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Peripheral arterial bypass is an effective procedure for the management of patients with critical limb ischaemia. However, it is commonly associated with high rates of graft occlusion and subsequent limb loss. This is particularly apparent when the distal anastomosis is to the below-knee arterial segment. A number of studies have suggested that an arteriovenous fistula (AVF) sited at the distal anastomosis may reduce afterload, improve graft patency, and boost subsequent limb salvage. The aim of this study was to assess the effects of adjuvant AVF on the outcomes of peripheral arterial bypass.
Methods
The following databases were searched up to May 2015: Medline through Pubmed; the Cochrane Library; EMBASE; and reference lists of articles.
Study eligibility
All randomised controlled and observational studies that assessed the role of AVF as an adjunct to peripheral arterial bypass were included. Studies were required to include at least one pre-defined outcome. Data were extracted and assessed by two reviewers with any disagreements adjudicated on by the senior author. Pooled risk ratios were calculated using a random effects model. Additional subgroup analyses were performed.
Results
Two randomised controlled trials and seven retrospective cohort studies comprising 966 participants were included. Pooled standardized data showed no difference in primary graft patency (pooled RR = 1.25, 95% CI 0.73–2.16), secondary patency (pooled RR = 1.16, 95% CI 0.82–1.66), or limb salvage at 12-months (pooled RR = 1.13, 95% CI 0.80–1.60) for the peripheral bypass with AVF group compared with peripheral bypass alone. Subgroup analysis indicated a reduction in reintervention rates associated with AVF when performed in conjunction with a synthetic graft (pooled RR = 0.55, 95% CI 0.30–0.98).
Conclusion
Although adjuvant AVF is not associated with additional operative complication there is little evidence to support its use. The evidence assessing its merits is weakened by small, retrospective studies with heterogeneous cohorts.
Peripheral bypass is commonly associated with high rates of graft occlusion and subsequent limb loss. This is particularly apparent when the distal anastomosis is to the below knee arterial segment. Because of this challenge, a number of adjuncts to distal bypass have been assessed, with some studies suggesting that an arteriovenous fistula (AVF) sited at the distal anastomosis may improve operative outcomes. These data have not previously been systematically analysed. This review indicates that although distal AVF formation is not associated with additional morbidity compared with standard bypass, there is little evidence to support the use of adjuvant AVF in peripheral bypass.
Introduction
Peripheral arterial disease (PAD) is a common problem
Prevalence of and risk factors for peripheral arterial disease in the United States: results from the National Health and Nutrition Examination Survey, 1999–2000.
recommends open surgical bypass for TASC type C and D lesions. Unfortunately, despite its undoubted benefits, lower limb bypass continues to be associated with high graft failure rates.
These smaller crural vessels are often heavily diseased and anastomosis of a bypass graft to these vessels distally is associated with lower graft patency rates. This is more pronounced the more distant the anastomosis from the tibio-peroneal trunk.
The high resistance, low flow state seen in distal bypass contributes to graft occlusion in a predictable fashion. This concept has been proposed by Sauvage et al.
The thrombotic threshold velocity described is a flow rate below that arterial thrombosis occurs predictably. The fashioning of an arteriovenous fistula (AVF) at the distal anastomosis is hypothesized to counteract this flow limiting state. It provides an alternative flow conduit through which blood can be diverted thus reducing the afterload created by the high resistance of a diseased infrapopliteal segment. This allows maintenance arterial flow above the thrombotic threshold velocity.
Unfortunately, to date, the literature assessing the use of adjunctive AVF is characterized by small, heterogeneous studies with wide-ranging outcomes. Hence the true effect of adjunctive AVF on graft patency and limb salvage remains unclear. This systematic review aims to assess the effect of AVF on graft patency and limb salvage in peripheral arterial bypass.
Methods
Statement of design
This review was carried out in accordance with the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses.”
All randomised controlled trials (RCT) and observational studies that compared the role of AVF as an adjunct to peripheral arterial bypass with peripheral arterial bypass without AVF were included. Case reports were excluded from analysis. No limitation was set as per the date, journal or language of publication.
