Tibial Bypass Research Articles

Outcomes of Prosthetic and Biological Grafts Compared to Arm Vein Grafts in Patients with Chronic Limb Threatening Ischemia

ObjectivesThe optimal conduit for infrainguinal bypass (IIB) is single segment great saphenous vein (GSV). Unfortunately, GSV is not always available in patients with chronic limb threatening ischemia (CLTI). Other graft choices include arm vein grafts (AV), prosthetic grafts (PG) or biologic grafts (BG). Current data regarding the durability and limb salvage rates of those options is scarce, hence we aimed to investigate the impact of alternative graft types on post-operative and long-term outcomes on IIB in patients with CLTI. MethodsThe Vascular Quality Initiative (VQI) database was queried for patients undergoing IIB from January 2003 to April 2024. Patients were stratified into three groups: arm vein (cephalic, basilic), prosthetic grafts [Dacron, polytetrafluoroethylene (PTFE)], and biologic grafts (cadaveric, homograft, or xenograft). Saphenous vein grafts (greater and lesser saphenous) were excluded. Multivariate logistic regression analyzed postoperative outcomes: 30-day mortality, major adverse cardiovascular events (MACE), graft occlusion, prolonged length of stay >7days (PLOS), packed red blood cell (pRBC) transfusion >2 units, and infection. Cox Regression was used to report one-year outcomes: mortality, major amputation (above-ankle), and major adverse limb events (MALE defined as major amputation, thrombectomy or reintervention). ResultsA total of 9165 IIB procedures have been analyzed: AV 417 (4.55%); PG 7520 (82.05%); BG 1228 (13.40%). Compared to AV, patients receiving PG had higher odds of infection (aOR 2.89, p=0.045) and higher hazard of one-year mortality (aHR 1.51, p=0.035). On the other hand, patients receiving BG had higher risk of graft occlusion (aOR 4.55, p=0.040) and infection (aOR 2.78, p=0.046) as well higher hazard of one-year mortality (aHR 1.53, p=0.040), amputation (aHR 1.72, p=0.019) and amputation or death (aHR 1.52, p=0.005) compared to AV. After stratifying by bypass configuration, AV had the highest overall survival and amputation-free survival among the three alternative conduits in below-knee popliteal and tibial bypass targets. ConclusionsIn this large multi-institutional study investigating alternative conduits to GSV, AV are found to be the most resistant to infections and are associated with the best overall survival and limb salvage outcomes compared to PG and BG particularly in below-knee distal targets. In cases where no GSV is available, AV and PG are acceptable alternatives with comparable one-year amputation-free survival and MALE-free survival rates. On the other hand, BG are associated with higher risk of graft occlusion and lower freedom from major amputation and death compared to AV.

Prosthetic conduits have worse outcomes compared with great saphenous vein conduits in femoropopliteal and infrapopliteal bypass in patients with chronic limb-threatening ischemia

ObjectiveSingle segment great saphenous vein (SSGSV) traditionally has been considered the gold standard conduit for infrainguinal bypass. There are data supporting similar outcomes with prosthetic femoral-popliteal bypass. Moreover, some investigators have advocated for prosthetic conduit for femoral tibial bypass when GSV is inadequate or unavailable. We sought to evaluate long-term outcomes of infrainguinal bypass based on conduit type for treating chronic limb-threatening ischemia (CLTI). MethodsData from the Best Endovascular vs Best Surgical Therapy of Patients with CLTI multicenter, prospective, randomized controlled trial, comparing infrainguinal bypass with endovascular therapy in patients with CLTI, were evaluated. In this as-treated analysis, we compared outcomes of infrainguinal bypass using prosthetic, alternative autogenous vein (AAV), and cryopreserved vein (Cryo) with SSGSV bypass. Kaplan-Meier and multivariable analyses were performed to examine the associations of conduit type with major adverse limb events (MALE), reinterventions, above-ankle amputations, and all-cause death rates. ResultsIn total, 784 bypasses were analyzed (120 prosthetic, 33 AAV, 21 Cryo, AND 610 SSGSV). For prosthetic and SSGSV, the distribution was 357 femoropopliteal (93 prosthetic and 264 GSV) and 373 infrapopliteal (27 prosthetic and 346 GSV). The mean age for the overall cohort was 67.1 years; 27.4% were female, 29.9% were non-White, and 11.5% were of Hispanic ethnicity. Patients undergoing prosthetic bypass were older (69.2 years vs 66.7 years); more likely to have chronic obstructive pulmonary disease (22.5% vs 14.0%), prior coronary artery bypass grafting (88.9% vs 66.5%), and prior stroke (23.3% vs 14%); but less often were of Hispanic ethnicity (5.8% vs 12.6%) and had diabetes (59.2% vs 71.3%) (P < .05 for all). For femoropopliteal bypass, use of prosthetic conduit was associated with increased major reinterventions at 3 years overall (19.0% vs 11.5%; P = .06) and on risk-adjusted analysis (hazard ratio [HR], 2.13; 95% confidence interval [CI], 1.09-4.2; P = .028). No significant differences in MALE or death, above-ankle amputation, or death were observed. Outcomes were similar for bypasses to above-knee popliteal targets and below-knee popliteal targets. For infrapopliteal bypass, the use of a prosthetic conduit was associated with increased major reintervention (25.3% vs 10.3%; P = .005), death (68.6% vs 34.8%; P < .001), and MALE or death (90.0% vs 48.1%; P < .001) at 3 years. After risk adjustment, infrapopliteal bypass with prosthetic conduit was associated with higher major reintervention (HR, 4.14; 95% CI, 1.36-12.6; P = .012), above-ankle amputation (HR, 4.64; 95% CI, 1.59-13.5; P = .005), death (HR, 2.96; 95% CI, 1.4-6.2; P = .004), and MALE or death (HR, 3.59; 95% CI, 1.64-7.86; P = .001) compared with bypass with SSGSV. Overall, AAV had similar outcomes at 3 years as SSGSV; however, Cryo had significantly higher above-ankle amputation (50.0% vs 12.8%) (HR, 4.2; 95% CI, 1.68-10.5; P = .002), major reintervention (41.9% vs 10.7%) (HR, 3.12; 95% CI, 1.18-8.22; P = .02), and MALE/death (88.8% vs 37.8%) (HR, 2.96; 95% CI, 1.43-6.14; P = .004). ConclusionsThe use of a prosthetic conduit in infrainguinal bypass is associated with inferior outcomes compared with bypass using SSGSV, particularly for bypass to infrapopliteal targets. Cryo grafts were infrequent and also demonstrated inferior outcomes. SSGSV remains the preferred conduit of choice for infrainguinal bypass.

