Alternative Conduits Have Worse Outcomes Than Prosthetic Grafts for Infrainguinal Bypass

Abstract

Single-segment great saphenous vein (ssGSV) is the preferred conduit for infrainguinal bypass. Alternative autologous conduits (AACs) and nonautologous biologic conduits (NABCs) are thought to be a better alternative to traditional prosthetic conduits (PCs) in the absence of the ssGSV. We analyzed the outcomes of these alternative conduits in lower extremity bypass (LEB) in patients with chronic limb threatening ischemia. The Vascular Quality Initiative LEB database from 2003 to 2020 was queried to identify LEB in patients with chronic limb threatening ischemia. The primary outcomes were graft patency, major adverse limb events (MALE), and MALE-free survival at 1 year. Standard statistical methods were used as appropriate. We identified 22,671 LEB procedures (12,810 ssGSVs, 6002 PCs, 1907 AACs, and 1952 NABCs). Compared with the ssGSV group, the other conduit patients were significantly older, had more comorbidities, had an increased rate of prior lower extremity interventions, had a higher rate of infrageniculate bypass targets, and had been less ambulatory at baseline. The PC, AAC, and NABC groups had significantly higher rates of postoperative morbidity compared with the ssGSV group. The PC group had higher 30-day mortality compared with the ssGSV, AAC, and NABC groups (3% PC vs 2% ssGSV, 2% AAC, and 2% NABC; P = .049). The PC and NABC groups had higher 1-year mortality compared with the ssGSV and AAC groups (13% PC and 13% NABC vs 10% ssGSV and 10% AAC; P = .02). In an adjusted Cox regression model (Fig; stratified by infrageniculate target and adjusted for age, comorbidities, and prior vascular interventions), AAC (hazard ratio [HR], 1.41; 95% confidence interval [CI], 1.19-1.67; P < .001) and NABC (HR, 1.9; 95% CI, 1.61-2.25; P < .001) were associated with an increased risk of loss of primary patency compared with PC. A similar association with MALE was observed: both AAC (HR, 1.35; 95% CI, 1.15-1.58; P < .001) and NABC (HR, 1.8; 95% CI, 1.53-2.11; P < .001) were associated with an increased risk of MALE compared with PC. However, PC was not significantly different from ssGSV. In the absence of ssGSV, alternative autologous or nonautologous biologic materials do not confer a benefit with regard to graft patency or MALE compared with PCs. The increased operating time or costs associated with the use of these conduits was not justified from the results from the present study.