Population intervention comparison outcome
The study group consisted of patients with significant peripheral arterial disease requiring bypass surgery. Who had undergone peripheral bypass with adjunctive AVF. Subjects with peripheral bypass but no adjunctive AVF were used as the control. The primary outcome was primary graft patency at 12 months.
Secondary outcomes included:
•
secondary graft patency at 12 months
•
limb salvage rate at 12 months
•
reintervention rate: any reported graft reintervention with a view to re-establishing or maintain graft arterial flow
•
30-day mortality rate
•
operative complication rate: any reported complication as a result of the original bypass procedure.
Of note was significant arterial disease including debilitating claudicants and patients with critical limb ischaemia. Eligible studies were required to report on any or all outcomes including patency rates, limb salvage rates, reintervention rates, complication rates, and mortality rates of both the intervention and control group. Meta-analysis data for patency and limb salvage rates were extracted from the numbers at risk attached to Kaplan–Meier curves.
Search methodology
Online medical literature databases including Medline through Pubmed, EMBASE and CENTRAL were systematically searched. A comprehensive literature search was last carried out in May 2015 by two reviewers (TA/DO’N). We searched Medline through Pubmed without date or language restriction using the following search strategy: ((((fistula) OR arteriovenous fistula) OR AV fistula) OR A-V fistula) AND bypass. A total of 1961 articles were retrieved. After the filter was applied, (Comparative study, Clinical study, Observational study, Randomised controlled trial), 117 studies were identified. Both Embase and the Cochrane library were also searched in a similar fashion using the above strategy.
Data collection
Data were collected and assessed for inaccuracies by two reviewers (TA/DO’N) using a standardized data collection sheet. Any disagreements were discussed between both reviewers with any residual disagreements resolved by consultation with the senior author. Two studies had missing data of interest
Pre-gangrenous or gangrenous changes in 100%. No comparison of baseline patient characteristics between groups
Glutaraldehdye stabilized umbilical vein (GUV) to tibial or peroneal artery with adjuvant AVF (61) vs. distal bypass (GUV) alone (49)
Patients requiring peripheral bypass with evidence of pre-gangreneprogressive frank gangreneevidence of poor crural vessel quality either pre- or intraoperatively
Non critical ischaemia in the intervention group alone A pre-op angiogram demonstrating healthy crural vessels with intact pedal archintraoperative evidencehealthy artery with good run off Not reported for comparative group
Majority had critical limb ischaemia. Groups well matched for age, sex, diabetes, smoking, previous surgery and degree of rest pain/tissue loss
Synthetic femorocrural bypass with adjuvant AVF and vein cuff (43) vs. synthetic femorocrural bypass with adjuvant AVF (76) vs. vein femorocrural bypass alone (179)
Patients requiring peripheral femorocrural bypass for lower limb ischaemia
Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
69 years (AVF group) 77 years (control group) Significant
52% female (AVF group) 50% female (control group)
Critical limb ischaemia with no suitable vein for grafting in 100%. Reported difference between groups for age, Fontaine class and toe pressures. No difference for diabetes, smoking, hypertension, ABPI and cholesterol
Infrapopliteal synthetic bypass with adjuvant AVF (44) vs. infrapopliteal synthetic bypass alone (12)
Patients requiring peripheral bypass with critical limb ischaemia
Critical limb ischaemia with suitable vein for grafting in 100%. No reported difference between groups for age, diabetes, hypertension, ischaemic heart disease, and renal failure
Infrapopliteal autogenous bypass with adjuvant AVF (77) vs. infrapopliteal autogenous bypass alone (77)
Patients requiring peripheral bypass with critical limb ischaemia presence of autogenous vein
ScanPAC Study Group Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
Critical limb ischaemia with no suitable vein for grafting in 100%. No reported difference between groups for diabetes, hypertension, ischaemic heart disease, smoking, cerebrovascular disease and renal failure
Below knee PTFE bypass with both interposition vein cuff and adjuvant AVF (31) vs. below knee PTFE bypass and vein cuff alone (28)
outcomes: primary and secondary outcomes were extracted.
The risk of bias in each individual study was assessed using the Downs and Black quality assessment tool for both randomised and non randomised studies.