Long-Term Outcomes of Vein Adjuncts in Distal Infrainguinal Bypass

IntroductionAutologous vein is recommended for infrainguinal bypass due to improved freedom from occlusion compared to prosthetic graft. In patients without adequate vein, vein adjunct at the distal anastomosis has been suggested to improve patency in small studies. This study aimed to determine if performance of a distal vein adjunct was associated with improved freedom from occlusion in below knee popliteal and tibial bypasses compared to prosthetic bypass alone. MethodsA retrospective review of the Vascular Quality Initiative Infrainguinal Bypass database was conducted. Patients undergoing prosthetic-only and prosthetic with vein adjunct were compared. Inclusion criteria included age >18 years, and bypass to below knee popliteal or tibial vessels. Exclusion criteria included autologous vein conduits and prior interventions. Groups were further divided into below knee popliteal and tibial subgroups. ResultsA cohort of 3,939 patients underwent bypass to the below knee popliteal artery, with 287 (7.3%) receiving vein adjunct. More patients were male (68.8 vs 57.8%, p<.001) and had higher rates of CHF (21.1 vs 16.0%, p=.040) within the below knee popliteal group. Two-year bypass occlusion was decreased in patients receiving vein adjuncts (11.6 vs 17.1%, p=.004). A cohort of 2,378 patients underwent tibial bypass, with 473 (19.9%) receiving vein adjunct. Within the tibial group, patients were similar in age, BMI, race, comorbidities, and indications. Bypass occlusion (24.8 vs. 17.6%, p=.005) and amputation (20.5 vs. 15.9%, p=.048) rates at two years were worse for patients who did not receive a distal vein adjuncts to tibial arteries. ConclusionDistal vein adjuncts are associated with improved freedom from occlusion, amputation, MALEs, and overall survival when compared to bypasses performed with prosthetic graft alone for tibial bypasses within the VQI. Vein adjunct was not associated with improved freedom from occlusion in below knee popliteal bypasses. Consideration should be given to utilization of a distal vein adjunct to improve prosthetic bypass longevity and limb salvage for patients requiring tibial bypasses.

Hybrid interventions on distal sections of the main arteries in extended chronic occlusions of the superficial femoral artery in patients with critical limb ischemia

