Bovine Carotid Artery Graft connecting to a human leg.

Bovine Carotid Artery Graft: A Promising Solution for Leg Bypass?

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Beau Callahan in Health & Wellness October 2026 • 4 min read.

"Exploring the Long-Term Success of Artegraft in Lower Extremity Revascularization"


For years, biological grafts have played a vital role as vascular conduits in leg bypass surgeries. However, information specifically on bovine carotid artery grafts (BCAG) in lower extremity revascularization has been limited. This article explores the outcomes of lower leg bypass procedures using BCAG, offering insights into its effectiveness and long-term results.

This analysis is based on a retrospective review of a prospectively collected database, examining patients who underwent lower extremity bypass using BCAG from 2002 to 2017. The study focused on clinical outcomes, including graft patency (how long the graft stays open and functional) and limb salvage rates.

A total of 124 BCAG (Artegraft, North Brunswick, NJ) were implanted in 120 patients for lower extremity revascularization. The surgical indications varied, including disabling claudication (12%), rest pain (36%), tissue loss (48%), and infected prosthetic graft replacement (3%). In a significant number of cases (72%), the patient's own saphenous vein was either inadequate or absent, making BCAG a crucial alternative.

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BCAG Case Series

Reports of bovine carotid artery grafts (BCAGs) in lower-extremity revascularization have been scarce, although biological grafts have been used as vascular conduits for leg bypass for many years. A retrospective analysis of a prospectively collected database examined 124 Artegraft BCAGs implanted in 120 patients between 2002 and 2017. Indications included disabling claudication in 12% of cases, rest pain in 36%, tissue loss in 48%, and infected prosthetic-graft replacement in 3%.

Established Bypass Options

Lower-extremity bypass generally relies on selecting an appropriate vascular conduit and connecting it around an obstructed arterial segment. The available source material does not identify a single accepted standard method or provide comparative figures for its limitations. Accordingly, the relative advantages and disadvantages of conventional approaches cannot be established from the supplied evidence alone.

Landmarks in Bypass Surgery

A 2024 review, titled “Lower Extremity Bypass for Occlusive Disease: A Brief History,” examined the development of modern lower-extremity bypass surgery. Its reported focus was the identification of critical conceptual, technological, and technical landmarks. The supplied summary does not specify those landmarks individually, so their sequence and clinical effects cannot be described reliably here.

Why Choose BCAG for Lower Extremity Bypass?

Bovine Carotid Artery Graft connecting to a human leg.

BCAG was used in 46 patients (37%) who had a prior failed ipsilateral leg bypass. The distal anastomosis, where the graft connects to the artery, was performed in different locations: above-knee popliteal artery (25%), below-knee popliteal artery (26%), and tibial artery (39%). Notably, a distal anastomotic patch was created in all tibial artery cases to allow for BCAG-tibial reconstruction.

The study revealed promising long-term results. The yearly primary patency rates, indicating how well the graft remained open, were 86.5%, 76.4%, 72.2%, 68.3%, and 67.5% over five years, respectively. Secondary patency rates, which account for interventions to maintain graft function, were even higher at 88.5%, 84.7%, 82.4%, 78.5%, and 75.6%.

  • Compliant.
  • Thromboresistant.
  • Durable.
  • Easy to handle with surgical manipulation and suturing.
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Evidence Still Developing

The supplied source material does not include a specific recent research study or review for this subsection. It therefore does not establish current efficacy, durability, or safety conclusions for bovine carotid artery grafts. Any assessment of the latest evidence would require additional identified research sources.

Unresolved Limitations

The supplied source material does not identify specific failure rates, complications, or counterarguments concerning bovine carotid artery grafts. It consequently cannot support a quantified discussion of graft failure or comparative risk. These issues should be addressed only with studies that report relevant adverse outcomes.

Comparing Conduits

Research has compared autologous vein (AV) with bovine carotid artery graft (BCAG) in traumatic arterial injuries requiring bypass or interposition graft. A separate 2024 study analyzed alternative conduits for infrapopliteal bypass in patients with chronic limb-threatening ischemia. The supplied summaries identify these comparative questions but do not provide outcome figures, so they do not establish that AV or BCAG is superior.

The limb salvage rate at one year was 83.6%, and at five years, it stood at 86.2% for patients with critical limb ischemia, a severe condition characterized by reduced blood flow to the limbs. Multivariate analysis identified a poor runoff score (P = 0.03, 95% CI, 1.3–5.3; OR, 1.6) as independently associated with graft occlusion.

The Future of BCAG in Vascular Surgery

BCAG emerges as a reliable vascular conduit, offering good long-term results in lower extremity bypass procedures. This is particularly significant for patients lacking suitable autologous vein grafts.

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Evidence and Clinical Context

A 2025 systematic review and meta-analysis was designed to compare bypass surgery with endovascular interventions for peripheral artery disease using randomized controlled trials. Separately, the BCAG study addressed lower-leg bypass and noted that reports of BCAG use in lower-extremity revascularization had been scarce. Together, these sources frame BCAG within a broader debate about revascularization strategies, but the supplied summaries do not establish a definitive treatment preference.

Questions for Future Study

The supplied source material does not provide a specific forecast or research program for the future of bovine carotid artery grafts. Important future conclusions therefore cannot be assigned to a named study, date, or projected figure from the available evidence. Further work would need to define which clinical outcomes and comparisons should guide adoption.

Limited Published Experience

The available source describes biological grafts as established vascular conduits for leg bypass while emphasizing that reports of BCAG use in lower-extremity revascularization have been scarce. This limited reporting is an important context for interpreting claims about the graft's broader role. The supplied material does not identify specific access, cost, regulatory, or health-system barriers.

