Is arterial reconstruction to the ankle worthwhile in the absence of autologous vein?

Autologous vein from either the arm or the leg is the preferred conduit for femoro-crural grafting. Limb salvage rates using prosthetic grafts have been sufficiently disappointing for many surgeons to consider primary amputation in the absence of suitable vein. We have attempted to improve prosthetic graft patency by the creation of a compliant, wide diameter vein collar at the distal anastomosis. Thirty patients with critical ischaemia (i.e.: rest pain with distal tissue loss or doppler ankle pressure less than 40 mmHg2.3) have undergone grafting to a crural vessel in the lower third of the calf using 6 mm externally supported PTFE (IMPRA) with a vein collar (17% of all lower calf grafts, 9% of all femoro-distal procedures). Five of the grafts occluded in the peri-operative period, resulting in major amputations. Another 4 grafts occluded within 12 months of operation resulting in amputation. A further 7 grafts have occluded but not required amputation. Fourteen (47%) grafts remain patent at a mean follow-up of 13.9 months (range 1-49) with a mean graft patency of 10 months. The aim of salvage surgery is to maintain independence until death supervenes. In this series 6 (20%) patients have died during follow-up and the best possible result in the 30 patients would have been a total of 417 "amputation avoided" months. In fact 300 "amputation avoided" months were achieved. Moreover, 21 legs (70%) have avoided amputation during the patient's lifetime, or at the most recent follow-up. These results suggest that femorocrural grafting using PTFE with a vein collar is worthwhile and preferable to primary amputation in the elderly patient.