RESULTS OF A POLICY WITH ARM VEINS USED AS THE FIRST ALTERNATIVE TO AN UNAVAILABLE IPSILATERAL GREATER SAPHENOUS-VEIN FOR INFRAINGUINAL BYPASS

Purpose: Aggressive policies for distal bypass and coronary revascular ization increase the need to identify alternatives to autologous saphe nous vein grafts. We examined the performance of arm vein as the prima ry alternative to contralateral saphenous vein when the ipsilateral sa phenous vein was not available. Methods: A total of 250 arm vein graft s were studied retrospectively in 224 patients (143 men, 81 women, 82. 6% with diabetes, mean age 68.3 years) from February 1989 to April 199 4. Intraoperative angioscopy was carried out to observe valve lysis, r emove abnormalities, and select optimal vein segments. Results: A tota l of 85 primary, 103 repeat, and 62 graft revision procedures were don e for limb salvage in 99.2% of the patients. A total of 41 femoropopli teal, 114 femorotibial-pedal, 33 popliteodistal, and 62 jump or interp osition grafts were constructed. A total of 199 grafts were single vei n, and 51 were composite vein. The source was cephalic vein alone in 5 0.4%, cephalic and basilic vein in 35.6%, and basilic vein only in 14% . The contralateral saphenous vein as an alternative conduit was avail able in 97 (38.8%) instances. Interventions guided by angioscopy to '' upgrade'' the graft were necessary in 51.6%. Overall early patency (le ss than or equal to 30 days) was 94.8% (n = 13 occlusions). The cumula tive primary patency rate at 1 year was 70.6%, the secondary patency r ate was 76.9%, and the limb salvage rate was 88.2%. The 3-year patency rate (limb salvage) was 51.9% (92.4%) for primary grafts, 56.7% (67.1 %) in revision grafts, and 42.4% (79.9%) in repeat grafts. In 22.7% (2 2 of 97) the available contralateral saphenous vein was used for dista l revascularization within the follow-up period. Conclusions: Arm vein s are an easily accessible autologous conduit of sufficient length to reach the midtibial level. Excellent patency rates allow durable limb salvage in otherwise difficult circumstances. Vein configuration and s plicing do not affect patency rates, but vein quality and repeat opera tions do. Angioscopy is a valuable adjunct to upgrade graft quality. T he contralateral saphenous should be saved for subsequent contralatera l revascularization or coronary artery bypass grafting.