Predictive factors for better bypass patency and limb salvage after prosthetic above-knee bypass reconstruction.

Peripheral arterial disease (PAD) is one of the most underestimated diseases because of its high prevalence and unfavorable prognosis. Many PAD patients without suitable autologous veins or options for endovascular treatment receive prosthetic above-knee femoropopliteal bypass (PAKB). Until now predictors of prosthetic bypass failure and of increased amputation risk remain indistinct. This study aimed to identify predictive factors associated with better bypass patency and limb salvage to achieve a more favorable outcome after PAKB reconstruction. Pre-, intra-, and postoperative data of 244 PAKB procedures performed at a German university medical center were collected and analyzed using univariate and multivariate methods. To our knowledge this 12-year experience is the largest retrospective study to identify predictors for patency and limb salvage after PAKB reconstruction. Of the PAD patients 94% (229/244) were followed for an average of 34.9 months. Patient cohorts characteristics were: mean age, 66.1 years, 181 men (74%), claudication (64%), rest pain (16%), ischemic lesions (20%), arterial hypertension (92%), smoking (79%), hyperlipidemia (65%) and type 2 diabetes (43%). Cumulative primary 1- and 3-year graft patency rates were 60.8% and 50.7%, respectively, and cumulative 1- and 3-year limb salvage rates were 89.3% and 86.1%, respectively. One hundred seven bypasses (43.9%) failed, 26 patients (10.7%) required a major and seven patients (2.9%) required a minor amputation. Overall survival rates of PAD patients after 1- and 3-years were 94.4% and 82.9%, respectively. Subjective symptom improvement was found to be the most important prognostic follow-up factor for graft patency and limb salvage. Patients with recurrent symptoms in the follow-up had an increased risk of emerging bypass failure compared with patients with subjective symptom improvement (patency at 1 year: 40.8% vs 100% and at 3 years: 26% vs 100%; P < .001). No patient with subjective improvement in symptoms during follow-up underwent an amputation (limb salvage at 1 year: 100% vs 79% and at 3 years: 100% vs 72.8%; P < .001). Therefore, subjective symptom improvement should be the decisive criterion to determine follow-up intervals of PAD patients. In univariate analysis further significant factors associated with better graft patency and limb salvage rates were: claudication compared with critical ischemia, larger graft diameter (>6 mm), pre- and postoperative antiplatelet therapy, statin therapy independent from lipid values after PAKB revascularization, and an experienced vascular surgeon. In our study, we determined the subjective improvement in symptoms as the most important prognostic factor for bypass function and limb salvage after PAKB. Furthermore, disease stage of critical ischemia, graft diameter, preoperative aspirin use, and postoperative statin medication were independent predictive factors. Therefore, PAD patients should be treated with aspirin pre- and postoperatively as well as with a statin postoperatively. In case of PAKB reconstruction only prostheses with a large diameter (>6 mm) should be used and the procedure should be performed by an experienced surgeon. Considering these results with regard to the predictive factors for better graft patency and limb salvage rates a significant more favorable outcome during the follow-up and an increased 5-year patency rate for PAKB reconstructions can be expected.

Klingelhoefer E ，Bergert H ，Kersting S ，Ludwig S ，Weiss N ，Schönleben F ，Grützmann R ，Gäbel G ... -  《-》

Aspirin usage is associated with improved prosthetic infrainguinal bypass graft patency.

Gassman AA ，Degner BC ，Al-Nouri O ，Philippi L ，Hershberger R ，Halandras P ，Aulivola B ，Milner R ... -  《Vascular》

Results from a multicenter registry of heparin-bonded expanded polytetrafluoroethylene graft for above-the-knee femoropopliteal bypass.

The aim of the study was to retrospectively analyze early and follow-up results of above-the-knee femoropopliteal bypasses (AKb) performed with a bioactive heparin-bonded expanded polytetrafluoroethylene (HB-ePTFE) graft in patients with peripheral arterial obstructive disease in a multicentric retrospective registry involving seven Italian vascular centers. During a 14-year period ending in March 2016, an HB-ePTFE graft was used in 1401 interventions performed for peripheral arterial obstructive disease. Comorbidities, risk factors, and follow-up outcomes were collected in a multicenter registry with a dedicated database. A post hoc analysis of the database was performed to identify 364 (25.9%) patients who underwent AKb. Early (intraoperative and <30 days) results were analyzed in terms of death, thrombosis, amputations, reinterventions, and the occurrence of major local and systemic complications. Follow-up results were analyzed by life-table analysis (Kaplan-Meier test) in terms of primary and secondary graft patency, assisted primary patency, limb preservation, and amputation-free survival. The analysis of follow-up results was stopped in December 2016. In 61 (16.7%) patients, AKb was performed after the failure of a previous ipsilateral revascularization. Critical limb ischemia was present in 164 (45%) cases; the remaining patients had life-limiting intermittent claudication. Perioperative mortality occurred in three (0.8%) patients: in the hospital (n = 2) due to acute myocardial infarction and after discharge (n = 1) due to fatal arrhythmia. Early thromboses occurred in six (1.6%) patients; all these patients had primary AKb for critical limb ischemia. The cumulative rate of perioperative amputations was 0.5% (2 cases), whereas the cumulative rate of early reinterventions was 3% (11 cases). Median duration of follow-up was 28 months (range, 1-168 months); the median cumulative follow-up index for survival was 0.75 (range, 0.05-1). Estimated survival at 5 years was 75.3% (standard error [SE], 0.03). Estimated 5-year primary patency was 64% (SE, 0.04); the corresponding figure in terms of assisted primary patency was 65% (SE, 0.035). Secondary patency rate at 5 years was 74.5% (SE, 0.03). The rate of limb preservation at 5 years was 95% (SE, 0.02); the corresponding figure in terms of amputation-free survival was 74% (SE, 0.04). In an era of endovascular enthusiasm, with conflicting results for the treatment of long or complex lesions of the superficial femoral artery, AKb with the use of HB-ePTFE graft remains an effective option, with low rate of perioperative complications and satisfactory long-term results.

