Hamouda Mohammed, Zarrintan Sina, Vootukuru Nishita, Thandra Sneha, Quatromoni Jon G, Malas Mahmoud B, Gaffey Ann C
Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), UC San Diego (UCSD), San Diego, CA.
Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ.
J Vasc Surg. 2025 Mar;81(3):682-692. doi: 10.1016/j.jvs.2024.10.069. Epub 2024 Oct 28.
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 arm vein grafts (AVs), prosthetic grafts (PGs), or biologic grafts (BGs). 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 Vascular Quality Initiative (VQI) database was queried for patients undergoing IIB from January 2003 to April 2024. Patients were stratified into three groups: AVs (cephalic, basilic), PGs (Dacron, polytetrafluoroethylene [PTFE]), and BGs (cadaveric, homograft, or xenograft). Saphenous vein grafts (greater and lesser saphenous) were excluded. Multivariate logistic regression analyzed postoperative outcomes: 30-day mortality, major adverse cardiovascular events, graft occlusion, prolonged length of stay >7 days, packed red blood cell transfusion >2 units, and infection. Cox regression was used to report 1-year outcomes: mortality, major amputation (above-ankle), and major adverse limb events (defined as major amputation, thrombectomy, or reintervention).
A total of 9165 IIB procedures have been analyzed: AV, 417 (4.55%); PG, 7520 (82.05%); and BG, 1228 (13.40%). Compared with AVs, patients receiving PGs had higher odds of infection (adjusted odds ratio [aOR], 2.89; P = .045) and higher hazard of 1-year mortality (adjusted hazard ratio [aHR], 1.51; P = .035). On the other hand, patients receiving BGs had higher risk of graft occlusion (aOR, 4.55; P = .040) and infection (aOR, 2.78; P = .046), as well as higher hazard of 1-year mortality (aHR, 1.53; P = .040), amputation (aHR, 1.72; P = .019), and amputation or death (aHR, 1.52; P = .005) compared with patients receiving AVs. After stratifying by bypass configuration, patients with AVs had the highest overall survival and amputation-free survival among the three alternative conduits in below-knee popliteal and tibial bypass targets.
In this large multi-institutional study investigating alternative conduits to GSV, AVs are found to be the most resistant to infections and are associated with the best overall survival and limb salvage outcomes compared with PGs and BGs, particularly in below-knee distal targets. In cases where no GSV is available, AVs and PGs are acceptable alternatives with comparable 1-year amputation-free survival and major adverse limb events-free survival rates. On the other hand, BGs are associated with higher risk of graft occlusion and lower freedom from major amputation and death compared with AVs.
股下旁路移植术（IIB）的最佳血管 conduit 是单段大隐静脉（GSV）。不幸的是，对于慢性肢体威胁性缺血（CLTI）患者，GSV 并非总是可用。其他移植选择包括手臂静脉移植（AVs）、人工血管移植（PGs）或生物血管移植（BGs）。目前关于这些选择的耐久性和肢体挽救率的数据很少；因此，我们旨在研究替代移植类型对 CLTI 患者 IIB 术后及长期结局的影响。
查询血管质量倡议（VQI）数据库中 2003 年 1 月至 2024 年 4 月接受 IIB 的患者。患者被分为三组：AVs（头静脉、贵要静脉）、PGs（涤纶、聚四氟乙烯[PTFE]）和 BGs（尸体血管、同种异体移植物或异种移植物）。排除大隐静脉和小隐静脉移植。多因素逻辑回归分析术后结局：30 天死亡率、主要不良心血管事件、移植物闭塞、住院时间延长>7 天、浓缩红细胞输注>2 单位和感染。采用 Cox 回归报告 1 年结局：死亡率、主要截肢（踝关节以上）和主要不良肢体事件（定义为主要截肢、血栓切除术或再次干预）。
共分析了 9165 例 IIB 手术：AVs 417 例（4.55%）、PGs 7520 例（82.05%）、BGs 1228 例（13.40%）。与 AVs 相比，接受 PGs 的患者感染几率更高（调整优势比[aOR]，2.89；P = 0.045），1 年死亡率风险更高（调整风险比[aHR]，1.51；P = 0.035）。另一方面，与接受 AVs 的患者相比，接受 BGs 的患者移植物闭塞风险更高（aOR，4.55；P = 0.040）、感染风险更高（aOR，2.78；P = 0.046），1 年死亡率风险更高（aHR，1.53；P = 0.040）、截肢风险更高（aHR，1.72；P = 0.019）以及截肢或死亡风险更高（aHR，1.52；P = 0.005）。按旁路配置分层后，在膝下腘动脉和胫动脉旁路目标中，AVs 患者在三种替代血管 conduit 中总体生存率和无截肢生存率最高。
在这项研究替代 GSV 血管 conduit 的大型多机构研究中，发现 AVs 对感染的抵抗力最强，与 PGs 和 BGs 相比，总体生存率和肢体挽救结局最佳，尤其是在膝下远端目标中。在没有 GSV 的情况下，AVs 和 PGs 是可接受的替代方案，1 年无截肢生存率和无主要不良肢体事件生存率相当。另一方面，与 AVs 相比，BGs 移植物闭塞风险更高，主要截肢和死亡的自由度更低。
