• 1

    Kunlin J: The treatment of arterial obstruction by vein grafting [in French]. .Arch Mal Coeur Vx42.,1949. .

  • 2

    Conte MS, Belkin M, Upchurch GR, et al: Impact of increasing comorbidity on infrainguinal reconstruction: a 20-year perspective. .Ann Surg 233::445. ,2001. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Steg PG, Bhatt DL, Wilson PW, et al: One-year cardiovascular event rates in outpatients with atherothrombosis. .JAMA 297::1197. ,2007. .

  • 4

    Hirsch AT, Haskal ZJ, Hertzer NR, et al: ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. .Circulation 113::e463. ,2006. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Norgren L, Hiatt WR, Dormandy JA, et al: Inter-society consensus for the management of peripheral arterial disease (TASC II). .J Vasc Surg 45: (suppl S):S5. ,2007. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Adam DJ, Beard JD, Cleveland T, et al: Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. .Lancet 366::1925. ,2005. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Conte MS, Bandyk DF, Clowes AW, et al: Results of PREVENT III: a multicenter, randomized trial of edifoligide for the prevention of vein graft failure in lower extremity bypass surgery. .J Vasc Surg 43::742. ,2006. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Giles KA, Pomposelli FB, Spence TL, et al: Infrapopliteal angioplasty for critical limb ischemia: relation of TransAtlantic InterSociety Consensus class to outcome in 176 limbs. .J Vasc Surg 48::128. ,2008. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Schanzer A, Mega J, Meadows J, et al: Risk stratification in critical limb ischemia: derivation and validation of a model to predict amputation-free survival using multi-center surgical outcomes data. .J Vasc Surg 48::1464. ,2008. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Schanzer A, Goodney PP, Li Y, et al: Validation of the PIII CLI risk score for the prediction of amputation-free survival in patients undergoing infrainguinal autogenous vein bypass for critical limb ischemia. .J Vasc Surg 50::769. ,2009. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Bradbury AW, Adam DJ, Bell J, et al: Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: an intention-to-treat analysis of amputation-free and overall survival in patients randomized to a bypass surgery-first or a balloon angioplasty-first revascularization strategy. .J Vasc Surg 51: (suppl):5S. ,2010. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Bradbury AW, Adam DJ, Bell J, et al: Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: analysis of amputation free and overall survival by treatment received. .J Vasc Surg 51: (suppl):18S. ,2010. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Monahan TS, Owens CD: Risk factors for lower-extremity vein graft failure. .Semin Vasc Surg 22::216. ,2009. .

  • 14

    Taylor LM Jr, Edwards JM, Porter JM: Present status of reversed vein bypass grafting: five-year results of a modern series. .J Vasc Surg 11::193. ,1990. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Shah DM, Darling RC III, Chang BB, et al: Long-term results of in situ saphenous vein bypass: analysis of 2058 cases. .Ann Surg 222::438. ,1995. .

  • 16

    Pomposelli FB, Kansal N, Hamdan AD, et al: A decade of experience with dorsalis pedis artery bypass: analysis of outcome in more than 1000 cases. .J Vasc Surg 37::307. ,2003. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Owens CD, Ho KJ, Kim S, et al: Refinement of survival prediction in patients undergoing lower extremity bypass surgery: stratification by chronic kidney disease classification. .J Vasc Surg 45::944. ,2007. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Lantis JC II, Conte MS, Belkin M, et al: Infrainguinal bypass grafting in patients with end-stage renal disease: improving outcomes?. J Vasc Surg 33::1171. ,2001. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Taylor LM Jr, Edwards JM, Brant B, et al: Autogenous reversed vein bypass for lower extremity ischemia in patients with absent or inadequate greater saphenous vein. .Am J Surg 153::505. ,1987. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Panetta TF, Marin ML, Veith FJ, et al: Unsuspected preexisting saphenous vein disease: an unrecognized cause of vein bypass failure. .J Vasc Surg 15::102. ,1992. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Marin ML, Veith FJ, Panetta TF, et al: Saphenous vein biopsy: a predictor of vein graft failure. .J Vasc Surg 18::407. ,1993. .

  • 22

    Towne JB, Schmitt DD, Seabrook GR, et al: The effect of vein diameter on patency of in situ grafts. .J Cardiovasc Surg (Torino) 32::192. ,1991. .

    • Search Google Scholar
    • Export Citation
  • 23

    Wengerter KR, Veith FJ, Gupta, et al: Influence of vein size (diameter) on infrapopliteal reversed vein graft patency. .J Vasc Surg 11::525. ,1990. .