The feasibility of creating a checklist for the assessment of the methodological quality of both of the randomised and non-randomised studies of health care interventions.
Statistical heterogeneity between published works was assessed using Cochran's Q statistic. A p value < .05 was considered to be statistically significant. Bias evaluation was performed in conjunction with previously published guidance.
Following pooled data analysis, subgroup analyses were carried out including analysis of randomised studies, outcomes of synthetic graft in conjunction with AVF alone, and outcomes of vein graft in conjunction with AVF alone.
The initial search yielded 1,069 initial abstracts with 18 full text articles reviewed for potential inclusion. After eligibility assessment nine studies were identified for qualitative analysis. At this point, nine papers were excluded from the analysis
Complementary distal arteriovenous fistula and deep vein interposition: a five-year experience with a new technique to improve infrapopliteal prosthetic bypass patency.
Comparison between supra- and infrainguinal inflow sites for infrapopliteal PTFE bypasses with complementary arteriovenous fistula and vein interposition.
Polytetrafluoroethylene bypasses to infrapopliteal arteries without cuffs or patches: a better option than amputation in patients without autologous vein.
Complementary distal arteriovenous fistula and deep vein interposition: a five-year experience with a new technique to improve infrapopliteal prosthetic bypass patency.
Comparison between supra- and infrainguinal inflow sites for infrapopliteal PTFE bypasses with complementary arteriovenous fistula and vein interposition.
Polytetrafluoroethylene bypasses to infrapopliteal arteries without cuffs or patches: a better option than amputation in patients without autologous vein.
Update on the role of the distal arteriovenous fistula as an adjunct for improving graft patency and limb salvage rates after crural revascularization.
ScanPAC Study Group Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
The characteristics, inclusion criteria and outcomes of each study are summarised in Table 1. All studies compared the merits of adjunctive AVF with peripheral arterial bypass to a control peripheral bypass group. Two studies
Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
ScanPAC Study Group Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
compared the use of AVF in conjunction with synthetic peripheral bypass with a control synthetic bypass group. These studies included two randomised and five retrospective cohort studies
included patients with debilitating claudication for bypass, with all other patients included having critical limb ischaemia. Patient baseline demographics, inclusion, and exclusion criteria are reported in Table 1.
Risk of bias
Individual risk of bias for each study is summarised in Table 2 using the Downs and Black quality assessment tool.
The feasibility of creating a checklist for the assessment of the methodological quality of both of the randomised and non-randomised studies of health care interventions.
Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
ScanPAC Study Group Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
The evidence assessing the merits of adjunctive AVF was generally weakened by small, retrospective studies with heterogeneous cohorts. Individual Downs and Black scores are included in Table 2 with a median score of 18 calculated across all nine studies.
Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
ScanPAC Study Group Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
ScanPAC Study Group Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
including 408 bypass procedures included data suitable for meta-analysis. In the intervention group 84 of 203 bypasses remained patent at 12 months, with 69 of 205 remaining patent in the control (pooled RR = 1.25, 95% CI 0.73–2.16) (Fig. 2). Further subgroup analysis revealed no significant difference in primary patency rates when RCTs were separately analysed
ScanPAC Study Group Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
(primary patency of 29/79 intervention group vs. 26/69 control at 12 months) (RR = 0.98, 95% CI 0.64–1.48) or studies assessing synthetic grafts were compared
Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
ScanPAC Study Group Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
(primary patency of 54/126 intervention vs. 36/128 control) (pooled RR = 1.43, 95% CI 0.67–3.06).
Figure 2Forest plots show results of meta-analysis of peripheral arterial bypass with adjuvant arteriovenous fistula compared with bypass alone for primary graft patency of all studies. The solid squares represent the relative risk, the horizontal lines represent the 95% confidence intervals (CIs), and the diamond represent the pooled relative risk.
reporting a 2-year primary patency rate of 61% for prosthetic grafts with adjuvant AVF and vein cuff, 25% for grafts with AVF alone and 64% for vein grafts.
Secondary patency
All studies examined the role of AVF with regard to secondary patency. Seven studies provided data for meta-analysis.
Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
ScanPAC Study Group Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
A total of 842 procedures were included in this group. At 12 months 152 of 397 in the intervention group versus 164/445 in the control group maintained secondary patency (pooled RR = 1.16, 95% CI 0.82–1.66) (Fig. 3).
