The Use of Arm Veins in Femoral-Popliteal Bypass Grafts DAVID R. CAMPBELL, M.D., CARL S. HOAR, JR., M.D., GARY W. GIBBONS, M.D.
In view of the increasing debate as to the best alternative to saphenous vein for femoral popliteal bypass grafts, we present our experience with the use of arm vein grafts. Though there are many anecdotal reports, only one series has been previously published. Arm veins were used when saphenous vein was unavailable in 18 femoral popliteal or femoral tibial bypass grafts. Eighty-three per cent of the patients were diabetic. Ninety-four per cent of the patients were operated on for limb salvage, and in 67% the arteriograms showed only fair to poor run-off. Despite this, the one year patency rate was 82%, which is significantly better than the sixty-nine per cent one year patency rate reported by the senior author in an earlier series using cloth grafts. In view of these good results, we believe that autogenous vein remains the material of choice in femoral popliteal bypass grafts. We do not feel that expanded polytetrafluoroethylene grafts or umbilical vein grafts have yet been shown to be superior. We emphasize also the special techniques that are required when using arm veins.
From the Department of Surgery, New England Deaconess Hospital, Boston, Massachusetts
port our experience and some of the technical problems we have encountered. Our series consists of a largely diabetic population operated on for limb salvage and the good results are therefore all the more significant, as diabetics in general have worse run-off than nondiabetic patients.6
IN THE MANAGEMENT of patients with disabling claudication, rest pain, or gangrene, it is now accepted that saphenous vein bypass grafting is the procedure of choice for arterial reconstruction. A problem that has attracted a lot of attention recently is what to use in those patients who, for one reason or another, do not have a suitable saphenous vein available. Various alternatives have been tried and we reported in 1973 our experience using cloth femoral popliteal bypass grafts in diabetics2 and the accumulated five year patency rate was 59%. Since then, a number of reports have appeared in the literature, in which expanded polytetrafluoroethylene3'5 or umbilical vein4 have been used as substitutes for saphenous vein. Some of these have been extremely favorable; others less so, and all authors appear to agree that it is too early to say whether either of these will prove to be better than autogenous vein. We feel strongly that autogenous vein remains the best possible material at this time and, in situations where saphenous vein is not available, prefer to use arm vein. Only one series using arm veins has been reported to date, though there are many anecdotal reports, and we, therefore, felt it was important to reDavid R. Campbell, M.D., Department of Surgery, New England Deaconess Hospital, 185 Pilgrim Road, Boston, Massachusetts, 02215. Submitted for publication: March 19, 1979.
Materials and Methods In this series 18 operations were performed on 16 patients, 14 of whom were diabetic. There were five males and 11 females, and both the nondiabetics were female. The mean age was 62.3 years, (56.8 years for the male diabetics and 67 years for the female diabetics). All except two of the diabetics had maturity onset diabetes. Seven patients had previous bypass surgery for peripheral vascular disease and in four of these this was on the side later repaired with an arm vein. Of the 18 operations, one was for disabling claudication and this was a nondiabetic; six were operated on for rest pain, and 11 had severe ischemia with gangrenous toes or necrotic, nonhealing ulcers. Of eighteen limbs studied angiographically, five had two or three vessels patent below the trifurcation and were judged to have good run-off; eight had fair run-off with one vessel open, and five had poor run-off with no major vessels apparently patent below the popliteal. In general, we have preferred not to use saphenous veins less than 4 mm in diameter, as these have been associated with increased graft failure. If the saphenous vein is deemed inadequate by reason of size or inadequate length, then we turn to the arm vein, preferring to leave the other leg alone, as it may be needed for a later procedure. In patients with previous saphenous vein ligation and stripping, or who have had the vein used in prior surgery, attention is immediately directed to the arm vein. In our series, eight patients had saphenous veins that were in part too small, and so composite saphenousarm vein grafts were used. In four the saphenous vein
0003-4932/79/1200/0740 $00.65 © J. B. Lippincott Company
740
Vol. 190 . No. 6
ARM VEINS FO]R
