Contemporary Outcomes of Open Femoropopliteal Bypass by Autogenous Vein Graft in Infra-inguinal Arterial Occlusive Disease

Abstract

Although the majority of patients presenting with symptomatic peripheral arterial disease (PAD) are treated with the endovascular first approach, a significant number of these patients still require open bypass because of the extent of atherosclerotic burden or failure of the endovascular therapy. However, data available on the outcomes of femoropoliteal bypass in the contemporary era of PAD management is scarce. In this study, we evaluate realworld mid-term outcomes of femoropopliteal bypass for PAD. We identified all patients who underwent open femoropopliteal revascularization with autogenous vein conduits for PAD at one institution between January 2012 and December 2017. Main endpoints included primary patency, amputation-free survival, overall survival, and limb salvage at 2 years. Outcomes were defined as per the Society for Vascular Surgery standards. Descriptive statistics were performed using univariable analyses including the mean and standard deviation for continuous variables and frequency and percentage for categorical variables. Event-free survival rates were estimated using Kaplan-Meier methods. There were 129 patients who received autogenous vein grafts. Median follow-up was 19months (interquartile rangeIQR 11-26). Patients were predominantly male (59.7%), white (72.9%) with a mean age of 65±11years. The indications for surgery were disabling claudication in 36.4% of patients (n=47) and chronic limb threatening ischemia (CLTI) in 63.6% (n=82). Most patients had Trans-Atlantic Inter-Society Consensus C or D lesions (n=81, 62.8%). Seventeen cases (16.3%) were redoing bypasses. Arm veins and spliced vein conduits were used in 12% and 7%, respectively. In 66% of procedures, the distal anastomosis was below the knee. Primary patency estimates at 6months, 1year and 2years were 81.3%, 68.6% and 59.2%, respectively. Amputation-free survival rates were 93.4%, 88% and 82.1% at 6months, 1year and 2years, respectively. Limb salvage rates among patients with CLTI were 93.4%, 90.4% and 87.2% at 6months, 1year and 2years, respectively. Overall survival was 97.5%, 92.1% and 87.8% at 6months, 1year and 2years, respectively. In this contemporary cohort of patients, femoropopliteal bypass showed lower patency than previously described. The fact that bypass surgery is performed on sicker patients with more extensive disease in the endovascular era might explain this discrepancy. However, our results demonstrated satisfactory patency and limb salvage rates and suggest that vein should always be used if available.