Figure 3Forest plots show results of meta-analysis of peripheral arterial bypass with adjuvant arteriovenous fistula compared with bypass alone for secondary graft patency of all studies included. The solid squares represent the relative risk, the horizontal lines represent the 95% confidence intervals (CIs), and the diamond represent the pooled relative risk.
ScanPAC Study Group Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
ScanPAC Study Group Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
studies including 732 procedures providing data suitable for meta-analysis. At 1 year 158 of 336 in the AVF group and 173 of 396 in the non-AVF group had retained their limbs post bypass (pooled RR = 1.13, 95% CI 0.80–1.60) (Fig. 4).
Figure 4Forest plots show results of meta-analysis of peripheral arterial bypass with adjuvant arteriovenous fistula compared with bypass alone for limb salvage rates of all studies included. The solid squares represent the relative risk, the horizontal lines represent the 95% confidence intervals (CIs), and the diamond represent the pooled relative risk.
ScanPAC Study Group Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
ScanPAC Study Group Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
ScanPAC Study Group Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
included for meta-analysis. In total, 434 bypasses were included with 37 of 217 in the AVF group requiring reintervention after bypass compared with 51 of 217 in the non-AVF group (pooled RR = 0.74, 95% CI 0.51–1.06).
Significantly more reinterventions were seen in the control group when the pooled synthetic graft data
Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
ScanPAC Study Group Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
were examined (pooled RR = 0.55, 95% CI 0.30–0.98) (Fig. 5).
Figure 5Forest plots show results of meta-analysis of peripheral arterial bypass with adjuvant arteriovenous fistula compared with bypass alone for re-intervention of studies assessing synthetic grafts. The solid squares represent the relative risk, the horizontal lines represent the 95% confidence intervals (CIs), and the diamond represent the pooled relative risk.
ScanPAC Study Group Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
Three studies including 320 procedures reported on operative complications. In the AVF group 43 of 156 had a reported complication versus 57 of 164 in the non-AVF cohort. These were primarily cardiorespiratory and wound complications. Of note, a total of nine graft infections were reported, with three observed in the AVF group and six in the control group. Meta-analysis of three studies
Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
ScanPAC Study Group Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
confirmed no significant difference in operative complications between groups (pooled RR = 0.81, 95% CI 0.51–1.30) while meta-analysis of five further studies
Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
ScanPAC Study Group Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
revealed no significant difference in 30-day mortality (pooled RR = 0.84, 95% CI 0.19–3.75).
Risk of bias across studies
Bias was investigated using further sensitivity analyses of larger studies (>100 participants), studies excluding the incorporation of veins cuffs, and studies examining the relationship of cuffed grafts with or without AVF and AVF alone. Of note, only limb salvage in grafts associated with distal vein cuff displayed a statistically significant improvement in outcome (RR = 0.49, 95% CI 0.32–0.77).
Discussion
This review has shown that although the use of adjuvant AVF in peripheral arterial bypass is not associated with additional morbidity (with no impact on operative complications or 30-day mortality), it did not offer superior patency of the grafts at 12 months, increased rates of limb salvage, or reduced reintervention rates. However, those undergoing synthetic grafting with AVF experienced a lower reintervention rate than those with synthetic graft alone, suggesting that AVF may have a role to play in reducing graft occlusion in synthetic grafts only. Of note, included data were subject to a significant risk of bias (Table 2).
Quality of the evidence
This review comprised nine studies, including two RCTs and seven cohort studies. Each article reported on a minimum of two study outcomes, with four reporting on all six. However, variable methodological quality was identified with a median Downs and Black score of 18. Although both RCTs were deemed to be at a moderate risk of bias, the included cohort studies reported outcomes of small, retrospective studies with heterogeneous cohorts, with six studies deemed to be at a relatively high risk of bias (Table 2).
Significance of results to practice
Patency rates in femoral below-knee bypass remain relatively poor, particularly in patients with no available autologous venous conduit.
However, aggressive policies toward both limb salvage and coronary revascularization may increasingly necessitate the use of synthetic bypass materials as autogenous vein availability wanes.
