Challenges of distal bypass surgery in patients with
diabetes: Patient selection, techniques, and
Michael S. Conte, MD, San Francisco, Calif
Surgical revascularization of the lower extremity using bypass grafts to distal target arteries is an established, effective
therapy for advanced ischemia. Recent multicenter data confirm the primacy of autogenous vein bypass grafting, yet there
remains significant heterogeneity in the utilization, techniques, and outcomes associated with these procedures in current
practice. Experienced clinical judgment, creativity, technical precision, and fastidious postoperative care are required to
optimize long-term results. The patient with diabetes and a critically ischemic limb offers some specific challenges;
however, numerous studies demonstrate that the outcomes of vein bypass surgery in this population are excellent and
define the standard of care. Technical factors, such as conduit, and inflow/outflow artery selection play a dominant role
in determining clinical success. An adequate caliber, good quality great saphenous vein (GSV) is the optimal graft for
distal bypass in the leg. Alternative veins perform acceptably in the absence of GSV, whereas prosthetic and other
non-autogenous conduits have markedly inferior outcomes. Graft configuration (reversed, non-reversed, or in situ) seems
to have little influence on outcome. Shorter grafts have improved patency. Inflow can be improved by surgical or
endovascular means if necessary, and distal-origin grafts (eg, those arising from the superficial femoral or popliteal
arteries) can perform as well as those originating from the common femoral artery. The selected outflow vessel should
supply unimpeded runoff to the foot, conserve conduit length, allow for adequate soft tissue coverage of the graft, and
simplified surgical exposure. This review summarizes the available data linking patient selection and technical factors to
outcomes, and highlights the importance of surgical judgment and operative planning in the current practice of
infrainguinal bypass surgery. (J Vasc Surg 2010;52:96S-103S.)
The use of an autogenous vein graft to bypass periph-
eral artery occlusions, first reported by Kunlin in 1949,1is
firmly established as an effective method of revasculariza-
tion for chronic, advanced limb ischemia. Numerous stud-
ies over the last 4 decades have provided evidence of the
versatility, durability, and sustained hemodynamic benefit
of lower extremity bypass grafting in appropriately selected
patients. However, perioperative morbidity after lower ex-
tremity bypass (LEB) surgery may be substantial, and graft
failure remains a significant limitation that has not been
substantially reduced despite 5 decades of technical im-
provements. Therefore, considerable effort has been made
to define the clinical, anatomic, and technical factors which
predict perioperative and long-term success. Although
much of this literature is comprised of retrospective single
center experiences, recent multicenter prospective studies
porary outcomes of LEB. This review will describe an
approach to clinical and operative decision-making and
postoperative management based on the available evidence
and surgical experience.
Patient selection for LEB. Distal (ie, infrapopliteal)
bypass surgery in the leg is generally performed for signs or
symptoms of critical limb ischemia (CLI; Rutherford isch-
emia grade 4-6), and all of the ensuing discussion in this
review will pertain directly to that population at risk for
limb loss. Patients with CLI present with a large systemic
burden of atherosclerosis and multiple comorbidities.2The
primary goals of treatment are preservation of a functional
and improved/maintained quality of life. Numerous stud-
ies have demonstrated that advanced peripheral artery dis-
ease is the risk-equivalent (or worse) of advanced coronary
artery disease in terms of secondary cardiovascular events3;
therefore, minimizing such risk is an important overall goal
in patient management.4In considering treatment of the
limb, the primary choices are conservative management
(medical therapy, wound care), endovascular intervention,
open surgical bypass, or major amputation. Assessment of
the patient’s ambulatory function, quality of life, CLI se-
verity, long-term survival, and periprocedural risks are key
determinants in selecting a primary approach. Vascular
anatomy plays a final critical role in decision-making, par-
ticularly in regard to the selection of endovascular vs surgi-
is often quoted in the literature - mortality and major
amputation rates between 10% and 40% at 6 months5;
however, the clinical severity spectrum of CLI is broad and
From the Division of Vascular and Endovascular Surgery, University of
California – San Francisco.
Competition of interest: none.
Journal of the American Podiatric Medical Association.
Reprint requests: Michael S. Conte, MD, Professor and Chief, Division of
Vascular and Endovascular Surgery, University of California – San Fran-
cisco, 400 Parnassus Avenue, Suite A-581, San Francisco, CA 94143
The editors and reviewers of this article have no relevant financial relationships
to disclose per the JVS policy that requires reviewers to decline review of any
manuscript for which they may have a competition of interest.
Copyright © 2010 by the Society for Vascular Surgery and the American
Podiatric Medical Association.
many patients in Rutherford classes 4 and 5 who are not
good candidates for revascularization may be managed
conservatively for a considerable time. It is important to
keep this in mind not only when choosing the initial
strategy, but in the event of subsequent treatment failure
and recrudescence of symptoms. Primary amputation may
be the procedure of choice for patients at elevated systemic
risk or those without good options for revascularization.
