peripheral arterial disease ( pad ) is a worldwide problem that has significant impact on quality of life and can also lead to mortality ( 1 ) . as a result of the increased life expectancy and increased elderly population , patients with pad may be asymptomatic , or they may present with intermittent claudication or chronic critical limb ischemia . the management of patients with pad is complex and includes pharmacological therapy and/or surgery ( 3 ) . surgical reconstruction can be an effective treatment that improves quality of life in case of claudication and save the limb in severe ischemia ( 4 ) . however , since pad is encountered usually in elderly patients with comorbidities , post - operative complications are major concerns ( 2,5 ) . besides , failure of revascularization and graft patency are seen in a proportion of patients ; advent of endovascular intervention has provided alternate method of pad management ( 6,7 ) . this necessitates careful patient selection to achieve most beneficial result from surgical revascularization and avoid potential morbidity and complications . this study reviews experience of a referral center in infrainguinal surgical bypass and surveys patency rate and risk factors associated with failing in achievement of a durable vascular reconstruction . in this analytic prospective cohort study , 85 consecutive patients with chronic ischemia who underwent lower extremity surgical vascular reconstruction ( including 52 femoropopliteal bypass and 25 femorofemoral bypass ) were recruited . this study was done in a two year period from march 2007 to feb 2009 at imam hospital affiliated to tehran university of medical sciences . in addition to demographic data , patients comorbidities and risk factors including ischemic heart disease , diabetes mellitus , hypertension , hyperlipidemia , history of preoperative and post - operative smoking and opium use were also obtained . patency of patients grafts were evaluated before discharge from hospital and one year after the operation using duplex ultrasonography . relation between patients characteristics and one year patency was evaluated using independent - sample t - test , mann - whitney , fisher s exact test , and chi - square tests . in this analytic prospective cohort study , 85 consecutive patients with chronic ischemia who underwent lower extremity surgical vascular reconstruction ( including 52 femoropopliteal bypass and 25 femorofemoral bypass ) were recruited . this study was done in a two year period from march 2007 to feb 2009 at imam hospital affiliated to tehran university of medical sciences . in addition to demographic data , patients comorbidities and risk factors including ischemic heart disease , diabetes mellitus , hypertension , hyperlipidemia , history of preoperative and post - operative smoking and opium use were also obtained . patency of patients grafts were evaluated before discharge from hospital and one year after the operation using duplex ultrasonography . relation between patients characteristics and one year patency was evaluated using independent - sample t - test , mann - whitney , fisher s exact test , and chi - square tests . seventy seven patients were evaluated including 52 with femoropopliteal and 25 with femorofemoral vascular reconstruction . in all cases except for one femoropopliteal patient , saphenous vein grafts were used and in all femorofemoral patient synthetic graft was used . the meansd age of the patients was 61.110.8 year ( range : 39 - 89 year ) . fifty three patients ( 67.9% ) were male and 24 patients ( 32.1% ) were female . the meansdcreatinine level was 0.99  0.24 mg / dl ( range : 0.5 - 1.6 ) , and meansd cardiac ejection fraction ( ef ) was 45.2  6.8 percent ( range : 25 - 55 ) . male to female ratio among those who underwent femoropopliteal and femurofemural grafts were 2.5 to 1 and 1 to 1 , respectively . patient s characteristics and the analyzed correlation between preoperative risk factors and one year patency have been depicted in table 1 . three patients ( 3.8% ) died in post - operative period due to myocardial infarction . the meansd ef was 45.2  6.8 percent in alive and 32.8  6.4 percent in dead patients ( p=0.001 ) . thirty seven patients among those who underwent femoropopliteal graft ( 71% ) and 13 patients among those who underwent femorofemoral graft ( 52% ) showed a one - year complete vascular patency ( p=0.003 ) . among those with failed reconstruction , two ( 3.8% ) patients in the femoropopliteal group and 3 ( 12% ) patients in the femorofemoral group underwent amputation and other patients with failed reconstructions were managed medically . age , sex and creatinine level were not statistically different between those with and without vascular patency ( p<0.05 ) . the meansd ef was 46.2  7.4 percent in patent and 43.07  4.9 percent in non - patent group that showed a significant difference ( p=0.049 ) . patients with claudication , rest pain and ischemic ulcers had not different patency rates ; but diabetes mellitus , ischemic heart disease , hypertension , history of preoperative or postoperative smoking , and opium use were associated with failure of one year vascular patency . peripheral arterial occlusive disease is a major health problem and one of the most challenging vascular problems facing vascular surgeons . the complexity of the disease has been magnified by its association with other medical