Reoperative lower extremity revascularization with cadaver vein for limb salvage.
We evaluated our experience using cryopreserved cadaver vein allografts (CVGs) for infrageniculate revascularization in patients with a history of failed bypass or no suitable autogenous vein. Records of all patients who underwent lower extremity revascularization with CVG for critical limb ischemia were reviewed. Patient demographics, vessel treated, and postoperative course were analyzed. Patients who had a redo cadaver vein bypass were compared to those with a first-time cadaver vein bypass. Cumulative patency rates, limb salvage, mortality, and factors associated with outcomes were determined using the Kaplan-Meier method with Cox proportional hazards. Between January 2000 and December 2006, 66 CVGs were done in 56 patients out of 1,726 total bypasses. There were 36 men and 20 women, and the mean age was 71.67 +/- 10.50 years. Mean follow-up was 12.12 +/- 14.16 months. Seventy-eight percent of patients had previous bypasses, and 50% of all failed bypasses were failed expanded polytetrafluoroethylene bypasses. Operative indications were tissue loss (73%) and ischemic rest pain (27%). The mean preoperative ankle-brachial index was 0.43 +/- 0.16, and this increased to 0.89 +/- 0.18 at 30 days (p = 0.001). Procedure-related complications included graft infection (3, 4%), graft thrombosis (3, 4%), pseudoaneurysm (3, 4%), and bleeding (2, 3%). Cumulative 1-year primary, primary assisted, secondary patencies, limb salvage, and survival rates with confidence intervals were 0.19 (0.10-0.36), 0.29 (0.18-0.47), 0.42 (0.29-0.60), 0.73 (0.62-0.86), and 0.77 (0.65-0.90). Reoperative procedures fared the same as primary procedures. Multivariable analysis showed that predictors for increased risk of secondary patency loss were age >70 (hazard ratio [HR] = 3.13, p = 0.009) and patients with secondary revascularization (HR = 3.36, p = 0.015). Older patients (HR = 2.92, p = 0.042) and those with renal insufficiency (HR = 2.92, p = 0.019) were at increased risk of mortality. CVG remains an option for reoperative lower limb revascularization for limb salvage if there is no autogenous vein available. However, patency rates are poor, and patients older than 70 are more likely to have inferior outcomes.
Bannazadeh
Mohsen
M
Department of Vascular Surgery, The Cleveland Clinic Foundation, Cleveland, OH.
Sarac
Timur P
TP
Bena
James
J
Srivastava
Sunita
S
Ouriel
Kenneth
K
Clair
Daniel
D
D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000783:Aneurysm / Q000209:etiology; D000842:Ankle / Q000098:blood supply; D001794:Blood Pressure; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation; D001916:Brachial Artery / Q000503:physiopathology; D002102:Cadaver; D016638:Critical Illness; D015925:Cryopreservation; D005260:Female; D006083:Graft Occlusion, Vascular / Q000209:etiology; D006801:Humans; D007511:Ischemia / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D011138:Polytetrafluoroethylene; D016016:Proportional Hazards Models; D011474:Prosthesis Design; D016459:Prosthesis-Related Infections / Q000209:etiology; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013927:Thrombosis / Q000209:etiology; D013997:Time Factors; D014184:Transplantation, Homologous; D017211:Treatment Failure; D014654:Vascular Patency; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D014680:Veins / Q000637:transplantation*
D011138:Polytetrafluoroethylene