The approach to medical and cardiac risk stratification and
management is beyond the scope of this review, but is
clearly of central importance before embarking on a limb-
salvage treatment plan.
Selection of a revascularization strategy between
catheter-based and open surgical approaches is often consid-
eredas a trade-off between short-term risk and longer-term
efficacy. However, at least in terms of 30-day mortality,
there seems to be minimal difference between the two
modalities. Numerous single center and multicenter re-
ports demonstrate a 2% to 5% early mortality for surgical
bypass in the CLI population,6,7and endovascular out-
comes reported have been notably similar.6,8Early major
adverse cardiovascular event rates also seem relatively sim-
ilar (3% to 8%), although wound-related and other major
complications are clearly higher for open bypass, as is
length of initial hospitalization.6Estimating the likelihood
of long-term survival, therefore, becomes an important
consideration in treatment selection, as both the durability
and hemodynamic efficacy of surgical bypass with autoge-
nous veins are superior. Patient age, cardiopulmonary sta-
tus, renal function, cerebrovascular disease, and functional
state are important predictors of long-term survival. Re-
cently, there have been reports of risk-prediction models in
the CLI population, including one based on a surgical
bypass cohort (Project or Ex Vivo vein graft Engineering
via Transfection [PREVENT] III) that has been externally
on five easily defined preoperative variables; dialysis, tissue
loss (Rutherford grades 5/6), age ?75, anemia, and his-
tory of advanced coronary artery disease. Those in the
patients in the PREVENT III cohort) demonstrate a mark-
edly reduced (45% to 55%) amputation-free survival 1 year
after surgical bypass. In contrast, those in the low or mod-
erate risk categories (?90% of those receiving surgery for
CLI in the PREVENT III and the Vascular Surgery Group
of Northern New England data sets) can expect a 73% to
86% rate of survival with intact limbs at 1 year after bypass.
The PREVENT III Risk Score, and others like it, need to
as relevant guideposts for patient selection.
There is scant high-quality evidence to support thera-
peutic decision-making in CLI. The Bypass vs Angioplasty
for Severe Ischemia of the Leg (BASIL) trial, the only
randomized trial to date to compare endovascular and
surgical revascularization for advanced limb ischemia, re-
cently reported its long-term outcomes.11For those pa-
of the study population, open bypass was associated with
improved survival and a trend of improved amputation-free
survival. In a treatment-received analysis, which should be
interpreted with some caution, patients who initially re-
ceived a vein bypass graft fared significantly better than
those who had received a prosthetic, and those who under-
went bypass after failed angioplasty fared considerably
worse than those who received a bypass graft initi-
ally.12Taken together, these data suggest that a vein
bypass-first strategy is superior for patients likely to
survive to 2 years and beyond, and critically question the
“free-shot” view of angioplasty in the patients with CLI.
Fig 1. The PIII Risk Score was developed to predict amputation-free survival (AFS) following lower extremity bypass for
PREVENT III clinical trial. Right panel shows results of a validation study in the multicenter Vascular Study Group of
Northern New England (VSGNNE) cohort of 1166 patients who underwent vein bypass for CLI (from9,10).
JOURNAL OF VASCULAR SURGERY
Volume 52, Number 12S
Further studies are clearly needed to improve the evidence
author advocates a selective management approach to the
patient with CLI, favoring vein bypass for acceptable risk
candidates with an available autogenous vein conduit.
Those with elevated medical risk (eg, highest category
PREVENT III Risk Score), more favorable arterial anat-
omy (non-TransAtlantic InterSocietal Consensus D), inad-
equate veins, no or minor tissue loss, or other factors
the graft) are considered for a primary endovascular option.
Other authors have advocated an “endo-first” strategy for
all patients, but in my view, this is not substantiated by
current evidence (eg, BASIL) and a short-term treatment
mentality may do significant disservice to many patients
with CLI who are bypass candidates.
The impact of diabetes and renal failure, per se, on
treatment selection bear special mention. Data from a
number of large single-center series, and randomized trials
(PREVENT III), have demonstrated that diabetes is not a
risk factor for vein graft failure.13On the contrary, several
authors have observed that graft patency is higher in pa-
tients with diabetes as opposed to patients without diabe-
tes. This observation was also made in the PREVENT III
study which included 900 patients with diabetes and CLI.