AbstractBackground. Over two thirds of patients with CLI present with SFA disease, often a long CTOwith patent proximal popliteal artery and extensive occlusive lesions in the crural vessels. Westudied a series of hybrid interventions to treat this multilevel disease as an alternative to conventionalapproach.Aim. To improve the results of revascularization of the lower limb in cases of extended occlusionof the SFA in combination with crural runoff.Materials and Methods: A total of 40 patients (25% women; mean age 69.5 years), all with Rutherfordclass 5-6 disease, were included in the study. Angiography showed long (&gt;200 mm) SFA CTOin all cases (100%) accompanied by CTO of distal popliteal artery (n=9; 22.5%); all crural arteries(n=26; 65%) or all crural arteries but the peroneal (n=7; 17.5%).We performed femoropopliteal bypass with autologous vein in all patients (100%) followed byballoon angioplasty of distal popliteal and/or crural arteries done either on the same day (n=22;55%) or 2-14 days later (n=18; 45%). Direct angiosomic revascularization was achieved in 36 patients(90%).We used a series of 46 consecutive patients who underwent femoral tibial bypass as historic control.Results. The 30-day mortality and graft failure rate were 2.5% vs 4.3% (p&gt;0.05) and 5% vs 13%(p&lt;0.05) after hybrid and tibial bypass interventions, respectively.At 1 year the primary patency of bypass and amputation-free survival were 77.7% (95% CI 61.7-93.7) vs 57.1% (95% CI 42.9-71.3) and 82.1% (95% CI 66.8-97.4) vs 69.6% (95% CI 56.1-83.1) afterhybrid intervention and tibial bypass, respectively (all non-significant).Conclusions. Compared to femoral tibial bypass, a hybrid intervention comprised of a bypass to apatent popliteal artery and subsequent crural angioplasty decreased the early failure rate withoutany negative effect on the long-term outcomes in CLI patients with long SFA CTO and extensiverunoff disease.

Supra-Inguinal Inflow for Distal Bypasses Have Acceptable Patency and Limb Salvage Rates

There is a paucity of data evaluating outcomes of lower extremity bypass (LEB) using supra-inguinal inflow for revascularization of infra-inguinal vessels. The purpose of this study is to report outcomes after LEB originating from aortoiliac arteries to infra-femoral targets. The Vascular Quality Initiative database (2003-2020) was queried for patients undergoing LEB from the aortoiliac arteries to the popliteal and tibial arteries. Patients were stratified into 3 cohorts based on outflow targets (above-knee [AK] popliteal, below-knee [BK] popliteal, and tibial arteries). Perioperative and 1-year outcomes including primary patency, amputation-free survival (AFS), and major adverse limb events (MALEs) were compared. A Cox proportional hazards model was used to estimate the independent prognostic factors of outcomes. Of 403 LEBs, 389 (96.5%) originated from the external iliac artery, while the remaining used the aorta or common iliac artery as inflow. In terms of the distal target, the AK popliteal was used in 116 (28.8%), the BK popliteal in 151 (27.5%), and tibial vessels in 136 (43.7%) cases. BK popliteal and tibial bypasses, compared to AK popliteal bypasses, were more commonly performed in patients with chronic limb-threatening ischemia (69.5% and 69.9% vs. 48.3%; P<0.001). Vein conduit was more often used for tibial bypass than for AK and BK popliteal bypasses (46.3% vs. 21.9% and 16.3%; P<0.001). In the perioperative period, BK popliteal and tibial bypass patients had higher reoperation rates (16.9% and 13.2% vs. 5.2%; P=0.02) and lower primary patency (89.4% and 89% vs. 95.7%; P=0.04) than AK bypass patients. At 1year, compared with AK popliteal bypasses, BK and tibial bypasses demonstrated lower primary patency (81.9% vs. 56.7% vs. 52.4%, P<0.001) and freedom from MALE (77.6% vs. 70.2% vs. 63.1%, P=0.04), although AFS was not significantly different (89.7% vs. 90.6% vs. 83.8%, P=0.19).On multivariable analysis, compared with AK popliteal bypasses, tibial bypasses were independently associated with increased loss of primary patency (hazard ratio 1.9, 95% confidence interval, 1.03-3.51, P=0.04). Subanalysis of patients with chronic limb-threatening ischemia demonstrated significantly higher primary patency in the AK popliteal cohort at discharge and 1 year, but no difference in AFS or freedom from MALE between the cohorts at follow-up. LEB with supra-inguinal inflow appear to have acceptable rates of 1-year patency and limb salvage in patients at high risk of bypass failure. Tibial outflow target was independently associated with worse primary patency but not with MALE or AFS.

Surgery or endovascular therapy for patients with chronic limb-threatening ischemia requiring infrapopliteal interventions

