title: Outcomes of complex femorodistal sequential autologous vein and biologic prosthesis composite bypass grafts.
abstract: OBJECTIVE
  Femorodistal autologous vein bypass proves to be the preferred surgical therapy for long arterial occlusions and provides excellent early and long-term results in critical lower limb ischemia. Whenever vein length was insufficient and two distal outflow arteries were present, a sequential composite bypass configuration was chosen with human umbilical vein (HUV) or ovine collagen prosthesis (Omniflow II; Bio Nova International Pty Ltd, North Melbourne, Australia) as the proximal prosthetic part of the bypass. Single-center experience with this technique regarding limb salvage, graft function, secondary reinterventions, and biodegeneration is presented.
  
  
  METHODS
  Between January 1998 and January 2009, 122 consecutive sequential composite bypass operations were performed on 116 patients for short-distance claudication (2), chronic critical ischemia (117), or acute ischemia (3) in the absence of sufficient autologous vein length. HUV was used in 90 cases and Omniflow II in 32 cases. Grafts were followed by duplex scan supplemented by angiography in case of recurrent ischemia with prospective documentation of follow-up data in a computerized vascular database. Retrospective analysis of graft patency, limb salvage, and aneurysmal degeneration of the biologic prosthesis was performed.
  
  
  RESULTS
  Mean follow-up was 59 ± 45.5 months (range, 1-161 months). The 30-day mortality was 4.1%. Early postoperative complete or partial bypass thrombosis developed in 16% (20 cases) and required successful revision in 16 cases. During follow-up, 30 complete and 12 partial bypass occlusions occurred, necessitating selective surgical or interventional revision. Primary, primary assisted, and secondary patency rates and the limb salvage rate were 48%, 62%, 71%, and 87%, respectively, after 5 years and 26%, 46%, 54%, and 77%, respectively, after 10 years for all bypasses. Late biodegeneration of HUV prostheses was detected in four instances.
  
  
  CONCLUSIONS
  Late graft patency and limb salvage were good. These factors, combined with a tolerable rate of late aneurysmal degeneration, justify the use of biologic vascular conduits and autologous vein for complex femorodistal reconstructions.
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, Johannes Gutenberg University School of Medicine, Mainz, Germany. Electronic address: neufang@uni-mainz.de.
authors.forename: Achim
authors.initials: A
authors.lastname: Neufang
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, Johannes Gutenberg University School of Medicine, Mainz, Germany.
authors.forename: Bernhard
authors.initials: B
authors.lastname: Dorweiler
authors.affiliation: Department of Cardiology and Angiology, Johannes Gutenberg University School of Medicine, Mainz, Germany.
authors.forename: Christine
authors.initials: C
authors.lastname: Espinola-Klein
authors.affiliation: Department of Cardiology and Angiology, Johannes Gutenberg University School of Medicine, Mainz, Germany.
authors.forename: Savvas
authors.initials: S
authors.lastname: Savvidis
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, Johannes Gutenberg University School of Medicine, Mainz, Germany.
authors.forename: Marco
authors.initials: M
authors.lastname: Doemland
authors.affiliation: Department of Radiology, Johannes Gutenberg University School of Medicine, Mainz, Germany.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Schotten
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, Johannes Gutenberg University School of Medicine, Mainz, Germany.
authors.forename: Christian Friedrich
authors.initials: CF
authors.lastname: Vahl
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000818:Animals; D064592:Autografts; D001705:Bioprosthesis; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D005260:Female; D005263:Femoral Artery / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D064593:Heterografts; D006801:Humans; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D011474:Prosthesis Design; D011859:Radiography; D012189:Retrospective Studies; D012307:Risk Factors; D012756:Sheep; D013997:Time Factors; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex; D014471:Umbilical Veins / Q000637:transplantation*; D014654:Vascular Patency