had been used for previous grafting; in three the vein had been stripped, and in one the vein had multiple varicosities rendering part of the vein unsuitable. In this series, there were 16 femoral-popliteal grafts and two femoral-posterior tibial grafts. Preparation A thorough history is taken to include previous operations where the saphenous vein may have been removed for any possible reason. A previous history of an inadequate vein on the opposite leg is not necessarily indicative of an inadequate vein on the present side. Physical examination should include a thorough inspection of the leg for surgical incisions indicating removal of the saphenous vein. One patient reported a previous varicose vein operation and had lower leg incisional scars, but the absence of a thigh scar prompted exploration of the saphenous vein which was indeed present and usable. Palpation and percussion of the saphenous vein along its course has been useful in some patients. If it is suspected that an arm vein may be needed, careful examination is made of the arm for the best vein and any previous incisions over the arm are noted. The arm is spared of any further invasive testing, including venipuncture and intravenous placement. Venography is not necessary prior to surgery. At the operating table the arm is prepped in a similar fashion as the leg and draped in a manner to allow free movement of the arm. Two methods of vein harvesting have been used. The usual method is to choose the largest most distal vein on the wrist and dissect proximally, following the largest diameter vein. This usually results in the cephalic vein being taken, though occasionally the basilic is found to be more suitable. Another technique is to make a longitudinal incision over the cephalic vein or over its anatomical position at the elbow and to carry this incision proximally and distally, if the vein appears adequate. Thus far we have not failed to find an adequate graft in that arm. The arm veins are thinner-walled than the saphenous vein and one must be very meticulous and delicate in their dissection. For this reason, a continuous incision, rather than multiple interrupted incisions, is made along the course of the vein, carefully isolating individual tributaries under direct vision. The individual branches are ligated with 4-0 silk. The ligatures should be placed approximately 3-4 mm from the main vein to prevent constriction (dumbbelling) of the main segment (Fig. 1), because the vein will distend considerably with arterial pressures. Larger tributaries are also suture-ligated to prevent a blow-out, which has occurred with ligation only. Once the vein is harvested, it is reversed and
BYPASS GRAFTS
741 PROPER
- c,.- *.
BEFORE INSERTION
AFTER INSERTION
MPROPER
BEFORE INSERTION
AFTER INSERTION
(DUMBBELLING) FIG. 1. Proper and improper placement of ligatures.
gently distended with heparinized Ringer's solution to detect leaks, dumbbelling, or stenotic segments. The latter have been found in two instances. The stenotic segments can occur anywhere along the course of the vein and do not necessarily appear to be related to venipuncture. They require excision and oblique end-toend anastomosis. The vein is sewn in place with 6-0 monofilament sutures using the same technique as described for saphenous vein bypass. Again meticulous handling of the arm vein cannot be over-emphasized, since it is such a thin-walled vessel and in all probability is the last source of a vein graft. For this reason, it is strongly recommended that magnifying glasses be used when constructing the anastomosis. Great care is required when placing the vein in the femoral tunnel to ensure that it is not twisted, as this will cause obstruction. Similarly, excessive redundancy of the vein may lead to obstruction by kinking. When required, composite vein anastomoses are done between the saphenous segment and the arm vein in a long oblique fashion over a stent. Results In determining the results, a graft was assessed as being patent if the patient became and remained asymptomatic, if distal graft pulse was palpable, or if distal pulses reappeared. Of 18 operations there was one early postoperative death due to myocardial infarction. There were three graft closures, all early, necessitating major amputation. All of these patients were operated on for limb salvage and all had poor run-off on their angiograms.
742
CAMPBELL, HOAR AND GIBBONS TABLE 1. Results of Bypass Grafts
Patient Number
Date of Op.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
12/75 1/76 1/76 1/76 1/76 2/76
3/76 3/76 4/76 4/76 4/76 5/76 5/76 7/76 8/76 8/76 11/76 3/77 4/78 4/78 5/78 5/78 5/78 6/78 8/78 8/78 9/78 11/78 12/78 2/79 3/79 5/79 5/79
Estimated Length of Arm Vein
State of Graft
30 cm C. 60 cm A 30 cm C 35 cm C 40 cm C 30 cm C 40 cm A 40 cm A 30 cm C 20 cm C 30 cm C 40 cm A 35 cm C 40 cm A 20 cm C 60 cm A 45 cm A 45 cm A 40 cm A 18 cm C 40 cm A 16 cm C 40 cm A 30 cm A 60 cm A 40 cm A 30 cm C 40 cm A 40 cm A 60 cm A 40 cm A 40 cm A 40 cm A
Patent Patent Patent Patent Patent Patent Patent Failed Patent Patent Patent Patent Patent Patent Died Failed Failed Patent Patent Patent Patent Patent Patent Patent
Died Patent Patent Patent Patent Patent Patent Patent Failed
Months of F/U 41 40 40 40 39 38 38 37 37 36 36 34 34
26 13 13 12 12 12 11
9 8 6 5 3 2 1
A = arm vein alone. C = arm vein and saphenous vein composite
graft.
