerebrovascular accident. Two of the three patients were dia-
TABLE 2. One-Hundred Femoropopliteal Grafts for Limb Salvage; Profile of Associated Diseases
Cardiac Cerebrovascular (Stroke) Hypertension 150 Renal insufficiency Pulmonary insufficiency Diabetes mellitus
Salvage
Claudication
56 10 26 4 29 44
36 5 30 0 19 22
betic. After five years, 26 additional patients were known to have died, generally from complications of cardiovascular disease. Of the diabetic patients followed for five years, 44% (15 of 34) died. Among the nondiabetics, 35% (14 of 40) died. The mortality rate among those followed for five years with good run-off was 44% (22 of 50) but, surprisingly, among those with fair or poor run-off, only 29% (7 of 24). Graft Patency The graft patency rate, when calculated by the life table method (Table 3) in order to make these results comparable with other series, was 46.2%. Actually, 23 of 49 or 47% were patent at the end of five years, while 53% had thrombosed. Our results with operations for claudication contrast sharply with these findings. In that series, 70% of the grafts in surviving patients were patent at five years (Fig. 1). Among the 29 patients who died in this series, 18 grafts were known to be patent at the time of death. The patency rate at five years among diabetics was only 32% (9 of 28), whereas among nondiabetics 59% of grafts (16 of 27) remained patent. In contrast, among the claudicators the presence of diabetes did not appear to affect the patency of grafts at five years. When calculated on the basis of run-off, 51% of the grafts in the present series remained patent at five years
TABLE 3. Life Table Analysis for Patency of 100 Femoropopliteal Grafts for Limb Salvage
H 3 mo 6 mo 12 mo 18 mo 24 mo 30mo 36 mo 4 yr 5 yr
Lost to Follow-up 0 3 3 4 0 0 1 2 1 3
Death
Grafts at Risk
Grafts Occluded
Grafts Patent
Patient Rate
3 1 0 5 1 0 2 3 2 1
100 83 70 58 51 49 41 36 31 25
10 10 3 6 2 5 0 2 2 2
87 73 67 52 49 44 41 34 29 23
89.8 87.6 95.6 88.7 96.1 89.8 100 94.1 93.2 91.3
Cumulative Patient Rate
89.8 78.6 75.1 66.6 64.0 57.5 57.5 54.1
50.5 46.2
NAJI AND OTHERS
164 100
CLAUDICATION
s_CLAUDICATION
.& "I
'IV
One hundred consecutive patients with femoropopliteal autogenous vein grafts for lImb salvage were reviewed five years later. In this group 40% died and 30% of the limbs had been lost at the end of five years. Limb survival correlated best with adequacy of distal run-off, but not with the presence or absence of diabetes. Forty-seven per cent of the grafts were still patent among surviving patients, and when combined with the limbs that were viable despite failure of the orinal graft, 70% of the limbs were salvaged among the survivors at five years. Temporary graft patency was effective in preserving ischemic tissue by facilitating healing of ulcers or limited amputations. Femoral-popliteal bypass grafting in the presence of advanced ischemia is capable of improving the quality of life for many of these patients. E HAVE RECENTLY COMPLETED a review of our
63. These patients were generally older than those on whom we operated for claudication. The ratio of men to women in this series (7:3) did not demonstrate as high a predominance of males as was seen among the claudicators (6:1). Fifteen of the patients were black and 77 were white.
Associated Disease The incidence of associated disease was greater in this group (Table 2) than among the claudicators. Given the more advanced degree of peripheral vascular disease, this was not surprising. Forty-four per cent of these operations were done in diabetic patients, and many patients had more than one associated disease. Most of these were arteriosclerotic in etiology.
results of autogenous femoropopliteal grafts, beginning in 1963 and followed for a minimum of five years postoperatively. Those patients operated upon for relief of claudication alone are being reported separately.14 This series, similarly based on 100 consecutive operations, includes only patients thought to be imminently threatened with loss of limb because of severe ischemia, manifested by rest pain in the foot, frank gangrene of one or more toes, or ischemic ulcers which failed to heal under conservative management.
Smoking Data on the smoking habits of these patients was incomplete in this retrospective study. Of 69 patients for whom such information was recorded, all gave a history of smoking. In 23 charts the information was lacking.