However, on multivariable analysis when including other
patient and technical variables, a direct relationship be-
tween diabetes and graft patency is not retained. Quite
likely, this apparently protective association is confounded
by the higher percentage of shorter, distal-origin grafts (see
below) in the diabetic cohort. Although graft patency in
patients with diabetes is unaffected, limb salvage and long-
term patient survival are reduced in comparison to people
A negative relationship between clinical outcomes of
LEB and renal failure has been frequently observed. Patient
survival and limb salvage after LEB are linked to degree of
renal insufficiency, and both are markedly inferior for those
with an estimated glomerular filtration rate of less than 30
mL/(minutes ? 1.73 m2).14Conversely, vein graft pa-
tency does not seem to be linked to renal disease. The
distressing problem of amputation despite a patent bypass
graft is seen in 10% to 15% of patients with end-stage renal
disease who undergo bypass surgery for limb salvage, re-
flecting their poor substrate for wound healing and sepsis
control.15Therefore, advanced renal disease is a particular
subgroup that merits careful consideration for treatment
selection in CLI.
Technical factors and developing the operative
strategy. Although clinical risk factors play a dominant
role in patient survival and systemic complications after
LEB, technical factors are the primary determinants of
graft-related events. First and foremost among these is the
availability of good quality autogenous vein conduit, rec-
ognized as a relevant limitation of lower extremity vein
bypass surgery. Good quality ipsilateral great saphenous
vein (GSV) may be lacking in as many as 40% of patients
needing revascularization.16Assessment of vein availability
and quality is, therefore, a critical element of both preop-
erative planning and intraoperative decision-making. Qual-
ity of the venous conduit for bypass surgery encompasses a
range of attributes including lumen diameter, wall compli-
ance, and absence of pathologic changes such as sclerosis,
calcification, and varicosities.17,18Ultrasound scan vein
mapping allows accurate, objective evaluation before sur-
gery and has become standard in many centers. Vein diam-
eter, patency, and wall thickness may be estimated nonin-
vasively. Mapping also facilitates placement of harvest
incisions to avoid wound complications. Intraoperative as-
sessment of the vein is crucial to technical success in infrain-
guinal bypass surgery. The same features are evaluated by
direct inspection, and gentle distension with vein harvest-
ing solution allows the surgeon to determine venous
Several studies have demonstrated the strong influence
of vein diameter, and graft origin (GSV vs alternative
veins), on bypass graft patency. Most recently, post-hoc
analysis of the PREVENT III trial, which included protocol-
mandated ultrasound scan surveillance and clinical follow-up
to 1 year, have highlighted the strength of these relation-
ships.19Vein diameter was a strong predictor of early
(30-day) graft failure; loss of primary patency within 30
days was observed in 14%, 10%, and 7% of grafts ?3 mm, 3
to 3.5 mm, and ?3.5 mm, respectively. More impressively,
profound differences in primary and secondary patency
across these diameter groupings were observed within the
first year after surgery (Fig 2, A). On multivariable analysis,
or secondary vein graft patency at 1 year was vein diameter
?3 mm. Because of the known relationships between vein
diameter, vein origin (GSV vs alternative/spliced vein; Fig
2, B) and subsequent patency, the PREVENT III trial
applied a “high-risk” designation a priori to all vein grafts
that were either ?3 mm or comprised of anything other
than a single-segment GSV (SSGSV). In this trial of exclu-
sively patients with CLI, 24% of the cases fell into this
“high-risk conduit” category, and they demonstrated an
inferior 1-year performance, with 44% primary and 69%
secondary patency. Conversely, 43% of the PREVENT III
study population had their limb salvage surgery com-
pleted using an SSGSV graft with diameter ?3.5 mm,
and these “optimal conduits” demonstrated 1.7% 30-day
failure, 72% primary, and 87% secondary patency at 1
year (Fig 2, C).
In the absence of an adequate ipsilateral GSV, the best
available substitute for infrainguinal bypass is good quality,
contralateral GSV if the source limb is not at near-term
vascular risk.20The performance of alternative (arm, lesser
saphenous vein) and spliced vein grafts are known to be
inferior to that of SSGSV, but significantly better than
prosthetic grafts for patients with CLI or those requiring
bypass to infrageniculate targets.21-23These grafts require
intensive surveillance and have a higher reintervention rate,
yet long-term patency may be gratifyingly achieved in a
large percentage of cases.24The role of modified or un-
modified prosthetic grafts, or other biologic conduits re-
JOURNAL OF VASCULAR SURGERY
September Supplement 2010
mains unclear, but they may be acceptable substitutes in
specific circumstances and in some series have results com-
parable to spliced veins.
