Distal Anastomotic Hyperplasia in Superficial Femoral-Popliteal Vein Femoropopliteal Bypass Grafts

Abstract

The incidence of distal anastomotic hyperplasia (DAH) in superficial femoralpopliteal veins (SF-PVs) used as femoropopliteal bypass (FPB) grafts was investigated, with particular reference to the form of distal anastomotic construction. Seventy-seven SF-PV grafts that met specific angiographic follow-up criteria qualified as "studied" grafts. DAH was identified in 13 (17%). Cobra head anastomoses, 2 cm or less in length, were used in 21 grafts and yielded 6 instances of DAH (29%). When 8 sharply tapered 3 cm (swordfish) anastomoses were constructed, 3 grafts (37.5%) developed DAH. With 3 cm moderately tapered (fishmouth) anastomoses in 48 grafts, DAH was seen 4 times (8%). Because the distal 1 cm of the swordfish configuration was very narrow, the swordfish and cobra head constructions were functionally equivalent and were grouped together as "short" anastomoses. The difference in the incidence of DAH with long and short anastomoses, 8% vs 31%, was statistically significant (p = .016).In the 48 "studied" grafts with fishmouth anastomoses, the occurrence of all 4 DAHs among the 15 female diabetic limbs was also significant (p = .019).Constructing 3 cm moderately tapered anastomoses significantly reduced the incidence of DAH, the leading cause of graft failure, in SF-PV FPB grafts. The achievement of primary and assisted patency rates of 84% and 91% at both three and five years in the 93 SF-PVs placed as primary FPB grafts since October, 1982, was largely due to the reduction in DAH that resulted from anastomotic modification.

Regarding "Venous stasis complications of the use of the superficial femoral and popliteal veins for lower extremity bypass"

“…Although several of our patients have persistent swelling (a number that can be expanded or contracted depending on one's definition of persistent swelling), we have been quite satisfied with the minimal morbidity and durability of deep leg veins as primaty femoropopliteal bypass grafts. 4 The report from Providence does not contradict, and, in fact, actually supports, our experience.…”

Interposition vein cuff anastomosis alters wall shear stress distribution in the recipient artery

“…An association between anastomosis geometry and MIH has been demonstrated both in patient observation and in animal experiments. 13,14 Previous studies of cuffed anastomoses in vivo and in laboratory models have revealed specific flow patterns that occur consistently and periodically during the cardiac cycle. 15 It seemed likely that these flow patterns could minimize areas of low WSS and thus perhaps the development of MIH, but further experiments were required to quantify WSS.…”

Regarding “Autologous alternative veins may not provide better outcomes than prosthetic conduits for below-knee bypass when great saphenous vein is unavailable”

“…The need for extensive surgical dissection, need for preoperative venography, need for fasciotomy (w10%), risk of subsequent tibial-popliteal venous thrombosis (w10%), and being less familiar with the technique and the criteria for optimal patientvein selection are all associated to the low popularity of peripheral bypasses using FPVs. 3,4 Available preliminary results on use of FPVs may be encouraging, but we lack comparative studies, with the exception of the randomized trial by Shulman et al 5 comparing saphenous vein against FPVs for primary popliteal bypasses. They concluded that both conduits have similar patency and minimal morbidity.…”

“…Increasing experience and, we are sure, entering the "modern era" of FPB, were accompanied by increasingly better results, culminating in a 1991 report of significant primary and assisted primary patency rates of 84% and 91% at 5 years in 93 grafts. 3 Our early reports of inconsequential morbidity and saphenousequivalent patency were greeted with virtually unanimous disbelief. If Ali et al 4 had not used FPVs in complex aortic problems, our experience with their function and expendability might have remained unbelieved, unconfirmed, and essentially lost.We were confident FPV was expendable.…”