ObjectiveThe recent publication of randomized trials comparing open bypass surgery to endovascular therapy in patients with chronic limb-threatening ischemia, namely, Best Endovascular vs Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) and Bypass versus Angioplasty in Severe Ischaemia of the Leg-2 (BASIL-2), has resulted in potentially contradictory findings. The trials differed significantly with respect to anatomical disease patterns and primary end points. We performed an analysis of patients in BEST-CLI with significant infrapopliteal disease undergoing open tibial bypass or endovascular tibial interventions to formulate a relevant comparator with the outcomes reported from BASIL-2. MethodsThe study population consisted of patients in BEST-CLI with adequate single segment saphenous vein conduit randomized to open bypass or endovascular intervention (cohort 1) who additionally had significant infrapopliteal disease and underwent tibial level intervention. The primary outcome was major adverse limb event (MALE) or all-cause death. MALE included any major limb amputation or major reintervention. Outcomes were evaluated using Cox proportional regression models. ResultsThe analyzed subgroup included a total of 665 patients with 326 in the open tibial bypass group and 339 in the tibial endovascular intervention group. The primary outcome of MALE or all-cause death at 3 years was significantly lower in the surgical group at 48.5% compared with 56.7% in the endovascular group (P = .0018). Mortality was similar between groups (35.5% open vs 35.8% endovascular; P = .94), whereas MALE events were lower in the surgical group (23.3% vs 35.0%; P<.0001). This difference included a lower rate of major reinterventions in the surgical group (10.9%) compared with the endovascular group (20.2%; P = .0006). Freedom from above ankle amputation or all-cause death was similar between treatment arms at 43.6% in the surgical group compared with 45.3% the endovascular group (P = .30); however, there were fewer above ankle amputations in the surgical group (13.5%) compared with the endovascular group (19.3%; P = .0205). Perioperative (30-day) death rates were similar between treatment groups (2.5% open vs 2.4% endovascular; P = .93), as was 30-day major adverse cardiovascular events (5.3% open vs 2.7% endovascular; P = .12). ConclusionsAmong patients with suitable single segment great saphenous vein who underwent infrapopliteal revascularization for chronic limb-threatening ischemia, open bypass surgery was associated with a lower incidence of MALE or death and fewer major amputation compared with endovascular intervention. Amputation-free survival was similar between the groups. Further investigations into differences in comorbidities, anatomical extent, and lesion complexity are needed to explain differences between the BEST-CLI and BASIL-2 reported outcomes.

Short-term patency of iliofemoral to tibial bypass with vascular allografts in a minority population: A retrospective analysis of a single center acute care facility.

The aim of this study was to examine the short-term patency rates and associated factors of open lower limb, iliofemoral to tibial bypass using cryopreserved saphenous vein (CSV) in a minority population at an acute care hospital in New York City. A retrospective analysis of patients undergoing infra-inguinal bypass from iliofemoral vessels to tibial arteries with CSV between March 2020-April 2022 at an acute care facility (Harlem Hospital Center, Harlem, New York) was performed. Data including patient demographics, comorbidities, type of operation, follow-up surveillance, and salvage procedures were collected. Results were presented in patency line graphs and a life table. Target limb revascularization (TLR) and amputation free survival (AFS) were also calculated. Eleven bypass procedures were included in the analysis. Patients were followed for a mean of 10.8months. Cumulative primary patency rates at 1, 6, and 12months were 72.7%, 54.5%, and 40.9%, respectively. TLR was 36.4% and the AFS was 66.67% at the mean 10.8-month follow-up. The patency rates of minority patients undergoing bypass with CSV were analyzed with creation of a life table and calculation of patency rates, TLR and AFS. The short-term primary patency rates and post-operative outcomes were found to be comparable to larger studies in non-minority cohorts. These results suggest that larger studies as well as prospective analyses and randomized controlled trials in this patient cohort and demographic are needed, as well as optimal selection of patients to determine true clinical implications.

Readmission After Lower Extremity Bypass Following Discharge to a Rehabilitation or Nursing Facility

IntroductionHospital readmission after lower extremity arterial bypass (LEB) is common. Patients are often discharged to a facility after LEB as a bridge to home. Our objective was to define the association between discharge to a facility and readmission after LEB. MethodsWe used the Vascular Quality Initiative to study patients who underwent LEB from 2017 to 2022. The primary exposure was discharge location. The primary outcome was 30-d hospital readmission. ResultsWe included 6076 patients across 147 centers. The overall 30-d readmission rate was 18%. Readmission occurred among 15% of patients discharged home, 22% of patients discharged to a rehabilitation facility, and 25% of patients discharged to a nursing home. After controlling for patient and procedural factors, there was no significant association between discharge location and 30-d readmission (rehabilitation versus home odds ratio: 1.06, 95% confidence interval: 0.87-1.29; nursing facility versus home odds ratio: 1.21, 95% confidence interval: 0.99-1.47). Female sex, end-stage renal disease, diabetes, heart failure, pulmonary disease, smoking, preoperative functional impairment, tibial bypass target, critical limb threatening or acute ischemia, and postoperative complications including surgical site infection, change in renal function and graft thrombosis were associated with an increased likelihood of readmission. ConclusionsPatients discharged home after LEB experienced a similar likelihood of readmission as those discharged to a facility. While discharge to a facility may aid in care transitions, it did not appear to lead to reduced 30-d readmissions. The recommended discharge location should be predicated on patient care needs and not as a perceived mechanism to reduce readmissions.

