Difficult Decisions: What To Use When the Ideal Bypass Conduit is not Available in Critical Limb Ischemia Patients?

The optimal conduit for Infrainguinal bypass (IIB) is single-segment great saphenous vein (GSV). Unfortunately, GSV is not always available in patients with chronic limb-threatening ischemia (CLTI). Other graft choices include alternate autogenous veins (AV), prosthetic grafts (PG), or biologic grafts (BG). Current data regarding the durability and limb salvage rates of those options is scarce; hence, we aimed to investigate the impact of alternative graft types on postoperative and long-term outcomes on IIB in patients with CLTI. The VQI database was queried for patients undergoing IIB from January 2012 to October 2023. Patients were stratified into three groups based on graft material used: AV (upper arm veins, short saphenous vein, or spliced autogenous vein), PG (Dacron or polytetrafluoroethylene), and BG (cadaveric, homograft, or xenograft). Composite vein and prosthetic graft were excluded. Logistic regression modeling analyzed differences for primary outcomes, which include in-hospital death, graft patency, major amputation, and blood transfusion. Multivariable Cox regression analysis, log rank test, and Kaplan-Meier estimates were used to report 1-year survival. Backward stepwise selection was implemented to identify significant variables for inclusion in the final models. A total of 16,810 IIB procedures have been analyzed, Seventy-three percent (12,366) of those procedures were performed using PG, while 16.84% (2831) and 9.60% (1613) were performed using BG and AV, respectively. Patients receiving AV had the longest operative time and were more likely to be male, White, obese, diabetic, and on statin. BG group had higher proportion of patients who are on dialysis, Hispanic, and with prior contralateral major amputation. Compared to AV, patients in the BG and PG groups had almost double the odds of in-hospital major amputation (BG: OR, 2.45; 95% CI, 1.49-4.06; P < .001; PG: OR, 1.91; 95% CI, 1.20-3.02; P = .006) (Table I). Furthermore, the AV group had the highest one-year survival compared to BG and PG (BG: HR, 1.40; 95% CI, 1.12-1.75; P = .004; PG: HR, 1.27; 95% CI, 1.05-1.54; P = .014) (Fig 1). BG was associated with two-thirds higher odds of graft occlusion compared to AV (OR, 1.67; 95% CI, 1.02-2.76; P = .043). PG and BG were both associated with lower risk of receiving more than two units of blood compared to AV (P < .05). Alternative AV grafts provide better postoperative durability, freedom from in-hospital major amputation, and 1-year survival compared to PGs and BGs. Further evidence is required to support this conclusion.TableOutcomes of PG vs AV, BG vs AV, and PG vs BGPG vs AVBG vs AVPG vs BGOR/HR (95% CI)P valueOR/HR (95% CI)P valueOR/HR (95% CI)P valueIn-hospital Death1.27 (0.77-2.11).3540.81 (0.45-1.47).4961.49 (1.05-2.12).026 Occluded graft0.83 (0.54-1.27).3841.67 (1.02-2.76).0430.74 (0.54-1.01).054 Major amputation1.91 (1.20-3.02).0062.45 (1.49-4.06)<.0010.86 (0.64-1.15).309 RTOR0.86 (0.73-1.01).0721.19 (0.96-1.48).1180.77 (0.65-0.91).002 Transfusion > 2 pRBC0.81 (0.68-0.96).0170.72 (0.60-0.87).0011.09 (0.94-1.27).269Follow-up 30-day mortality1.02 (0.69-1.52).9210.75 (0.48-1.20).2321.42 (1.06-1.91).020 1-year mortality1.27 (1.05-1.54).0141.40 (1.12-1.75).0040.99 (0.88-1.12).877CI, Confidence interval; HR, hazard ratio; OR, odds ratio; pRBC, packed red blood cells; RTOR, return to operating room. Open table in a new tab