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Contemporary Outcomes of Open Femoropopliteal Bypass by Autogenous Vein Graft in Infra-inguinal Arterial Occlusive Disease

Published:April 22, 2022DOI:https://doi.org/10.1016/j.avsg.2022.04.023

      Background

      Although the majority of patients presenting with symptomatic peripheral arterial disease (PAD) are treated with the endovascular first approach, a significant number of these patients still require open bypass because of the extent of atherosclerotic burden or failure of the endovascular therapy. However, data available on the outcomes of femoropoliteal bypass in the contemporary era of PAD management is scarce. In this study, we evaluate realworld mid-term outcomes of femoropopliteal bypass for PAD.

      Methods

      We identified all patients who underwent open femoropopliteal revascularization with autogenous vein conduits for PAD at one institution between January 2012 and December 2017. Main endpoints included primary patency, amputation-free survival, overall survival, and limb salvage at 2 years. Outcomes were defined as per the Society for Vascular Surgery standards. Descriptive statistics were performed using univariable analyses including the mean and standard deviation for continuous variables and frequency and percentage for categorical variables. Event-free survival rates were estimated using Kaplan-Meier methods.

      Results

      There were 129 patients who received autogenous vein grafts. Median follow-up was 19 months (interquartile rangeIQR 11-26). Patients were predominantly male (59.7%), white (72.9%) with a mean age of 65 ± 11 years. The indications for surgery were disabling claudication in 36.4% of patients (n = 47) and chronic limb threatening ischemia (CLTI) in 63.6% (n = 82). Most patients had Trans-Atlantic Inter-Society Consensus C or D lesions (n = 81, 62.8%). Seventeen cases (16.3%) were redoing bypasses. Arm veins and spliced vein conduits were used in 12% and 7%, respectively. In 66% of procedures, the distal anastomosis was below the knee. Primary patency estimates at 6 months, 1 year and 2 years were 81.3%, 68.6% and 59.2%, respectively. Amputation-free survival rates were 93.4%, 88% and 82.1% at 6 months, 1 year and 2 years, respectively. Limb salvage rates among patients with CLTI were 93.4%, 90.4% and 87.2% at 6 months, 1 year and 2 years, respectively. Overall survival was 97.5%, 92.1% and 87.8% at 6 months, 1 year and 2 years, respectively.

      Conclusions

      In this contemporary cohort of patients, femoropopliteal bypass showed lower patency than previously described. The fact that bypass surgery is performed on sicker patients with more extensive disease in the endovascular era might explain this discrepancy. However, our results demonstrated satisfactory patency and limb salvage rates and suggest that vein should always be used if available.
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      References

