Neufang Achim, Espinola-Klein Christine, Dorweiler Bernhard, Messow Claudia Martina, Schmiedt Walther, Vahl Christian Friedrich
Department of Cardiothoracic and Vascular Surgery, Johannes Gutenberg-University School of Medicine, Mainz, Germany.
J Vasc Surg. 2007 Aug;46(2):280-8. doi: 10.1016/j.jvs.2007.03.054. Epub 2007 Jun 27.
Femoropopliteal bypass still is the standard surgical therapy for disabling claudication and critical ischemia. When autologous vein is not suitable synthetic or biological prostheses may be considered. Second generation glutaraldehyde tanned human umbilical vein (HUV) graft was chosen for above and below knee femoropopliteal bypass when autologous vein was not available. A single center experience regarding long-term graft function, secondary reinterventions, and potential biodegeneration of the HUV is presented.
Between January 1994 and January 2005, 211 consecutive femoropopliteal bypass operations with HUV (65 above knee and 146 below knee) were performed in 197 patients for disabling claudication (57), chronic critical ischemia (130), popliteal artery aneurysm (9), acute ischemia (14), or aneurysmal degeneration of a synthetic graft (1) in the absence of suitable ipsilateral great saphenous vein. Grafts were followed with duplex scan supplemented by additional angiography in case of recurrent ischemia with prospective documentation of follow-up data in a computerized vascular database. Surveillance of the HUV included routine evaluation of potential biodegeneration with duplex scan. Retrospective analysis of graft patency, limb salvage, and signs of aneurysmal degeneration was performed.
Mean (median) follow-up was 44 (35) months (range 1 to 143 months). Thirty-day mortality was 2.4%. Early postoperative bypass thrombosis after a median of 4 days postoperatively (0 to 30 days) prompted revision with thrombectomy in 16% of cases. Besides late bypass thrombosis in 14.7%, additional operative or endovascular reinterventions during follow-up to maintain or restore graft patency was necessary in 8.5% of bypasses. Primary, primary assisted, secondary patency rate, and limb salvage rate after 5 years were 54%, 63%, 76%, and 92%, respectively, for all bypasses with no significant difference between above and below knee anastomosis. Duplex scan identified segmental aneurysmal degeneration in six grafts, which led to operative reintervention in three cases. The rate of detected aneurysm for grafts patent for more than three years was 7% with a rate of reintervention for aneurysm of 3.5%.
Although a considerable rate of early thrombotic occlusions occurred, excellent secondary graft patency and limb salvage combined with a tolerable rate of late aneurysmal degeneration detected by means of duplex scan surveillance justify the use of the HUV in femoropopliteal bypass surgery when ipsilateral autogenous vein is not suitable.
股腘动脉搭桥术仍是治疗致残性间歇性跛行和严重肢体缺血的标准外科疗法。若自体静脉不适用，可考虑使用合成或生物假体。当无法获取自体静脉时，第二代戊二醛鞣制的人脐静脉（HUV）移植物被用于膝上和膝下股腘动脉搭桥术。本文介绍了关于HUV移植物长期功能、二次干预及潜在生物降解的单中心经验。
1994年1月至2005年1月期间，197例患者连续接受了211例使用HUV的股腘动脉搭桥手术（65例膝上搭桥和146例膝下搭桥），用于治疗致残性间歇性跛行（57例）、慢性严重肢体缺血（130例）、腘动脉瘤（9例）、急性肢体缺血（14例）或在无合适同侧大隐静脉情况下合成移植物的动脉瘤样退变（1例）。通过双功超声扫描对移植物进行随访，若出现反复缺血则辅以额外的血管造影，并将随访数据前瞻性记录在计算机血管数据库中。对HUV的监测包括通过双功超声扫描对潜在生物降解进行常规评估。对移植物通畅情况、肢体挽救情况及动脉瘤样退变迹象进行回顾性分析。
平均（中位）随访时间为44（35）个月（范围1至143个月）。30天死亡率为2.4%。术后中位4天（0至30天）出现早期搭桥血栓形成，16%的病例需行血栓切除术进行翻修。除14.7%的晚期搭桥血栓形成外，8.5%的搭桥在随访期间需要额外的手术或血管腔内干预以维持或恢复移植物通畅。所有搭桥术后5年的一期、一期辅助、二期通畅率及肢体挽救率分别为54%、63%、76%和92%，膝上和膝下吻合术之间无显著差异。双功超声扫描发现6例移植物存在节段性动脉瘤样退变，其中3例导致手术再次干预。移植物通畅超过三年的动脉瘤检出率为7%，动脉瘤再次干预率为3.5%。
尽管早期血栓闭塞发生率较高，但通过双功超声扫描监测发现，其二次移植物通畅率和肢体挽救情况良好，且晚期动脉瘤样退变率可接受，这证明在同侧自体静脉不适用时，HUV可用于股腘动脉搭桥手术。
