The fate of femoropopliteal and femorodistal bypass grafts in relation to intraoperative flow measurement: an analysis of 100 consecutive reconstructions for limb salvage.

Abstract

Adequacy of outflow is the key determinant for success in peripheral arterial reconstructions. In an attempt to obtain reliable information on this parameter, we developed a new concept: the outflow through the recipient arterial bed is measured perioperatively. For this purpose, the recipient artery is cannulated and perfused with a saline solution from an open reservoir for 1 minute with a pressure of 120 cm H2O. In a prospective study, the outcome of 100 femoropopliteal and femorodistal bypass procedures, all performed for unremitting rest pain, nonhealing ischemic ulcers, or gangrenous tissue loss, is analyzed according to this 1-minute flow rate. Six grafts occluded, and major amputations were unavoidable in three additional patients despite an open bypass. Eight of these crucial events occurred in the group with a flow rate less than 50 ml/min. Two of four Gore-Tex grafts in the low flow category failed within the first postoperative month. In contrast, only one of 24 vein bypasses occluded within the same observation period. All patients having a postoperative flow exceeding 100 ml/min had open grafts in the 2-year observation period. It is concluded that although a diminished outflow rate of less than 50 ml/min represents a high risk failure of reconstructive vascular surgery, attempting a femorodistal bypass is still justified, especially if a vein of adequate size and quality is available as a graft substitute. However, the implantation of a prothetic bypass conduit to a single tibial vessel should be performed only in selected patients.