Components of outflow resistance and their correlation with graft patency in lower extremity arterial reconstructions

We have used a simple reproducible method to measure total outflow resistance (OR) and its proximal and distal components in 101 bypasses (46 femoropopliteal [FP] and 55 femorodistal [FD]). All bypasses with a distal OR >1.2 mm Hg/ml/min failed within 3 months and all with distal OR <1.2 mm Hg/ml/min remained patent for at least 3 months. To evaluate the contribution of vasospasm to OR and its role in graft failure, 60 bypasses (29 FP, 31 FD) had OR measurements before and after local infusion of papaverine hydrochloride (60 mg). Within 3 months, nine grafts (all FD) occluded and 51 remained patent. All nine failures had distal OR >1.2 mm Hg/ml/min before papaverine infusion. After infusion, the mean percentage decrease in both total and distal OR for all grafts was 30% and 31%, respectively. However, there was no significant difference between these papaverine-induced decreases in OR and 3-month graft failure or success. Moreover, in three bypasses, even though papaverine lowered the distal OR from >1.2 to <1.2 mm Hg/ml/min, early occlusion occurred. In six grafts (1 FP, 5 FD) when total and distal OR before and after papaverine was >1.2 mm Hg/ml/min, the graft was extended to a second distal artery as a sequential bypass. These six grafts have remained patent over 3 months. Thus measurement of OR and particularly distal OR is a most accurate predictor of early graft success or failure. Pharmacologic manipulation does not enhance the predictive value of the OR measurement. OR measurements also help to select those FD bypass cases in which extension to a second distal artery as a sequential bypass improves patency.