Long-term results of venous bypass for lower extremity arteries with selective short segment prosthetic reinforcement of varicose dilatations.

摘要

The long-term benefit of venous bypass has been clearly demonstrated, but procedure feasibility is contingent upon availability of a suitable vein. In this study, we evaluated the outcome of venous bypasses performed by the first author using veins presenting dilatations that were selectively reinforced with a short prosthesis. The purpose was to answer three questions. First, should ectasis be reduced before reinforcement? Second, do hyperplasia and stenosis develop in reinforced zones? Third, do dilatation and rupture develop in unreinforced zones? Twelve patients, including 10 men and 2 women ranging in age from 36 to 77 years (median 68), underwent bypass for peripheral artery disease in seven cases, popliteal aneurysm in four, and prosthetic rupture in one. Ten patients had poor distal runoff. The bypass was femoral-to-popliteal in eight cases, femoral-to-infrapopliteal in three, and popliteal-to-popliteal in one. The graft was reversed in nine cases and ex situ devalvulated in three. The number of prosthetic reinforcements used was one in two cases, two in three cases, three in six cases, and four in one case. All but one prosthetic reinforcement were made of polytetrafluoroethylene (PTFE). Bypass occlusion was observed in two cases, including one case observed in the early postoperative period after bypass for limb salvage in a young man in whom distal runoff was limited to a few collaterals and one case that occurred 4 years after a repeat bypass procedure. The other 10 bypasses remained patent throughout follow-up, which varied from 1 to 11 years (median 4). There were three deaths during follow-up. Doppler ultrasound revealed no stenosis in the reinforced zones and no dilatation in the unreinforced zones but demonstrated progressive deterioration of the runoff in 50% of cases. At the last follow-up examination, two bypasses were patent despite poor runoff. Although the number of patients in this series was small, the outcome of venous bypass using reinforced vein grafts appeared clearly better than outcomes of prosthetic bypass reported in the literature. Reinforcement can be easily achieved using a short, thin-walled PTFE prosthesis adjusted to the proper diameter by gentle dilatation using forceps. Unlike most authors, we do not recommend reducing dilatation by resection or oversewing. Reinforced zones did not develop stenosis and unreinforced intermediate zones showed little or no dilatation and no risk of rupture.