Surgical bypass is an integral part of the care for patients with symptomatic lower extremity peripheral artery disease (PAD), particularly in the setting of unfavorable endovascular arterial anatomy. Major decision algorithms for a surgical bypass include type of conduit, target vessel selection, postoperative graft surveillance, and adjunctive antithrombotic regimen. Graft thrombosis and associated sequelae remain the most feared long-term limb complications following bypass despite optimal surgical technique. Greater saphenous vein (GSV) is well established as the optimal conduit for infra-inguinal bypass with vein quality being the greatest determinant of long-term outcomes of lower extremity bypass. Unfortunately, a large subgroup of PAD patients will not have adequate saphenous vein available.

Alternate veins have been used with success in many centers, but this is far from universal practice. Therefore, prosthetic conduits are frequently used, particularly when the distal target artery is above the knee joint. While some earlier trials suggested no difference between prosthetic and vein conduits for above-knee bypass, more recent trial data demonstrated that saphenous vein is superior to prosthetic for bypass to the above-knee popliteal artery. For bypass targets below the knee, prosthetic conduits have inferior patency rates compared to venous. Reports of heparin bonded prosthetic conduits have been limited to registries.

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Mishita
Jornal co-ordinator
Journal of Heart and Cardiovascular Research