comorbidities such as cardiovascular and cerebrovascular disease . therefore , risk factor modification seems to be essential to improve long - term survival of these patients ( 3 ) . this study was performed to demonstrate the success and patency rate of infrainguinal vascular reconstruction for peripheral vascular disease and related factors affecting this patency . similar results for femoropopliteal bypasses have been reported in other studies ( 8,9 ) . goodney et al surveyed results of 2036 bypass procedures and reported a one year patency of 79% in patients suffering from claudication and 73% in patient with critical limb ischemia ( 9 ) . in our study , patency rate was not statistically different in patients with critical ischemia compared to patients with claudication . this difference might be due the older mean age of patients in those studies comparing to ours . a cut off age of around 65 - 75 have been shown as a risk factor for patency failure ( 7,8 ) . we found no relation between advanced age and patency rate that is consistent with some other reports ( 9,10 ) . association of opium addiction with increased post - operative complications has been investigated and yielded different results ( 11 - 13).adverse effects of opium on cardiovascular system in experimental and clinical settings has been shown ( 14 - 16 ) . it may be reasonable to consider opium addiction as a risk factor affecting results of surgical reconstruction . it is particularly true when considering that opium addicts may have less compliance to treatment and follow up . diabetes mellitus , hypertension , ischemic heart disease and smoking was associated with decreased patency as are reported in other studies ( 17,18).diabetes has been shown to increase risk of pad , but the effectiveness of tight glycemic control with regard to halting the progression of pad , relieving symptoms of claudication , or increasing amputation - free survival is unclear ( 3,4 ) . hypertension should be treated according to the recommendations of the eighth joint national committee ( 19 ) . while some controversy exists regarding the effect of smoking cessation on regression of symptoms of claudication , the effects of smoking on progression of symptoms , increased risk of amputation , and failure of surgical therapy have been studies . therefore , all patients with pad should be advised to stop smoking ( 3,20 ) . while endovascular treatments have appealing advantage of lower morbidity and mortality , bypass surgery still has better long term outcome for femoropopliteal lesions with reported patency rate of up to 70% at 5 years ( 4 ) . lower extremity endovascular interventions may also result in some complications such as those related to puncture site , intervention site , distal vessel , and also systemic complications ( 21).the use of stent grafts has been studied for treatment of long segment femoropopliteal occlusive disease as well . similar long - term patency has been reported when compared to conventional femoral - popliteal bypass using synthetic conduit ( 22,23 ) . nevertheless , further studies are required to prove long - term effect and cost - effective benefit of these studies . feinglas et al , in their study of 28128 patients who underwent lower extremity surgical bypass reported 30 mortality of 4.8% . they also showed that 31.4% of patients were alive 5 years after their initial operation without major amputation or subsequent bypass or revision procedures ( 24 ) . assessing risk factors that predict perioperative mortality and graft patency is essential for selecting patients that would benefit from surgery . presence of such factors would suggest increased probability of graft occlusion and help surgeons in selecting best candidates for surgery . omitting surgical reconstruction and endovascular intervention may be preferable especially when multiple risk factors are present or in the absence of critical limb ischemia .
background : peripheral arterial disease is a source of morbidity and mortality . surgical vascular 
 reconstruction is a treatment option but probability of failure and complications are important concerns . 
 in this study , we evaluated outcome of surgical infrainguinal reconstruction and factors affecting 
 graft patency for a period of one year . 
 methods : in this cohort study , 85 consecutive patients with chronic ischemia who underwent lower 
 extremity surgical vascular reconstruction ( including 52 femoropopliteal and 25 femorofemoral bypass ) 
 from march 2007 to feb 2009 were recruited . 
 graft patency was evaluated before discharge 
 from hospital and one year after the surgical operation using duplex ultrasonography . 
 association 
 between possible risk factors and graft patency were evaluated . 
 results : in general , 71% ( 37 patients ) of femoropopliteal and 52% ( 13 patients ) of femorofemoral 
 reconstructions were patent during the follow up period . 
 diabetes mellitus , hypertension , smoking , 
 opium use and ischemic heart disease were significantly associated with decreased rate of patency 
 ( p<0.05 ) . 
 conclusion : assessing risk factors that predict perioperative mortality and graft patency is essential 
 for selecting patients that would benefit from surgery . 
 omitting surgical reconstruction and endovascular 
 intervention may be preferable especially when multiple risk factors are present or in the absence 
 of critical limb ischemia .