Two of these had below-knee amputations on the other side and were nearly 80 years of age at the time of surgery, and this played a part in the initial decision to attempt to save the limb. Two of these grafts closed within the first week postoperatively. One of these patients was a nondiabetic. The third closure occurred six months after surgery following a severe episode of congestive heart failure from which the patient subsequently died. One patient required a TMA and one a toe amputation, although in each case the limb was salvaged. Though our policy was to take the best arm vein available, the cephalic vein was used on 13 occasions and the basilic on four. Of the three failures, one was with the cephalic vein, one with the basilic vein, and one a composite saphenous and cephalic graft. Thus, excluding the early postoperative death due to myocardial infarction, there was a patency rate of 82.4% at one year for all patients and 85.8% for the diabetics alone. These patients have now been followed from 26-40 months with no further failures. Other than the one postoperative death, there were no major complications noted, though one patient developed
Ann. Surg. * December 1979
keloid in the arm incision. During the last 13 months another 15 arm vein bypass procedures have been done with one postoperative death and one early failure (Table 1). Discussion Because of the excellent results we have obtained using arm veins, we now use them in preference to cloth grafts in almost all situations where saphenous vein is not available. Our results with the arm vein are virtually identical to our results with saphenous vein bypass grafts. In the past it has been reported that cloth grafts are more likely to close if used to cross a joint, or as a short segment jump graft, or for a smaller artery graft in the lower leg. We have found that arm veins could be used satisfactorily in all these situations. Our only indication now for using a cloth graft is where there is insufficient length of arm vein available, though this has not been a problem in our experience, or where the length of time of the operation is a significant factor. We feel that careful handling of the vein and meticulous suture technique is essential if good results are to be obtained and therefore stress the importance of using a magnifying system. We are currently using 2½/2 power lenses. Though this series is small, we feel these results are highly significant. This may be appreciated when one considers the percentage (66.6%) of patients with fair-to-poor run-off, the percentage (94.4%) operated on for limb salvage, and the incidence of diabetes mellitus (83.3%). In a series from this hospital reported in 1973 of 29 diabetic patients operated on by the same surgeon as in this series, in whom cloth grafts were used, the patency rate at one year was only 69% and in this group nearly a third were bypassed for claudication alone. Thus, from our experience and that of Clayson, et al.,I we conclude that when autogenous saphenous vein is not available, the use of arm veins is preferred to cloth for bypass grafting. References 1. Clayson, K. R. and Dale, W. A.: Arm Veins for Peripheral Arterial Reconstruction. Arch. Surg., 111:1276, 1976. 2. Harmon, S. W. and Hoar, C. S.: Cloth Femoral Popliteal Bypass Grafts in Twenty-Nine Diabetic Patients. Arch. Surg., 106:282, 1973. 3. Hastings, 0. M. and Krishna, M. S.: A Prospective Randomized Study of Three Expanded Polytetrafluoroethylene (PTFE) Grafts as Small Arterial Substitutes. Am. Surg., 188:743, 1978. 4. Lee, B. T., Trainar, F. S., Kauner, D., et al.: Evaluation of Modified Human Umbilical Vein as an Arterial Substitute in Femoropopliteal Reconstructive Surgical Procedures. Surg. Gynecol. Obstet., 147:721, 1978. 5. Veith, F. S., Moss, C. M., Fell, S. C., et al.: Comparison of Expanded Polytetrafluoroethylene and Autologous Saphenous Vein Grafts in High Risk Arterial Reconstruction for Limb Salvage. Surg. Gynecol. Obstet., 147:749, 1978. 6. Wheelock, F. C. and Filtzer, H. S.: Femoral Grafts in Diabetics. Arch. Surg., 99:776, 1979.
