A decade of experience with the glutaraldehyde-tanned human umbilical cord vein graft for revascularization of the lower limb

Between October 1975 and November 1985, 907 lower limb bypasses were constructed in 715 patients (799 limbs) with glutaraldehyde-stabilized umbilical veins (UV-G) used as the predominant, or sole, graft material. Each reconstruction was classified in one of eight categories depending on the site of the distal anastomosis: above- and below-knee popliteal, anterior and posterior tibial, peroneal, trifurcation, sequential, and crural (tibial or peroneal) bypasses with adjunctive distal arteriovenous fistulas. Primary and secondary cumulative graft patency rates were determined for each category as well as cumulative actual palliation that combines end points of graft failure, amputation, and death. Halflife patencies for popliteal, tibial, and peroneal bypasses were 6.5, 2.3, and 1.7 years, respectively. Perioperative graft thrombosis occurred in 11% of popliteal reconstructions compared with 22% for the crural group. Nonocclusive graft failure caused by infection, aneurysm, or progressive foot gangrene occurred in 87 grafts (8%). The overall infection rate was 4.3%. Anastomotic aneurysms (1.4%) and strictures (2.1%) occurred infrequently as isolated phenomena. The incidence of graft dilatation and aneurysms assumed significant proportion after 5 years (36% aneurysms and 21% dilation); the diagnosis was particularly facilitated by B-mode imaging. Nevertheless, the overall clinical impact of graft degradation remained minimal (6% after 5 years). Twenty-two of 26 graft aneurysms were excised with successful graft replacement achieved in 10. During this 10-year period, our attitudes did change with regard to the indication for UV-Gs in relation to the maturation of infrapopliteal reconstructive surgery, appreciation of the superior results attainable with in situ saphenous vein, recognition of morphologic changes in long-term UV-G implants, and the growing documentation of poor results with polytetrafluorethylene in the crural position. We believe that UV-G is an acceptable alternative to the absent or deficient autologous vein, particularly in patients with limited life expectancy and where expediency may be a critical factor.