Infrapopliteal Bypass

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Infrapopliteal bypass is a major lower-extremity arterial reconstruction, the goal of which is to establish in-line flow to target vessels such as the tibial, peroneal, or pedal arteries. Arterial supply (inflow) sites therefore include the common femoral, deep femoral (profunda femoris), superficial femoral, and popliteal arteries. Occasionally, a tibial artery may become the inflow vessel.

The primary indication for infrapopliteal bypass is critical limb ischemia (CLI) due to atherosclerotic peripheral arterial disease (PAD). This method of surgical arterial reconstruction can be applied to patients with nonatherosclerotic conditions such as aneurysmal disease and traumatic arterial injuries. The bypass conduit should usually be composed of autogenous vein, but prosthetic material can be used in the absence of suitable autogenous conduit. ^[1]

With regard to conduit type, vein grafts are superior to all prosthetic conduits for infrapopliteal bypass, regardless of target vessel. ^{[2, 3]}  The great saphenous vein (GSV; also referred to as the long or greater saphenous vein) is the most commonly utilized autogenous conduit; however, the small saphenous vein (SSV; also referred to as the short or lesser saphenous vein), the superficial femoral vein, ^[4]  and spliced vein grafts from the arm can also be used. ^[5]

Numerous varieties of prosthetic conduits are available; options include the following:

Of these, PTFE is the most commonly used material. All prosthetic grafts perform with similar patency rates in the infrapopliteal position and are inferior to autogenous grafts, regardless of type; composite grafts appear to be no better than prosthetic grafts in this regard. ^[3]  The 1-year patency rates of vein conduit in the infrapopliteal position reach 70-80%, whereas those of prosthetic grafts reach 30-50% at best. ^[2]  If a prosthetic graft is used in the infrapopliteal position, an adjunctive vein cuff at the distal anastomosis improves patency. ^[6]

Indications for infrapopliteal bypass include the following:

Contraindications for infrapopliteal bypass include the following:

The principles of surgical revascularization are based on the following three components:

The inflow vessel (ie, the artery from which the bypass will originate) must have adequate flow and pressure and allow suturing. Significant vascular calcification or atherosclerotic disease of the inflow artery can present technical challenges. The outflow vessel should be the least diseased vessel with runoff to the foot. On imaging, inflow and outflow arteries must be well characterized. If disease exists in the proposed inflow vessel and a less diseased more proximal artery cannot be accessed or used because of bypass graft length constraints, an adjunctive procedure to address the inflow disease (eg, endarterectomy) must be added to the operative plan.

The distal target artery must be confirmed to be the dominant vessel to the foot. Tissue distribution of the outflow vessels must correlate with the operative indication. For example, whereas revascularization of the pedal arteries will aid in healing of ischemic foot ulcers, it will not improve calf claudication. In general, shorter reconstructions, if feasible, have better long-term patency. ^{[2, 7]}

With regard to conduit assessment, duplex vein mapping is vital for ensuring a graft of appropriate size and quality. The venous conduit should be at least 2.5 mm in diameter and soft throughout the length needed to perform the bypass. Calcified or sclerotic veins should not be used.

Measures to help prevent complications include the following:

Gasper WJ, Runge SJ, Owens CD. Management of infrapopliteal peripheral arterial occlusive disease. Curr Treat Options Cardiovasc Med. 2012 Apr. 14(2):136-48. [Medline].

Veith FJ, Gupta SK, Ascer E, White-Flores S, Samson RH, Scher LA. Six-year prospective multicenter randomized comparison of autologous saphenous vein and expanded polytetrafluoroethylene grafts in infrainguinal arterial reconstructions. J Vasc Surg. 1986 Jan. 3(1):104-14. [Medline].

Nguyen BN, Neville RF, Abugideiri M, Amdur R, Sidawy AN. The effect of graft configuration on 30-day failure of infrapopliteal bypasses. J Vasc Surg. 2014 Apr. 59 (4):1003-8. [Medline].

Londrey GL, Bosher LP, Brown PW, Stoneburner FD Jr, Pancoast JW, Davis RK. Infrainguinal reconstruction with arm vein, lesser saphenous vein, and remnants of greater saphenous vein: a report of 257 cases. J Vasc Surg. 1994 Sep. 20(3):451-6; discussion 456-7. [Medline].

Faries PL, Arora S, Pomposelli FB Jr, Pulling MC, Smakowski P, Rohan DI. The use of arm vein in lower-extremity revascularization: results of 520 procedures performed in eight years. J Vasc Surg. 2000 Jan. 31(1 Pt 1):50-9. [Medline].

Stonebridge PA, Prescott RJ, Ruckley CV. Randomized trial comparing infrainguinal polytetrafluoroethylene bypass grafting with and without vein interposition cuff at the distal anastomosis. The Joint Vascular Research Group. J Vasc Surg. 1997 Oct. 26(4):543-50. [Medline].

Rashid H, Slim H, Zayed H, Huang DY, Wilkins CJ, Evans DR, et al. The impact of arterial pedal arch quality and angiosome revascularization on foot tissue loss healing and infrapopliteal bypass outcome. J Vasc Surg. 2013 May. 57(5):1219-26. [Medline].

[Guideline] Society for Vascular Surgery Lower Extremity Guidelines Writing Group., Conte MS, Pomposelli FB, Clair DG, Geraghty PJ, McKinsey JF, et al. Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: management of asymptomatic disease and claudication. J Vasc Surg. 2015 Mar. 61 (3 Suppl):2S-41S. [Medline]. [Full Text].

Julliard W, Katzen J, Nabozny M, Young K, Glass C, Singh MJ, et al. Long-term results of endoscopic versus open saphenous vein harvest for lower extremity bypass. Ann Vasc Surg. 2011 Jan. 25 (1):101-7. [Medline].

Cheong Jun Lee, MD Assistant Professor of Surgery, Division of Vascular Surgery, Medical College of Wisconsin

Cheong Jun Lee, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, Association for Academic Surgery, Michigan State Medical Society, Society for Vascular Surgery

Disclosure: Nothing to disclose.

Mark D Morasch, MD, RPVI Vascular Surgeon, Section Head of Vascular and Endovascular Services, Billings Clinic; John Marquardt Clinical Research Professor in Vascular Surgery, Division of Vascular Surgery, Northwestern University, The Feinberg School of Medicine

Mark D Morasch, MD, RPVI is a member of the following medical societies: Society for Vascular Surgery, Western Surgical Association, Southern Association for Vascular Surgery, American Venous Forum, Vascular and Endovascular Surgery Society, Society for Clinical Vascular Surgery, Western Vascular Society, Midwestern Vascular Surgical Society, American College of Surgeons, American Medical Association, American Heart Association, Central Surgical Association, Western Vascular Society, Southern Association for Vascular Surgery

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Surgical Association, Pacific Coast Surgical Association, Society for Clinical Vascular Surgery, Society for Vascular Surgery, Western Vascular Society

Disclosure: Nothing to disclose.

Infrapopliteal Bypass

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