Adjuvant distal arteriovenous shunt with femorotibial bypass for critical ischaemia.

In a series of 59 femorotibial bypass operations for critical ischaemia an arteriovenous (A-V) shunt was constructed at the distal anastomosis in 36 patients whose pedal angiograms showed an occlusion in the primary pedal arch. Mean blood flow recorded in the grafts without the shunt in the patients whose primary pedal arch was occluded was 83.6 +/- 9.9 ml/min (mean +/- s.e.m.) compared with 152 +/- 16.2 ml/min in those patients whose primary pedal arch was intact (P less than 0.01). This increased to 236 +/- 20.5 ml/min with the shunt open (P less than 0.001). Twelve months after operation the cumulative patency rate for grafts with an A-V shunt was 46.5 per cent compared with 40.5 per cent for grafts in the better risk patients with a patent primary pedal arch who did not receive a shunt. No side effects were observed due to the presence of a shunt. The importance of the primary pedal arch and the rationale of adjuvant distal arteriovenous shunt are discussed. The results indicate that the addition of an arteriovenous shunt at the distal anastomosis of a long femorotibial bypass is of benefit when blood flow through the graft is limited by occlusive disease in the pedal arteries.