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Neville R. F., Babrowicz J., Amdur R., Sidawy A.
Division of Vascular Surgery, Department of Surgery, George Washington University, Medical Faculty Associates, Washington, DC, USA
BACKGROUND: Several series have reported that heparin bonded PTFE (HePTFE) grafts perform in an equivalent manner to saphenous vein (SVG) for tibial bypass. This series reports a single center, US experience for tibial bypass using the HePTFE and SVG over a contemporaneous time period.
METHODS: A retrospective analysis of prospectively collected data was conducted for 112 tibial bypasses performed from November 2006 to January 2009 including 62 HePTFE, and 50 SVG. Patient demographics were similar between the two groups with respect to age, sex (65% male), race (44% white, 54% AA), DM (57%), and ESRD (15%). Indications for revascularization were similar; claudication 9%, rest pain 25%, and tissue loss 66%. The HePTFE group included more re-operative procedures (45% vs. 26%). Postoperative graft surveillance by pulse exam, ABI, and Duplex ultrasound was at one, three, six, and 12 months. The follow-up period ranged from 1 to 12 months with Kaplan-Meier and Cox regression analysis used to evaluate results in those patients with all variables non-missing.
RESULT: HePTFE and SVG bypasses demonstrated no difference in target artery; AT (15 vs. 17), DP (4 vs. 5), PT (22 vs. 16), and peroneal (21 vs. 12). Venous conduit was absent in the HePTFE group due to prior bypass (32%), CABG (29%), stripping (12%) or poor quality vein (27%). 19 patients (18.6%) suffered graft occlusion or death during follow-up. There was no significant difference in primary patency due to gender (male 78% vs female 84%), race (white 82%, AA 77%), or diabetes (non-DM 84%, DM 76%). ESRD resulted in decreased patency (57%) with an 8 fold reduction (95% CI 1.8-39.8). Patency was highest for claudicants (95%) with rest pain (81%), gangrene (71%) and ulcer (72%) decreased respectively. Primary patency based on conduit was HePTFE 75% and SVG patency 86%. SVG patients had a 78% lower risk of occlusion/death (P>.05, 95% CI 14.2-94.5%). 37 patients had a secondary procedure (33%); HePTFE 23, SVG 14. Significant factors related to a second procedure included age and ESRD. There were 16 amputations (14%) with a mean time to amputation of 4.9 months. There was no difference based on conduit; HePTFE 9, SVG 7.
CONCLUSION: This is a single center contemporaneous experience with HePTFE and vein for tibial bypass. Three factors were related to decreased one year patency; ESRD, non-healing ulcer, and type of conduit. There was no difference in limb salvage based on the bypass conduit employed. This initial experience demonstrates the superiority of a quality saphenous vein as a conduit for tibial bypass, but HePTFE may represent an alternative with multicenter data required to further define its role for tibial bypass.