Piffaretti G ，Dorigo W ，Castelli P ，Pratesi C ，Pulli R ，PROPATEN Italian Registry Group ... -  《-》

Statin therapy after infrainguinal bypass surgery for critical limb ischemia is associated with improved 5-year survival.

Although statin therapy has been linked to fewer short-term complications after infrainguinal bypass, its effect on long-term survival remains unclear. We therefore examined associations between statin use and long-term mortality, graft occlusion, and amputation after infrainguinal bypass. We used the Vascular Study Group of New England registry to study 2067 patients (71% male; mean age, 67 ± 11 years; 67% with critical limb ischemia [CLI]) who underwent infrainguinal bypass from 2003 to 2011. Of these, 1537 (74%) were on statins perioperatively and at 1-year follow-up, and 530 received no statin. We examined crude, adjusted, and propensity-matched rates of 5-year surviva1, 1-year amputation, graft occlusion, and perioperative myocardial infarction. Patients taking statins at the time of surgery and at the 1-year follow-up were more likely to have coronary disease (38% vs 22%; P < .001), diabetes (51% vs 36%; P < .001), hypertension (89% vs 77%; P < .001), and prior revascularization procedures (50% vs 38%; P < .001). Despite higher comorbidity burdens, long-term survival was better for patients taking statins in crude (risk ratio [RR], 0.7; P < .001), adjusted (hazard ratio, 0.7; P = .001), and propensity-matched analyses (hazard ratio, 0.7; P = .03). In subgroup analysis, a survival advantage was evident in patients on statins with CLI (5-year survival rate, 63% vs 54%; log-rank, P = .01) but not claudication (5-year survival rate, 84% vs 80%; log-rank, P = .59). Statin therapy was not associated with 1-year rates of major amputation (12% vs 11%; P = .84) or graft occlusion (20% vs 18%; P = .58) in CLI patients. Perioperative myocardial infarction occurred more frequently in patients on a statin in crude analysis (RR, 2.2; P = .01) but not in the matched cohort (RR, 1.9; P = .17). Statin therapy is associated with a 5-year survival benefit after infrainguinal bypass in patients with CLI. However, 1-year limb-related outcomes were not influenced by statin use in our large observational cohort of patients undergoing revascularization in New England.

Suckow BD ，Kraiss LW ，Schanzer A ，Stone DH ，Kalish J ，DeMartino RR ，Cronenwett JL ，Goodney PP ，Vascular Study Group of New England ... -  《-》

Factors Affecting Long-Term Results of Above-Knee Femoropopliteal Bypass: A Single-Center Contemporary Study.

The aim of this study was to assess whether individual patients' or bypass characteristics may influence long-term results of prosthetic above-knee femoropopliteal bypasses in patients with claudication in today's endovascular era. Seventy-one consecutivee Expanded Polytetrafluoroethylene (e-PTFE) bypasses were considered. All patients presented a debilitating claudication. Patency of grafts was achieved by Kaplan-Meier method. The association between individual patients' or graft characteristics and primary patency (PP) or secondary patency (SP) was assessed via Cox regression models. An immediate technical success was achieved in all cases. No patient was lost during follow-up (8-90 months, median = 34 months). The median PP was 48 months. Occlusion occurred in 32 bypasses (45%). Eight (25%) of these were treated conservatively. Fifty-two bypasses (73%) were still patent at the end of follow-up, and 13 (25%) of these had been submitted to one or more surgical revisions. There were 2 graft infections. Of 17 (25%) patients with occluded graft at the end of follow-up, 2 (2.8%) had significant aggravation followed by limb loss. The PP was directly influenced by undetected minor distal anastomosis technical defects (hazard ratio [HR] = 5.89, P value = .000002), popliteal artery size (HR = 0.62, P value = 0.007), and distal anastomosis angle ≥40° (HR = 5.55, P value = .003). The SP was associated strictly to technical defects (HR = 11.08, P value = .000007). Multivariable analyses confirmed the influence of technical defects (HR = 6.42, P value = .000003) and anastomosis angle (HR = 1.05, P value = .009) on PP and that of technical defects on SP (HR = 10.84, P value = .00003). A significantly shorter SP was also observed after a previous failed endovascular treatment on the superficial femoral artery (HR = 3.73, P value = .02). An adequate arterial size, an ideal anastomotic angle, and the absence of minor, technical defects have a major role in prosthetic above-knee femoropopliteal bypass long-term outcome. A previous, failed endovascular procedure on the superficial femoral artery could markedly alter the natural history of patients with claudication because this approach seems to have a detrimental effect on long-term outcome of grafts needing surgical revisions.

De Santis F ，Pattaro C ，Mani G ，Pramstaller PP ，Loreni G ，Martini G ... -  《-》