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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
Predictors of amputation-free survival and wound healing after infrainguinal bypass with alternative conduits
Zachary A Matthay1, William A Pace1, Eric J Smith2
1Department of Surgery, University of California, San Francisco, San Francisco, CA.
Insights
For chronic limb-threatening ischemia (CLTI), autogenous arm/spliced vein or PTFE bypass offers better amputation-free survival (AFS) than cryopreserved vein grafts. Cryopreserved grafts should be used cautiously in high-risk patients.
Area of Science:
- Vascular Surgery
- Limb Salvage Surgery
- Regenerative Medicine
Background:
- Autologous single segment greater saphenous vein (ssGSV) is often unsuitable for infrainguinal bypass in chronic limb-threatening ischemia (CLTI).
- Predictors of outcomes using alternative conduits for CLTI bypass are not well-defined.
Purpose of the Study:
- To investigate patient outcomes, specifically amputation-free survival (AFS), after infrainguinal bypass using alternative conduits in CLTI patients.
- To identify predictors of AFS based on limb presentation, bypass target, and conduit type.
Main Methods:
- Retrospective analysis of 139 infrainguinal bypasses for CLTI (2013-2020).
- Conduits included cryopreserved ssGSV (cryovein), polytetrafluoroethylene (PTFE), and arm/spliced vein grafts.
- Analysis using multivariable Cox proportional hazards and classification and regression tree models for AFS predictors.
Main Results:
- Two-year AFS was 53% for cryovein, 78% for spliced/arm vein, and 79% for PTFE.
- Cryovein use was associated with significantly lower AFS (adjusted hazard ratio, 2.5; P=.02).
- In cryovein group, WIfI stage 3/4, age >70, and prior failed bypass predicted lowest AFS (36%).
Conclusions:
- Autogenous arm/spliced vein and PTFE conduits demonstrate superior AFS compared to cryovein for CLTI bypass when ssGSV is unavailable.
- Cryovein grafts, despite lower patency, achieved wound healing in most cases.
- Cryovein should be used judiciously in older CLTI patients with high WIfI stage and previous failed bypass due to poor AFS.
Objective:
Inadequate vein quality or prior harvest precludes use of autologous single segment greater saphenous vein (ssGSV) in many patients with chronic limb-threatening ischemia (CLTI). Predictors of patient outcome after infrainguinal bypass with alternative (non-ssGSV) conduits are not well-understood. We explored whether limb presentation, bypass target, and conduit type were associated with amputation-free survival (AFS) after infrainguinal bypass using alternative conduits.
Methods:
A single-center retrospective study (2013-2020) was conducted of 139 infrainguinal bypasses performed for CLTI with cryopreserved ssGSV (cryovein) (n = 71), polytetrafluoroethylene (PTFE) (n = 23), or arm/spliced vein grafts (n = 45). Characteristics, Wound, Ischemia, and foot Infection (WIfI) stage, and outcomes were recorded. Multivariable Cox proportional hazards and classification and regression tree analysis modeled predictors of AFS.
Results:
Within 139 cases, the mean age was 71 years, 59% of patients were male, and 51% of cases were nonelective. More patients undergoing bypass with cryovein were WIfI stage 4 (41%) compared with PTFE (13%) or arm/spliced vein (27%) (P = .04). Across groups, AFS at 2 years was 78% for spliced/arm, 79% for PTFE, and 53% for cryovein (adjusted hazard ratio for cryovein, 2.5; P = .02). Among cases using cryovein, classification and regression tree analysis showed that WIfI stage 3 or 4, age >70 years, and prior failed bypass were predictive of the lowest AFS at 2 years of 36% vs AFS of 58% to 76% among subgroups with less than two of these factors. Although secondary patency at 2 years was worse in the cryovein group (26% vs 68% and 89% in arm/spliced and PTFE groups; P < .01), in patients with tissue loss there was no statistically significant difference in wound healing in the cryovein group (72%) compared with other bypass types (72% vs 87%, respectively; P = .12).
Conclusions:
In patients with CLTI lacking suitable ssGSV, bypass with autogenous arm/spliced vein or PTFE has superior AFS compared with cryovein, although data were limited for PTFE conduits for distal targets. Despite poor patency with cryovein, wound healing is achieved in a majority of cases, although it should be used with caution in older patients with high WIfI stage and prior failed bypass, given the low rates of AFS.
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