Autogenous arterial bypass grafts: Durable patency and limb salvage in patients with inframalleolar occlusive disease and endstage renal disease

Objective: The purposes of this study were to determine whether autogenous arterial grafts to distal pedal arteries improve the patency of grafts and limb salvage in patients with end-stage renal disease and nonhealing ischem ic wounds and to better define the indications for autogenous arterial graf ts. Design: A review of consecutive patients with end-stage renal disease under going autogenous arterial grafts from 1994 through 1999 was carried out. Th e setting was a university hospital. All 11 patients with end-stage renal d isease and nonhealing, ischemic wounds (stage IV SVS-ISCVS classification) undergoing autogenous arterial grafting from 1994 to 1999 were evaluated. N oninvasive studies confirmed inadequate perfusion pressures in all patients . Pre-bypass arteriography identified no major arteries parent at the level of the malleolus, with reconstitution of only a distal or branch pedal or plantar vessel less than 1 mm in diameter. Five patients with patent tibial vessels to just above the ankle underwent bypass surgery with autogenous a rterial grafts alone. Six patients also had proximal occlusive disease that required grafts longer than the autogenous arterial grafts; in each of the se six patients, an autogenous vein graft proximal to the autogenous arteri al graft was placed through use of a composite technique. Inflow was from t he common femoral artery in one patient, the popliteal artery in five patie nts, and a tibial artery in five patients. Outflow was to the medial planta r artery in five patients, the distal dorsalis pedis artery in three patien ts, the lateral plantar artery in two patients, and the superficial arch in one patient. The conduit was the subscapular artery in four patients, the deep inferior epigastric artery in four patients, the superficial inferior epigastric artery in two patients, and the radial artery in one patient. Th e main outcome measures were assisted primary graft patency and functional limb salvage rate. Results: Follow-up ranged from 6 to 63 months (mean, 20 months); graft pate ncy was determined by means of duplex scanning. All 11 patients are alive, and nine grafts are patent, including three after revision for graft stenos is. Assisted primary patency was 82% at 3 years. All nine patients with pat ent grafts remained ambulatory and had healed wounds or limited forefoot am putations. Conclusion: Autogenous arterial grafts were effective in treating limb-thre atening ischemia in patients with end-stage renal disease and inframalleola r arterial insufficiency. Graft patency and limb salvage rates were higher than those reported for autogenous vein graft in these patients. Autogenous arterial grafting may therefore prove to be an effective alternative to au togenous vein grafting in selected patients.