Infrainguinal bypass with alternative conduits in diabetic patients with chronic limb-threatening ischemia

Chronic limb-threatening ischemia (CLTI) patients with diabetes mellitus (DM) have increased risk for major amputation despite surgical revascularization. As demonstrated in BEST-CLI (Best Surgery versus Best Endovascular Therapy in Critical Limb Ischemia), autologous great saphenous vein (GSV) remains the standard for revascularization in CLTI. However, alternative conduits such as autologous arm vein (AAV) and nonautologous biologic (cryovein) were infrequently used in the trial. Using data from the Vascular Quality Initiative, this study examined the outcomes of patients with DM undergoing infrainguinal bypass with AAV and cryovein for CLTI.

The prospectively collected Vascular Quality Initiative database was retrospectively queried for all patients with DM undergoing infrainguinal bypass for CLTI between 2010 and 2023. Patients were stratified into three cohorts according to the type of graft they received. Baseline characteristics and outcomes for the AAV and cryovein cohorts were compared individually with the GSV group. The primary outcome was amputation-free survival; long-term freedom from index limb reintervention and freedom from major adverse limb events (MALEs) were analyzed as secondary outcomes.

Of 17,701 patients with DM undergoing bypass, 87.0% (n = 15,393) received a GSV, 3.5% (n = 616) received an AAV, and 9.6% (n = 1692) received a cryovein. There was no difference in perioperative mortality and early thrombosis between the AAV and GSV groups. Patients in the cryovein cohort, however, demonstrated significantly higher rates of perioperative graft occlusion (3.8% vs 1.5%; P < .001) and major amputation (4.1% vs 1.9%; P < .001) compared with GSV patients, with no difference in mortality. Kaplan-Meier analyses demonstrate that amputation-free survival rates at 5 years were lower for patients receiving cryovein as compared with those receiving GSV (55.8% vs 70.4%; P < .001). Patients receiving AAV exhibited similar rates of amputation-free survival (69.0% vs 70.4%; P = .9) and freedom from MALEs (66.4% vs 68.4%; P = .5) compared with GSV patients at 5 years, whereas cryovein patients experienced significantly more MALEs (55.0% vs 68.4%; P < .001). After multivariate regression analysis, cryovein was independently associated with increased amputation or death (hazard ratio, 1.64; 95% confidence interval, 1.4-1.8) when compared with GSV, whereas AAV demonstrated no difference (hazard ratio, 0.91; 95% confidence interval, 0.7-1.1).

AAV is an effective alternative conduit to GSV in patients with DM undergoing infrainguinal bypass for CLTI. Cryovein has inferior outcomes to GSV, but seems to offer acceptable limb salvage in patients with no other options for conduit.