Surgical harvesting of the vein results in mechanical
injury, endothelial disruption, and vasospasm. It has long
been known that careful handling of the vein, avoiding
endothelial loss and a reduced early inflammatory re-
sponse.25The optimal solution for vein harvesting and
storage has undergone a good deal of investigation with
limited clinical translation.26Buffered, balanced salt solu-
tions, such as Plasmalyte, offer neutral pH in comparison to
saline solutions which are acidic. The use of a vasodilator,
such as papaverine, reduces reactive spasm during harvest-
ing, and heparin (4-10 units/mL) is generally added for its
Lower extremity vein grafts may be implanted in re-
versed, non-reversed (excised), or in situ bypass configura-
tions. Large single-center series demonstrate comparable
results for midterm and long-term patency,27-29and a
single, small randomized trial showed no difference in
outcomes between reversed and in situ grafts.30In specific
circumstances, there may be technical advantages to select
Fig 2. Vein quality is the dominant factor in determining long
term outcome of LEB for CLI. Data from post-hoc analyses of the
PREVENT III multicenter cohort. A, Influence of vein diameter
on graft patency. B, Relationship of vein type (Composite, spliced
vein segments; LSV, lesser saphenous vein; SSGSV, single segment
great saphenous vein) to patency. C, Performance of “optimal vein
conduits” (SSGSV ? 3.5mm) in the PREVENT III trial; note that
distal anastomotic site has minimal influence on the patency of
these grafts. (A, B, from19; C, unpublished data from PREVENT
III clinical trial).
Fig 3. Distal origin vein grafts (DOGs; inflow from superficial
femoral or popliteal arteries) are particularly useful and effective in
diabetic patients. A, Secondary patency and B, Limb salvage rates
for DOGs in a series of 190 diabetic and 90 non-diabetic subjects
(P ? .04; from33).
JOURNAL OF VASCULAR SURGERY
Volume 52, Number 12S
one configuration over the other, such as optimizing the
artery-vein size match at anastomoses and minimizing graft
length. The author tends to use non-reversed grafts fre-
quently for these reasons. Several studies have suggested
that graft length is a factor that influences patency,19,31,32
suggesting a benefit to shorter configurations.
A fundamental principle of bypass surgery is the re-
quirement for unimpeded proximal arterial inflow. In the
ideal circumstance, the proximal anastomosis is performed
to a disease-free vessel with a widely patent native system
upstream. However, treatment of inflow disease by either
endovascular or surgical means has been a successful strat-
egy in infrainguinal bypass surgery. The durability of these
interventions for aortoiliac disease is generally as good if
not superior to that of isolated distal bypass, although more
liberal use of endovascular treatment for diffuse iliac disease
bypasses originating at the superficial femoral, popliteal, or
distal vessels, have performed well in selected patients.
Short bypasses are particularly applicable to patients with
diabetes (Fig 3)33because of the pattern of arterial occlu-
sive disease that develops in a distinct subset of patients
with diabetes, with sparing of the common and superficial
femoral arteries and severe disease of the trifurcation ves-
sels. More recently, the use of infrainguinal angioplasty to
support inflow of a distally placed vein graft has also shown
success, albeit in small numbers of very selected cases.34
This approach is reasonable for patients with favorable
(TransAtlantic InterSocietal Consensus A/B) lesions in the
superficial femoral, and may also be useful when conduit
length is a major constraint. In these cases, postoperative
surveillance should also include the upstream area of inter-
Selection of the outflow artery requires considerable
surgical judgment, correlating several anatomic and hemo-
dynamic factors. In general, the most proximal vessel that
provides continuous runoff to the foot is selected as the
primary target. Extensively calcified tibial and pedal arteries
should be avoided if possible, but can be used with success.
For patients with extensive tissue loss, there is controversy
regarding the choice between peroneal, pedal, and plantar
targets.35-37Some have advocated an “angiosome” ap-
proach, selecting the target artery based on location of the
area of tissue loss on the foot.38In patients with diabetes,
excellent long-term results have been achieved with bypass
to the dorsalis pedis artery.35,39The relationship between
runoff and graft performance is somewhat unclear. Al-
though some studies have suggested that poor runoff is a
major factor,40many others have not found strong corre-
lations and measurement of graft runoff is not straightfor-
ward. The implication from such data is that conduit qual-
ity, graft length, and adequate inflow are stronger
predictors of vein graft patency than level of the distal
anastomosis. However, such retrospective data are intrinsi-
cally flawed by careful selection, and the technical chal-
lenges associated with anastomoses to small, diseased ves-
sels with poor runoff can be a significant cause of early and
late graft failure.
Lower extremity bypass grafts using excised veins may
superficially. There are no data to suggest that graft loca-
tion influences patency. In situ GSV grafts have demon-
strated excellent long-term durability in the subcutaneous
location. In addition, superficial location facilitates Duplex
scan surveillance and greatly simplifies surgical revisions
a deeper position is improved soft tissue coverage, greatly
reducing the chance that a wound complication will
threaten the bypass. When there are concerns about acute
or chronic skin conditions, soft tissue quality, or increased
likelihood of wound breakdown or infection, deeper tun-
neling of the graft is preferred.
