Long Term Outcome of Femoropopliteal
Bypass for Claudication and Critical
Masayoshi Kobayashi, MD, Kenji Hida, MD, Hiroo Shikata, MD,
Shigeru Sakamoto, MD, Junichi Matsubara, MD
Department of Thoracic and Cardiovascular Surgery
Kanazawa Medical University
We performed 167 femoropopliteal bypass surgeries in 151 patients (95 patients
underwent above-knee bypass and 56 below-knee bypass) from December 1985 to
December 2000 with the use of prosthetic graft or autologous vein graft. We compared
primary patency rates between age, sex, graft material, distal anastomotic site and
severity of ischemia, considering their survival rates to elucidate the long-term outcome
of above-knee and below-knee femoropopliteal bypass. The 10 year patency rate
for above-knee bypass was 47.4%, compared to 36.9% for below-knee ( p < 0.01).
Better results were found after bypass surgery for claudicants than for critical
ischemia ( p < 0.05). With regard to graft material and age categories, there were
unexpectedly no statistical differences in either above-knee or below-knee anastomosis.
The survival rate at 10 years in claudicants was 51.2%, compared to 15.9% with
critical ischemia ( p < 0.01). Mortality was much inﬂuenced by ischemic heart
disease ( p < 0.002) and the age of patient ( p < 0.05). The results after above-knee
bypass had comparable patency, whereas the results after below-knee bypass were
disappointing. Below-knee arterial reconstruction for claudicants should be carefully
considered and might be recommended only to patients with critical ischemia.
(Asian Cardiovasc Thorac Ann 2004;12:208–12)
INTRODUCTION equivalent to the use of autologous vein graft,7-10 and
Both operative indications and procedures to treat because others advocated the use of autologous vein both
intermittent claudication caused by arteriosclerosis for above and below knee (BK) arterial reconstruction.11,12
obliterans have been controversial. There are many Otherwise, for infrageniculate arterial bypass, the opinion
options, however the criteria for conservative therapy, that autologous vein is the best conduit is widely
endovascular treatment, or surgical treatment have not yet accepted.13,14 However, patients with arteriosclerosis
been established. Some reports recommend conservative obliterans (ASO) can suffer from potential ischemic
therapy1,2 whilst others recommend surgical treatment.3-6 heart disease (IHD) concomitantly and they need to
Even in the case of bypass surgery, the best choice of undergo some interventional coronary angioplasty and/
conduit for above-knee (AK) femoropopliteal (FP) bypass or coronary bypass surgery. Their autologous saphenous
has not been established yet. This is due to some authors vein might be implanted at cardiac surgery prior to
reporting results with the use of prosthetic graft being lower limb surgery. In such cases we should consider
For reprint information contact:
Masayoshi Kobayashi, MD Tel: 81 52 744 2224 Fax: 81 52 744 2226 Email: email@example.com
Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku,
Nagoya 466–8550, Japan.
ASIAN CARDIOVASCULAR & THORACIC ANNALS 208 2004, VOL. 12, NO. 3
Kobayashi Long-term Outcome Of AK And BK Bypass
Table 1. Patient Characteristics
Variable All (n = 151) AK (n = 97) BK (n = 54) Claudication (n = 98) Critical Ischemia (n = 53)
Age (years) 68.5 ± 7.8 68.9 ± 7.7 67.7 ± 8.1 68.5 ± 7.5 68.5 ± 8.3
DM (%) 35.3 41.1 25.0 34.9 36.1
IHD (%) 33.5 29.9 40.0 31.1 37.7
Smoker (%) 72.5 70.1 76.7 74.5 68.9
HT (%) 63.5 65.4 60.0 62.3 65.6
Age = 70 years 45.5 45.8 45.0 55.7 52.5
DM = diabetes mellitus; IHD = ischemic heart disease; HT = hypertension.
Table 2. Graft Materials Implanted at Bypass Surgery
All (n = 167) AK (n = 107) BK (n = 60) Claudication (n = 108) Critical Ischemia (n = 59)
Dacron (%) 85.0 88.8 78.3 87.7 80.3
PTFE (%) 4.2 5.6 1.7 3.8 4.9
GSV (%) 10.8 5.6 20.0 8.5 14.8
PTFE = polytetraﬂuoroethylene; GSV = greater saphenous vein.
an alternative conduit for below knee revascularization disease was usually considered and routine cardiac
without appropriate autologous saphenous vein. Basically, ultrasound sonography and cardiac scintigraphy have
we use prosthetic grafts for above knee bypass and use been performed since the 1990’s. Coronary angiography
either saphenous veins or prosthetic grafts (Dacron or was considered necessary based on scintigram results.
