title: An expanded series of distal bypass using the distal vein patch technique to improve prosthetic graft performance in critical limb ischemia.
abstract: OBJECTIVE
  The endovascular first approach has led to increasing complexity for surgical bypass especially in those patients without autogenous conduit. The use of vein interposed at the distal anastomosis has been reported to improve the results of prosthetic grafts. This series expands our initial experience with the distal vein patch technique (DVP) reporting a larger cohort with enhanced follow-up.
  
  
  METHODS
  A retrospective review of prospectively collected data was performed for distal bypasses from July 1995 to November 2008.
  
  
  METHODS
  1296 tibial bypasses were performed with 270 using the DVP technique. Patient demographics included; 49% diabetes, 20% chronic renal failure, 33% prior failed bypass. Indications for revascularization were claudication (9.3%), rest pain (27.8%), gangrene (22.2%), and non-healing ulceration (40.7%). Lack of vein for the bypass conduit resulted from previous failed grafts (55%), coronary bypass (18%), poor quality vein (23%), or prior vein stripping (8%). Follow-up ranged from 1 to 48 months with graft surveillance by pulse exam, ABI, and Duplex ultrasound. Primary patency and limb salvage ± SE were determined by Kaplan-Meier life-table analysis using Rutherford criteria.
  
  
  RESULTS
  Bypasses originated from the external iliac (29%), CFA (55%), SFA (13%), popliteal (1%), and prior grafts (2%). Recipient arteries were below knee popliteal (6%), anterior tibial (25%), posterior tibial (30%), and peroneal (39%). Perioperative graft failure occurred in 13 cases with a total of 41 graft failures leading to 39 major amputations. Primary graft patency from one to four years was 79.8%, 75.6% 65.9%, and 51.2%. Corresponding limb salvage rates were 80.6%, 78.0%, 75.7%, and 67.5%.
  
  
  CONCLUSIONS
  Although not addressed by a randomized trial, we believe this expanded series is a more accurate reflection of expected results confirming that the DVP bypass leads to reasonable long-term results for those challenging patients that require prosthetic distal bypass for lower extremity revascularization.
authors.affiliation: Department of Surgery, MFA at George Washington University, Washington, DC 20037, USA. rneville@mfa.gwu.edu
authors.forename: R F
authors.initials: RF
authors.lastname: Neville
authors.forename: M
authors.initials: M
authors.lastname: Lidsky
authors.forename: A
authors.initials: A
authors.lastname: Capone
authors.forename: J
authors.initials: J
authors.lastname: Babrowicz
authors.forename: R
authors.initials: R
authors.lastname: Rahbar
authors.forename: A N
authors.initials: AN
authors.lastname: Sidawy
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D055109:Ankle Brachial Index; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000295:instrumentation; D016638:Critical Illness; D004219:District of Columbia; D005260:Female; D006083:Graft Occlusion, Vascular / Q000209:etiology / Q000503:physiopathology / Q000601:surgery; D006801:Humans; D007511:Ischemia / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D011474:Prosthesis Design; D011475:Prosthesis Failure; D011859:Radiography; D012086:Reoperation; D012189:Retrospective Studies; D016909:Tibial Arteries / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D013997:Time Factors; D014182:Transplantation, Autologous; D016896:Treatment Outcome; D018608:Ultrasonography, Doppler; D014654:Vascular Patency; D014680:Veins / Q000637:transplantation*