Usefulness of autogenous bypass grafts originating distal to the groin

Abstract

Purpose: Infrainguinal bypass grafting with a proximal anastomosis distal to the groin has been used increasingly to conserve available conduit and reduce wound morbidity and recovery time. The usefulness of the liberalized use of distal origin grafts (DOGs) is unknown.

Methods: Consecutive autogenous DOG procedures that were performed between 1978 and 2000 were reviewed retrospectively with a computerized registry. Procedures performed as revisions to earlier infrainguinal bypass grafting procedures and for popliteal aneurysm were excluded.

Results: In the 22-year study period, 249 autogenous DOG procedures were performed in 217 patients. Comparison of the 159 DOGs in patients with diabetes mellitus (+DM) with the 90 grafts in patients without diabetes mellitus (-DM) revealed more associated renal disease (33% vs 9%), preoperative foot necrosis (80% vs 52%), distal popliteal artery graft origins (49% vs 37%), and non-greater saphenous conduits used (30% vs 19%) among the +DM subgroup than the -DM subgroup (P <.05). The operative mortality rate was 2.0%, the major morbidity rate was 8.8%, the early graft failure rate was 6.4%, and the early amputation rate was 2.4%, with no differences related to diabetes mellitus. Follow-up was complete in 92% of patients in a mean interval of 27 months. At 5 years, cumulative primary graft patency rates were 62% overall, 73% for the +DM subgroup, and 45% for the -DM subgroup (P <.001). The overall limb salvage rate after DOG procedures for critical ischemia was 79%, and it was 84% for the +DM subgroup and 69% for the -DM subgroup (P <.04). The overall patient survival rate was 45%, with no difference related to diabetes mellitus.

Conclusion: Outcome after autogenous DOG revascularization is satisfactory overall. Graft patency and limb salvage after DOG for critical ischemia are significantly better among patients with diabetes mellitus than patients without diabetes mellitus, despite significantly more bypass grafting procedures performed for foot necrosis. DOG revascularization appears to be an appropriate preference for patients with diabetes mellitus with good inflow below the groin; it should be used less liberally among patients without diabetes mellitus.