Arm veins versus contralateral greater saphenous veins for lower extremity bypass reconstruction: preliminary data of a randomized study

Descriptive Analysis of Amputation-Free Survival After First Time Infra-Inguinal Bypass Occlusion

INTRODUCTION

Occlusion after infra-inguinal bypass surgery for peripheral artery disease is a major complication with potentially devastating consequences. In this descriptive analysis, we sought to describe the natural history and explore factors associated with long-term major amputation-free survival following occlusion of a first-time infra-inguinal bypass.

METHODS

Using a prospective database from a tertiary care vascular center, we conducted a retrospective cohort study of all patients with peripheral artery disease who underwent a first-time infra-inguinal bypass and subsequently suffered a graft occlusion (1997-2021). The primary outcome was longitudinal rate of major amputation-free survival after bypass occlusion. Cox proportional hazard models were used to generate hazard ratios (HRs) and 95% confidence intervals (CIs) to explore predictors of outcomes.

RESULTS

Of the 1318 first-time infra-inguinal bypass surgeries performed over the study period, 255 bypasses occluded and were included in our analysis. Mean age was 66.7 (12.6) years, 40.4% were female, and indication for index bypass was chronic limb threatening ischemia (CLTI) in 89.8% (n = 229). 48.2% (n = 123) of index bypass conduits used great saphenous vein, 29.0% (n = 74) prosthetic graft, and 22.8% (n = 58) an alternative conduit. Median (interquartile range) time to bypass occlusion was 6.8 (2.3-19.0) months, and patients were followed for median of 4.3 (1.7-8.1) years after bypass occlusion. Following occlusion, 38.04% underwent no revascularization, 32.94% graft salvage procedure, 25.1% new bypass, and 3.92% native artery recanalization. Major amputation-free survival following occlusion was 56.9% (50.6%-62.8%) at 1 y, 37.1% (31%-43.3%) at 5 y, and 17.2% (11.9%-23.2%) at 10 y. In multivariable analysis, factors associated with lower amputation-free survival were older age, female sex, advanced cardiorenal comorbidities, CLTI at index procedure, CLTI at time of occlusion, and distal index bypass outflow. Initial treatment after occlusion with both a new surgical bypass (HR 0.44, CI: 0.29-0.67) or a graft salvage procedure (HR 0.56, CI: 0.38-0.82) showed improved amputation-free survival. One-year rate of major amputation or death were 59.8% (50.0%-69.6%) for those who underwent no revascularization, 37.9% (28.7%-49.0%) for graft salvage, and 26.7% (17.6%-39.5%) for new bypass.

CONCLUSIONS

Long-term major amputation-free survival is low after occlusion of a first-time infra-inguinal bypass. While several nonmodifiable risk factors were associated with lower amputation-free survival, treatment after graft occlusion with either a new bypass or a graft salvage procedure may improve longitudinal outcomes.

Case report of superficial femoral artery and popliteal artery aneurysm repair using brachial vein

BACKGROUND

Several veins have been well-recognized as acceptable conduits for infrainguinal bypass surgery when the ipsilateral greater saphenous vein is unavailable. However, there is a paucity of literature describing the brachial vein as an adequate alternative. In the absence of other viable autogenous conduits, we describe the use of a brachial vein as a successful alternative for lower extremity revascularization.

METHODS

A 70-year-old man presented with a chief complaint of right calf pain. Duplex ultrasound imaging of his right lower extremity revealed right-sided 2.5 cm acutely thrombosed superficial femoral artery and popliteal artery aneurysms. The patient underwent a suction thrombectomy with tissue plasminogen activator using the Power Pulse feature and Solent catheter from the AngioJet® (Boston-Scientific, Marlborough, MA) system. To repair the thrombosed aneurysms, an open bypass was planned. Due to lack of viable alternative traditionally used venous conduits, a bypass was created using the patient's brachial vein.

RESULTS

A bypass was created from the superficial femoral artery to the P2 segment of the popliteal artery using a non-reversed brachial vein with ligation of the side branches of the superficial femoral artery and popliteal artery aneurysm from within the sac lumen. Completion angiogram revealed runoff through the anterior tibial artery only. Follow-up imaging at three months demonstrated a patent brachial bypass.

CONCLUSION

Brachial veins can be safely used as viable venous conduits for lower extremity bypass surgery and should therefore be considered as an alternative when more commonly used veins are unsuitable or unavailable. However, more research is needed to determine the potential opportunities and challenges this alternative may present.

