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- W1577690164 abstract "Purpose:The purpose of this study has been to investigate the results of above-kneeprosthetic femoropopliteal bypass surgery and to identify risk factors forcomplications and graft failure. The influence of comorbidity, degree of chronic legischaemia, preoperative angiographic run-off score and intraoperative flowmeasurements on long-term results were investigated. Furthermore, local infectionsand the outcome of treating occluded prosthetic grafts were studied.Methods:Two-hundred-and-thirty-seven patients (156 men, 81 women) were subjectedto 252 above-knee prosthetic femoropopliteal bypass operations at HaukelandUniversity Hospital between Jan 1990 and Dec 2001. One hundred and forty-onegraft implantations (129 patients) were done for intermittent claudication and 111(108 patients) for critical ischaemia. Patient data were prospectively recorded in adatabase registry. Some data were supplemented from patients records. Occlusiondates, complications, re-operations including amputations, and mortality were alsorecorded. Patient characteristics, anatomical risk factors and intraoperative flowmeasurements were analysed for impact on results after surgery.Survival, limb salvage and patency rates were analysed with the Product limitmethod and illustrated as Kaplan-Meier curves. The risk factors were subjected tounivariate analysis using the log rank test for impact on survival, limb salvage andpatency rates. Variables approaching significance were included in multivariateanalysis performed with the Cox proportional hazard model. Results:Paper I. Surgical site infection was recorded after 7.8 % of the operations and graftinfection after 12 %. The risk of developing a local infection was significantlycorrelated with postoperative lymph fistula. Redo surgery was associated with graftinfection. Graft infections caused by Staph. Aur. always warranted surgery, eitherlocal revision or graft excision.Paper II. For grafts implanted for intermittent claudication, the assisted primarypatency rates were 62 % at 2 years and 44 % at 5 years. The 5-year patency rate forsmokers was 24 % versus 67 % for non-smokers (p < 0.01). A previous history ofcerebral infarction was significantly associated with reduced graft patency.Preoperative s-creatinine > 125 mmol/L was significantly associated with reducedsurvival.Paper III. The 30-day mortality rate of patients operated for critical ischaemia was5.5 %. The 2- and 5-year survival was 72 % and 42 %, whereas the limb salvage ratesat 2 and 5 years were 83 % and 73 %, respectively. The 2-year primary patency ratefor smokers was 38 % versus 62 % for non-smokers (p = 0.018, hazard ratio 2.18).Smoking and tissue loss were significantly associated with reduced secondarypatency.Paper IV. Basal flow measurements were not related to patency. The 2- and 5-yearpatency rates for grafts with a papaverine flow < 500 ml/min were 48 % and 18 %compared with 66 % and 52 % for grafts with a papaverine flow ≥ 500 ml/min (p =0.012, hazard ratio 2.6). Two and 5-year patency rates for smokers vs non-smokerswere 44 % and 18 % vs 69 % and 54 %. Smoking (p = 0.008, hazard ratio 2.38) andpoor run-off score (p = 0.009, hazard ratio 2.38) were independent risk factors forreduced patency. Poor run-off score did not correlate with low values of measuredbasal or papaverine flow.Paper V. Half the 24 initial procedures to restore patency of occluded graftsoriginally implanted for critical ischaemia failed within a month. Outcome of second or third-time redo procedures were similar. Primary patency rates of all 55 redoprocedures were 32 % at three months, 28 % at six months and 12 % at 12 months.The results of thrombectomy and thrombolysis were similar. Re-opened graftsadditionally treated for an underlying anastomotic stenosis had significantly betterpatency, as compared with re-opened grafts without a pre-existing stenosis (p =0.027, hazard ratio 2.813).Conclusions:The results regarding survival, limb salvage and patency are comparable toprevious reports. The results underline that a long observation period is necessary toachieve full overview of complications and the impact of risk factors.Infectious complications after prosthetic femoropopliteal bypass in the studygroup were higher than previously reported. The results suggest that a selectiveapproach should be taken towards excision of infected femoropopliteal prosthesesaccording to the clinical presentation of the graft infection and the type of bacteriaeinvolved.A conservative attitude is recommended towards placing a prosthetic graft inthe above-knee femoropopliteal position for intermittent claudication. The finding ofreduced patency rates in patients with a history of a cerebral insult operated forintermittent claudication need further studies to be verified. Patients with intermittentclaudication and renal impairment reveal poor survival, indicating renal impairmentas a relative contraindication for surgical treatment. Smokers have inferior patencyrates when operated for intermittent claudication as well as for critical ischaemia.Poor angiographic run-off score was also associated with inferior patency rates.These findings indicate that prosthetic femoropopliteal bypass is not very suitable forthese groups of patients. Furthermore, the poor secondary patency rates of smokers as well as for patients with tissue loss suggest that these patients may benefit fromalternative treatment modalities to re-opening an occluded bypass.A papaverine flow of < 500 ml/min is associated with reduced patency.Additional antithrombotic medication and frequent follow-up may be considered forthese grafts. Redo procedures for occluded grafts originally implanted for criticalischaemia are of limited value and cannot be recommended except in cases with aproven graft-related stenosis. Other cases in need of re-intervention should be treatedwith either a new arterial reconstruction or an amputation.Based on the findings in this study, the following issues must be evaluatedwhen offering an above-knee prosthetic femoropopliteal bypass for chronic limbischaemia: patient comorbidity, smoking, degree of ischaemia and angiographic runoffscore. Careful selection of patients subjected to above-knee prosthetic bypasssurgery for chronic ischaemia is mandatory to achieve the optimal gain of theoperation." @default.
- W1577690164 created "2016-06-24" @default.
- W1577690164 creator A5042280543 @default.
- W1577690164 date "2007-05-24" @default.
- W1577690164 modified "2023-09-27" @default.
- W1577690164 title "The use of prosthetic grafts in above-knee femoropopliteal bypass surgery : a clinical study of long-term results and risk factors for failure" @default.
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