Chang Heepeel, Veith Frank J, Rockman Caron B, Maldonado Thomas S, Jacobowitz Glenn R, Cayne Neal S, Garg Karan
Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA.
Department of Surgery, New York University Langone Medical Center, New York, NY, USA.
Vascular. 2023 Oct;31(5):931-940. doi: 10.1177/17085381221088082. Epub 2022 Apr 22.
Autologous great saphenous vein (GSV) is considered the conduit of choice for lower extremity bypass (LEB). However, the optimal configuration remains the source of debate. We compared outcomes of patients undergoing LEB using in-situ and reversed techniques.
The Vascular Quality Initiative database was queried for patients undergoing LEB with a single-segment GSV in in-situ (ISGSV) and reversed (RGSV) configurations for symptomatic occlusive disease from 2003 to 2021. Patient demographics, procedural detail, and in-hospital and follow-up outcomes were collected. The primary outcome measures included primary patency at discharge or 30 days and one year. Secondary outcomes were secondary patency, and reinterventions at discharge or 30 days and one year. Cox proportional hazards models were created to determine the association between bypass techniques and outcomes of interest.
Of 8234 patients undergoing LEBs, in-situ and reversed techniques were used in 3546 and 4688 patients, respectively. The indication for LEBs was similar between the two cohorts. ISGSV was performed more frequently from the common femoral artery and to more distal targets. RGSV bypass was associated with higher intraoperative blood loss and longer operative time. Perioperatively, ISGSV cohort had higher rates of reinterventions (13.2 vs 11.1%; = 0.004), surgical site infection (4.2 vs 3%; = 0.003), and lower primary patency (93.5 vs 95%; = 0.004) but a comparable rate of secondary patency (99 vs 99.1%; = 0.675). At 1 year, in-situ bypasses had a lower rate of reinterventions (19.4% vs 21.6%; =0.02), with similar rates of primary (82.6 vs 81.8%; = 0.237) and secondary patency (88.7 vs 88.9%; = 0.625). After adjusting for significant baseline differences and potential confounders, in-situ bypass was independently associated with decreased risks of primary patency loss (HR 0.9; 95% CI, 0.82-0.98; = 0.016) and reinterventions (HR 0.88; 95% CI, 0.8-0.97; = 0.014) but a similar risk of secondary patency loss (HR 0.99; 95% CI, 0.86-1.16; = 0.985) at follow-up, compared to reversed bypass. A subgroup analysis of bypasses to crural targets showed that in-situ and reversed bypasses had similar rates of primary patency loss and reinterventions at 1 year. Among patients with chronic limb-threatening ischemia, in-situ bypass was associated with a decreased risk of reinterventions but similar rates of primary and secondary patency and major amputations at 1 year.
In patients undergoing LEBs using the GSV, in-situ configuration was associated with more perioperative reinterventions and lower primary patency rate. However, this was offset by decreased risks of loss of primary patency and reinterventions at 1 year. A thorough intraoperative graft assessment with adjunctive imaging may be performed to detect abnormalities in patients undergoing in-situ bypasses to prevent early failures. Furthermore, closer surveillance of reversed bypass grafts is warranted given the higher rates of reinterventions.
自体大隐静脉（GSV）被认为是下肢旁路移植术（LEB）的首选血管。然而，最佳的血管配置仍存在争议。我们比较了采用原位和翻转技术进行LEB的患者的治疗结果。
查询血管质量改进计划数据库，纳入2003年至2021年期间因症状性闭塞性疾病采用单段GSV原位（ISGSV）和翻转（RGSV）配置进行LEB的患者。收集患者的人口统计学资料、手术细节以及住院期间和随访结果。主要结局指标包括出院时或30天及1年时的原发性通畅率。次要结局指标为继发性通畅率，以及出院时或30天及1年时的再次干预情况。建立Cox比例风险模型以确定旁路技术与感兴趣的结局之间的关联。
在8234例行LEB的患者中，分别有3546例和4688例采用了原位和翻转技术。两组患者LEB的适应证相似。ISGSV更多地从股总动脉进行，且移植到更远端的目标血管。RGSV旁路移植术与术中失血量更多和手术时间更长相关。围手术期，ISGSV组的再次干预率更高（13.2%对11.1%；P = 0.004）、手术部位感染率更高（4.2%对3%；P = 0.003），原发性通畅率更低（93.5%对95%；P = 0.004），但继发性通畅率相当（99%对99.1%；P = 0.675）。在1年时，原位旁路移植术的再次干预率更低（19.4%对21.6%；P = 0.02），原发性通畅率（82.6%对81.8%；P = 0.237）和继发性通畅率（88.7%对88.9%；P = 0.625）相似。在调整了显著的基线差异和潜在混杂因素后，与翻转旁路移植术相比，原位旁路移植术与原发性通畅丧失风险降低（HR 0.9；95%CI，0.82 - 0.98；P = 0.016）和再次干预风险降低（HR 0.88；95%CI，0.8 - 0.97；P = 0.
