Systematic Review and Meta-Analysis of Vein Cuffs for Below-Knee Synthetic Bypass

Abstract

Conclusion: There is a small but significant benefit for vein cuffs in conjunction with synthetic grafts used for femoral to below-knee popliteal anastomoses. There is little benefit for more distal anastomoses. Summary: The Trans-Atlantic Inter-Society Consensus (TASC) for the Management of Peripheral Arterial Disease guidelines advocate use of vein cuffs for bypass grafts of synthetic material to infrageniculate arteries. Evidence favoring use of vein cuffs for polytetrafluroethylene (PTFE) infrainguinal grafts comes primarily from case series. One randomized trial from the Joint Vascular Research Group did show a significant benefit in the favor of vein cuffs for below-knee bypasses (Stonebridge PA, et al, Vasc Surg 1997;26:543-50). However, a more contemporary randomized study, the Scandinavian Miller Cuff Study (SCAMICOS) showed no benefit for vein cuffs as adjuncts to below-knee synthetic grafts (SCAMICOS, Eur J Vasc Endovasc Surg 2010;39:747-54). There has also been a Cochrane Review on the use on vein cuffs, but it was performed without the SCAMICOS data (Cochrane Database Syst Rev 2010;CD001487). The authors note that a meta-analysis of all available data has not been performed on the use of vein cuffs to enhance patency of synthetic below-knee bypass grafts. They sought to combine the results of the two major randomized trials with pertinent cohort studies to provide the most complete estimate on the use of vein cuffs as adjuncts to synthetic grafts to below-knee arteries. The authors identified three cohort and two randomized studies for inclusion in their meta-analysis. This involved an analysis of data from 885 patients. That analysis was preformed according to recommendations of the Cochrane Collaboration, and the PRISMA guidelines (Liberati A, et al, PLoS Med 2009;6:e1000100; and Higgins JPT et al, Cochrane handbook for systematic reviews of interventions, version 5.0.2., Chicester: John Wiley & Sons; 2010). Nonrandomized studies were included in the review if they had sufficient quality as assessed by the Newcastle-Ottawa scale. In this study, analysis was ultimately carried out on 483 patients with cuff grafts and 402 with no cuff. Analysis was divided into below-knee popliteal (377 cuffed, 279 uncuffed) and distal (106 cuffed, 123 uncuffed) grafts. Graft material was PTFE in all cases. Follow-up was limited to 3 years. Analysis for below-knee popliteal bypasses showed a significant improvement in primary patency for cuffed grafts at 2 years, but not at 1 or 3 years (odds ratio at 2 years, 0.46; 95% confidence interval, 0.22-0.97; P = .04). Limb salvage was significantly improved in cuffed grafts up to 2 years. For more distal grafts, cuffs did not provide any improvement in primary patency at any time interval. However, it did appear that limb salvage was improved for cuffed distal grafts at 2 years (odds ratio, 0.29; 95% confidence interval, 0.11-0.75; P = .01). There was no significant difference at any other time interval. Comment: A reasonable conclusion from this study is that there is a small benefit for using vein cuffs as adjuncts to PTFE grafts to the below-knee popliteal artery. There is minimal to no benefit to the use of a vein cuff as an adjunct to a PTFE graft to a tibial vessel. However, it does not appear that a vein cuff, under any circumstances, worsens outcomes. Vein cuffs can be safely used at the discretion of the operating surgeon even for synthetic bypasses to tibial vessels.