  • 24

    Chew DK, Conte MS, Donaldson MC, et al: Autogenous composite vein bypass graft for infrainguinal arterial reconstruction. .J Vasc Surg 33::259. ,2001. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Londrey GL, Bosher LP, Brown PW, et al: Infrainguinal reconstruction with arm vein, lesser saphenous vein, and remnants of greater saphenous vein: a report of 257 cases. .J Vasc Surg 20::451. ,1994. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Schanzer A, Hevelone N, Owens CD, et al: Technical factors affecting autogenous vein graft failure: observations from a large multicenter trial. .J Vasc Surg 46::1180. ,2007. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Chew DK, Owens CD, Belkin M, et al: Bypass in the absence of ipsilateral greater saphenous vein: safety and superiority of the contralateral greater saphenous vein. .J Vasc Surg 35::1085. ,2002. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Faries PL, Arora S, Pomposelli FB Jr, et al: The use of arm vein in lower-extremity revascularization: results of 520 procedures performed in eight years. .J Vasc Surg 31::50. ,2000. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Armstrong PA, Bandyk DF, Wilson JS, et al: Optimizing infrainguinal arm vein bypass patency with duplex ultrasound surveillance and endovascular therapy. .J Vasc Surg 40::724. ,2004. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    LoGerfo FW, Quist WC, Cantelmo NL, et al: Integrity of vein grafts as a function of initial intimal and medial preservation. .Circulation 68::II117. ,1983. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Adcock OT Jr, Adcock GL, Wheeler JR, et al: Optimal techniques for harvesting and preparation of reversed autogenous vein grafts for use as arterial substitutes: a review. .Surgery 96::886. ,1984. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Belkin M, Knox J, Donaldson MC, et al: Infrainguinal arterial reconstruction with nonreversed greater saphenous vein. .J Vasc Surg 24::957. ,1996. .

  • 33

    Wengerter KR, Veith FJ, Gupta SK, et al: Prospective randomized multicenter comparison of in situ and reversed vein infrapopliteal bypasses. .J Vasc Surg 13::189. ,1991. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Ascer E, Veith FJ, Gupta SK, et al: Short vein grafts: a superior option for arterial reconstructions to poor or compromised outflow tracts?. J Vasc Surg 7::370. ,1988. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Ballotta E, Renon L, De Rossi A, et al: Prospective randomized study on reversed saphenous vein infrapopliteal bypass to treat limb-threatening ischemia: common femoral artery versus superficial femoral or popliteal and tibial arteries as inflow. .J Vasc Surg 40::732. ,2004. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Reed AB, Conte MS, Belkin M, et al: Usefulness of autogenous bypass grafts originating distal to the groin. .J Vasc Surg 35::48. ,2002. .

  • 37

    Schanzer A, Owens CD, Conte MS, et al: Superficial femoral artery percutaneous intervention is an effective strategy to optimize inflow for distal origin bypass grafts. .J Vasc Surg 45::740. ,2007. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Pomposelli FB Jr, Jepsen SJ, Gibbons GW, et al: Efficacy of the dorsal pedal bypass for limb salvage in diabetic patients: short-term observations. .J Vasc Surg 11::745. ,1990. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Raftery KB, Belkin M, Mackey WC, et al: Are peroneal artery bypass grafts hemodynamically inferior to other tibial artery bypass grafts?. J Vasc Surg 19::964. ,1994. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    Bergamini TM, George SM Jr, Massey HT, et al: Pedal or peroneal bypass: which is better when both are patent?. J Vasc Surg 20::347. ,1994. .

  • 41

    Neville RF, Attinger CE, Bulan EJ, et al: Revascularization of a specific angiosome for limb salvage: does the target artery matter?. Ann Vasc Surg 23::367. ,2009. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42

    Desai TR, Meyerson SL, Skelly CL, et al: Patency and limb salvage after infrainguinal bypass with severely compromised (“blind”) outflow. .Arch Surg 136::635. ,2001. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43

    Peterkin GA, LaMorte WW, Menzoian JO: Runoff resistance and early graft failure in infrainguinal bypass surgery. .Arch Surg 123::1199. ,1998. .