In view of the increasing debate as to the best alternative to saphenous vein for femoral popliteal bypass grafts, we present our experience with the use of arm vein grafts. Though there are many anecdotal reports, only one series has been previously published. Arm veins were used when saphenous vein was unavailable in 18 femoral popliteal or femoral tibial bypass grafts. Eighty-three per cent of the patients were diabetic. Ninety-four per cent of the patients were operated on for limb salvage, and in 67% the arteriograms showed only fair to poor run-off. Despite this, the one year patency rate was 82%, which is significantly better than the sixty-nine per cent one year patency rate reported by the senior author in an earlier series using cloth grafts. In view of these good results, we believe that autogenous vein remains the material of choice in femoral popliteal bypass grafts. We do not feel that expanded polytetrafluoroethylene grafts or umbilical vein grafts have yet been shown to be superior. We emphasize also the special techniques that are required when using arm veins.
From the Department of Surgery, New England Deaconess Hospital, Boston, Massachusetts
port our experience and some of the technical problems we have encountered. Our series consists of a largely diabetic population operated on for limb salvage and the good results are therefore all the more significant, as diabetics in general have worse run-off than nondiabetic patients.6
IN THE MANAGEMENT of patients with disabling claudication, rest pain, or gangrene, it is now accepted that saphenous vein bypass grafting is the procedure of choice for arterial reconstruction. A problem that has attracted a lot of attention recently is what to use in those patients who, for one reason or another, do not have a suitable saphenous vein available. Various alternatives have been tried and we reported in 1973 our experience using cloth femoral popliteal bypass grafts in diabetics2 and the accumulated five year patency rate was 59%. Since then, a number of reports have appeared in the literature, in which expanded polytetrafluoroethylene3'5 or umbilical vein4 have been used as substitutes for saphenous vein. Some of these have been extremely favorable; others less so, and all authors appear to agree that it is too early to say whether either of these will prove to be better than autogenous vein. We feel strongly that autogenous vein remains the best possible material at this time and, in situations where saphenous vein is not available, prefer to use arm vein. Only one series using arm veins has been reported to date, though there are many anecdotal reports, and we, therefore, felt it was important to reDavid R. Campbell, M.D., Department of Surgery, New England Deaconess Hospital, 185 Pilgrim Road, Boston, Massachusetts, 02215. Submitted for publication: March 19, 1979.
Materials and Methods In this series 18 operations were performed on 16 patients, 14 of whom were diabetic. There were five males and 11 females, and both the nondiabetics were female. The mean age was 62.3 years, (56.8 years for the male diabetics and 67 years for the female diabetics). All except two of the diabetics had maturity onset diabetes. Seven patients had previous bypass surgery for peripheral vascular disease and in four of these this was on the side later repaired with an arm vein. Of the 18 operations, one was for disabling claudication and this was a nondiabetic; six were operated on for rest pain, and 11 had severe ischemia with gangrenous toes or necrotic, nonhealing ulcers. Of eighteen limbs studied angiographically, five had two or three vessels patent below the trifurcation and were judged to have good run-off; eight had fair run-off with one vessel open, and five had poor run-off with no major vessels apparently patent below the popliteal. In general, we have preferred not to use saphenous veins less than 4 mm in diameter, as these have been associated with increased graft failure. If the saphenous vein is deemed inadequate by reason of size or inadequate length, then we turn to the arm vein, preferring to leave the other leg alone, as it may be needed for a later procedure. In patients with previous saphenous vein ligation and stripping, or who have had the vein used in prior surgery, attention is immediately directed to the arm vein. In our series, eight patients had saphenous veins that were in part too small, and so composite saphenousarm vein grafts were used. In four the saphenous vein
0003-4932/79/1200/0740 $00.65 © J. B. Lippincott Company
740
Vol. 190 . No. 6
ARM VEINS FO]R
