THE POSTERIOR APPROACH TO POPLITEAL-CRURAL BYPASS

Purpose: An evaluation of the posterior approach to popliteal-crural bypass was performed to assess the feasibility and results of this technique. Methods: A posterior approach to the popliteal and crural vessels was performed in 21 patients in the prone position over a 24-month period, with use of lesser saphenous vein and a novel exposure of the crural arteries through the vein harvest incision. Results: Diabetes mellitus was present in 17 (81%) patients, and all had limb-threatening ischemia with rest pain (15 patients, 71%), ulceration (7 patients, 33%), and gangrene (8 patients, 38%). The inflow site was the supragenicular popliteal artery in four patients (19%) and the infragenicular popliteal artery in 17 patients (81%). The outflow sites were the tibioperoneal trunk in six patients (29%), the peroneal artery in nine patients (43%), the posterior tibial artery in four patients (19%), and the anterior tibial artery in two patients (10%). The distal anastomosis was performed in the proximal one third of the crural artery in 16 (76%) of the patients, with a mean lesser saphenous vein graft length of 11.2 +/- 1.7 cm. The toe-brachial pressure indexes rose from 0.20 +/- 0.07 to 0.77 +/- 0.16 (p = 0.001), all wounds healed without complication, and 19 patients (90%) were discharged with open bypass grafts and salvaged extremities. The 6-, 12-, and 18-month primary graft patency rates were 88%, 88%, and 83%, respectively (Kaplan-Meier methods). Conclusions: Thus the posterior approach to infragenicular occlusive disease represents a durable alternative to traditional approaches; sparing the greater saphenous vein, facilitating exposure of the proximal crural arteries, and minimizing the wound healing problems commonly experienced with standard techniques.