Adjunctive techniques to improve patency of distal prosthetic bypass grafts: Polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs

Purpose: The long-term patency for infrapopliteal bypass grafting with pros thetic material is less than optimal. Our experience demonstrates a 40% pat ency at 2 years for these grafts. Several adjuvant techniques have been dev eloped to improve patency rates, two of which are a remote distal arteriove nous fistula and the creation of a distal vein cuff. This study summarizes our experience with these two techniques. Methods: Between 1987 and 1998, 107 bypass graftings were performed to the below-knee popliteal or tibial vessels with the use of pol polytetrafluoroe thylene. One group (48 bypass grafts) had polytetrafluoroethylene with adju vant distal arteriovenous fistula (DAVF), and a second group (59 bypass gra fts) was reconstructed with a distal vein cuff (DVC). The type of bypass gr afting that was performed was based on surgeon experience and preference. I ndications and demographics were similar in the two groups. All patients un derwent the operation for limb-threatening ischemia, including gangrene (DA VF, 23%; DVC, 9%), ulceration (DAVF,27%; DVC, 51%), and rest pain (DAVF, 50 %; DVC,, 40%). Results: The primary patency rate was 48% and 38% at 3 years for DAVF and D VC, respectively. Secondary patency was 48% and 47% at 3 years, with limb s alvage rates of 76% and 92% for DAVF and DVC, respectively (P < .05). Attem pted thrombectomy without continuation of patency was undertaken in two pat ients with a failed DAVF Attempts at restoration after thrombosis were made in eight patients with failed DVCs. Five patients underwent thrombectomy, of which four procedures were successful. Three patients had thrombolytic t herapy, and two of these remained patent. Conclusion: Adjuvant techniques, including DAVF and DVC, produce acceptable long term patency and limb salvage rates in bypass grafts performed to the below-knee popliteal and tibial vessels. This study suggests that DVCs may offer improved limb salvage rates and a greater opportunity for revision w hen bypass graft failure occurs.