Society for Clinical Vascular Surgery
December 17, 2007

DISTAL VEIN PATCH FOR TIBIAL BYPASS; A DURABLE OPTION FOR REVASCULARIZATION IN THE LIMB SALVAGE PATIENT

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Michael Lidsky, BS, John Steinberg, DPM, David Deaton, MD, James Laredo, MD, PhD, Joe Babrowicz, MD, Christopher E. Attinger, MD, Richard F. Neville, MD.
Georgetown University, Washington, DC, USA.

Objective: Tibial artery bypass for limb threatening ischemia is often required despite the lack of adequate autogenous conduit. Having reported on our initial experience using polytetrafluoroetheylene and a distal vein patch (DVP), this series addresses the longterm results of the DVP technique in a large population of patients with limb threatening ischemia.
Methods: A retrospective review was performed from July 1994 to July 2006 with 705 tibial bypasses performed. 198 bypasses used DVP in patients (n=182) with critical limb ischemia. Patient demographics included; 99 men, 83 women, 104 diabetics (57.1%), 46 chronic renal failure (25.3%), and 62 after previous revascularization (31.3%). Indications for bypass were rest pain (n=58,29.3%) or tissue loss (n=140,70.7%). Follow-up ranged from 1 to 48 months. Graft function was evaluated by exam, ABI, and Duplex surveillance. Primary patency and limb salvage ± SE were determined by life-table analysis using Rutherford criteria.
Results: Bypasses originated from the external iliac (n=58,29.3%), CFA (110,55.6%), SFA (26,13.1%), popliteal (1,0.5%), and prior grafts (3,1.5%). The recipient arteries were AT (54,27.2%), PT (64,32.3%), and peroneal (80,40.4%). Perioperative graft failure occurred in 10 cases with a total of 31 graft failures leading to 29 major amputations. Primary patency and limb salvage rates are noted below.

6 month12 months24 months36 months48 months
Primary patency91.3% + 2.0%
N = 178		79.8% + 3.4%
N = 108		75.6% + 4.4%
N = 71		65.9% + 5.9%
N = 40		51.2% + 8.4%
N = 18
Limb Salvage90.7% + 2.1%
N = 178		80.6% + 3.2%
N = 110		78.0% + 4.0%
N = 76		75.7% + 5.3%
N = 45		67.5% + 8.0%
N = 23

Conclusion: Durable patency and limb salvage can be achieved using the DVP technique in patients requiring tibial bypass without adequate vein. Although not yet addressed by a randomized trial, we believe the DVP bypass leads to reasonable longterm results for those challenging patients without vein that require tibial bypass to save the limb.
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