title: Experience with a modified composite sequential bypass technique for limb-threatening ischemia.
abstract: BACKGROUND
  Composite sequential femoro-popliteal-distal bypass is a valuable option for treatment of critical limb ischemia when autogenous vein is limited and an isolated popliteal or distal arterial segment exists. We report a modified technique for composite sequential bypass and the results with its use over a 14-year period.
  
  
  METHODS
  Twenty-five modified composite sequential bypass procedures were performed on 24 patients to treat gangrene, ischemic ulceration, and severe rest pain. Vein grafts were anastomosed from blind popliteal or blind distal arterial segments above-knee (7) or below-knee (18) to a distal outflow vessel including the below-knee popliteal (1), posterior tibial (5), anterior tibial (7), or peroneal (12) artery. Polytetrafluoroethylene bypass grafts were then placed from a suitable inflow artery to the proximal hood of the vein graft.
  
  
  RESULTS
  Cumulative primary patency rates were 80% at 3 years, and 65% at 5 years. The limb-salvage rate was 85% at 4 years. Occlusion of the prosthetic segment with a patent distal vein segment was recognized in two patients who presented with less severe recurrent ischemia. Limb-salvage in these patients was achieved by a secondary prosthetic graft to the patent vein graft.
  
  
  CONCLUSIONS
  Our modified configuration of the prosthetic-vein anastomosis for composite sequential bypass is an alternative to the conventional procedure and may help preserve vein graft patency should the polytetrafluoroethylene graft thrombose.
authors.affiliation: Division of Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA.
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Gargiulo
authors.forename: Frank J
authors.initials: FJ
authors.lastname: Veith
authors.forename: David J
authors.initials: DJ
authors.lastname: O'Connor
authors.forename: Evan C
authors.initials: EC
authors.lastname: Lipsitz
authors.forename: William D
authors.initials: WD
authors.lastname: Suggs
authors.forename: Larry A
authors.initials: LA
authors.lastname: Scher
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation; D016638:Critical Illness; D005260:Female; D006083:Graft Occlusion, Vascular / Q000209:etiology / Q000601:surgery; D006801:Humans; D007511:Ischemia / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D011138:Polytetrafluoroethylene; D011474:Prosthesis Design; D012086:Reoperation; D012501:Saphenous Vein / Q000000981:diagnostic imaging / Q000637:transplantation*; D013997:Time Factors; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex; D014481:United States; D058017:Vascular Grafting / Q000009:adverse effects; D014654:Vascular Patency
chemical_list: D011138:Polytetrafluoroethylene