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Role of Bypass with Preoperatively Diagnosed Small Caliber Veins in Chronic Limb-Threatening Ischemia
Keisuke Miyake1, Takashi Nakamura2, Hironobu Fujimura3
1Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan; Department of Vascular Surgery, Japan Organization of Occupational Health and Safety, Osaka Rosai Hospital, Sakai, Osaka, Japan.
Insights
Bypass surgery using small caliber vein grafts can achieve good wound healing in chronic limb-threatening ischemia (CLTI) patients. Despite lower primary patency, these grafts offer comparable wound healing and recurrence-free rates, making them a viable option.
Area of Science:
- Vascular Surgery
- Limb Salvage
- Ischemia Management
Background:
- Chronic limb-threatening ischemia (CLTI) often requires bypass surgery, but graft availability is a limitation.
- Preoperative assessment of vein diameter is crucial for graft selection in bypass procedures.
- The efficacy of using small caliber veins (<2.5 mm) for infrainguinal bypass in CLTI remains under investigation.
Purpose of the Study:
- To evaluate the effectiveness of infrainguinal bypass using small caliber vein grafts (SMGs) for wound healing in CLTI patients.
- To compare wound-related outcomes between SMGs and sufficient caliber grafts (SUGs) in WIfI stage 3/4 CLTI.
Main Methods:
- Ninety-five CLTI limbs (WIfI stage 3/4) underwent infrainguinal bypass with veins, categorized by diameter (<2.5 mm for SMGs, ≥2.5 mm for SUGs).
- Wound healing rate (WHR), wound recurrence-free rate (WRF), and wound recurrence-free amputation-free survival rate (WRAFS) were assessed.
- Propensity score matching was used to compare outcomes between 21 matched pairs of SMGs and SUGs.
Main Results:
- SMGs showed significantly lower 1-year primary patency rates (51.0% crude, 41.6% matched) compared to SUGs (82.1% crude, 77.7% matched).
- Secondary patency rates were comparable between SMGs and SUGs (83.1% vs. 81.8% crude, 78.4% vs. 77.7% matched).
- One-year WHR, WRF, and WRAFS were equivalent between SMGs and SUGs in both crude and matched analyses.
Conclusions:
- Infrainguinal bypass with small caliber vein grafts achieves comparable wound healing and recurrence-free rates to sufficient caliber grafts in CLTI.
- Despite inferior primary patency, secondary patency and wound outcomes support the use of SMGs when grafts remain patent.
- Small caliber vein grafts represent a valuable option for limb salvage in CLTI patients, addressing graft unavailability limitations.
Background:
In chronic limb-threatening ischemia (CLTI), although recent studies suggested that limbs classified as a higher Wound, Ischemia, foot Infection (WIfI) stage would benefit more from bypass surgery than endovascular therapy (EVT), graft unavailability is a major limitation for bypass. However, such graft unavailability is not clearly defined. This study aimed to assess whether bypass with veins judged as small by preoperative ultrasound is acceptable to achieve wound healing.
Methods:
Ninety-five limbs classified as WIfI stage 3/4 that underwent infrainguinal bypass with veins were enrolled and divided into two groups based on the preoperative inner diameter of veins. Those with a diameter <2.5 mm were classified as small caliber grafts (SMGs, n=28) and those with a diameter ≥2.5 mm as sufficient caliber grafts (SUGs, n=67), and wound-related outcomes were evaluated. Wound healing rate (WHR) was analyzed in all cohort, and wound recurrence-free rate (WRF) and wound recurrence-free amputation-free survival rate (WRAFS) were calculated for limbs that achieved wound healing. A propensity score matched analysis was also performed to minimize the background difference, and 21 matched pairs were included for the analysis.
Results:
Although the primary patency rate was significantly worse in SMGs (1-year patency, Crude model: 82.1% in SUGs and 51.0% in SMGs, P=0.0003; matched model: 77.7% in SUGs and 41.6% in SMGs, P = 0.005), the secondary patency rate was maintained in the equivalent level (1-year patency, Crude model: 81.8% in SUGs and 83.1% in SMGs, P=0.26; matched model: 77.7% in SUGs and 78.4% in SMGs, P = 0.24). One-year WHR was equivalent between the groups in both crude and matched models (Crude model: 87.0% in SUGs and 83.8% in SMGs, P=0.13; matched model: 66.3% in SUGs and 61.4% in SMGs, P = 0.65). One-year WRF and WRAFS were also equivalent (Crude model: WRF, 95.9% in SUGs and 100% in SMGs, P = 0.71; WRAFS, 87.2% in SUGs and 88.0% in SMGs, P = 0.78. Matched model: WRF, 100% in SUGs and 100% in SMGs, P = 0.85; WRAFS, 92.9% in SUGs and 78.6% in SMGs, P = 0.38).
Conclusions:
Although bypass with small caliber veins showed an inferior primary patency rate, WHR and WRF were equally good if grafts are maintained patent. Bypass with small caliber vein grafts would be an important option to achieve wound healing.
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