Careful preoperative LEB planning involves assessment
of conduit availability and selection of arterial anastomotic
sites based on imaging studies. There are few “short-cuts”
of value in the performance of lower extremity vein bypass
surgery; however, errors in planning, judgment, and tech-
nique can greatly lengthen the operation, increase the risk
of complications, and reduce the long-term benefit for the
patient. Few operations in vascular surgery are as techni-
cally demanding, or require as much creativity. As in all
surgical procedures, minimizing intraoperative surprises
and having well-thought-out primary and secondary strat-
egies correlate directly with success. The major unknown
and the most critical element is the conduit. If there is
concern about the GSV from either clinical evaluation or
preoperative vein mapping, the next best available vein
should be identified before starting the operation, and that
extremity prepared. When an issue of vein quality is unex-
pectedly encountered, the surgeon must weigh the options
carefully based on knowledge of alternative veins available
and other factors. In general, a spliced vein graft made of
good quality segments is preferable to retaining a segment
of poor/marginal quality within the bypass. Small diame-
ter, sclerotic, or non-distensible vein segments are the
source of both early failure and subsequent reinterventions,
and are best excised. Intraoperative, completion imaging
and can also identify unsuspected problems which should
be treated aggressively. A normal intraoperative scan is
highly predictive of early technical success, whereas abnor-
malities associated with increased velocity (ratio ?2) or low
flow (velocity ?45 cm/second) should be addressed pre-
that it demonstrates the runoff bed more completely; how-
ever, duplex scan is likely more sensitive for abnormalities
within the conduit, especially for conduits in which valve
lysis has been used. The use of completion imaging, incor-
porating one or both of these modalities, is highly recom-
Anastomotic techniques vary widely among surgeons
and have not been directly correlated with outcome. My
strong preference is to perform the proximal anastomosis
first in all cases. This allows the graft to be tunneled while
under arterial pressure, minimizing the chance of kinks or
twists. Furthermore, it allows for greater flexibility in case
JOURNAL OF VASCULAR SURGERY
September Supplement 2010
of unsuspected issues arising at the distal target artery,
leaving excess distal vein length in place until after the
artery is opened and prepared for anastomosis. Calci-
fied arteries pose a technical challenge particularly for the
often an excellent adjunctive method, minimizing manip-
ulation of the target artery, and greatly facilitating re-do
bypass surgery. In cases of extensive arterial calcification, it
may or may not be adequate. In such cases, intraluminal
balloon control or microvascular clamps are the remaining
options. Sometimes circumferential (“egg-shell”) calcifica-
tion can be gently cracked with forceps without producing
extensive intimal disruption, but this must be done with
great care and any loose debris removed from the lumen.
Limited endarterectomy is sometimes needed and if a
longer arteriotomy is required, then a primary vein patch
angioplasty is recommended. In all cases, direct visualiza-
tion of an unobstructed downstream lumen is required to
execute the distal anastomosis with precision. “Parachut-
ing” at the distal anastomosis is an excellent technique for
tibial/pedal bypass, allowing full visualization of all of the
sutures placed at the critical heel and toe areas.
Postoperative management. Long-term success after
LEB is the benchmark of excellence, and necessitates dili-
gent postoperative care and compliance with medications
and surveillance. More so than many other surgical proce-
dures, sustained benefit after lower extremity revasculariza-
tion requires long-term commitment on the part of both
provider and patient.
All patients with advanced limb ischemia should be
treated with cardioprotective, anti-atherosclerotic medica-
tions in accordance with guidelines; including the use of
antiplatelet agents, statins, and treatment of hypertension
and diabetes to accepted goals.4The beneficial impact of
these therapies on performance of the lower extremity
bypass graft is less clear, but the benefit on overall survival
and cardiovascular events has been well demonstrated. In
PREVENT III, statin use in patients with CLI undergoing
bypass surgery was associated with reduced 1-year mortal-
ity.43Recent data also strongly suggest that statin drugs
markedly reduce perioperative events in vascular patients.44
There has been some data to suggest that statins may
impact on graft failure45and restenosis in various circum-
stances; further work in this area is required.
