ORIGINAL ARTICLE

Year : 2022  |  Volume : 9  |  Issue : 5  |  Page : 377-380

Outcomes following spliced vein graft and composite graft as conduit for infrainguinal bypass: An institutional experience

S Arun Prasath, Arunagiri Viruthagiri, Nedounsejiane Mandjini
Department of Vascular and Endovascular Surgery, Kauvery Hospital, Tiruchirappalli, Tamil Nadu, India

Correspondence Address:
Dr. S Arun Prasath
Department of Vascular and Endovascular Surgery, Kauvery Hospital, Tiruchirappalli, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ijves.ijves_73_22

Background: Peripheral arterial disease is a significant health care burden globally. Treatment options for limb salvage include open surgical bypass or endovascular revascularization. One of the vital prerequisite for successful infrainguinal bypass is the availability of good conduit. Not all patients have good quality great saphenous vein of adequate length to facilitate bypass. In these scenarios, splicing of available autologous veins and synthetic graft with vein cuff are alternate options. Aim: To compare the outcomes of infrainguinal bypass done for patients with chronic limb threatening ischemia in two groups In Group I, non spliced GSV was the conduit used. In Group II, either spliced vein graft or synthetic graft with vein cuff was used. Materials and Methods: This is a retrospective study done in a tertiary care centre over a period of 40 months. Ipsilateral Great Saphenous Vein (GSV) was our preferred conduit. In the absence of good calibre GSV, splicing of available autologous veins were done. Only when autologous veins were not available synthetic graft was used with distal vein cuff. Results: A total of 52 patients have undergone bypass during the study period of which 15 patients (28.8%) did not have good calibre GSV. Splicing of autologous veins were done for 10 patients (19.2 %) and synthetic graft with vein cuff was used for 5 patients (9.6%). One year graft patency in group I was 81% and in group II was 66.6%. Limbs were salvaged in 86% of patients in either groups. The mortality rate was 8.1% and 6.6% in groups I & II respectively. Conclusion: When good caliber GSV is not available, splicing of available autologous veins provide comparable patency and should be preferred over synthetic graft. Synthetic graft provides acceptable limb salvage rate when used with an adjunctive procedure like vein cuff for tibial bypasses and should be used when autologous veins are not available or when the patient carries a high risk for major surgery.

Keywords: Conduit, great saphenous vein, infrainguinal bypass, peripheral arterial disease

Introduction

• To compare the outcomes of infrainguinal bypass done for patients with symptomatic PAD in two groups of population
• In Group I, non spliced GSV was the conduit used
• In Group II, either spliced vein graft or composite graft, i.e., synthetic graft with vein cuff was used.

Materials and Methods

• Type of study – Retrospective study in a tertiary care center
• Time interval – March 2019–June 2022
• Time duration – 40 months.

• All patients underwent preoperative duplex imaging of leg veins and arm veins if necessary
• Vein was considered to be of good caliber if its diameter was at least 3 mm, compressible throughout, nonphlebitic and nonvariceal
• Veins that were <3 mm and phlebitic were not preferred for bypass surgery
• Ipsilateral GSV was our preferred conduit. In the absence of ipsilateral GSV, our next choice was GSV of opposite leg
• When both GSV were not suitable, splicing of leg veins and/or arm veins was done
• Veins were used in reverse configuration
• Synthetic graft for infrapopliteal bypass was used when adequate length vein graft was not available in all four limbs or when the patient was considered high risk for major bypass surgery
• In this situation, a vein cuff was used at the distal anastomosis to prevent exposure of native endothelium to synthetic graft.

• Postoperative follow-up was done at 1^st month, every 3^rd month for 1^st year, and every 6 months for the next 1 year
• Surveillance was done by palpation of pulse, hand Doppler signal, and duplex screening if considered necessary.

Results

• A total of 52 patients have undergone infrainguinal bypass during the above period
• Among these 52 patients, 37 patients underwent bypass using GSV of the same leg as conduit. 15 (28.8%) patients did not have adequate good caliber GSV
• Splicing of both thigh/leg veins was done for 7 patients; arm veins were spliced with leg veins in 3 patients [Figure 1] and [Figure 2]
• Five patients underwent infrapopliteal bypass requiring prosthetic graft with vein cuff [Figure 3].
• Our demographic data and results are given in [Table 1] and [Table 2] respectively.

Figure 1: Upper limb vein harvest Click here to view

Figure 2: Spliced vein Click here to view

Figure 3: Femoro distal bypass using synthetic graft with vein cuff Click here to view

Table 1: Demographic data Click here to view

Table 2: Results Click here to view

Discussion

• Our 1-year patency rate was 81%. This is comparable to the study done by Pasha Normahani et al. where the 1-year primary patency of vein graft was 81.6%.^[8] Although the 1-year patency was only 68.4% in the study conducted by Hani Slim and co, their limb salvage rate was 84% which was comparable with our study – our salvage rate being 86%^[9]
• There was one early graft thrombosis in vein graft group due to poor caliber vein (varicose vein)
• One patient had subacute graft thrombosis due to compromised outflow
• Two patients had late graft thrombosis of which one patient ended up in below knee amputation.

• All 10 patients had patent graft at the end of 1 month. One year patency rate in our study was 70% (7 patients) comparable to 72% in the study by Chang et al.^[10]
• Late graft thrombosis was seen in three patients (30%)
• Eight patients (80%) had their limb salvaged, one patient (10%) needed amputation following late graft thrombosis, and one patient lost to follow-up.

• Limbs were salvaged in all patients
• The primary patency was 100% at 1 month and 60% at the end of 1 year. This is less compared to patency rate of Stonebridge et al. which has a 1-year patency of 80% where polytetrafluoroethylene graft was used with vein cuff^[11]
• Neville et al. had a primary patency of 82% at the end of 1 year. Here, tibial bypass with synthetic graft was done with a distal vein patch as adjunct^[12]
• Late mortality was seen in one patient (20%) due to cardiac complication
• One patient (20%) had subacute graft thrombosis (2 months' postoperative) due to poor distal runoff
• Another patient had impending graft thrombosis due to stenosis at proximal anastomosis detected during graft surveillance 9 months postoperatively. Patency was restored by redo patch plasty with graft thrombectomy.

Conclusion

• Preoperative duplex mapping of veins is mandatory for all patients undergoing infrainguinal bypass
• When good caliber GSV is not available, splicing of available leg/arm veins provide an alternate conduit with comparable patency and should be preferred over synthetic graft
• Synthetic graft provides acceptable limb salvage rate inspite of lower patency rate when combined with an adjunctive procedure like vein cuff for tibial bypass.

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