Because of this challenge a number of adjuncts to distal synthetic bypass have been assessed. Vein cuffs have previously been subject to review with Khalil et al.
who noted marginally improved patency and limb salvage at 2 years for femoral below-knee popliteal cuffed bypass with no benefit seen distally. This has also been suggested by the results of this analysis examining the relationship of cuffed grafts with or without AVF and AVF alone.
This review has not indicated that an AVF has any impact on the patency or limb salvage rates associated with either synthetic or vein grafts. However, the intervention was not associated with any increase in operative complications or mortality, although it is associated with longer operating times.
ScanPAC Study Group Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
Thus, at the very least it offers a similar complication rate to standard bypass procedures and may be associated with a modest reduction in reintervention rates when a synthetic graft is used.
Comparisons beyond 12 months (12–36 months) have been carried out by many of the included studies with the majority
Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
ScanPAC Study Group Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
ScanPAC Study Group Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
Update on the role of the distal arteriovenous fistula as an adjunct for improving graft patency and limb salvage rates after crural revascularization.
published series data comparing the use of AVF as an adjunct to bypass over three decades. Interestingly, primary and secondary patency rates as well as limb salvage progressively improved over the study period. These outcomes would suggest that the continued refinement of this operative technique and improved patient selection might result in a continued evolution in outcomes. However, until these endpoints are consistently identified by randomised data this technique is likely to remain an underused adjunct to peripheral bypass.
Study strengths and limitations
This review is subject to a number of limitations. Many of the included studies were deemed to be at significant risk of bias. The majority were retrospectively performed cohort studies involving small numbers of patients. In fact, the expected superiority of venous conduits for bypass was not identified on subgroup analysis, suggesting that numbers in this particular analysis were too small to identify a meaningful outcome. In addition, studies were generally old with no recent comparative studies, suggesting that adjunctive AVF is not a widely used technique in modern bypass surgery. The randomised studies included assessed relatively small numbers of procedures with no power calculations. Although study groups in the RCT were well matched, a number of the cohort studies reported on heterogeneous sets of patients. In addition, while each study compared the use of an adjunctive fistula with a suitable control, there was some variation in the exact operative technique employed in each individual study with further sensitivity analysis suggesting that cuffed grafts may have resulted in a degree of data contamination. Finally, raw data from two studies
could not be attained and were not included for meta-analysis.
The comprehensive protocol-derived methodology is the primary strength of this review. All data-based studies assessing AVF have been systematically identified by two independent reviewers, assessed for bias, and included for systematic review. To date, this is the most complete assessment of adjunctive AVF to peripheral arterial bypass.
Conclusions
Peripheral arterial bypass remains the gold standard of care in patients with severe lower limb arterial disease with long-segment vessel occlusion. However, graft patency and limb salvage continue to challenge surgeons, particularly in bypasses to the distal arterial segment. To date, the literature assessing the use of adjunctive AVF is subjected to bias, weakened by small, retrospective studies with heterogeneous cohorts (Table 2). Data from this analysis suggest that while the use of an AVF is associated with a similar complication rate to standard bypass, there is little evidence to support its use to improve either graft patency or limb salvage rates.
Conflict of Interest
None.
Funding
None.
References
Criqui M.H.
Franek A.
Barrett-Connor E.
Klauber M.R.
Gabriel S.
Goodman D.
The prevalence of peripheral arterial disease in a defined population.
Prevalence of and risk factors for peripheral arterial disease in the United States: results from the National Health and Nutrition Examination Survey, 1999–2000.
The feasibility of creating a checklist for the assessment of the methodological quality of both of the randomised and non-randomised studies of health care interventions.
Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
Complementary distal arteriovenous fistula and deep vein interposition: a five-year experience with a new technique to improve infrapopliteal prosthetic bypass patency.
Comparison between supra- and infrainguinal inflow sites for infrapopliteal PTFE bypasses with complementary arteriovenous fistula and vein interposition.
Polytetrafluoroethylene bypasses to infrapopliteal arteries without cuffs or patches: a better option than amputation in patients without autologous vein.
Update on the role of the distal arteriovenous fistula as an adjunct for improving graft patency and limb salvage rates after crural revascularization.
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