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

Abstract

Regarding "Autologous alternative veins may not provide better outcomes than prosthetic conduits for below-knee bypass when great saphenous vein is unavailable"We read the report on autologous alternative veins 1 for belowknee (B-K) bypass with great admiration and a healthy serving of nostalgia.It is generally agreed there is no good substitute for the saphenous vein (SV) in tibial and pedal bypasses. What particularly interested us, however, were the 44 B-K femoropopliteal bypasses (FPBs) where autologous alternative veins or prostheses were necessary. Between one-half and two-thirds of those FPBs appeared to be primary operations. The purpose of this letter is to call attention to the availability and potential of femoropopliteal veins (FPVs) for B-K FPBs when SV is unavailable.From 1981 to 1992, a series of reports described our use of FPVs as primary FPB grafts. A randomized comparative study 2 in 1987 showed FPV patency was comparable to SV at 3 years, with no significant 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. In the 1980s it was universally believed, with no evidentiary basis, that FPVs could not be resected without incurring excessive limb morbidity. Overlooked was that in the late 1940s, FPV ligation was frequently performed for the treatment or prophylaxis of thrombophlebitis. In one-third of ligations, the entire FPV thrombosed, 5 with no late morbidity ever reported.The safety, durability, and unique function of SFVs in infected fields has been demonstrated in a myriad of surgical situations. In 2002, Meneghetti et al 6 reported 20 grafts used for crossover femoral bypass, with 12 in infected fields. Mean follow-up was 24 months, and primary patency was 100%.The feasibility of FPV use for B-K FPBs has been questioned. In our 145 FPV FPBs, 77 were B-K. Origins were 64 distal (superficial femoral artery, 52%; deep femoral artery [DFA], 31%) and 13 common femoral (17%). By incorporating the entire popliteal vein and, in 4 instances, the tibioperoneal trunk, adequate vein length was achieved in 76 of 77 limbs. One proximal DFA endarterectomy and patch graft, with distal DFA origin, was necessary. The significant point: 76 of 77 B-K FPV FPBs were done without an adjunctive procedure.Using FPVs for primary FPBs has not "caught on." Our reports have been neither refuted nor confirmed, although FPV use in other areas provides tangential confirmation. A graft shown to be saphenous-equivalent, infection resistant, and free of late morbidity is simply n...