PTFE) for below knee bypass. Postoperative antiplatelet drugs or coumarin potassium
were given daily to all patients after bypass surgery.
The purpose of this study was to review the results of
primary above or below knee bypass surgery considering Postoperative graft surveillance was studied at our
severity of ischemia, concomitant diseases and patient outpatient clinic with ABPI and duplex scanning. Graft
survival rates. occlusion was diagnosed on the basis of ABPI decrease,
duplex scanning ﬁndings or patient’s symptoms.
PATIENTS AND METHODS
One hundred and sixty seven FP bypass surgeries Operative mortality and postoperative complications were
performed on 151 patients from December 1985 to considered when they occurred within 30 days of the
December 2000 at our institution were reviewed. AK operation. Primary patency was deﬁned as uninterrupted
bypass was reconstructed in 107 (64.1%) limbs and BK patency of the graft without any intervention. Occluded
in 60 (35.9%) limbs. These patients were characterized grafts, which were not revasculized but replaced with
by sex, age, risk factors, implanted graft materials and new grafts, were considered as occluded. With regard to
manifestation of lower limb ischemia. Severity of limb amputation, limited toe amputation was not considered a
ischemia was divided into two categories: intermittent failure, however, at the ankle or above was considered
claudication and critical ischemia. Critical ischemia was limb loss.
deﬁned as rest pain or gangrene. Furthermore, two age
groups were deﬁned, 70 years and older, the other The data was analyzed statistically using chi-square test
less than 70 years, at time of surgery. Graft materials and Student’s t test for group comparison. Kaplan-Meier
implanted were Dacron, PTFE and autogenous saphenous survival analysis was applied to calculate the cumulative
vein. In terms of bypass counduit numbers, Dacron graft graft patency and survival rates with long-rank test.
was implanted in 142 (85.0%) limbs, PTFE graft in
7 (4.0%)limbs, and saphenous vein in 18 (11.0%) limbs RESULTS
(13 reversed vein, 5 “in situ” ). Pre and postoperative The mean and median follow-up periods were 51.3 months
ankle brachial pressure index (ABPI) was measured and and 47 months, respectively (range, 1 to 159 months).
arteriography was performed regularly. Ischemic heart Twenty two patients were lost during the follow-up
2004, VOL. 12, NO. 3 209 ASIAN CARDIOVASCULAR & THORACIC ANNALS
Long-term Outcome Of AK And BK Bypass Kobayashi
Claudication period. The mean ± SD age at operation of all the
(n = 106)
patients was 68.5 ± 7.78 years (range, 46 to 87).
(n = 61) Additionally, the mean age of patients who underwent
12ms 24ms 60ms 120ms p < 0.05
AK and BK femoropopliteal bypass surgeries was
1.0 81.6% 68.9 and 67.6, respectively, and the mean age of the
77.8% 66.5% patients who had intermittent claudication and critical
47.4% ischemia was 68.5 and 68.5, respectively. There were
0.6 no statistical differences in terms of age. There were
0.4 56.7% 135 (89.5%) men, and 16 (10.5%) women in the
50.1% study. Of the 151 patients, 59 (35.3%) had diabetes
mellitus (DM), 56 (33.5%) patients had ischemic heart
0 disease (IHD), 106 (63.5%) had hypertension (HT) and
121 (72.5%) were smokers. The number of patients
0 20 40 60 80 100 120 140 160
who had risk factors are summarized in Table 1. The
Figure 1. Cumulative primary patency for both claudication and
number of patients who underwent AK bypass surgery
critical ischemia groups, calculated by Kaplan-Meier method. was signiﬁcantly more than those who underwent BK
Signiﬁcant difference was recognized. bypass surgery among DM patients ( p < 0.05).