The Upper-Arm Basilic-Cephalic Loop: A Valueable Alternative for Below-Knee Arterial Reconstruction

INTRODUCTION

Despite advances of endovascular interventions, bypass surgery remains the gold standard for treatment of long and complex arterial occlusions in the lower limb. Autologous vein is regarded superior to other options. As the graft of first choice, the great saphenous vein (GSV) is often not available due to previous bypass, stripping or poor quality. Other options like arm veins (AV) are important alternatives. As forearm portions of AVs are often unusable, a graft created from the upper arm basilic and cephalic veins provides a valuable alternative.

PATIENTS AND METHODS

We analyzed consecutive patients treated at an academic tertiary referral center between 01/1998 and 07/2018 using arm veins as the main peripheral bypass graft. Study endpoints were primary patency, secondary patency, limb salvage and survival.

RESULTS

In the observed time period 2702 bypass procedures were performed at our institution for below-knee arterial reconstructions. Vein grafts used included the ipsilateral GSV (iGSV; n = 1937/71.7%), contralateral GSV (cGSV; 192/7.1%), small saphenous vein (SSV; 133/4.9%), prosthetic conduits (61/2.3%) and different configurations of AV (379/14%). In the majority of patients receiving AV grafts a complete continuous cephalic or basilic vein (CAV) was used (n = 292/77%). If it was not possible to use major parts of these 2 veins, either spliced arm vein grafts (SAV) (42/11%) or an upper arm basilic-cephalic loop graft (45/12%) were used. Median follow-up was 27 (interquartile range: 8-50) months. After 3 years secondary patency (CAV: 85%; SAV: 62%; loop: 66%; p = 0.125) and limb salvage rates (CAV: 79%, SAV: 68%; loop: 79%; p = 0.346) were similar between the 3 bypass options.

CONCLUSION

The encouraging results of alternative AV configurations highlight their value in case the basilic or cephalic veins are not useable in continuity. Especially for infragenual redo-bypass procedures, these techniques should be considered to offer patients durable revascularization options.

Arm Vein versus Small Saphenous Vein for Lower Extremity Bypass in the Absence of Both Great Saphenous Veins

BACKGROUND

Bypass surgery remains the gold standard for long and complex arterial occlusions in the lower limb. The vein is regarded superior to prosthetic conduits in peripheral arterial bypass surgery. However, this option is often limited because of previous bypass, stripping, or poor quality of the ipsilateral and/or contralateral great saphenous vein (GSV). Under these circumstances, the arm vein (AV) and small saphenous vein (SSV) are the only alternative autologous vein grafts.

METHODS

We analyzed all consecutive patients treated at an academic tertiary referral center between January 1998 and July 2018 using either the AV or SSV as the main peripheral bypass graft. Study end points were primary patency, secondary patency, limb salvage, and survival.

RESULTS

In total, 416 bypass procedures using exclusively AV (n = 327) or SSV (n = 89) were performed. There was a predominance of male gender. The majority of risk factors were evenly distributed between groups. The mean follow-up period was 2.3 years (0.9 to 13.3 years). Five-year primary and secondary patency rates were 39% (95% CI: 31-47%) and 67% (59-75%) for AV and 53% (41-66%) and 76% (67-86%) for SSV, respectively (P = 0.2 and 0.25). The five-year limb salvage and survival rates were 71% (68-81%) and 84% (77-90%) for AV and 78% (67-88%) and 90% (82-98%) for SSV, respectively (P = 0.52 and 0.11).

CONCLUSIONS

Both AV and SSV are equally effective alternatives for peripheral bypass if no GSV is available. Although there was a trend toward better results with the SSV, there was no significant difference between the 2 options.

The role of infragenicular spliced vein bypass surgery in patients with chronic limb-threatening ischemia: single center long-term results

BACKGROUND

In patients requiring infrageniculate surgical revascularization a single-segment great saphenous vein (SS-GSV) is the optimal conduit. In the absence of a SS-GSV, the small saphenous vein and arm veins can also be used to obtain an all-autologous bypass. The aim of this study was to compare the long-term results of infrageniculate SS-GSV bypasses and spliced vein bypasses in patients with chronic limb-threatening ischemia (CLTI).

