There is some evidence that a vein cuff at the distal anastomosis site improves primary graft patency rates for below knee PTFE graft, but this does not reduce the risk of limb loss. Evidence for this beneficial effect of vein cuffed PTFE grafts is weak and based on an underpowered trial. Pre-cuffed PTFE grafts have comparable patency and limb salvage rates to vein cuff PTFE grafts. The use of spliced veins improved secondary patency but this did not translate into improved limb salvage. The use of an AVF alone showed no added benefits. A large study with a specific focus on below knee vein cuff prosthetic grafts, including PTFE, is required.
Randomized trial comparing infrainguinal polytetrafluoroethylene bypass grafting with and without vein interposition cuff at the distal anastomosis. The Joint Vascular Research Group.
A multicenter randomized prospective study was undertaken to determine whether an interposition vein cuff improved the short-term and medium-term patency and limb salvage rates of femoral-above-knee and femoral-below-knee popliteal artery polytetrafluoroethylene (PTFE) bypass procedures.
                Two hundred sixty-one bypass operations were randomized (133 to vein cuff and 128 to no vein cuff). One hundred fifty grafts were to the above-knee popliteal artery, 96 to the below-knee popliteal artery, and 15 to tibial vessels. The median follow-up was 617 days.
                The 12-month patency rates for cuffed and uncuffed above-knee popliteal artery PTFE bypass grafts were 80% and 84%, and the 2-year patency rates were 72% and 70%, respectively. The patency rates for bypass grafts to the below-knee popliteal artery at 12 months were 80% and 65% and at 2 years 52% and 29%, respectively (p = 0.03). At the below-knee site, this was reflected in 24-month difference in limb salvage rates of 84% and 62%, respectively (p = 0.08).
                There was no improvement in the patency rate with the use of a distal anastomosis interposition vein cuff in femoral-above-knee popliteal PTFE bypass grafts, but there was a statistically significant advantage when PTFE bypass grafts were anastomosed to the popliteal artery below the knee.