Management of foot and extremity wounds in the
patient with dysvascular diabetes is beyond the scope of this
review; however, it is clearly critical to overall clinical suc-
cess. Recent technology, such as negative pressure wound
therapy, has made a major impact on inpatient and outpa-
tient care of patients with CLI before and after bypass
surgery. Special attention must be paid to wounds in prox-
imity to grafts. An aggressive approach to debridement,
re-closure, graft repositioning, and skin and muscle flaps is
preferred in all cases of questionable bypass graft coverage,
and may require a team effort with plastics and reconstruc-
Vein graft stenosis will occur in 30% to 50% of patients
within the first 3 to 5 years, at least half of which takes place
in the initial postoperative year. Although still debated in
some corners, duplex ultrasound scan surveillance of lower
extremity vein grafts has become the standard of care in
most vascular practices. Surveillance allows detection of
asymptomatic lesions that may lead to graft failure. Because
durable restoration of a thrombosed vein graft is not com-
mon, identification of graft lesions before thrombosis is
critical to maintain long-term patency. We advocate close
surveillance during the first year, with duplex ultrasound
scanning following the protocol suggested by Bandyk and
others at 1, 3, 6, and 12 months post-bypass.46If there are
abnormal findings, additional observation points may be
warranted. Beyond 1 year, scans are done twice a year at
least until year 3, and annually thereafter. Criteria for
angiography and potential reintervention are those consis-
tent with a critical (?70%) stenosis by ultrasound scan, or
low velocities suggestive of impending failure. These crite-
ria have been reviewed extensively by others.47
Expected outcomes after LEB. Five-year patency
rates for vein bypass grafts to infrapopliteal targets range
from 50% to 70% from retrospective series. Limb salvage
rates for the CLI population undergoing LEB are generally
greater than 80% at 5 years. As mentioned above, conduit
factors such as vein diameter and quality exert dominant
effects on graft patency and specific clinical risk factors for
graft hyperplasia remain to be determined. An interesting
certain racial and ethnic groups.48,49In particular, the
PREVENT III data demonstrated notably inferior graft
patency and limb salvage for African-American women in
an analysis that included multiple covariates inclusive of
technical determinants.50Therefore, it remains unclear if
specific patients have an enhanced propensity to develop
vein graft disease which would place them under more
aggressive surveillance. Clearly, grafts constructed using
alternative veins, spliced veins, or other high-risk conduits
should be monitored more closely.
As mentioned above, several studies have confirmed
that diabetes is not a risk factor for vein graft failure;
however, diabetes does portend an increased risk for both
long-term mortality and limb loss in the patient with CLI.
The issues regarding the postoperative limb are multifacto-
associated comorbidities such as renal failure, nutritional/
metabolic derangements, and microvascular dysfunction.
Therefore, aggressive management of the systemic milieu
and the limb is mandatory to achieve a successful outcome
after revascularization for CLI. Series from centers of
excellence have demonstrated the efficacy of aggressive
revascularization to tibial/pedal targets, multidisciplinary
wound and foot care, and long-term surveillance in man-
agement of the patient with diabetes with a dysvascular
limb. Such efforts should be led by dedicated vascular
specialists with broad expertise in these areas, and promul-
and amputation for all patients at risk.
JOURNAL OF VASCULAR SURGERY
Volume 52, Number 12S
1. Kunlin J. [The treatment of arterial obstruction by vein grafting].
[Article in French] Arch Mal Coeur Vx 1949;42.
2. Conte MS, Belkin M, Upchurch GR, Mannick JA, Whittemore AD,
Donaldson MC. Impact of increasing comorbidity on infrainguinal
reconstruction: a 20-year perspective. Ann Surg 2001;233:445-52.
3. Steg PG, Bhatt DL, Wilson PW, D’Agostino R Sr, Ohman EM, Röther
J, et al. One-year cardiovascular event rates in outpatients with athero-
thrombosis. JAMA 2007;297:1197-206.
4. Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin
JL, et al. ACC/AHA 2005 Practice Guidelines for the management of
patients with peripheral arterial disease (lower extremity, renal, mesen-
teric, and abdominal aortic): a collaborative report from the American
Association for Vascular Surgery/Society for Vascular Surgery, Society
for Cardiovascular Angiography and Interventions, Society for Vascular
Medicine and Biology, Society of Interventional Radiology, and the
ACC/AHA Task Force on Practice Guidelines (Writing Committee to
Develop Guidelines for the Management of Patients With Peripheral
Arterial Disease): endorsed by the American Association of Cardiovas-
cular and Pulmonary Rehabilitation; National Heart, Lung, and Blood
Institute; Society for Vascular Nursing; TransAtlantic Inter-Society
Consensus; and Vascular Disease Foundation. Circulation 2006;113:
5. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes
FG; TASC II Working Group. Inter-Society Consensus for the Man-
agement of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007;45
6. Adam DJ, Beard JD, Cleveland T, Bell J, Bradbury AW, Forbes JF, et al.
Bypass versus angioplasty in severe ischaemia of the leg (BASIL):
multicentre, randomised controlled trial. Lancet 2005;366:1925-34.
al. Results of PREVENT III: a multicenter, randomized trial of edifo-
ligide for the prevention of vein graft failure in lower extremity bypass
surgery. J Vasc Surg 2006;43:742-51; discussion 751.
8. Giles KA, Pomposelli FB, Spence TL, Hamdan AD, Blattman SB,
Panossian H, et al. Infrapopliteal angioplasty for critical limb ischemia:
relation of TransAtlantic InterSociety Consensus class to outcome in
176 limbs. J Vasc Surg 2008;48:128-36.
