MANAGEMENT OF THE FAILED PRIMARY INFRAINGUINAL RECONSTRUCTION - TREATMENT OPTIONS AND LONG-TERM OUTCOME

Patients presenting with critical limb ischemia following failed infra inguinal grafts have been reported to have a significant amputation ra te and reduced long-term survival. The authors reviewed their three-ye ar experience with 33 patients with failed infrainguinal reconstructio n. The median age was 63.1 years of age (range forty-three to eighty-s even years). There were 19 women and 14 men. Risk factors included the following: hypertension 31 (94%), diabetes 21 (64%), and tobacco use 30 (91%). All patients had limb-threatening ischemia, 15 had gangrene (45.4%), 8 had ulceration (24.2%), and 10 had rest pain 10 (30.3%). Th ere had been 42 previous revascularizations (1.27 per patient, range 1 to 6). The authors performed 45 revascularization operations (1.36 pe r patient, range 1 to 4). Inflow was as follows: common femoral artery in 29 (64.4%), superficial femoral artery in 9 (20%), profunda femori s in 4 (8.9%), aortobifemoral graft limb in 2 (4.4%), and femoral-femo ral bypass graft in 1 (2.2%). Outflow was as follows: posterior tibial artery 12 (26.7%), peroneal artery in 17 (37.8%), anterior tibial art ery in 7 (15.6%), popliteal artery in 5 (11.1%), and tibioperoneal tru nk in 4 (8.9%). The conduits were as follows: great saphenous vein (GS V) from the opposite lower limb in 8 (17.8%), GSV/lesser saphenous vei n (LSV) composites in 8 (17.8%), expanded polytetrafluoroethylene in ( ePTFE) 5 (11.1%), LSV composite in 10 (22.2%), ePTFE/GSV composite in 5 (11.1%), cadaveric vein in 2 (4.4%), superficial femoral vein/ePTFE composite in 2 (4.4%), endarterectomized superficial femoral artery/GS V composite in 1 (2.2%), GSV/upper limb vein composite in 1 (2.2%); an d upper limb vein in 3 (6.7%). There was one perioperative death (2.2% ). Six patients died during the follow-up period (74.1% survival). Lim b salvage was obtained in 28 patients (83.1%). Cumulative secondary pa tency was 73.2% at three years. These results indicate that: (1) aggre ssive revascularization for failed infrainguinal grafts can result in significant limb salvage, and (2) Long-term survival is common in this patient population.