METHODS

A total of 308 consecutive CLTI patients who underwent a primary infragenicular, autologous bypass between January 2000 and December 2016 were included. The definition of a spliced vein bypass was a graft consisting of at least two venous segments.

RESULTS

A SS-GSV graft was used in 235 patients, and a spliced vein graft was used in 73 patients. Significantly more infrapopliteal bypasses were performed in the spliced vein group (P=0.024), and in this group the mean operation time was almost 60 minutes longer (P<0.001). The overall morbidity rate was 44%. The overall 30-day mortality was 3.2%, and overall in-hospital mortality was 4.9%. No significant differences were observed between the groups in mortality, overall morbidity or any specific complication. Comparing the SS-GSV group with the spliced vein group, no significant differences were observed between overall survival (53.2% vs. 45.7%), primary patency (55.5% vs. 53.2%), assisted primary patency (78.5% vs. 76.5%), secondary patency (87.9% vs. 90.6%) and limb salvage (83.3% vs. 82.0%).

CONCLUSIONS

The use of infrageniculate spliced vein bypasses for the treatment of CLTI patients results in similar results compared with infrageniculate SS-GSV bypass grafts. A strict surveillance protocol in the first 2 years and a liberal reintervention strategy may result in excellent long-term patency rates.

Graft type for femoro-popliteal bypass surgery

BACKGROUND

Femoro-popliteal bypass is implemented to save limbs that might otherwise require amputation, in patients with ischaemic rest pain or tissue loss; and to improve walking distance in patients with severe life-limiting claudication. Contemporary practice involves grafts using autologous vein, polytetrafluoroethylene (PTFE) or Dacron as a bypass conduit. This is the second update of a Cochrane review first published in 1999 and last updated in 2010.

OBJECTIVES

To assess the effects of bypass graft type in the treatment of stenosis or occlusion of the femoro-popliteal arterial segment, for above- and below-knee femoro-popliteal bypass grafts.

SEARCH METHODS

For this update, the Cochrane Vascular Information Specialist searched the Vascular Specialised Register (13 March 2017) and CENTRAL (2017, Issue 2). Trial registries were also searched.

SELECTION CRITERIA

We included randomised trials comparing at least two different types of femoro-popliteal grafts for arterial reconstruction in patients with femoro-popliteal ischaemia. Randomised controlled trials comparing bypass grafting to angioplasty or to other interventions were not included.

DATA COLLECTION AND ANALYSIS

Both review authors (GKA and CPT) independently screened studies, extracted data, assessed trials for risk of bias and graded the quality of the evidence using GRADE criteria.