9. Schanzer A, Mega J, Meadows J, Samson RH, Bandyk DF, Conte MS.
Risk stratification in critical limb ischemia: derivation and validation of a
model to predict amputation-free survival using multicenter surgical
outcomes data. J Vasc Surg 2008;48:1464-71.
10. Schanzer A, Goodney PP, Li Y, Eslami M, Cronenwett J, Messina L, et
al. Validation of the PIII CLI risk score for the prediction of
vein bypass for critical limb ischemia. J Vasc Surg 2009;50:769-75;
Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial:
an intention-to-treat analysis of amputation-free and overall survival in
patients randomized to a bypass surgery-first or a balloon angioplasty-
first revascularization strategy. J Vasc Surg 2010;51(5 Suppl):5S-17S.
Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial:
analysis of amputation free and overall survival by treatment received. J
Vasc Surg 2010;51(5 Suppl):18S-31S.
13. Monahan TS, Owens CD. Risk factors for lower-extremity vein graft
failure. Semin Vasc Surg 2009;22:216-26.
14. Owens CD, Ho KJ, Kim S, Schanzer A, Lin J, Matros E, et al.
Refinement of survival prediction in patients undergoing lower extrem-
ity bypass surgery: stratification by chronic kidney disease classification.
J Vasc Surg 2007;45:944-52.
15. Lantis JC 2nd, Conte MS, Belkin M, Whittemore AD, Mannick JA,
renal disease: improving outcomes? J Vasc Surg 2001;33:1171-8.
16. Taylor LM Jr, Edwards JM, Brant B, Phinney ES, Porter JM. Autoge-
nous reversed vein bypass for lower extremity ischemia in patients with
absent or inadequate greater saphenous vein. Am J Surg 1987;153:
17. Panetta TF, Marin ML, Veith FJ, Goldsmith J, Gordon RE, Jones AM,
et al. Unsuspected preexisting saphenous vein disease: an unrecognized
cause of vein bypass failure. J Vasc Surg 1992;15:102-10; discussion
18. Marin ML, Veith FJ, Panetta TF, Gordon RE, Wengerter KR, Suggs
Surg 1993;18:407-14; discussion 414-5.
19. Schanzer A, Hevelone N, Owens CD, Belkin M, Bandyk DF, Clowes
AW, et al. Technical factors affecting autogenous vein graft failure:
observations from a large multicenter trial. J Vasc Surg 2007;46:1180-
90; discussion 1190.
20. Chew DK, Owens CD, Belkin M, Donaldson MC, Whittemore AD,
Mannick JA, et al. Bypass in the absence of ipsilateral greater saphenous
vein: safety and superiority of the contralateral greater saphenous vein.
J Vasc Surg 2002;35:1085-92.
21. 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;20:451-6; discussion 456-7.
22. Faries PL, Arora S, Pomposelli FB Jr, Pulling MC, Smakowski P, Rohan
DI, et al. The use of arm vein in lower-extremity revascularization:
results of 520 procedures performed in eight years. J Vasc Surg 2000;
31(1 Pt 1):50-9.
23. Chew DK, Conte MS, Donaldson MC, Whittemore AD, Mannick JA,
Belkin M. Autogenous composite vein bypass graft for infrainguinal
arterial reconstruction. J Vasc Surg 2001;33:259-64; discussion 264-5.
24. Armstrong PA, Bandyk DF, Wilson JS, Shames ML, Johnson BL, Back
MR. Optimizing infrainguinal arm vein bypass patency with duplex
ultrasound surveillance and endovascular therapy. J Vasc Surg 2004;40:
724-30; discussion 730-1.
25. LoGerfo FW, Quist WC, Cantelmo NL, Haudenschild CC. Integrity of
vein grafts as a function of initial intimal and medial preservation.
Circulation 1983;68(3 Pt 2):II117-24.
26. Adcock OT Jr, Adcock GL, Wheeler JR, Gregory RT, Snyder SO Jr,
Gayle RG. Optimal techniques for harvesting and preparation of re-
versed autogenous vein grafts for use as arterial substitutes: a review.
cases. Ann Surg 1995;222:438-46; discussion 446-8.
28. Taylor LM Jr, Edwards JM, Porter JM. Present status of reversed vein
bypass grafting: five-year results of a modern series. J Vasc Surg 1990;
11:193-205; discussion 205-6.
29. Belkin M, Knox J, Donaldson MC, Mannick JA, Whittemore AD.
Infrainguinal arterial reconstruction with nonreversed greater saphe-
nous vein. J Vasc Surg 1996;24:957-62.
30. Wengerter KR, Veith FJ, Gupta SK, Goldsmith J, Farrell E, Harris PL,
et al. Prospective randomized multicenter comparison of in situ and
reversed vein infrapopliteal bypasses. J Vasc Surg 1991;13:189-97;
31. Ascer E, Veith FJ, Gupta SK, White SA, Bakal CW, Wengerter K, et al.
Short vein grafts: a superior option for arterial reconstructions to poor
or compromised outflow tracts? J Vasc Surg 1988;7:370-8.
