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Outcome of Infragenicular Prosthetic Grafts with and without Distal Anastomotic Modification - A Retrospective Single Center Study

Author(s): Abhay Setia, Omid Yousefi, Patrick Felix Samp, Peter Knez, Farzin Adili

Background

Peripheral revascularization with below-knee bypass (REBEL) utilizing prosthetic grafts demonstrate inferior patency and amputation-free survival rates, as compared to venous conduits. Because of improved hemodynamics, adding a venous modification to distal anastomoses in REBEL with prosthetic grafts is assumed to improve both patency and amputation-free survival. The aim of this study was to assess the performance of prosthetic grafts with and without venous modifications of the distal anastomosis (MOD) and compare the results with venous conduits, in terms of patency rates, amputation prevention and survival.

Methods

The present single center retrospective, non-randomized observational study involved 221 REBEL in 201 patients. Data was collected by viewing hospital records and follow-up clinical and duplex ultrasound examinations (up to 48 months). For analysis, the patients were divided in 3 groups; REBEL using prosthetic grafts with MOD (PGY) or without (PGN) anastomotic modification and REBEL using plain venous conduits without anastomotic modifications (VG). Primary patency, assisted primary patency, secondary patency, amputation-free survival and overall survival was analyzed.

Results

The median follow-up was 27 months. The most common site of distal anastomosis in PGY were the crural arteries (77.8%) and 50% of PGY patients had already undergone vein-harvesting for peripheral revascularization. Average duration of surgery for PGY was 284 minutes, >70 minutes more as compared to PGN (p=0,001). In PGY a statistically insignificant tendency to decreased primary and secondary patency rates as compared to PGN was observed at 12 and 36 months. PGY displayed a significant lower amputation-free survival rate at 12 and 48 months as compared to PGN (62.9% vs 87.6% and 43.4% vs 69.75%; p=0.038). Overall survival for the three groups was not different (p=0.375).

Conclusion

To summarize, modification of the distal anastomotic site using venous cuff techniques did not result in improved patency or amputation prevention. Nonetheless, from a technical view of facilitating the creation of anastomoses between relatively rigid, large bore prosthetic grafts and calcified delicate small diameter infrapopliteal arteries, anastomotic modelling offers potential anatomic and hemodynamic advantages, thus improving outcome on long term follow up. However, prospective randomized studies are required to corroborate this hypothesis. 

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