        • Conte M.S.
        • Pomposelli F.B.
        • Clair D.G.
        • et al.
        Society for vascular surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: management of asymptomatic disease and claudication.
        J Vasc Surg. 2015; 61: 2S-41S.e1
        • Adam D.J.
        • Beard J.D.
        • Cleveland T.
        • et al.
        Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial.
        Lancet. 2005; 366: 1925-1934
        • Reifsnyder T.
        • Arhuidese I.J.
        • Hicks C.W.
        • et al.
        Contemporary outcomes for open infrainguinal bypass in the endovascular era.
        Ann Vasc Surg. 2016; 30: 52-58
        • Conte M.S.
        • Belkin M.
        • Upchurch G.R.
        • et al.
        Impact of increasing comorbidity on infrainguinal reconstruction: a 20-year perspective.
        Ann Surg. 2001; 233: 445-452
        • Conte M.S.
        • Bradbury A.W.
        • Kolh P.
        • et al.
        Global vascular guidelines on the management of chronic limb-threatening ischemia.
        Eur J Vasc Endovasc Surg. 2019; 58: S1-S109.e33
        • Bradbury A.W.
        • Adam D.J.
        • Bell J.
        • et al.
        Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: an intention-to-treat analysis of amputation-free and overall survival in patients randomized to a bypass surgery-first or a balloon angioplasty-first revascularization strategy.
        J Vasc Surg. 2010; 51: 5S-17S
        • Bradbury A.W.
        • Adam D.J.
        • Bell J.
        • et al.
        Multicentre randomised controlled trial of the clinical and cost-effectiveness of a bypass-surgery-first versus a balloon-angioplasty-first revascularisation strategy for severe limb ischaemia due to infrainguinal disease. The Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial.
        Health Technol Assess. 2010; 14: 1-210
        • Veith F.J.
        • Gupta S.K.
        • Ascer E.
        • et al.
        Six-year prospective multicenter randomized comparison of autologous saphenous vein and expanded polytetrafluoroethylene grafts in infrainguinal arterial reconstructions.
        J Vasc Surg. 1986; 3: 104-114
        • Ambler G.K.
        • Twine C.P.
        Graft type for femoro-popliteal bypass surgery.
        Cochrane Database Syst Rev. 2018; 2CD001487
        • Popplewell M.A.
        • Davies H.O.
        • Narayanswami J.
        • et al.
        A comparison of outcomes in patients with infrapopliteal disease randomised to vein bypass or plain balloon angioplasty in the Bypass vs. Angioplasty in Severe Ischaemia of the Leg (BASIL) trial.
        Eur J Vasc Endovasc Surg. 2017; 54: 195-201
        • Popplewell M.A.
        • Davies H.O.
        • Renton M.
        • et al.
        Comparison of outcomes following infrapopliteal plain balloon angioplasty in the BASIL trial (1999-2004) and in a contemporary series (2009-2013).
        Vasc Endovascular Surg. 2020; 54: 141-146
        • Jaff M.R.
        • White C.J.
        • Hiatt W.R.
        • et al.
        • TASC Steering Committee
        An update on methods for revascularization and expansion of the TASC lesion classification to include below-the-knee arteries: a supplement to the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II).
        Vasc Med. 2015; 20: 465-478
        • Norgren L.
        • Hiatt W.R.
        • Dormandy J.A.
        • et al.
        Inter-society consensus for the management of peripheral arterial disease (TASC II).
        J Vasc Surg. 2007; 45: S5-S67
        • Müller A.M.
        • Räpple V.
        • Bradaric C.
        • et al.
        Outcomes of endovascular treatment for infrapopliteal peripheral artery disease based on the updated TASC II classification.
        Vasc Med. 2021; 26: 18-25
        • van Haelst S.T.
        • Teraa M.
        • Moll F.L.
        • et al.
        Prognostic value of the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification in patients with no-option chronic limb-threatening ischemia.
        J Vasc Surg. 2018; 68: 1104-1113
        • Kodama A.
        • Meecham L.
        • Popplewell M.
        • et al.
        Editor’s choice–Relationship between global limb anatomic staging system (GLASS) and clinical outcomes following revascularisation for chronic limb threatening ischaemia in the bypass versus angioplasty in severe ischaemia of the leg (BASIL)-1 trial.
        Eur J Vasc Endovasc Surg. 2020; 60: 687-695
        • McAllister F.F.
        The fate of patients with intermittent claudication managed nonoperatively.
        Am J Surg. 1976; 132: 593-595
        • Mazari F.A.
        • Khan J.A.
        • Carradice D.
        • et al.
        Randomized clinical trial of percutaneous transluminal angioplasty, supervised exercise and combined treatment for intermittent claudication due to femoropopliteal arterial disease.
        Br J Surg. 2012; 99: 39-48
        • Wolfe J.H.
        • Wyatt M.G.
        Critical and subcritical ischaemia.
        Eur J Vasc Endovasc Surg. 1997; 13: 578-582
        • Kalman P.G.
        • Johnston K.W.
        • Walker P.M.
        The current role of isolated profundaplasty.
        J Cardiovasc Surg. 1990; 31: 107-111
        • Nolan B.W.
        • De Martino R.R.
        • Stone D.H.
        • et al.
        Vascular Study Group of New England. Prior failed ipsilateral percutaneous endovascular intervention in patients with critical limb ischemia predicts poor outcome after lower extremity bypass.
        J Vasc Surg. 2011; 54: 730-736