Polytetrafluoroethylene grafts have been used extensively for infrainguinal vascular reconstruction either as the conduit of choice or as a substitute when saphenous vein is unavailable. Although numerous studies have shown satisfactory early patency rates, the long-term efficacy of these grafts in a large number of patients for specific indications and in various positions has been less well defined. From 1977 to 1987 we used four PTFE grafts from three different manufacturers to perform 300 infrainguinal reconstructions on 240 patients on our vascular service. The indications for surgery were disabling claudication in 28% and limb salvage in 72%. The 30-day operative mortality of 1% was not different from the 1.4% associated with infrainguinal autogenous vein grafting. The 5-year cumulative patency rate achieved with all infrainguinal polytetrafluoroethylene grafts was 35%, significantly higher for grafts placed for claudication (57%) than those placed for limb salvage (24%). There were no significant differences between the above-knee and below-knee locations for distal anastomoses regardless of indication, but femoropopliteal grafts provided significantly higher 5-year patency (37%) than infrapopliteal grafts (12%). Comparison of the 5-year patency rates among the three manufacturers of polytetrafluoroethylene grafts showed no significant differences. Fifty-four polytetrafluoroethylene grafts that failed underwent 67 revisions after catheter thrombectomy or thrombolysis, which resulted in a minimal 11% 5-year patency rate. Based on this experience, it is concluded that infrainguinal polytetrafluoroethylene prostheses provide significantly inferior results when compared with autogenous reconstruction.
Saphenous vein is the optimal conduit for infrainguinal vascular reconstruction. In instances in which this vein is unavailable or of "poor quality," reliance has been placed on a variety of prosthetic materials for bypass grafting. However, long-term patency with these prosthetic grafts has been disappointing. In January 1985 we instituted a policy of using exclusively autogenous tissue for infrainguinal arterial reconstruction. During the ensuing 3-year period, 203 patients underwent 266 arterial operations below the inguinal ligament, with a prosthetic graft used in only 11 instances (4%). No patient was denied surgery for limb salvage because of a lack of available autogenous vein. Thirty-three percent of procedures were performed for failure of prior revascularization and 73% for limb salvage. The 3-year cumulative primary patency rate for all autogenous procedures was 72%. Procedures were divided into those that used greater saphenous vein (patency 77%) vs autogenous alternatives such as bypass with arm vein or lesser saphenous vein, vein patch angioplasty, and endarterectomy (patency 64%). The operative mortality rate was 1.4% and the 3-year limb salvage rate was 89%. Autogenous infrainguinal reconstruction can be performed in almost every instance with acceptable results, suggesting that the need for prosthetic bypass grafts in the lower extremity is less than has been previously reported.
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