EARLY RESULTS OF INFRAGENICULATE ARTERIAL RECONSTRUCTION USING CRYOPRESERVED HOMOGRAFT SAPHENOUS CONDUIT (CADVEIN) AND COMBINATION LOW-DOSESYSTEMIC IMMUNOSUPPRESSION

BACKGROUND: The search continues for the ideal conduit for infragenicu late arterial reconstructions when the autogenous vein is unsuitable o r unavailable, Based on experimental observations in our laboratory de monstrating improvement in canine cryopreserved allograft vein patency using systemic immunosuppression (Imsup), and the remarkable clinical success achieved in older (greater than 60 years of age) solid organ transplant recipients using combination low-dose Imsup, we studied the effects of Imsup on patency of cryopreserved homograft saphenous vein (CADVEIN) used for infrageniculate arterial reconstructions. STUDY DE SIGN: Under the Institutional Review Board protocol, 21 infrageniculat e CADVEIN grafts were placed in 19 patients between July 1993 and Augu st 1994 for limb salvage when autogenous veins were unavailable, An im munopharmacologic protocol consisting of low-dose cyclosporine A, azat hioprine, prednisone, warfarin, aspirin, and vasodilators given orally was instituted, For various reasons, 15 patients in group 1 received Imsup; five patients never received Imsup, and one patient in group 2 received Imsup briefly, Follow-up examinations were completed using th e time range of six to Is months (mean, eight plus or minus one month) . RESULTS: One patient died (5.3 percent) 30 days after emergency comb ined venous graft and bilateral CADVEIN bypass, The actuarial 12-month primary patency in group 1 was 59.4 percent compared with 16.7 percen t in group 2 (p<0.015, log-rank test), Cellular rejection was typicall y seen in explanted (CADVEIN, Systemic morbidity related to Imsup was minimal, The CADVEIN morbidity rate was significant: three graft aneur ysms and four early graft ruptures, Major amputations were necessary i n eight of 12 patients with graft closure. CONCLUSIONS: The data sugge st that Imsup significantly improves CADVEIN patency with limited syst emic morbidity; however, complications related to the conduit itself o ccurred with greater frequency and cause greater morbidity than when t he autogenous veins were used, Much has yet to be learned regarding th e preservation characteristics of CADVEIN and the immunologic interact ions in patients receiving CADVEIN grafts, before further clinical use of this conduit can be recommended.