Sex Disparities in Infra-inguinal Vein Bypass for Peripheral Artery Disease

Although studies demonstrate sex-based differences in peripheral arterial disease (PAD), contemporary outcomes in surgically managed PAD remains largely under-characterized. We sought to discern the differences in perioperative outcomes between males and females with PAD who received infra-inguinal vein bypasses. The infra-inguinal bypass Vascular Quality Initiative (VQI) registry was queried between 2010 and 2020. We evaluated patients with infra-inguinal vein bypasses for occlusive disease, excluding non-occlusive disease, asymptomatic, acute limb ischemia, and emergent procedures. Baseline demographics, comorbidities, prior medical and surgical management, and perioperative outcomes were compared between men and women using the χ2 analysis and t test. Socioeconomic status was defined using Distressed Community Index (DCI). Bypass patency at 1 year was compared between single-segment vein bypasses of the same inflow and outflow targets, using Kaplan-Meier analysis. We identified 28,845 infra-inguinal vein bypasses; 30.6% of patients were female. Female patients were older and had a higher portion of black race, non-ambulatory status, and disadvantaged socioeconomic DCI (Table I). Males had higher rates of smoking, chronic obstructive pulmonary disease, cardiac disease, and coronary percutaneous/bypass interventions. More women were on more likely to be taking P2Y inhibitors, possibly related to a significantly higher rate of prior lower extremity endovascular interventions (P < .001). Alternatively, males had higher rates of prior ipsilateral bypass. Men presented with less clinical disease severity, with a higher proportion of claudication in men vs rest pain in women. Females had a higher rate of popliteal bypass targets suggestive of proximal disease, whereas more males had tibial bypass targets suggestive distal disease (Table II). Women had a higher utilization of non-reversed GSV compared with men (24.2% vs 22.6%; P < .001). No significant differences were seen in total procedure time, blood loss, or postoperative infection. More males underwent postoperative amputation. Fewer women returned home or were ambulatory on discharge. Males were also more likely to be on aspirin and statin both prior to intervention and on discharge (P < .001). There was no significant differences between men and women in 5-year survival (74.6% vs 74.2%; P = .98) or 1-year primary patency in femoral-above knee popliteal (58.6% vs 58.0%; P = .720), femoral-below knee popliteal (57.2% vs 56.7%; P = .816), femoral-tibial (56.5% vs 57.7%; P = .520), or popliteal-tibial (58.0% vs 55.7%; P = .950) bypass. Females present with a unique demographic, socioeconomic, and PAD disease pattern, with diminished perioperative medical management and advanced clinical disease. Acknowledgment of these differences should guide increasing attention to screening programs, medical optimization, and post intervention disposition planning. Although less women were discharged on optimal medical management, bypass patency was similar to men at 1 year.Table ICategorical variables for patients receiving infra-inguinal vein bypassMaleFemaleP-valueDemographics Age, years66 ± 1067 ± 12<.001 Body mass index, kg/m227.7 ± 5.728.0 ± 6.9.042 Race<.001White82.2%76.7%Black13.8%19.7%Others4.0%3.6% Ambulatory status<.001Ambulatory95.5%93.5%Non-ambulatory4.5%6.5% DCI<.001Prosperous23.1%20.8%Comfortable21.3%20.3%Mid-tier20.7%19.4%At-risk18.3%19.6%Distressed16.7%19.9% Smoking history87.0%76%<.001 Chronic obstructive pulmonary disease24.6%26.3%<.001 Hypertension87.8%89.6%<.001 Diabetes mellitus52.6%49.0%.008 Coronary disease31.2%27.1%<.001 Heart failure17.1%16.9%.018 Peripheral endovascular42.9%47.9%<.001 Peripheral bypass25.3%23.6%.015 Minor amputation10.7%8.6%<.001 Percutaneous coronary22.6%20.1%<.001 Coronary bypass19.1%16.9%<.001 Aspirin74.3%73%.071P2Y inhibitor28.9%32.9%<.001 Statin75.1%71.7%<.001 Claudication26.6%21.0%<.001 Rest pain24.3%28.6% Tissue loss49.2%50.4%DCI, Disadvantaged Community Index. Open table in a new tab Table IIPerioperative outcomes for patients receiving infra-inguinal vein bypassMale, %Female, %P-valueBypass category<.001 Femoral-above knee popliteal13.319.8 Femoral-below knee popliteal31.635.1 Femoral-tibial42.235.3 Popliteal-tibial12.89.8Perioperative antibiotics82.779.7<.001SSI3.03.9<.002Postoperative amputation12.111.9<.001Discharge medications Aspirin86.684.7<.001 P2Y inhibitor41.645.1<.001 Statin83.979.2<.001Discharge status<.001 Home72.364.6 Rehab16.019.8 Nursing home10.914.5 Other0.81.1Discharge graft patency.002 Primary95.093.5 Primary-assisted2.53.1 Secondary1.72.2 Occluded0.81.2SSI, Surgical site infection. Open table in a new tab

