A comparative study of alternative conduits for lower extremity revascularization: All-autogenous conduit versus prosthetic grafts

Purpose: In the absence of an adequate ipsilateral greater saphenous vein, various alternative conduits have been used for the performance of lower ex tremity revascularization. In this study we compared the effectiveness of a ll-autogenous arm vein bypass grafts with that of prosthetic grafts. Methods: Seven hundred forty lower extremity revascularization procedures ( 506 arm vein, 234 prosthetic) performed between 1990 and 1999 were followed prospectively by means of a computerized vascular registry Results: Bypass graft configurations mere femoro-above-knee-popliteal (26 a rm vein, 100 prosthetic); femoro-below-knee-popliteal (38 arm vein, 29 pros thetic); femorotibial (174 arm vein, 55 prosthetic); femoropedal (23 arm ve in, 2 prosthetic); popliteotibial/pedal (101 arm vein, 1 prosthetic); and e xtension "jump" grafts (144 arm vein, 47 prosthetic). The indications for s urgery were limb salvage (98.0% ann vein, 89.7% prosthetic) and disabling c laudication (2.0% arm vein, 10.3% prosthetic). The mean follow-up was 23.4 months (range, 1 month-7.4 years). Overall patient survival at 4 pears was 54% (arm vein) and 69% (prosthetic). Cumulative patency varied with graft c onfiguration. The 1-year primary patency rates for femorotibial grafts were 81.6% +/- 3.6% (arm vein) and 58.0% +/- 8.4% (prosthetic); the 3-year rate s were 68.3% +/- 6.1% (arm vein) and 41.1% +/- 9.8% (prosthetic) (P < .01). The 1-year limb salvage rates for femorotibial grafts were 91.1% +/- 2.8% (arm vein) and 69.1% +/- 8.8% (prosthetic); the 3-year rates were 81.4% +/- 5.6% (arm vein) and 63.2% +/- 10.3% (prosthetic) (P = .02). The 1-year pri mary patency rates for femoro-below-knee-popliteal grafts were 92.9% +/- 5. 1% (arm vein) and 83.4% +/- 8.0% (prosthetic); the 3-year rates were 72.8% +/- 10.1% (arm vein) and 55.5% +/- 12.1% (prosthetic) (P = .05). The 1-year limb salvage rates for femoro-below-knee-popliteal grafts were 100% (arm v ein) and 91.3% +/- 7.0% (prosthetic); the 3-year rates were 94.7% +/- 7.3% (arm vein) and 75.3% +/- 14.6% (prosthetic) (P = NS). Conclusion: In this study autogenous arm vein grafts demonstrated increased patency and limb salvage, compared with prosthetic grafts. These increases achieved statistical significance in the femoro-below-knee-popliteal and f emorotibial configurations. An effort to use an all-autogenous vein conduit is justified on the basis of these results; however, if no autogenous vein is available, prosthetic grafts provide a reasonable alternative to primar y amputation.