MAIN RESULTS

We included nineteen randomised controlled trials, with a total of 3123 patients (2547 above-knee, 576 below-knee bypass surgery). In total, nine graft types were compared (autologous vein, polytetrafluoroethylene (PTFE) with and without vein cuff, human umbilical vein (HUV), polyurethane (PUR), Dacron and heparin bonded Dacron (HBD); FUSION BIOLINE and Dacron with external support). Studies differed in which graft types they compared and follow-up ranged from six months to 10 years.Above-knee bypassFor above-knee bypass, there was moderate-quality evidence that autologous vein grafts improve primary patency compared to prosthetic grafts by 60 months (Peto odds ratio (OR) 0.47, 95% confidence interval (CI) 0.28 to 0.80; 3 studies, 269 limbs; P = 0.005). We found low-quality evidence to suggest that this benefit translated to improved secondary patency by 60 months (Peto OR 0.41, 95% CI 0.22 to 0.74; 2 studies, 176 limbs; P = 0.003).We found no clear difference between Dacron and PTFE graft types for primary patency by 60 months (Peto OR 1.67, 95% CI 0.96 to 2.90; 2 studies, 247 limbs; low-quality evidence). We found low-quality evidence that Dacron grafts improved secondary patency over PTFE by 24 months (Peto OR 1.54, 95% CI 1.04 to 2.28; 2 studies, 528 limbs; P = 0.03), an effect which continued to 60 months in the single trial reporting this timepoint (Peto OR 2.43, 95% CI 1.31 to 4.53; 167 limbs; P = 0.005).Externally supported prosthetic grafts had inferior primary patency at 24 months when compared to unsupported prosthetic grafts (Peto OR 2.08, 95% CI 1.29 to 3.35; 2 studies, 270 limbs; P = 0.003). Secondary patency was similarly affected in the single trial reporting this outcome (Peto OR 2.25, 95% CI 1.24 to 4.07; 236 limbs; P = 0.008). No data were available for 60 months follow-up.HUV showed benefits in primary patency over PTFE at 24 months (Peto OR 4.80, 95% CI 1.76 to 13.06; 82 limbs; P = 0.002). This benefit was still seen at 60 months (Peto OR 3.75, 95% CI 1.46 to 9.62; 69 limbs; P = 0.006), but this was only compared in one trial. Results were similar for secondary patency at 24 months (Peto OR 4.01, 95% CI 1.44 to 11.17; 93 limbs) and at 60 months (Peto OR 3.87, 95% CI 1.65 to 9.05; 93 limbs).We found HBD to be superior to PTFE for primary patency at 60 months for above-knee bypass, but these results were based on a single trial (Peto OR 0.38, 95% CI 0.20 to 0.72; 146 limbs; very low-quality evidence). There was no difference in primary patency between HBD and HUV for above-knee bypass in the one small study which reported this outcome.We found only one small trial studying PUR and it showed very poor primary and secondary patency rates which were inferior to Dacron at all time points.Below-knee bypassFor bypass below the knee, we found no graft type to be superior to any other in terms of primary patency, though one trial showed improved secondary patency of HUV over PTFE at all time points to 24 months (Peto OR 3.40, 95% CI 1.45 to 7.97; 88 limbs; P = 0.005).One study compared PTFE alone to PTFE with vein cuff; very low-quality evidence indicates no effect to either primary or secondary patency at 24 months (Peto OR 1.08, 95% CI 0.58 to 2.01; 182 limbs; 2 studies; P = 0.80 and Peto OR 1.22, 95% CI 0.67 to 2.23; 181 limbs; 2 studies; P = 0.51 respectively)Limited data were available for limb survival, and those studies reporting on this outcome showed no clear difference between graft types for this outcome. Antiplatelet and anticoagulant protocols varied extensively between trials, and in some cases within trials.The overall quality of the evidence ranged from very low to moderate. Issues which affected the quality of the evidence included differences in the design of the trials, and differences in the types of grafts they compared. These differences meant we were often only able to combine and analyse small numbers of participants and this resulted in uncertainty over the true effects of the graft type used.

AUTHORS' CONCLUSIONS

There was moderate-quality evidence of improved long-term (60 months) primary patency for autologous vein grafts when compared to prosthetic materials for above-knee bypasses. In the long term (two to five years) there was low-quality evidence that Dacron confers a small secondary patency benefit over PTFE for above-knee bypass. Only very low-quality data exist on below-knee bypasses, so we are uncertain which graft type is best. Further randomised data are needed to ascertain whether this information translates into an improvement in limb survival.

Lower Extremity Arterial Bypass with Arm Vein Conduits and Literature Review

Purpose:

The superiority of autogenous vein conduits is well known in lower extremity arterial bypass (LEAB). Among various alternative conduits for LEAB, long-term results of arm vein grafts were investigated in this study.

Materials and Methods:

We retrospectively reviewed clinical characteristics of 28 patients who underwent infrainguinal LEAB with autogenous arm vein grafts at a single institute between January 2003 and December 2015. All procedures were performed in the absence of adequate saphenous veins. Graft patency was determined by periodic examinations with duplex ultrasonography.

Results:

Autologous arm vein grafts were implanted for 28 patients (mean age, 60.4±16.8 years; range, 20–82 years; male, 92.9%; atherosclerosis, 19 [67.9%]; and non-atherosclerotic disease 9 [32.1%] including 5 patients with Buerger’s disease). Source of arm vein were basilic 13 (46.4%), cephalic 4 (14.3%) and composition graft with other veins in 11 (39.3%) cases. The level of distal anastomosis was distributed as popliteal in 5 (17.9%), tibio-peroneal in 21 (75.0%) and inframalleolar artery in 2 (7.1%) cases. Mean duration of follow-up was 41.5±46.9 months (range, 1–138 months). Cumulative primary patency rates at 1, 3, and 5 years were 66.5%, 60.9% and 60.9%, respectively. Assisted-primary patency rates at 1, 3 and 5 years were 66.5%, 66.5% and 66.5%, respectively. Secondary patency rates at 1, 3 and 5 years were 70.8%, 70.8% and 70.8%, respectively. There was one limb amputation during the follow-up period.

Conclusion:

Arm veins are a useful alternative conduit when great saphenous veins are not available during LEAB.