A comparison of tibial artery bypass performed with heparin-bonded expanded polytetrafluoroethylene and great saphenous vein to treat critical limb ischemia

Abstract

Background: Expanded polytetrafluoroethylene (ePTFE) bonded with heparin (HePTFE) has been reported to perform equivalent to saphenous vein graft (SVG) for below-knee bypass. This series examines outcomes for tibial artery bypass using HePTFE and SVG over a contemporaneous time period.

Methods: A retrospective analysis of prospectively collected data was conducted for 112 tibial bypasses (62 HePTFE, 50 SVG) performed from November 2006 to January 2009. Demographics for age, sex, race, diabetes mellitus, and end-stage renal disease were similar. Indications for revascularization were also similar: disabling claudication, 9%; rest pain, 25%; and tissue loss, 66%. The HePTFE group included more reoperative procedures (45% vs 26%). All HePTFE bypasses were performed using an autologous vein patch at the distal anastomosis. Postoperative graft surveillance by pulse examination, ankle-brachial index, and duplex ultrasound imaging occurred at 1, 3, 6, and 12 months. Follow-up ranged from 1 to 12 months. Kaplan-Meier and Cox regression analysis evaluated results in patients with no missing variables.

Results: HePTFE and SVG bypasses demonstrated no significant differences in target tibial artery distribution: anterior tibial (15 vs 17), dorsalis pedis (4 vs 5), posterior tibial (22 vs 16), and peroneal (21 vs 12). Graft occlusion occurred in 19 patients (16.9%) during follow-up. Primary patency at 1 year was 75.4% for HePTFE and 86.0% for SVG. There was no significant difference in primary patency due to sex (male, 78%; female, 84%), race (white, 82%; African American, 77%), or diabetes mellitus (no diabetes mellitus, 84%; diabetes mellitus, 76%). End-stage renal disease resulted in decreased patency (57%), with an eightfold reduction (95% confidence interval, 1.8%-39.8%; P = .006). SVG patients had a lower risk of occlusion/death (95% confidence interval, 14.2%-94.5%; P > .05). Sixteen amputations were performed, with no significant difference based on conduit.

Conclusions: This experience indicates a trend for single-segment quality saphenous vein to remain the conduit of choice for tibial artery bypass compared with HePTFE. Factors relevant to decreased 1-year patency for the entire cohort were end-stage renal disease and nonhealing ulceration as the indication for revascularization. Although relatively short-term, these results do support HePTFE as a viable alternative conduit for patients with absent or poor quality saphenous vein who need a tibial bypass.