    • Search Google Scholar
    • Export Citation
  • 44

    Seeger JM, Pretus HA, Carlton LC, et al: Potential predictors of outcome in patients with tissue loss who undergo infrainguinal vein bypass grafting. .J Vasc Surg 30::427. ,1999. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45

    Bandyk DF, Mills JL, Gahtan V, et al: Intraoperative duplex scanning of arterial reconstructions: fate of repaired and unrepaired defects. .J Vasc Surg 20::426. ,1994. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46

    Johnson BL, Bandyk DF, Back MR, et al: Intraoperative duplex monitoring of infrainguinal vein bypass procedures. .J Vasc Surg 31::678. ,2000. .

  • 47

    Schanzer A, Hevelone N, Owens CD, et al: Statins are independently associated with reduced mortality in patients undergoing infrainguinal bypass graft surgery for critical limb ischemia. .J Vasc Surg 47::774. ,2008. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 48

    Schouten O, Boersma E, Hoeks SE, et al: Fluvastatin and perioperative events in patients undergoing vascular surgery. .N Engl J Med 361::980. ,2009. .

  • 49

    Abbruzzese TA, Havens J, Belkin M, et al: Statin therapy is associated with improved patency of autogenous infrainguinal bypass grafts. .J Vasc Surg 39::1178. ,2004. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 50

    Tinder CN, Chavanpun JP, Bandyk DF, et al: Efficacy of duplex ultrasound surveillance after infrainguinal vein bypass may be enhanced by identification of characteristics predictive of graft stenosis development. .J Vasc Surg 48::613. ,2008. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 51

    Tinder CN, Bandyk DF: Detection of imminent vein graft occlusion: what is the optimal surveillance program?. Semin Vasc Surg 22::252. ,2009. .

  • 52

    Shah DM, Chang BB, Fitzgerald KM, et al: Durability of the tibial artery bypass in diabetic patients. .Am J Surg 156::133. ,1988. .

  • 53

    Morrissey NJ, Giacovelli J, Egorova N, et al: Disparities in the treatment and outcomes of vascular disease in Hispanic patients. .J Vasc Surg 46::971. ,2007. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 54

    Robinson WP III, Owens CD, Nguyen LL, et al: Inferior outcomes of autogenous infrainguinal bypass in Hispanics: an analysis of ethnicity, graft function, and limb salvage. .J Vasc Surg 49::1416. ,2009. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 55

    Nguyen LL, Hevelone N, Rogers SO, et al: Disparity in outcomes of surgical revascularization for limb salvage: race and gender are synergistic determinants of vein graft failure and limb loss. .Circulation 119::123. ,2009. .

    • PubMed
    • Search Google Scholar
    • Export Citation

Challenges of Distal Bypass Surgery in Patients with Diabetes

Patient Selection, Techniques, and Outcomes

Michael S. Conte Division of Vascular and Endovascular Surgery, University of California, San Francisco, 400 Parnassus Ave, Ste A-581, San Francisco, CA 94143. (E-mail: michael.conte@ucsfmedctr.org)

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Surgical revascularization of the lower extremity using bypass grafts to distal target arteries is an established, effective therapy for advanced ischemia. Recent multicenter data confirm the primacy of autogenous vein bypass grafting, yet there remains significant heterogeneity in the utilization, techniques, and outcomes associated with these procedures in current practice. Experienced clinical judgment, creativity, technical precision, and fastidious postoperative care are required to optimize long-term results. The diabetic patient with a critically ischemic limb offers some specific challenges; however, numerous studies demonstrate that the outcomes of vein bypass surgery in this population are excellent and define the standard of care. Technical factors, such as conduit and inflow/outflow artery selection, play a dominant role in determining clinical success. An adequate-caliber, good-quality great saphenous vein is the optimal graft for distal bypass in the leg. Alternative veins perform acceptably in the absence of the great saphenous vein, whereas prosthetic and other nonautogenous conduits have markedly inferior outcomes. Graft configuration (reversed, nonreversed, or in situ) seems to have little effect on outcome. Shorter grafts have improved patency. Inflow can be improved by surgical or endovascular means if necessary, and distal-origin grafts (eg, those arising from the superficial femoral or popliteal arteries) can perform as well as those originating from the common femoral artery. The selected outflow vessel should supply unimpeded runoff to the foot, conserve conduit length, and allow for adequate soft-tissue coverage of the graft and simplified surgical exposure. This review summarizes the available data linking patient selection and technical factors to outcomes and highlights the importance of surgical judgment and operative planning in the current practice of infrainguinal bypass surgery. (J Am Podiatr Med Assoc 100(5): 429–438, 2010)