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Synergizing Antegrade Endoscopic with Bridging Vein Harvesting for Improvement of Great Saphenous Vein Graft Quality from the Lower Leg
Published on: November 19, 2019
Optimal conduit choice for open lower extremity bypass in chronic limb-threatening ischemia
Jones P Thomas1, Kristine L So1, Jason T Turner1
1Department of Surgery, Division of Vascular Surgery and Endovascular Therapies, University Hospitals Cleveland Medical Center, Case Western University, Cleveland, OH.
Insights
Open bypass surgery is key for chronic limb-threatening ischemia (CLTI). New research shows low-dose rivaroxaban with aspirin improves outcomes for revascularized patients, reducing adverse events without significant bleeding risk.
Area of Science:
- Vascular Surgery
- Cardiovascular Medicine
- Regenerative Medicine
Background:
- Chronic limb-threatening ischemia (CLTI) management requires tailored revascularization strategies based on clinical presentation (rest pain vs. tissue loss).
- Autologous saphenous vein grafts are preferred conduits for bypass surgery due to superior patency and low infection rates.
- Alternative conduits including arm veins, small saphenous veins, prosthetic grafts, and cryovein offer viable options when saphenous vein is unavailable.
Purpose of the Study:
- To review current strategies for open bypass surgery in CLTI.
- To discuss the role of different bypass conduits and their patency rates.
- To highlight the impact of the VOYAGER PAD trial on postoperative management.
Main Methods:
- Review of established surgical techniques for CLTI bypass.
- Analysis of patency data for various autologous and prosthetic conduits.
- Discussion of postoperative surveillance methods (ABI, duplex ultrasound) for graft monitoring.
- Inclusion of findings from the VOYAGER PAD trial regarding pharmacotherapy.
Main Results:
- Saphenous vein grafts offer the best outcomes, with alternatives like arm vein, small saphenous vein, and prosthetic grafts providing acceptable patency.
- Postoperative surveillance using ankle-brachial index and duplex ultrasound is crucial for detecting graft failure.
- The VOYAGER PAD trial demonstrated that low-dose rivaroxaban plus aspirin significantly reduced major adverse events in revascularized patients without increasing bleeding risk.
Conclusions:
- Open bypass surgery remains a critical intervention for limb salvage in CLTI.
- Graft selection should be individualized, with saphenous vein as the primary choice, supported by alternatives and prosthetic options.
- Pharmacotherapy with low-dose rivaroxaban and aspirin represents a significant advancement in reducing adverse outcomes post-CLTI revascularization.
Abstract:
Open bypass surgery remains a major tool for limb salvage in chronic limb-threatening ischemia (CLTI). Although rest pain and tissue loss both fall into the category of CLTI, goals of revascularization are markedly different for each context. Rest pain mandates long-term patency considerations. Tissue loss, however, requires consideration of infection risks and patency enough to heal the wound. Of the major conduit options, autologous saphenous vein graft continues to be the conduit of choice, given both superior patency and low risk of infection. When saphenous vein graft is not available or not available in appropriate length, arm vein, small saphenous vein, and spliced combinations of these have acceptable patency rates. Heparin-bonded polytetrafluoroethylene and Dacron grafts are prosthetic conduits with excellent patency rates when vein is not available. For infected wounds without other options, cryovein continues to provide acceptable patency for limb salvage. Creation of a bypass is only part of CLTI management. Appropriate postoperative surveillance with noninvasive studies, including ankle-brachial index and duplex ultrasound, can alert to impending graft failure, with a drop in ankle-brachial index of 0.15 and velocity ratios of 3 or more suggestive of significant stenoses. Anticoagulation has only been found in limited contexts (such as poor conduit or poor outflow) to offer some patency benefit, however, findings from the VOYAGER PAD (Vascular Outcomes Study of ASA [Acetylsalicylic Acid] Along With Rivaroxaban in Endovascular or Surgical Limb Revascularization for PAD) trial were a major breakthrough, showing a reduction in the composite outcome of major adverse limb, cardiac, and cerebrovascular events in revascularized patients taking low-dose rivaroxaban in conjunction with aspirin, without a substantial increase in bleeding risk.
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