AK (n = 107)
BK (n = 60) There was a total of 61 graft occlusion cases during
follow-up, of which 28 cases were AK bypass,
12ms 24ms 60ms 120ms p < 0.01 and 33 BK bypass. Early graft failure, which occurred
1.0 79.1% within 30 days of operation, counted 8 cases in the
75.2% AK group and 3 in the BK group. In the AK group,
0.8 7 of 8 cases were implanted with a Dacron graft,
and 1 case with a vein graft. In the BK group, 1 of
the 3 cases was Dacron graft and 2 vein graft. Four
early graft occlusion cases in the AK group were
46.3% conservatively observed and 2 underwent immediate
thrombectomy, with the other 2 undergoing late bypass
0 operation. In BK cases, revisional bypass surgery was
done for 1 case and conservative therapy for 2 cases.
0 20 40 60 80 100 120 140 160
Only 1 case required subsequent amputation in BK cases
Figure 2. Cumulative primary patency for both AK and
despite early alternative revisional surgery because of
BK groups. There was signiﬁcant difference between these progression of an infected foot ulcer. All these cases
groups. suffered from severe diabetes mellitus.
(n = 98) The patency rates at 1, 5 and 10 years in claudicants were
Critical Ischemia 81.6%, 66.5% and 47.4%, respectively. This compares
(n = 53) with 56.7% and 47.8% and 36.9%, respectively, in
12ms 24ms 60ms 120ms p < 0.01
critical ischemia cases (Figure 1). The rates at 1,
91.1% 5 and 10 years in AK were 79.1%, 69.1% and 58.6%,
77.2% compared to 63.1%, 46.3% and 23.9%, respectively,
0.8 in BK (Figure 2). Comparison of the patency rates
51.2% between claudicants and critical ischemic patients,
0.6 and also between AK and BK bypass, were statistically
73.6% signiﬁcant ( p < 0.05, p < 0.01, respectively). As for
53.9% graft materials, the patency rates at 1, 5 and 10 years
0.2 using prosthetic graft for AK were 81.3%, 69.3% and
15.9% 57.6%, respectively. The rates for BK were 73.7%, 50.6%
and 26.1%, respectively. For vein graft, the patency
0 20 40 60 80 100 120 140 160 180
rates at 1, 5 and 10 years for AK were 83.3%, 66.7%
and 66.7%, respectively, and 67.5%, 56.3% and 56.3%,
Figure 3. Cumulative survival rate for both claudication and respectively, for BK (Table 2). There was no signiﬁcant
critical ischemia groups, calculated by Kaplan-Meier method. difference between the prosthetic graft and vein graft.
Signiﬁcant difference was recognized. There were a total of four operative deaths; three
ASIAN CARDIOVASCULAR & THORACIC ANNALS 210 2004, VOL. 12, NO. 3
Kobayashi Long-term Outcome Of AK And BK Bypass
underwent AK bypass and one BK bypass. Three of AK (n = 97)
BK (n = 54)
these patients had life-threatening leg ischemia and were
12ms 24ms 60ms 120ms
already in poor condition on admission. One patient 87.1% N.S
had claudication and cause of death was uncertain. 83.6%
The survival rates at 1, 5 and 10 years in claudicants 1.0 74.1%
were 91.1%, 77.2% and 51.2%, respectively, compared 0.8
to 79.2%, 53.9% and 15.9%, respectively, in patients
with critical ischemia (Figure 3). The rates at 1, 5 and 0.6
10 years, characterized by distal anastomotic site, were 73.0%
87.1%, 60.0% and 39.0%, respectively, in AK and 59.5%
86.3%, 59.5% and 35.9%, respectively, in BK (Figure 4). 0.2
Obviously, patients under 70 survived longer than patients 35.9%
70 years old and over (Figure 5). Statistically signiﬁcant 0
differences were detected both in severity of ischemia
0 20 40 60 80 100 120 140 160 180
and age categories ( p < 0.01, p < 0.05, respectively), Month
however, no difference was detected in the survival rates Figure 4. Cumulative survival rate for both AK and BK groups.
between those who underwent AK and BK anastomosis. There was signiﬁcant difference between these groups.
Furthermore, only IHD affected mortality of the patients More than 70
among these risk factors (Figure 6) ( p < 0.002). years old
(n = 71)
12ms 24ms 60ms 120ms 69 or less
DISCUSSION 90.8% (n = 80)
The indications for femoropopliteal bypass in patients 1.0 80.7%
71.7% p < 0.05
with intermittent claudication are controversial and
universal acceptance has not been established. In the 0.8
western world, especially in the US, conservative therapy 0.6
may be the ﬁrst choice and reconstructive surgery is 81.8%
not recommended2,15 because claudication does not mean 0.4 64.5%
critical ischemia resulting in limb loss. Unless symptoms
improve with appropriate medication and/or exercise, 0.2
patients ﬁnd limitations in their activities. Daily life 19.6%
could be much improved after successful bypass surgery.
