Adjunctive Techniques: Distal Anastomosis of an Infrainguinal Prosthetic Bypass

Abstract

Neointimal hyperplasia is a leading cause of bypass failure in the intermediate postoperative period (2–24 months). In prosthetic bypasses, neointimal hyperplasia is most likely to develop at the level of the distal anastomosis. Several techniques have been developed in an attempt to improve the patency of infrainguinal prosthetic bypasses. These techniques involve incorporating a segment of vein between the prosthetic bypass and the recipient artery. The theory behind these techniques is that the interposition of the vein segment may ameliorate the future development of neointimal hyperplasia at the level of the distal anastomosis. In addition, incorporating the vein segment could facilitate the construction of the distal anastomosis and improve bypass patency in the immediate postoperative period. Although these techniques were often used, there are very few prospective randomized trials to date that show their efficacy. Furthermore, there are no prospective randomized trials that compare these various techniques in an attempt to identify which technique is best. With the advancement of endovascular technology and the availability of aggressive infrainguinal and infrapopliteal revascularization options, including retrograde pedal and popliteal access, tibial prosthetic bypasses are rarely performed nowadays. Nevertheless, when used as a last resort prior to an amputation, adjunctive techniques may be useful.