Real-Time Assessment of Tissue Oxygen Saturation Using a Novel Oximeter During Revascularization for Acute Limb Ischemia: A Case Report

Emergency surgery was performed to treat acute lower limb ischemia caused by heart thromboembolism and concomitant popliteal artery aneurysm. Using a near-infrared spectroscopy oximeter, regional tissue oxygen saturation (rSO2) was monitored to assess the tissue perfusion pre-, intra-, and postoperatively. rSO2 values did not increase sufficiently following thromboembolectomy of the superficial femoral artery, but they dramatically recovered after additional popliteal-anterior tibial bypass surgery. The affected limb was successfully salvaged. rSO2 monitoring was easily measured intraoperatively, which might be beneficial in evaluating tissue perfusion in patients with acute limb ischemia.

Short-term Patency of Iliofemoral to Tibial Bypass with Vascular Allografts in a Minority Population; a Retrospective Analysis of a Single Center Acute Care Facility

Short-term Patency of Iliofemoral to Tibial Bypass with Vascular Allografts in a Minority Population; a Retrospective Analysis of a Single Center Acute Care Facility

Duplicate Great Saphenous Vein Utilization for Long Segment Tibial Bypass Without Need for Spliced Re-Anastomosis.

There is significant benefit to utilizing autologous venous conduit in lower extremity arterial bypass surgery. Specifically, improved patency is well documented relative to prosthetic or non-autologous biological conduits. The smaller caliber the target artery, the more critical using an autologous conduit becomes in striving to achieve long term graft survival. Another benefit to venous conduit is resistance to infection. Presented herein are the technique and images of a duplicate great saphenous vein (GSV) system with a common trunk being utilized to create a single long autologous venous conduit. Intraoperative images as well as conceptual drawing are provided. The non-reversed segment of the bypass is treated with a valvulatome. This allows for creation of a non-spliced autologous conduit when the distal aspect of the primary GSV is too diminutive for bypass. Surveillance duplex imaging 3months after surgery revealed no evidence of stenosis in the bypass and a normalization of the ABI. The area corresponding to the repair of the common trunk was identified on duplex and noted to have a robust diameter. He is doing well with full resolution of rest pain and claudication symptoms. This technique of utilizing a duplicate greater saphenous vein system to maintain a single lower extremity autologous venous conduit for arterial bypass is beneficial to keep in the armamentarium of vascular surgeons.

Aortic-tibial transiliac wing extra-anatomic bypass with distal fistula for treatment of an infected deep femoral pseudoaneurysm.

