Long Term Outcome of Femoropopliteal Bypass for Claudication and by MikeJenny



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
Ishikawa, Japan

           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: koba@med.nagoya-u.ac.jp
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.
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)
                                                                   Critical Ischemia
                                                                                                 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
 Patency Rate

                                                       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
                 0.2                   47.8%
                                                                                                 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,
 Patency Rate

                                                                                                 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%,
                 1.0       82.8%
                                 77.2%                                                           compared to 63.1%, 46.3% and 23.9%, respectively,
                 0.8                                                                             in BK (Figure 2). Comparison of the patency rates
 Survival Rate

                                                        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

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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

                                                                      Survival Rate
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
                                                                    Survival Rate

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
                                                                      Survival Rate

also reveals IHD to be one of the most significant risk                                                                      53.1%
                                                                                      0.6 83.4%
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
underwent FP bypass surgery, despite all patients who                                in the operating theatre. Eur J Vasc Endovasc Surg
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
                                                                                     surgical treatment for intermittent claudication. J Vasc Surg.
What is the best conduit for AK or BK bypass                                         1996;24:65–73.
surgery? According to our study, no statistical                                 7.   AbuRahma AF, Robinson PA, Holt SM. Prospective controlled
differences in patency rates were recognized among                                   study of polytetrafluoroethylene versus saphenous vein in claudicant
graft materials in either AK or BK bypass surgery.                                   patients with bilateral above knee femoropopliteal bypasses. Surgery
These results were surprising as it was thought that
greater saphenous vein (GSV) graft must be the                                  8.   Prendiville EJ, Yeager A, O’Donnel TF Jr, Coleman JC,
                                                                                     Jaworek A, Callow AD, et al. Long-term results with the
preferred material to other prosthetic grafts for BK                                 above-knee popliteal expanded polytetrafluoroethylene graft.
revascularization. Dacron graft was not worse than the                               J Vasc Surg 1990;11:517–24.
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.
prosthetic graft for above 2nd portion of popliteal artery                          Euro J Vasc Endovasc Surg 1995;10:220–5.
and choose autogenous GSV for distal BK system at                               12. Archie JP Jr. Femoropopliteal bypass with either adequate ipsilateral
                                                                                    reversed saphenous vein or obligatory polytetrafluoroethylene. Ann
first. One reason is that, even if coronary bypass grafting                          Vasc Surg 1994;8:475–84.
is mandatory prior to the FP bypass surgery, we do                              13. O’Donnell TF Jr, Farber SP, Richmand DM, Deterling RA,
use not GSV graft, but arterial graft, e.g. radial artery,                          Callow AD. Above-knee polytetrafluoroethylene femoropopliteal
internal thoracic artery, for coronary revascularization                            bypass graft: is it a reasonable alternative to the below-knee
                                                                                    reversed autogenous vein graft? Surgery 1983;94:26–31.
in recent times. Another reason is that distal bypass in
the future could be difficult after GSV has already used                         14. Bennion RS, Williams RA, Stabile BE, Fox MA, Owens ML,
                                                                                    Willson SE. Patency of autogenous saphenous vein versus
for AK bypass surgery.                                                              polytetrafluoroethylene grafts in femoropopliteal bypass for
                                                                                    advanced ischemia of the extremity. Surg Gynecol Obstet
In conclusion, AK bypass surgery should be offered                                  1985;160:239–42.
only to the patients with disabling claudication and                            15. Hiatt WR, Regensteiner JG, Hargarten ME, Wolfel EE, Brass EP.
                                                                                    Benefits of exercise conditioning for patients with peripheral arterial
critical ischemia who have their quality of life much                               disease. Circulation 1990;81:602–9.
limited, though AK bypass surgery could be advocated                            16. Stephenson JM, Kenny S, Stevens LK, Fuller JH, Lee E. Proteinuria
as a safe and durable operation based on our study.                                 and mortality in diabetes: the WHO Multinational Study of Vascular
However, BK bypass should be carefully considered                                   Disease in Diabetes. Diabet Med 1995;12:149–55.
for the claudicant and might be recommended for limb                            17. Kobayashi M, Kurose K, Kobata T, Hida K, Shikata H,
salvage procedures.                                                                 Sakamoto S, et al. Long-term Results of Arterial Reconstruction
                                                                                    for Intermittent Claudication in Patients with Arteriosclerosis
                                                                                    Obliterans. J Jpn Coll Angiol 2001:41;321–5.
REFERENCES                                                                      18. Kallero KS, Bergqvist D, Cederholm C, Jonsson K,
1.   Regensteiner JG, Steiner JF, Hiatt WR. Exercise training                       Olsson PO, Takolander R. Late mortality and morbidity after
     improves functional status in patients with peripheral arterial                arterial reconstruction: the influence of arteriosclerosis in popliteal
     disease. J Vasc Surg 1996;23:104–15.                                           artery trifurcation. J Vasc Surg 1985;2:541–6.
2.   Patterson RB, Pinto B, Marcus B, Colucci A, Braun T, Roberts M.            19. Hurwitz RL, Johnson JM, Hufnagel CE. Femoropopliteal bypass
     Value of a supervised exercise program for the therapy of arterial             using externally supported polytetrafluoroethyrene grafts. Early
     claudication. J Vasc Surg 1997;25:312–9.                                       results in a multiinstitutional study. Am J Surg 1985;150:574–6.
3.   Matsi PJ, Manninen HI, Vanninen RL, Suhonen MT, Oksala I,                  20. Matsubara J, Nagasue M, Tsuchishima S, Nakatani B, Shimizu T.
     Laakso M, et al. Femoropopliteal angioplasty in patients with                  Clinical results of femoropopliteal bypass using externally supported
     claudication: primary and secondary patency in 140 limbs with                  (EXS) Dacron grafts: with a comparison of above- and below-knee
     1–3 year follow-up. Radiology 1994;191:727–33.                                 anastomosis. J Cardiovasc Surg 1990;31:731–4.

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