Predictors of amputation-free survival and wound healing after infrainguinal bypass with alternative conduits

J Vasc Surg. 2024 Jun;79(6):1447-1456.e2. doi: 10.1016/j.jvs.2024.01.209. Epub 2024 Feb 2.

Abstract

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.

Keywords: Chronic limb-threatening ischemia; Limb salvage; Vascular grafting.

Publication types

  • Comparative Study

MeSH terms

  • Aged
  • Aged, 80 and over
  • Amputation, Surgical*
  • Blood Vessel Prosthesis
  • Blood Vessel Prosthesis Implantation / adverse effects
  • Blood Vessel Prosthesis Implantation / instrumentation
  • Blood Vessel Prosthesis Implantation / mortality
  • Chronic Limb-Threatening Ischemia / surgery
  • Cryopreservation
  • Female
  • Humans
  • Limb Salvage*
  • Male
  • Middle Aged
  • Peripheral Arterial Disease* / mortality
  • Peripheral Arterial Disease* / physiopathology
  • Peripheral Arterial Disease* / surgery
  • Polytetrafluoroethylene
  • Progression-Free Survival
  • Retrospective Studies
  • Risk Assessment
  • Risk Factors
  • Saphenous Vein* / transplantation
  • Time Factors
  • Treatment Outcome
  • Vascular Grafting / adverse effects
  • Vascular Grafting / methods
  • Vascular Grafting / mortality
  • Vascular Patency
  • Wound Healing*

Substances

  • Polytetrafluoroethylene