New technique for construction of coposite Dacron vein grafts for femoro-distal popliteal bypass in the severely ischemic leg.

Vascular surgeons are in agreement that autogenous saphenous veins are best suited for bypasses from the common femoral artery to the distal popliteal artery in the management of femoropopliteal occlusive disease associated with the severely ischemic foot. Such a graft should be of adequate size (more than 3 mm in diameter) throughout its length for a successful outcome. In some patients the vein is of good size for 15 or 20 cm then branches into several small veins. Reports by most surgeons are unfavorable concerning the use of prostheses and bovine heterografts for anastomosis to the distal popliteal artery or to one of its branches. Our experience with composite dacron vein graft bypasses employing a fluted end-to-end anastomosis had been unfavorable and was similar to the experience of Dale (1962). In July 1973 we were forced to improvise the technique of end-to-side anastomosis joining the end of a dacron prosthesis to the side of the vein graft for a femorodistal popliteal bypass. During the ensuing 15 months we have carried out this composite graft only when the greater saphenous vein was not of adequate size throughout. In 17 limbs the composite graft was placed between the common femoral artery and the distal popliteal artery and on 6 occasions to the posterior tibial and peroneal arteries. Nineteen limbs exhibited either gangrene, impending gangrene, ischemic ulceration or severe rest pain. In four extremities intermittent claudication of a progressive and disabling degree was the indication for operation. Eleven of the 22 patients were diabetic. Run-off beyond the popliteal artery was poor in 16 of the 23 limbs and inflow was subnormal in three patients. During the followup period, 10 grafts have occluded, one day to 6 1/2 months postoperatively, two due to inflow deficiency, 5 due to poor outflow, one to an error in technique, and two occluded without known cause. Two patients came to major amputation following closure of their grafts, 3 and 7 months postoperatively. Results with the composite graft are compared with the bovine heterograft and the homologous vein graft.