Use of arm and lesser saphenous vein compared with prosthetic grafts for infrapopliteal arterial bypass: are they worth the effort?

PURPOSE

Arm and lesser saphenous veins (ALSVs) are generally considered to be the best alternative for infrapopliteal arterial bypass grafts when greater saphenous vein is not available. The need for additional incisions and repositioning of the patient, along with occasional use of general anesthesia for arm vein harvesting, led to our perception that the use of ALSVs increased operative time and possibly patient discomfort. Therefore, we compared the outcome of ALSVs with that of prosthetic infrapopliteal arterial bypass procedures performed at our hospital.

METHODS

Between July 1, 1991, and Dec. 31, 1996, we performed 96 infrapopliteal arterial bypass procedures using 45 ALSVs (28 arm vein, 17 lesser saphenous) and 51 polytetrafluoroethylene (PTFE) grafts. Seventy grafts were single-length ALSV or PTFE bypass grafts, and 26 grafts were placed as the distal segment of a sequential or composite bypass graft. Every attempt was made to use ALSV and avoid the use of PTFE, even if a short segment of the vein graft measured less than 4.0 mm in diameter. There were no significant differences between patients with ALSV compared with PTFE grafts in terms of age, sex, indication for surgery, or number of previous revascularization procedures (2.1 vs 1.7), respectively (p > 0.05). However, ALSV grafts had more factors associated with an expected worse outcome: they were more commonly anastomosed to pedal arteries (17% [8 of 45] vs 0%; p = 0.0009), less commonly single-segment grafts (62% [28 of 45] vs 82% [42 of 51]; p = 0.03), had higher average runoff resistance values (2.3 vs 1.5; p = 0.001), and were less frequently treated with lifelong warfarin (65% [29 of 45] vs 95% [48 of 51]; p = 0.0001).

RESULTS

The hospital mortality rate was 3.1% (3 of 96; 3 PTFE). All deaths were cardiac-related. Despite the potential factors associated with worse patency rates for ALSVs, 2-year assisted primary patency rates tended to be higher for arm veins (46%) than for lesser saphenous veins (23%) and PTFE grafts (26%), although this difference was not statistically significant. Limb salvage rates were similar between ALSV and PTFE grafts (76% vs 71%, respectively). The average operative time was significantly longer for ALSV bypass procedures (mean, 6.2 hours) than for PTFE bypass procedures (mean, 4.9 hours; p = 0.003), and for single-length conduits when revision of previously placed grafts was not attempted, the operative time was 4.0 hours for ALSV grafts and 2.5 hours for PTFE grafts.

CONCLUSION

In our experience ALSV bypass grafts to infrapopliteal arteries do not function as well as reported by some others. In spite of the extra effort involved, arm vein grafts are preferred over PTFE grafts for their likely higher assisted primary patency rates and equivalent, if not better, limb salvage rates.