Availability of a Suitable Single-Segment Great Saphenous Vein in Patients with Severe Peripheral Arterial Disease

The Best Endovascular versus Best Surgical Therapy in Patients with chronic limb-threatening ischemia (BEST-CLI) trial found that in patients with an adequate (≥3.0 mm) single-segment great saphenous vein (GSV), surgical bypass resulted in superior outcomes when compared to endovascular intervention. Thus, the prevalence of an adequate GSV is an essential factor in planning appropriate intervention for patients with chronic limb-threatening ischemia (CLTI). However, the percentage of patients with an adequate GSV remains unknown. The objective of this study was to report the prevalence of an adequate GSV in patients with CLTI.

This was a single-center retrospective analysis of patients with CLTI, defined as an ankle-brachial index (ABI) ≤ 0.60 with appropriate symptoms (i.e., rest pain, arterial ulceration), who underwent bilateral sonographic GSV mapping from May 2023 to November 2023. Ipsilateral GSV was defined as the symptomatic limb with the lowest recorded ABI. GSV diameter measurements were collected in 7 locations from the saphenofemoral junction (SFJ) to the distal calf. To be considered an adequate GSV, all unilateral GSV diameter measurements from the SFJ to the midcalf must have been at least 3.0 mm. Patients who underwent previous lower extremity bypass procedures were excluded.

Seventy patients with CLTI were identified during the study period. Only 11.4% (8/70) of patients had a completely adequate ipsilateral GSV; if the contralateral vein was also included, rates of GSV adequacy increased to 14.3% (10/70). There were no differences in demographics between patients who had adequate GSV and those who did not. Seven patients (10%) were missing an ipsilateral GSV due to a previous coronary bypass, and 1 patient (1.4%) had superficial venous thrombosis in their GSV. Patients with an inadequate ipsilateral GSV were less likely to have an adequate contralateral GSV (4.8% vs. 50.0%, P < 0.001). The rates of GSV diameter ≥3 mm decreased as measurements were recorded more distally: 80% of GSVs were adequate at the level of the SFJ, 21% were adequate at the proximal-calf level, and only 9% were adequate at the distal-calf level.

The majority of patients presenting with CLTI at our institution did not have a sonographically adequate ipsilateral nor contralateral GSV available for surgical bypass to the infrageniculate popliteal or tibial arteries. The rates of GSV diameter ≥3 mm in the calf were extremely low overall. Despite the improved outcomes in surgical bypass patients demonstrated in BEST-CLI, endovascular intervention will likely remain frequently utilized due to the low prevalence of an adequate GSV.