had been used for previous grafting; in three the vein had been stripped, and in one the vein had multiple varicosities rendering part of the vein unsuitable. In this series, there were 16 femoral-popliteal grafts and two femoral-posterior tibial grafts. Preparation A thorough history is taken to include previous operations where the saphenous vein may have been removed for any possible reason. A previous history of an inadequate vein on the opposite leg is not necessarily indicative of an inadequate vein on the present side. Physical examination should include a thorough inspection of the leg for surgical incisions indicating removal of the saphenous vein. One patient reported a previous varicose vein operation and had lower leg incisional scars, but the absence of a thigh scar prompted exploration of the saphenous vein which was indeed present and usable. Palpation and percussion of the saphenous vein along its course has been useful in some patients. If it is suspected that an arm vein may be needed, careful examination is made of the arm for the best vein and any previous incisions over the arm are noted. The arm is spared of any further invasive testing, including venipuncture and intravenous placement. Venography is not necessary prior to surgery. At the operating table the arm is prepped in a similar fashion as the leg and draped in a manner to allow free movement of the arm. Two methods of vein harvesting have been used. The usual method is to choose the largest most distal vein on the wrist and dissect proximally, following the largest diameter vein. This usually results in the cephalic vein being taken, though occasionally the basilic is found to be more suitable. Another technique is to make a longitudinal incision over the cephalic vein or over its anatomical position at the elbow and to carry this incision proximally and distally, if the vein appears adequate. Thus far we have not failed to find an adequate graft in that arm. The arm veins are thinner-walled than the saphenous vein and one must be very meticulous and delicate in their dissection. For this reason, a continuous incision, rather than multiple interrupted incisions, is made along the course of the vein, carefully isolating individual tributaries under direct vision. The individual branches are ligated with 4-0 silk. The ligatures should be placed approximately 3-4 mm from the main vein to prevent constriction (dumbbelling) of the main segment (Fig. 1), because the vein will distend considerably with arterial pressures. Larger tributaries are also suture-ligated to prevent a blow-out, which has occurred with ligation only. Once the vein is harvested, it is reversed and
BYPASS GRAFTS
741 PROPER
- c,.- *.
BEFORE INSERTION
AFTER INSERTION
MPROPER
BEFORE INSERTION
AFTER INSERTION
(DUMBBELLING) FIG. 1. Proper and improper placement of ligatures.
gently distended with heparinized Ringer's solution to detect leaks, dumbbelling, or stenotic segments. The latter have been found in two instances. The stenotic segments can occur anywhere along the course of the vein and do not necessarily appear to be related to venipuncture. They require excision and oblique end-toend anastomosis. The vein is sewn in place with 6-0 monofilament sutures using the same technique as described for saphenous vein bypass. Again meticulous handling of the arm vein cannot be over-emphasized, since it is such a thin-walled vessel and in all probability is the last source of a vein graft. For this reason, it is strongly recommended that magnifying glasses be used when constructing the anastomosis. Great care is required when placing the vein in the femoral tunnel to ensure that it is not twisted, as this will cause obstruction. Similarly, excessive redundancy of the vein may lead to obstruction by kinking. When required, composite vein anastomoses are done between the saphenous segment and the arm vein in a long oblique fashion over a stent. Results In determining the results, a graft was assessed as being patent if the patient became and remained asymptomatic, if distal graft pulse was palpable, or if distal pulses reappeared. Of 18 operations there was one early postoperative death due to myocardial infarction. There were three graft closures, all early, necessitating major amputation. All of these patients were operated on for limb salvage and all had poor run-off on their angiograms.
742
CAMPBELL, HOAR AND GIBBONS TABLE 1. Results of Bypass Grafts
Patient Number
Date of Op.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
12/75 1/76 1/76 1/76 1/76 2/76
3/76 3/76 4/76 4/76 4/76 5/76 5/76 7/76 8/76 8/76 11/76 3/77 4/78 4/78 5/78 5/78 5/78 6/78 8/78 8/78 9/78 11/78 12/78 2/79 3/79 5/79 5/79
Estimated Length of Arm Vein
State of Graft
30 cm C. 60 cm A 30 cm C 35 cm C 40 cm C 30 cm C 40 cm A 40 cm A 30 cm C 20 cm C 30 cm C 40 cm A 35 cm C 40 cm A 20 cm C 60 cm A 45 cm A 45 cm A 40 cm A 18 cm C 40 cm A 16 cm C 40 cm A 30 cm A 60 cm A 40 cm A 30 cm C 40 cm A 40 cm A 60 cm A 40 cm A 40 cm A 40 cm A
Patent Patent Patent Patent Patent Patent Patent Failed Patent Patent Patent Patent Patent Patent Died Failed Failed Patent Patent Patent Patent Patent Patent Patent
Died Patent Patent Patent Patent Patent Patent Patent Failed
Months of F/U 41 40 40 40 39 38 38 37 37 36 36 34 34
26 13 13 12 12 12 11
9 8 6 5 3 2 1
A = arm vein alone. C = arm vein and saphenous vein composite
graft.