Transiliac wing bypass has been reported to be a viable extra-anatomic alternative technique for patients presenting with a history of groin infection or irradiation.1Enzmann F.K. Nierlich P. Eder S.K. Aspalter M. Dabernig W. Aschacher T. et al.Trans-iliac bypass grafting for vascular groin complications.Eur J Vasc Endovasc Surg. 2019; 58: 930-935Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Of the 32 reported cases, only two patients had undergone transiliac aortic–tibial or iliotibial bypass.2Sekanina G. Lemminger F. Bruecher D. Iliaco-crural bypass through a borehole in the iliac fossa as extra-anatomic vascular bypass in infected inguinal canal and posterior aspect of the knee.Chirurg. 1995; 66: 142-145PubMed Google Scholar,3Heldenberg E. Lorber J. Cheyn D. Bass A. Transiliac wing alternate route bypass for infected groin vascular graft.J Vasc Surg. 2014; 60: 504-505Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar We report the case of a 72-year-old man with a complex history of multiple lower limb revascularizations, who had been admitted for a deep femoral infected anastomotic pseudoaneurysm (A) and left chronic limb threatening ischemia. Computed tomography showed chronic occlusions at the femoropopliteal level, with a previous thrombosed obturator canal bypass. The only patent lower leg artery was the posterior tibial artery (PTA) from its mid-third to the foot.A transiliac wing aortic–tibial prosthetic bypass was performed through a pararectal retroperitoneal approach (B/Cover). The infrarenal aorta and common iliac arteries were cross-clamped before implanting an 8-mm expanded polytetrafluoroethylene graft soaked in rifampicin at the terminal aorta level. It was tunneled into the retroperitoneal space, over the psoas muscle. A U-shape osteotomy was performed at the anterior left iliac wing border through a second lateral incision to guide the bypass. Another incision was made at the lateral side of the thigh to guide the graft route between the femoral condyles. It was associated with a distal arteriovenous bypass between the PTA and a fibular vein (C), before the distal anastomosis of the aortic–tibial bypass, to partially deviate the aortic blood flow from the PTA into the venous circulation.The second part of the procedure consisted of deep femoral pseudoaneurysm repair. It was developed at the distal anastomosis level of the thrombosed obturator canal bypass, which was removed to the obturator canal during the same procedure. The deep femoral artery was then ligated with 5-0 polypropylene suture. Transiliac wing bypass has been reported to be a viable extra-anatomic alternative technique for patients presenting with a history of groin infection or irradiation.1Enzmann F.K. Nierlich P. Eder S.K. Aspalter M. Dabernig W. Aschacher T. et al.Trans-iliac bypass grafting for vascular groin complications.Eur J Vasc Endovasc Surg. 2019; 58: 930-935Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Of the 32 reported cases, only two patients had undergone transiliac aortic–tibial or iliotibial bypass.2Sekanina G. Lemminger F. Bruecher D. Iliaco-crural bypass through a borehole in the iliac fossa as extra-anatomic vascular bypass in infected inguinal canal and posterior aspect of the knee.Chirurg. 1995; 66: 142-145PubMed Google Scholar,3Heldenberg E. Lorber J. Cheyn D. Bass A. Transiliac wing alternate route bypass for infected groin vascular graft.J Vasc Surg. 2014; 60: 504-505Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar We report the case of a 72-year-old man with a complex history of multiple lower limb revascularizations, who had been admitted for a deep femoral infected anastomotic pseudoaneurysm (A) and left chronic limb threatening ischemia. Computed tomography showed chronic occlusions at the femoropopliteal level, with a previous thrombosed obturator canal bypass. The only patent lower leg artery was the posterior tibial artery (PTA) from its mid-third to the foot. A transiliac wing aortic–tibial prosthetic bypass was performed through a pararectal retroperitoneal approach (B/Cover). The infrarenal aorta and common iliac arteries were cross-clamped before implanting an 8-mm expanded polytetrafluoroethylene graft soaked in rifampicin at the terminal aorta level. It was tunneled into the retroperitoneal space, over the psoas muscle. A U-shape osteotomy was performed at the anterior left iliac wing border through a second lateral incision to guide the bypass. Another incision was made at the lateral side of the thigh to guide the graft route between the femoral condyles. It was associated with a distal arteriovenous bypass between the PTA and a fibular vein (C), before the distal anastomosis of the aortic–tibial bypass, to partially deviate the aortic blood flow from the PTA into the venous circulation. The second part of the procedure consisted of deep femoral pseudoaneurysm repair. It was developed at the distal anastomosis level of the thrombosed obturator canal bypass, which was removed to the obturator canal during the same procedure. The deep femoral artery was then ligated with 5-0 polypropylene suture. Appendix

Long-Term Outcomes of Extra-Anatomic Femoro-Tibial Bypass Reconstructions in Chronic Limb-Threating Ischemia.

(1) Background: While tibial bypass surgery still plays a role in the treatment of patients with chronic limb-threatening ischemia and diabetic foot syndrome; only a few centers have recorded considerable numbers of these conditions. The current study aimed to determine contemporary practice with special focus on the performance of extra-anatomic grafting to the infrapopliteal arteries. (2) Methods: A retrospective, single-center study included patients with tibial bypass grafts from 1 January 2008 to 31 December 2019. Primary endpoints were complication rate, graft patency, amputation, overall survival, and major adverse cardiac (MACE) or limb event (MALE). The cohort was stratified by extra-anatomic vs. anatomic position. (3) Results: A total of 455 patients (31% female) with Rutherford stage 4 (12.5%) and 5/6 (69.5%) were included (thereof, 19.5% had high amputation risk according to the Wound Ischemia Foot Infection score). Autologous reconstruction was performed in 316 cases, and prosthetic reconstruction in 131 cases, with a total of 51 (11.2%) extra-anatomic grafts. Early occlusion rate was 9.0% with an in-hospital overall mortality of 2.8%. The in-hospital rate of MACE was 2.4% and of MALE, 1.5%. After one, three and five years, the primary patency of venous bypasses was 74.5%, 68.6% and 61.7%, respectively. For prosthetic grafts, this was 55.1%, 46.0%, and 38.3%, respectively (p < 0.001). The patency of extra-anatomic prosthetic grafts performed significantly better compared with anatomically positioned prosthetic grafts (log-rank p = 0.008). In multivariate analyses, diabetes (hazard ratio, HR 1.314, CI 1.023–1.688, p = 0.032), coronary artery disease (HR 1.343, CI 1.041–1.732, p = 0.023), and dialysis dependency (HR 2.678, CI 1.687–4.250, p < 0.001) were associated with lower odds of survival (4) Conclusion: In this large, single-center cohort, tibial bypass surgery demonstrated satisfactory results with overall low perioperative complication rates and long-term patency rates of 60% and 38%, respectively. Extra-anatomic bypasses represent a feasible alternative to venous grafts in terms of patency. A tailored, patient-centered approach considering predictors such as diabetes, dialysis dependency, and coronary artery disease along with prediction models may further improve the long-term results in the future.

