State of femoral runoff and the outcome of inflow operations for occlusive disease

Anantha K. Ramanathan, MD, Linda M. Harris, MD, Mollie O'Brien - Irr, RN, Richard G. Curl, MD, Hasan H. Dosluoglu, MD, Gregory Cherr, MD and Maciej L Dryjski, MD
Millard Fillmore Gates Hospital, Veteran's Administration Hospital and Buffalo General Hospital, Buffalo, NY

Objective(s):
The impact of the disease of the femoral vessels on the patency of inflow operations has been previously reported with variable results. We evaluated the outcomes of inflow procedures in relation to the degree of disease in femoral arteries.
Methods:
This is a retrospective review of bypasses with the femoral artery as outflow done in a University Health system between 1994 and 2000. Runoff limbs were studied for primary and secondary patency rates, and limb salvage. Femoral arteries were classified as normal, irregular, >50% stenosed and occluded. Femoral vessels were evaluated in the following segments: origin of SFA, origin of profunda femoris, upper 1/3 of SFA, mid 1/3 of SFA, lower 1/3 of SFA, and SFA as a whole. The data was analyzed using SPSS (Chicago, Illinois)
Results:
Seventy-five patients who underwent 85 procedures, with 122 runoff limbs were analyzed. Fourteen runoff limbs had a patent femoro popliteal/distal bypass. The mean age was 63 years. Fifty-five percent were males. Eighty percent had a history of smoking and 29% had diabetes. The operations performed included: femorofemoral (32), aortobifemoral (23) and axillobifemoral bypasses (14). Forty-five percent were done for claudication and 55% for critical limb ischemia. Mean follow up was 46 months.
Five year primary and secondary patency and limb salvage rates were significantly worse in those with SFA disease involving >50% of the lumen (45% vs. 71%, 63% vs. 83%, and 76% vs. 96% respectively) (Table 1). Disease in the SFA origin or proximal segment had a significant impact on the outcome, whereas disease in the remainder of the SFA influenced only limb salvage (Table 2). Pre-existing or post-procedure bypass distal to the index operation did not improve patency or limb salvage. There was no significant difference between SFA stenosis vs. occlusion. Finally, disease at the origin of profunda did not significantly affect patency or limb salvage.
Conclusions:
SFA disease significantly reduced primary and secondary patency of inflow operations, and limb salvage. The difference is more pronounced for disease at the origin or upper third of the SFA. A preexisting or post-procedure bypass of the SFA did not significantly improve the outcome. SFA occlusions did not do significantly better than stenoses, contrary to some previous reports. The need for concurrent endovascular intervention to improve outflow remains to be investigated.