However, our study reveals that most patients with lower 0 20 40 60 80 100 120 140 160 180
limb peripheral arterial disease simultaneously had other Month
vascular diseases, such as coronary artery disease and Figure 5. Cumulative survival rate for age category groups,
cerebral vascular disease. Therefore, bypass surgery for calculated by Kaplan-Meier method. Signiﬁcant difference
was recognized between older than 70 years and 69 or less
intermittent claudication is not recommended without
appropriate estimation of the patient’s general condition.
From this point of view, the present data is reasonable IHD (−)
(n = 95)
in that only one operative death (uncertain reason) after 12ms 24ms 60ms 120ms IHD (+)
reconstructive surgery for intermittent claudication and 88.5% (n = 56)
only 3 death cases for severe critical ischemia occurred. 1.0 83.3% p < 0.002
IHD is the most common cause of fatal event among 78.5%
patients with peripheral arteriosclerosis,16 and our report 0.8
also reveals IHD to be one of the most signiﬁcant risk 53.1%
factors which greatly inﬂuences the mortality rate with
femoropopliteal occlusive disease. The reason for 0.4 71.0%
only one operative death after surgery for claudicants 46.3%
to date, we think, was that cardiac condition was 0.2
estimated routinely by means of ultrasonography and/ 13.6%
or scintigraphy. If necessary, interventional radiology
or coronary bypass surgery was performed prior to 0 20 40 60 80 100 120 140 160 180
bypass surgery.17 Fifteen patients underwent cardiac Month
revascularization prior to FP bypass surgery. DM is Figure 6. Cumulative survival rate for the patients with
a well recognized risk factor for death and for graft IHD and without IHD. Signiﬁcant difference was recognized
failure.16,18 It was surprising that DM inﬂuenced neither between these groups.
2004, VOL. 12, NO. 3 211 ASIAN CARDIOVASCULAR & THORACIC ANNALS
Long-term Outcome Of AK And BK Bypass Kobayashi
the mortality nor the graft patency of the patients who 4. O’Donohoe MK, Sultan S, Colgan MP, Moore DJ, Shanik GD.
Outcome of the ﬁrst 100 femoropopliteal angioplasties performed
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needed revisional BK bypass being diagnosed as having 1999;17:66–71.
diabetes mellitus with poor run-off. It was probable that 5. Kent KC, Donaldson MC, Attinger CE, Couch NP, Mannick JA,
the combination of DM and poor run-off might progress Whittemore AD. Femoropopliteal reconstruction for claudication.
peripheral arteriosclerosis and graft failure. The risk to life and limb. Arch Surg 1988;123:1196–8.
6. Zannetti S, L’Italien GJ, Cambria RP. Functional outcome after
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These results were surprising as it was thought that
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GSV conduit, unexpectedly. Our better patency rates, 9. Allen BT, Reilly JH, Rubin BG, Thompson RW, Anderson
especially with regard to BK bypass, were thought to CB, Flye MW, et al. Femoropopliteal bypass for claudication:
vein vs. PTFE. Ann Vasc Surg 1996;10:178–85.
be due to the lack of kinking and compressibility of the
10. Rosenthal D, Evans RD, McKinsey J, Seagraves MA, Lamis PA,
Dacron graft, the avoidance of clamps with the use of Clark MD, et al. Prosthetic above-knee femoropopliteal bypass
tourniquet, and to the policy of making a wide distal for intermittent claudication. J Cardiovasc Surg 1990;31:462–8.
anastomotic site ﬁrst (more than 2 cm).19,20 Despite 11. Wilson YG, Wyatt MG, Currie IC, Baird RN, Lamont PM.
obtaining this preferential result, currently we choose Preferential use of vein for above-knee femoropopliteal grafts.
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and choose autogenous GSV for distal BK system at 12. Archie JP Jr. Femoropopliteal bypass with either adequate ipsilateral
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reversed autogenous vein graft? Surgery 1983;94:26–31.
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Willson SE. Patency of autogenous saphenous vein versus
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Beneﬁts of exercise conditioning for patients with peripheral arterial
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as a safe and durable operation based on our study. and mortality in diabetes: the WHO Multinational Study of Vascular
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