Prosthetic versus native artery inflow for infrainguinal bypass

Background: Infrainguinal bypass performed after previous prosthetic inflow reconstruction offers a choice of where to perform the proximal anastomosis. The hood of a previous inflow bypass might be technically easier to isolate during reoperative surgery. However, the more distal native artery might offer better patency to the outflow revascularization. The purpose of the present study was to compare the outcomes of infrainguinal bypass using the hood of a previous inflow bypass vs the native artery as the inflow source.Methods: A single vascular group's database was queried for all cases of infrainguinal bypass performed after previous prosthetic inflow bypass to a femoral artery from January 2006 to December 2016. The demographics, indications, operative details, and long-term results were recorded and analyzed. Two groups were compared stratified by the location of the proximal anastomosis for the distal bypass. In one group, the inflow source for the distal bypass was from the hood of a previous inflow graft (prosthetic). In the second group, the distal native arterial tree was used as the inflow source. A subset analysis of the patency of the distal bypass was also performed between the two groups for those in which the previous inflow reconstruction had become occluded. Patency was calculated using the Kaplan-Meier method.Results: A total of 197 patients had undergone infrainguinal bypass after previous inflow bypass from 2006 to 2016. Of the 197 procedures, 59 (30%) had used the hood of the previous bypass as the inflow source (prosthetic group) and 138 (70%) had used the native artery distal to the hood of the inflow bypass as the inflow source (native group). The indications were similar between the two groups. The two groups had a similar proportion of men and a similar incidence of hypertension, hyperlipidemia, coronary artery disease, tobacco use, and renal disease. The previous inflow procedures were also similar between the two groups. The native artery used for the inflow source in the native group was the profunda femoris in 80 (58%), common femoral artery in 51 (37%), and superficial femoral artery in 7 (5.1%). Patency was significantly greater for the native group at 1 year (91% vs 75%; P= .0221). Also, the patency after inflow bypass occlusion significantly favored the native group at 1 year (87% vs 40%; P = .0035).Conclusions: Infrainguinal bypass performed after previous ipsilateral inflow bypass offers the option of using the hood of the bypass or a native artery as the inflow source. The present study demonstrated greater patency rates when using the distal native artery as the inflow source. The native artery option also offered continued patency when the inflow bypass occluded.