Patients Represented in the Series

The reported BCAG experience involved 124 Artegraft grafts implanted in 120 patients for lower-extremity revascularization. The clinical indications included disabling claudication, rest pain, tissue loss, and infected prosthetic-graft replacement, showing that the series included patients with varied and serious limb-related needs. The supplied summary does not provide individual patient narratives or enough outcome detail to characterize personal long-term experiences.

BCAG offers several advantages. Biological grafts are associated with a lower risk of infection and enhanced graft anastomotic compliance due to their vessel elasticity, while BCAG's structural elasticity and ease of handling during suturing contribute to its appeal among surgeons.

While this study provides valuable insights, further prospective research is needed to compare BCAG with autogenous vein grafts directly. This will help refine our understanding of BCAG's role in lower extremity revascularization and optimize patient outcomes.

What a retrospective graft series can establish

Observational study (level 4 of 8)

Its population was patients undergoing lower-extremity bypass with BCAG; the series can characterize that experience, but it cannot by itself show that BCAG performs better than another conduit.[1]

How to read the bypass findings

The reported association between poor runoff and graft occlusion suggests that the condition of blood flow beyond the graft mattered in this series. It is an association from an observational analysis, not proof that poor runoff caused an occlusion.[1]

The findings describe a graft used in varied bypass settings, including after a previous failed bypass and with tibial reconstruction; they do not establish how outcomes would compare across those settings or against other conduits.[1]

The Artegraft bypass study at a glance

Study designObservational study[1]
PopulationPatients undergoing lower extremity bypass using BCAG[1]
Sample size124 BCAG implanted in 120 patients[1]
Duration2002 to 2017[1]
Main outcomeGraft patency and limb salvage[1]
Confidence interval95% CI 1.3–5.3[1]
p-valueP = 0.03[1]
Times cited35[1]

How other reports place bovine carotid grafts

A review of small-diameter vascular grafts described five-year primary patency for BCAG in a range spanning 50% to 75%, and characterized that result as comparable to autologous vein and possibly better than synthetic grafts.[2]

What a follow-up comparison would need to clarify

  • Would BCAG outcomes differ from autologous vein or synthetic graft outcomes when patient groups and follow-up are directly comparable?[1] [2]
  • How does the observed association between poor runoff and occlusion vary across bypass settings?[1]

Sources

  1. Lower Extremity Bypass Using Bovine Carotid Artery Graft (Artegraft): An Analysis of 124 Cases with Long‐Term Results (Wiley, 2017)
  2. Review: Tissue Engineering of Small-Diameter Vascular Grafts and Their In Vivo Evaluation in Large Animals and Humans (2021)

About this Article -

Written with AI assistance from published research, and reviewed by the Mystum team. See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.1007/s00268-017-4161-x, Alternate LINK

Title: Lower Extremity Bypass Using Bovine Carotid Artery Graft (Artegraft): An Analysis Of 124 Cases With Long-Term Results

Subject: Surgery

Journal: World Journal of Surgery

Publisher: Springer Science and Business Media LLC

Authors: Philip Lindsey, Angela Echeverria, Mathew Cheung, Elias Kfoury, Carlos F. Bechara, Peter H. Lin

Published: 2017-08-17

Everything You Need To Know

1

What exactly is a bovine carotid artery graft (BCAG) and how is it used in leg bypass surgery?

A bovine carotid artery graft (BCAG), such as Artegraft, is a biological graft sourced from a cow's carotid artery. It's surgically implanted to bypass blocked arteries in the leg, restoring blood flow. BCAGs are particularly useful when a patient's own saphenous vein isn't suitable for a traditional bypass.

2

Under what circumstances would a surgeon opt for a bovine carotid artery graft (BCAG) like Artegraft, over using a patient's own vein for a lower extremity bypass?

BCAG's were chosen when patients needed lower extremity bypass surgery and their own saphenous vein was either inadequate or absent in 72% of cases. Additionally, BCAG was utilized in 37% of patients who had a prior failed ipsilateral leg bypass. Indications for lower extremity revascularization with BCAG also included disabling claudication, rest pain, tissue loss, and infected prosthetic graft replacement.

3

What are the long-term success rates, specifically primary and secondary patency, observed with bovine carotid artery grafts (BCAG) in lower extremity bypass procedures?

Primary patency rates for BCAG, which indicate how well the graft remains open, were 86.5%, 76.4%, 72.2%, 68.3%, and 67.5% over five years, respectively. Secondary patency rates, accounting for interventions to maintain graft function, were even higher at 88.5%, 84.7%, 82.4%, 78.5%, and 75.6%. These results show good long-term functionality of the graft.

4

What does 'poor runoff score' mean, and why does it matter for patients who have received a bovine carotid artery graft (BCAG) in their leg?

A poor runoff score was identified as independently associated with graft occlusion after BCAG implantation. Runoff score refers to the quality of the arteries downstream from the bypass graft. A lower runoff score indicates poorer arterial health and reduced blood flow in the lower leg and foot, increasing the risk of graft failure.

5

Besides graft patency and limb salvage, what other outcomes are important to consider when evaluating the success of bovine carotid artery grafts (BCAG) in patients with critical limb ischemia?

Beyond limb salvage and graft patency, other factors influence the overall success and patient satisfaction following BCAG implantation. These include monitoring for infection, managing risk factors like diabetes and smoking, and assessing the patient's overall functional status and quality of life. Future research could explore the impact of these factors and compare BCAG outcomes with other graft types.

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