Two of these had below-knee amputations on the other side and were nearly 80 years of age at the time of surgery, and this played a part in the initial decision to attempt to save the limb. Two of these grafts closed within the first week postoperatively. One of these patients was a nondiabetic. The third closure occurred six months after surgery following a severe episode of congestive heart failure from which the patient subsequently died. One patient required a TMA and one a toe amputation, although in each case the limb was salvaged. Though our policy was to take the best arm vein available, the cephalic vein was used on 13 occasions and the basilic on four. Of the three failures, one was with the cephalic vein, one with the basilic vein, and one a composite saphenous and cephalic graft. Thus, excluding the early postoperative death due to myocardial infarction, there was a patency rate of 82.4% at one year for all patients and 85.8% for the diabetics alone. These patients have now been followed from 26-40 months with no further failures. Other than the one postoperative death, there were no major complications noted, though one patient developed
Ann. Surg. * December 1979
keloid in the arm incision. During the last 13 months another 15 arm vein bypass procedures have been done with one postoperative death and one early failure (Table 1). Discussion Because of the excellent results we have obtained using arm veins, we now use them in preference to cloth grafts in almost all situations where saphenous vein is not available. Our results with the arm vein are virtually identical to our results with saphenous vein bypass grafts. In the past it has been reported that cloth grafts are more likely to close if used to cross a joint, or as a short segment jump graft, or for a smaller artery graft in the lower leg. We have found that arm veins could be used satisfactorily in all these situations. Our only indication now for using a cloth graft is where there is insufficient length of arm vein available, though this has not been a problem in our experience, or where the length of time of the operation is a significant factor. We feel that careful handling of the vein and meticulous suture technique is essential if good results are to be obtained and therefore stress the importance of using a magnifying system. We are currently using 2½/2 power lenses. Though this series is small, we feel these results are highly significant. This may be appreciated when one considers the percentage (66.6%) of patients with fair-to-poor run-off, the percentage (94.4%) operated on for limb salvage, and the incidence of diabetes mellitus (83.3%). In a series from this hospital reported in 1973 of 29 diabetic patients operated on by the same surgeon as in this series, in whom cloth grafts were used, the patency rate at one year was only 69% and in this group nearly a third were bypassed for claudication alone. Thus, from our experience and that of Clayson, et al.,I we conclude that when autogenous saphenous vein is not available, the use of arm veins is preferred to cloth for bypass grafting. References 1. Clayson, K. R. and Dale, W. A.: Arm Veins for Peripheral Arterial Reconstruction. Arch. Surg., 111:1276, 1976. 2. Harmon, S. W. and Hoar, C. S.: Cloth Femoral Popliteal Bypass Grafts in Twenty-Nine Diabetic Patients. Arch. Surg., 106:282, 1973. 3. Hastings, 0. M. and Krishna, M. S.: A Prospective Randomized Study of Three Expanded Polytetrafluoroethylene (PTFE) Grafts as Small Arterial Substitutes. Am. Surg., 188:743, 1978. 4. Lee, B. T., Trainar, F. S., Kauner, D., et al.: Evaluation of Modified Human Umbilical Vein as an Arterial Substitute in Femoropopliteal Reconstructive Surgical Procedures. Surg. Gynecol. Obstet., 147:721, 1978. 5. Veith, F. S., Moss, C. M., Fell, S. C., et al.: Comparison of Expanded Polytetrafluoroethylene and Autologous Saphenous Vein Grafts in High Risk Arterial Reconstruction for Limb Salvage. Surg. Gynecol. Obstet., 147:749, 1978. 6. Wheelock, F. C. and Filtzer, H. S.: Femoral Grafts in Diabetics. Arch. Surg., 99:776, 1979.
