Cheng Thomas W, Farber Alik, Alonso Andrea, King Elizabeth G, Columbo Jesse A, Hicks Caitlin W, Patel Virendra I, Garg Karan, Stangenberg Lars, Siracuse Jeffrey J
Section of Vascular Surgery, Heart and Vascular Center, Dartmouth Hitchcock Medical Center, Lebanon, NH.
Division of Vascular and Endovascular Surgery, Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA.
J Vasc Surg. 2025 Sep;82(3):998-1006.e2. doi: 10.1016/j.jvs.2025.04.001. Epub 2025 Apr 8.
Cryopreserved vein grafts serve as alternative conduits for infrainguinal bypass when autogenous vein is unavailable or inadequate. Anticoagulation has been advocated to improve outcomes, but published studies demonstrate conflicting results. We assessed the association of anticoagulation on outcomes after infrainguinal bypass with cryopreserved vein in patients with chronic limb-threatening ischemia.
The Vascular Quality Initiative was queried (2003-2022) for infrainguinal bypass performed using cryopreserved vein graft for chronic limb-threatening ischemia. Baseline characteristics, procedural details, and outcomes between those discharged with or without anticoagulation were recorded. Univariable, Kaplan-Meier, and multivariable analyses were performed.
There were 2336 patients who underwent an infrainguinal bypass with cryopreserved vein conduit. The average age was 70.6 years and 63.5% were male. Bypass targets were femoral/popliteal (27.5%) and tibial (72.5%). Indication for intervention included rest pain (25.7%) and tissue loss (74.3%). Patients were discharged with aspirin (80.1%), a P2Y12 inhibitor (45.6%), and anticoagulation (47.3%). Patients discharged on postoperative anticoagulation more often were treated for rest pain (28.1% vs 23.5%), had a tibial bypass target (78.4% vs 67.2%), and less often underwent endarterectomy (27.8% vs 34.2%) (all P < .05). Kaplan-Meier analysis at 1 year demonstrated that postoperative anticoagulation had similar freedom from loss of primary patency/death (28.9% vs 34.3%), major amputation/death (62.3% vs 63.8%), and reintervention/major amputation/death (50.6% vs 53.8%) (all P > .05), but higher survival (85.1% vs 81.7%; P = .03). Multivariable analysis at 1 year demonstrated that postoperative anticoagulation had a similar likelihood for loss of primary patency/death (hazard ratio [HR], 0.95; 95% confidence interval [CI], 0.83.-1.09), major amputation/death (HR, 0.88; 95% CI, 0.74-1.05), and reintervention/major amputation/death (HR, 0.93; 95% CI, 0.79-1.08) (all P > .05), but a lower likelihood for death (HR, 0.59; 95% CI, 0.46-0.74; P < .001) compared with no anticoagulation. Postoperative aspirin was associated with a lower likelihood for amputation/death (HR, 0.74; 95% CI, 0.61-0.91; P = .003) and reintervention/major amputation/death (HR, 0.76; 95% CI, 0.64-0.9; P = .002). Postoperative P2Y12 inhibitor was associated with decreased likelihood for amputation/death (HR, 0.75; 95% CI, 0.63-0.9; P = .002) and reintervention/major amputation/death (HR, 0.78; 95% CI, 0.67-0.91; P = .001). Results were similar when analyzing patients who were not on anticoagulation preoperatively.
Postoperative anticoagulation after infrainguinal bypass using cryopreserved vein did not affect patency or limb salvage. Antiplatelet agents were associated with improved outcomes. Overall patency and limb salvage rates at 1 year were poor. When cryopreserved vein is used, surgeons should consider antiplatelet therapy for cryopreserved graft patency rather than anticoagulation.
当自体静脉不可用或不足时，冷冻保存的静脉移植物可作为腹股沟下旁路移植的替代管道。有人主张使用抗凝治疗来改善治疗效果，但已发表的研究结果相互矛盾。我们评估了抗凝治疗与慢性肢体威胁性缺血患者腹股沟下旁路移植术后治疗效果之间的关联。
查询血管质量倡议数据库（2003 - 2022年）中使用冷冻保存的静脉移植物进行的慢性肢体威胁性缺血腹股沟下旁路移植手术。记录出院时接受或未接受抗凝治疗患者的基线特征、手术细节和治疗效果。进行单变量分析、Kaplan - Meier分析和多变量分析。
共有2336例患者接受了冷冻保存静脉管道的腹股沟下旁路移植手术。平均年龄为70.6岁，63.5%为男性。旁路移植目标为股动脉/腘动脉（27.5%）和胫动脉（72.5%）。干预指征包括静息痛（25.7%）和组织缺损（74.3%）。出院时患者使用阿司匹林（80.1%）、P2Y12抑制剂（45.6%）和抗凝药物（47.3%）。术后接受抗凝治疗出院的患者更常因静息痛接受治疗（28.1%对23.5%），以胫动脉为旁路移植目标（78.4%对67.2%），且接受动脉内膜切除术的频率较低（27.8%对34.2%）（所有P < 0.05）。1年的Kaplan - Meier分析表明，术后抗凝治疗在原发性通畅率/死亡率（28.9%对34.3%）、大截肢/死亡率（62.3%对63.8%）以及再次干预/大截肢/死亡率（50.6%对53.8%）方面相似（所有P > 0.05），但生存率更高（85.1%对81.7%；P = 0.03）。1年的多变量分析表明，与未进行抗凝治疗相比，术后抗凝治疗在原发性通畅率/死亡率方面的可能性相似（风险比[HR]，0.95；95%置信区间[CI]，0.83 - 1.09），大截肢/死亡率（HR，0.88；95% CI，0.74 - 1.05）以及再次干预/大截肢/死亡率（HR，0.93；95% CI，0.79 - 1.08）（所有P > 0.05），但死亡可能性较低（HR，0.59；95% CI，0.46 - 0.74；P < 0.001）。术后使用阿司匹林与截肢/死亡率降低相关（HR，0.74；95% CI，0.61 - 0.91；P = 0.003）以及再次干预/大截肢/死亡率降低相关（HR，0.76；95% CI，0.64 - 0.9；P = 0.002）。术后使用P2Y12抑制剂与截肢/死亡率降低相关（HR，0.75；95% CI，0.63 - 0.9；P = 0.002）以及再次干预/大截肢/死亡率降低相关（HR，0.78；95% CI，0.67 - 0.91；P = 0.001）。对术前未接受抗凝治疗的患者进行分析时，结果相似。
使用冷冻保存静脉进行腹股沟下旁路移植术后的抗凝治疗不影响通畅率或肢体挽救率。抗血小板药物与改善治疗效果相关。1年时总体通畅率和肢体挽救率较差。当使用冷冻保存静脉时，外科医生应考虑使用抗血小板治疗以维持冷冻保存移植物的通畅，而非抗凝治疗。
