Long-term experience in autologous in vitro endothelialization of infrainguinal ePTFE grafts.
OBJECTIVE
Based on a previous randomized study showing significantly superior patency rates for in vitro endothelialized expanded polytetrafluoroethylene (ePTFE) grafts we investigated whether it was feasible for a nontertiary institution to offer autologous in vitro endothelialization to all elective infrainguinal bypass patients who had no suitable saphenous vein available.


METHODS
Over a period of 15 years, 310 out of 318 consecutive nonacute patients (age 64.7 +/- 8.6) received 341 endothelialized ePTFE grafts (308 femoropopliteal: 153 above knee [AK] and 155 below knee [BK] and 33 femorodistal). Autologous endothelial cells were harvested from short segments (3.9 +/- 1.1 cm) of subcutaneous veins (80% cephalic, 11% basilic, 2% external jugular, and 7% saphenous) and grown to mass cultures within 18.9 +/- 4.5 days before being confluently lined onto fibrin glue-coated ePTFE grafts. The graft diameter was 6 mm (64%) or 7 mm (36%). The overall procedure-related delay for graft implantation was 27.6 + 7.8 days. Growth failure prevented 2.5% of patients from receiving an endothelialized graft. The mean observation period was 9.6 years. Primary patencies were obtained from Kaplan-Meier survivorship functions. Explants for morphological analysis were obtained from eight patients.


RESULTS
The overall primary patency rate of femoropopliteal grafts was 69% at 5 years (68% [AK] vs 71% [BK]) and 61% at 10 years (59% [AK] vs 64% [BK]). Primary patency of 7 mm vs 6 mm grafts was 78%/62% at 5 years and 71%/55% at 10 years. The difference between the two groups was statistically significant (log rank test P = .023; Breslow test P = .017). Stage I vs II/III patients showed 5-year patencies of 67% vs 73% (N.S.) and 10-year patencies of 61%% vs 53% (N.S.). The primary patency of femorodistal grafts was 52% at 5 years and 36% at 10 years. The limb salvage rate was 94% (fempop) vs 86% (femdistal) at 5 years and 89% vs 71% at 10 years. All retrieved samples showed the presence of an endothelium after 38.9 +/- 17.8 months.


CONCLUSIONS
Autologous in vitro endothelialization was shown to be a feasible routine procedure at a nontertiary hospital. Explants confirmed the presence of an endothelium years after implantation while the primary patency in the particularly challenging subgroup of patients without a suitable saphenous vein resembles that of vein grafts.
Deutsch
Manfred
M
Department of Cardiovascular and Thoracic Surgery, Hospital Hietzing, Vienna, Austria.
Meinhart
Johann
J
Zilla
Peter
P
Howanietz
Norbert
N
Gorlitzer
Michael
M
Froeschl
Alexander
A
Stuempflen
Andreas
A
Bezuidenhout
Deon
D
Grabenwoeger
Martin
M
D000368:Aged; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation*; D018929:Cell Culture Techniques; D049109:Cell Proliferation; D042783:Endothelial Cells / Q000637:transplantation*; D005240:Feasibility Studies; D005260:Female; D015718:Fibrin Tissue Adhesive / Q000627:therapeutic use; D006083:Graft Occlusion, Vascular / Q000209:etiology; D006801:Humans; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D058729:Peripheral Arterial Disease / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D011138:Polytetrafluoroethylene; D011446:Prospective Studies; D011474:Prosthesis Design; D018570:Risk Assessment; D013997:Time Factors; D014014:Tissue Adhesives / Q000627:therapeutic use; D054457:Tissue Scaffolds; D014182:Transplantation, Autologous; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex; D014654:Vascular Patency
D015718:Fibrin Tissue Adhesive; D014014:Tissue Adhesives; D011138:Polytetrafluoroethylene