An argument against all-autogenous tissue for vascular bypasses below the inguinal ligament.

1. Femoropopliteal bypass, regardless of the conduit used, has a 5-year failure rate. 2. The majority of patients with initial reconstruction failure will require secondary repair. 3. Recognition of the ultimate need for secondary repair justifies a long range planning approach for the management of patients who require femoropopliteal reconstruction. 4. Secondary repairs have a dramatically higher patency rate when performed with autogenous saphenous vein than they do with PTFE grafts. 5. Patients who had the initial operation performed with PTFE will have autogenous saphenous vein available for secondary repair, in contrast to the patients who had saphenous vein used in the initial operation; they must rely upon second-best choices including amputation. 6. The greatest and longest term of effective palliation, relief from disabling claudication, or limb salvage will be achieved when PTFE is used preferentially for the first femoropopliteal reconstruction. In the majority of patients, this will be the only operation necessary; they will have had a simple operation, requiring a short period of time, and probably reduced hospitalization. For those who require secondary repair, autogenous saphenous vein is available for that purpose and will yield the best long-term results in comparison to the other alternatives including amputation. Thus, the concept of staged infrainguinal repair using first PTFE and, if necessary, saphenous vein for the secondary repairs provides the longest term palliation for patients with lower extremity arterial occlusive disease.