Clinical Material The 100 operations were carried out on 92 patients, eight of whom had bilateral operations. None of these bilateral procedures were performed simultaneously. This series represents the work of both resident and staff surgeons on private and service patients at the Hospital of the University of Pennsylvania. During the period of both studies, 70% of all femoropopliteal grafts were carried out to salvage threatened limbs and 30% were done to relieve intermittent claudication. Age and Sex Over 90% of the patients were in the sixth, seventh and eighth decades of life (Table 1), the mean age being Submitted for publication: December 1, 1977.
From the Harrison Department of Surgical Research and the Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
Arteriography Femoral arteriography was used routinely in the selection of patients for these operations. Run-off was deemed good or excellent if the popliteal artery was drained by two or three of its normal major branches in continuity, even though they were often diseased. If one or none of these vessels was open, run-off was called fair or poor. On this basis, 68% of the. operations were done on patients having good or excellent run-off, and 32% on those classified as fair to poor.
0003-4932-78-0800-0162-0060 C J. B. Lippincott Company
162
VOl. 188.o NO. 2
163
RESULTS OF VEIN GRAFTS
TABLE 1. One Hundred Consecutive Femoropopliteal Grafts for Limb Salvage; Age and Distribution
Age Years
No. of Operations
Male
Female
40-49 50-59 60-69 70-79 80-89
4 36 37 19 4
3 27 23 15 2
1 9 14 4 2
100
70
30
Total
Indications for Surgery Many of the patients in this series had several signs of limb-threatening disease. In the entire group, 62 had rest pain, 26 had frank gangrene of one or more toes, and 32 had nonhealing ischemic ulcers. Of these 100 vein grafts, the great majority originated from the common femoral artery. Seventy-eight of the distal anastomoses were placed in the popliteal artery above the level of the knee joint. The remaining 22 were carried to the popliteal below the knee.
Follow-up Eighteen patients were lost to follow-up within the five year period. Of these, only one patient's graft was known to have occluded prior to his being lost. We have surmised that many of these patients died outside of the hospital, but we cannot substantiate this. They are excluded from our analysis of mortality, graft patency and limb loss. Results Mortality Three operative deaths occurred, two as a result of myocardial infarction and one following a cerebrovascular accident. Two of the three patients were dia-
TABLE 2. One-Hundred Femoropopliteal Grafts for Limb Salvage; Profile of Associated Diseases
Cardiac Cerebrovascular (Stroke) Hypertension 150 Renal insufficiency Pulmonary insufficiency Diabetes mellitus
Salvage
Claudication
56 10 26 4 29 44
36 5 30 0 19 22
betic. After five years, 26 additional patients were known to have died, generally from complications of cardiovascular disease. Of the diabetic patients followed for five years, 44% (15 of 34) died. Among the nondiabetics, 35% (14 of 40) died. The mortality rate among those followed for five years with good run-off was 44% (22 of 50) but, surprisingly, among those with fair or poor run-off, only 29% (7 of 24). Graft Patency The graft patency rate, when calculated by the life table method (Table 3) in order to make these results comparable with other series, was 46.2%. Actually, 23 of 49 or 47% were patent at the end of five years, while 53% had thrombosed. Our results with operations for claudication contrast sharply with these findings. In that series, 70% of the grafts in surviving patients were patent at five years (Fig. 1). Among the 29 patients who died in this series, 18 grafts were known to be patent at the time of death. The patency rate at five years among diabetics was only 32% (9 of 28), whereas among nondiabetics 59% of grafts (16 of 27) remained patent. In contrast, among the claudicators the presence of diabetes did not appear to affect the patency of grafts at five years. When calculated on the basis of run-off, 51% of the grafts in the present series remained patent at five years
TABLE 3. Life Table Analysis for Patency of 100 Femoropopliteal Grafts for Limb Salvage
H 3 mo 6 mo 12 mo 18 mo 24 mo 30mo 36 mo 4 yr 5 yr
Lost to Follow-up 0 3 3 4 0 0 1 2 1 3
Death
Grafts at Risk
Grafts Occluded
Grafts Patent
Patient Rate
3 1 0 5 1 0 2 3 2 1
100 83 70 58 51 49 41 36 31 25
10 10 3 6 2 5 0 2 2 2
87 73 67 52 49 44 41 34 29 23
89.8 87.6 95.6 88.7 96.1 89.8 100 94.1 93.2 91.3
Cumulative Patient Rate
89.8 78.6 75.1 66.6 64.0 57.5 57.5 54.1
50.5 46.2
NAJI AND OTHERS
164 100
CLAUDICATION
s_CLAUDICATION
.& "I
'IV
