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Prospective randomized multicenter comparison of in situ and reversed vein infrapopliteal bypasses
K R Wengerter1, F J Veith, S K Gupta
1Division of Vascular Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY.
Insights
This study found no significant difference in vein graft patency for limb salvage surgery comparing in situ versus reversed vein grafts. Both methods demonstrated similar long-term success rates for critical lower extremity ischemia.
Area of Science:
- Vascular Surgery
- Regenerative Medicine
- Biomaterials Science
Background:
- Critical lower extremity ischemia necessitates advanced surgical interventions.
- Vein grafts are crucial for limb salvage bypass procedures.
- Comparing in situ and reversed vein graft techniques is vital for optimizing outcomes.
Purpose of the Study:
- To prospectively compare the efficacy of in situ versus reversed vein grafts for long limb salvage bypasses.
- To evaluate secondary patency rates and complication incidence between the two graft types.
- To analyze graft failure mechanisms in a randomized, multicenter setting.
Main Methods:
- Prospective, randomized, multicenter study involving 125 patients with critical lower extremity ischemia.
- Comparison of in situ (n=62) versus reversed (n=63) great saphenous vein grafts for femoropopliteal bypass.
- Assessment of secondary patency at 30 months and angiographic evaluation of graft lesions.
Main Results:
- Overall secondary patency rates at 30 months were similar: 69% +/- 8% for in situ and 67% +/- 9% for reversed grafts.
- For small diameter veins (<=3.0 mm), 24-month patency showed a trend favoring in situ grafts (61% vs. 37%), though not statistically significant.
- Graft failure analysis revealed similar lesion types (hyperplasia, stenosis) and frequencies in both groups.
Conclusions:
- In situ and reversed vein grafts demonstrate comparable overall patency rates for long limb salvage bypasses.
- While not statistically significant, smaller in situ grafts may offer better patency in select cases.
- Both techniques present similar risks of complications and mortality, indicating comparable safety profiles.
Abstract:
We have performed a prospective, randomized, multicenter study to compare in situ and reversed vein grafts for long limb salvage bypasses from the proximal thigh to an infrapopliteal artery. Three hundred eighty-four patients required an infrapopliteal bypass for critical lower extremity ischemia. Of these, 259 were excluded because a short vein bypass was performed or because the vein was considered inadequate. The remaining 125 patients had a randomized vein bypass, 63 reversed, 62 in situ. The two groups were similar with regard to risk factors, indications, graft dimensions, and outflow. Secondary patency at 30 months was similar for both techniques: reversed 67% +/- 9% (+/- SE); in situ 69% +/- 8%. For veins less than or equal to 3.0 mm in minimum distended diameter 24-month patency rates were 61% +/- 22% for 12 in situ veins and 37% +/- 29% for 10 reversed veins (p greater than 0.05). Angiographic evaluation of failing grafts revealed lesions similar in type and frequency in both types of grafts. These included focal (in situ, n = 4; reversed, n = 7) and diffuse vein hyperplasia (in situ, n = 2; reversed, n = 1), and inflow and outflow stenoses (in situ, n = 4; reversed, n = 3). The incidence of wound complications and the mortality rate were similar for the two groups. These data show no significant difference in overall patency rates for the two types of vein grafts at 2 1/2 years.(ABSTRACT TRUNCATED AT 250 WORDS)