32. Ballotta E, Renon L, De Rossi A, Barbon B, Terranova O, Da Giau G.
bypass to treat limb-threatening ischemia: common femoral artery
versus superficial femoral or popliteal and tibial arteries as inflow. J Vasc
33. Reed AB, Conte MS, Belkin M, Mannick JA, Whittemore AD, Donald-
son MC. Usefulness of autogenous bypass grafts originating distal to
the groin. J Vasc Surg 2002;35:48-54; discussion 54-5.
percutaneous intervention is an effective strategy to optimize inflow for
distal origin bypass grafts. J Vasc Surg 2007;45:740-3.
35. Pomposelli FB Jr, Jepsen SJ, Gibbons GW, Campbell DR, Freeman
DV, Miller A, et al. Efficacy of the dorsal pedal bypass for limb salvage
in diabetic patients: short-term observations. J Vasc Surg 1990;11:745-
51; discussion 751-2.
JOURNAL OF VASCULAR SURGERY
September Supplement 2010
36. Raftery KB, Belkin M, Mackey WC, O’Donnell TF. Are peroneal artery Download full-text
bypass grafts hemodynamically inferior to other tibial artery bypass
grafts? J Vasc Surg 1994;19:964-8; discussion 968-9.
37. Bergamini TM, George SM Jr, Massey HT, Henke PK, Klamer TW,
Lambert GE Jr, et al. Pedal or peroneal bypass: which is better when
both are patent? J Vasc Surg 1994;20:347-55; discussion 355-6.
38. Neville RF, Attinger CE, Bulan EJ, Ducic I, Thomassen M, Sidawy AN.
Revascularization of a specific angiosome for limb salvage: does the
target artery matter? Ann Vasc Surg 2009;23:367-73.
39. Pomposelli FB, Kansal N, Hamdan AD, Belfield A, Sheahan M, Camp-
bell DR, et al. A decade of experience with dorsalis pedis artery bypass:
analysis of outcome in more than 1000 cases. J Vasc Surg 2003;37:
40. Seeger JM, Pretus HA, Carlton LC, Flynn TC, Ozaki CK, Huber TS.
Potential predictors of outcome in patients with tissue loss who un-
dergo infrainguinal vein bypass grafting. J Vasc Surg 1999;30:427-35.
41. Bandyk DF, Mills JL, Gahtan V, Esses GE. Intraoperative duplex
scanning of arterial reconstructions: fate of repaired and unrepaired
defects. J Vasc Surg 1994;20:426-32; discussion 432-3.
42. Johnson BL, Bandyk DF, Back MR, Avino AJ, Roth SM. Intraoperative
duplex monitoring of infrainguinal vein bypass procedures. J Vasc Surg
43. Schanzer A, Hevelone N, Owens CD, Beckman JA, Belkin M, Conte
MS. Statins are independently associated with reduced mortality in
patients undergoing infrainguinal bypass graft surgery for critical limb
ischemia. J Vasc Surg 2008;47:774-81.
MR, et al. Fluvastatin and perioperative events in patients undergoing
vascular surgery. N Engl J Med 2009;361:980-9.
45. Abbruzzese TA, Havens J, Belkin M, Donaldson MC, Whittemore AD,
Liao JK, et al. Statin therapy is associated with improved patency of
autogenous infrainguinal bypass grafts. J Vasc Surg 2004;39:1178-85.
46. Tinder CN, Chavanpun JP, Bandyk DF, Armstrong PA, Back MR,
Johnson BL, et al. Efficacy of duplex ultrasound surveillance after
infrainguinal vein bypass may be enhanced by identification of charac-
teristics predictive of graft stenosis development. J Vasc Surg 2008;48:
47. Tinder CN, Bandyk DF. Detection of imminent vein graft occlusion:
what is the optimal surveillance program? Semin Vasc Surg 2009;22:
48. Morrissey NJ, Giacovelli J, Egorova N, Gelijns A, Moskowitz A,
McKinsey J, et al. Disparities in the treatment and outcomes of vascular
disease in Hispanic patients. J Vasc Surg 2007;46:971-8.
49. Robinson WP 3rd, Owens CD, Nguyen LL, Chong TT, Conte MS,
Belkin M. Inferior outcomes of autogenous infrainguinal bypass in
Hispanics: an analysis of ethnicity, graft function, and limb salvage. J
Vasc Surg 2009;49:1416-25.
GL, et al. Disparity in outcomes of surgical revascularization for limb
and limb loss. Circulation 2009;119:123-30.
JOURNAL OF VASCULAR SURGERY
Volume 52, Number 12S