EARLY EXPERIENCE WITH CRYOPRESERVED SAPHENOUS-VEIN ALLOGRAFTS AS A CONDUIT FOR COMPLEX LIMB-SALVAGE PROCEDURES

Purpose: The lack of a suitable alternative to autogenous vein is ofte n the limiting factor for complex lower extremity vascular reconstruct ion, especially when previously placed grafts have failed. Cryopreserv ed saphenous vein allografts have been used as an alternative conduit. This report reviews our early experience with this conduit in a serie s of complex redo revascularization procedures for limb salvage when n o suitable autogenous vein was available. Methods: Thirty-five patient s underwent 39 lower extremity bypass grafts on 36 limbs. These patien ts had undergone a combined total of 72 prior revascularization proced ures on the symptomatic limb, an average of two procedures per patient . Only five bypasses were performed as a primary procedure. There were 18 men and 17 women with a mean age of 71 years. Sixteen of the patie nts had diabetes. Thirty-four bypasses were performed for rest pain or ulceration, four for disabling claudication, and one for replacement of an aneurysmal vein graft. There were 35 femorotibial, three below-k nee femoropopliteal, and one femoropedal reconstruction. Twenty-five g rafts were constructed with cryopreserved vein only, whereas 14 were c omposite grafts; 10 were constructed with polytetrafluoroethylene, one with Dacron, and three with spliced native saphenous vein. The mean f ollow-up was 9 months (range 1 to 25 months). Results: There was one e arly death (< 30 days) and two late deaths. Two patients died with a p atent graft. There have been 12 early graft closures and an additional 17 late failures, resulting in primary cumulative graft patency rates of 67%, 56%, 43%, 28%, and 14% at 1, 3, 6, 12, and 18 months, respect ively. Surgically correctable causes, including technical error and an astomotic stenosis, could be identified in 13 of the 29 graft failures . Salvage of failed grafts resulted in secondary cumulative graft pate ncy rates of 87%, 77%, 61%, 46%, and 37% at these same intervals. Ther e was no significant difference in primary or secondary graft patency rates related to diabetes, ABO graft compatability, graft composition or orientation, indication for surgery, state of the outflow tract, or site of distal anastomosis. Limb salvage was attained in 24 (67%) of the 36 limbs. Two amputations were necessary despite patent grafts. Co nclusions: Because of the poor overall graft patency rates, cryopreser ved saphenous vein allografts should be used only as a last resort whe n no alternative autogenous conduit is available. Unless patency rates superior to those achievable with currently available prosthetic or b iologic conduits can be attained by adjunctive measures such as routin e anticoagulation or immunosuppressive therapy, the use of cryopreserv ed saphenous vein allografts for lower extremity revascularization sho uld be deferred until improved preparation techniques provide a more d urable conduit.