Impact of tibial bypass conduit on long-term amputation-free survival and primary patency in the Vascular Quality Initiative

ObjectiveMuch research remains focused on tibial bypass conduit selection. We sought to describe long-term amputation-free survival (AFS) and primary patency (PP) of patients undergoing tibial bypass by conduit type and configuration across several permutations in the Society for Vascular Surgery Vascular Quality Initiative. MethodsPatients in the Vascular Quality Initiative registry undergoing elective first-time femoral- or popliteal-to-tibial bypass for occlusive disease involving rest pain or tissue loss were identified. Prior ipsilateral infrainguinal bypass or concomitant procedures were excluded. Outcomes of interest included patient AFS at 22 months and PP at 1 year (defined as freedom from revision, thrombectomy, or graft occlusion). ResultsA total of 4192 bypasses were identified. The majority utilized great saphenous vein (GSV) (76.2%), followed by polytetrafluoroethylene (10.6%), nonautologous biologic (6.5%), composite (3.3%), arm vein (2.8%), and small saphenous vein (0.6%). Compared with all prosthetic and composite bypasses, vein grafts had the best AFS (76.4%; P < .0001) and PP (68.1%; P = .041). Of the single segment vein conduits, GSV bypasses had the best PP (69.1%) and arm vein the worst (60.2%). AFS and PP were similar between single-segment GSV orientations. Single-segment GSV bypasses exhibited better PP than multiple segment bypasses (69.1% vs 54.6%; P = .0016). PP was significantly better for polytetrafluoroethylene compared with nonautologous biologic (68.4% vs 51.2%; P = .0039). PP did not significantly differ between vein cuff for prosthetic bypass compared with no vein cuff (69.1% vs 59.7%; P = .091). PP was not significantly different between single-segment GSV and prosthetic grafts with vein cuff (69.1% vs 69.1%; P = .51). There were no significant differences in AFS comparing arm vein, prosthetic bypass with vein cuff, or composite grafts (67.2% vs 63.8% vs 59.3%; P = .092), as well as in PP (60.2% vs 69.1% vs 54.8%; P = .14). ConclusionsSingle-segment vein bypass was only marginally the most optimal conduit. Surprisingly, there may be more equipoise among conduit types, particularly in the absence of adequate GSV. Prosthetic grafts overall may not be as disadvantaged in the long term as initially thought, especially when compared with arm vein, as prosthetic bypass with vein cuff did not significantly differ in PP. Similarly, a composite conduit may not impact long-term outcomes. These data suggest that conduit choice may not impact outcomes to the degree previously thought and that other factors may have a greater impact than presumed, especially in conduit limited situations.

The predictive value of microperfusion assessments for the follow-up of tibial bypass grafts

ObjectiveWe conducted a prospective evaluation of microperfusion parameters after tibial bypass surgery was performed. Differences between grafts with occlusions during follow-up and patent grafts were analyzed in relation to the pedal arch quality. MethodsPatients receiving tibial bypass grafts for chronic limb-threatening ischemia from 2019 to 2020 were included. Assessment of microcirculation (parameters: hemoglobin oxygen saturation [sO2] and flow) was done by laser Doppler flowmetry and white light spectrometry (oxygen-to-see), supine and in elevation, whereas the macrocirculation was evaluated by the ankle-brachial index and duplex ultrasound examination. The quality of run-off was graded for each patient. Measurements were performed preoperatively, 1 day postoperatively, and after 6 months. Patients with graft occlusions during follow-up (OCCLUDED) and patients without occlusions (OPEN) were compared. ResultsWe included 42 patients (13 women, 29 men; mean age, 76.1 years; range, 60-89 years) were included. The patency of all grafts 1 day after the operation was confirmed by ultrasound examination. The overall analysis of the microcirculation showed significant changes in both the supine and elevated leg position between measurements taken preoperatively, 1 day after the operation, and after 6 months for the parameters sO2 and FLOW (sO2 supine, P = .001; sO2 elevated, P < .001; FLOW supine, P < .001; FLOW elevated, P < .001). The comparison of the values 1 day after the operation yielded significantly decreased microperfusion parameters (both O2 and FLOW) in the group that developed bypass occlusion in the later follow-up period (sO2 supine: OCCLUDED, 35.7% [7.3-65.0] and OPEN, 48.7% [25.0-72.3] P = .011; FLOW supine: OCCLUDED, 27.7 A.U. [12.7-52.7] and OPEN, 57.3 A.U. [16.0-106.7], P = .008). No significant differences in the severity of the arch impairment was found between the OPEN and OCCLUDED groups (P = .651). Absolute values of the parameters sO2 and flow showed no correlation with the pedal arch classification. ConclusionsSignificantly poorer microperfusion was detected postoperatively in patients with later occurrence of graft occlusions despite patent grafts on the first postoperative day. Microperfusion measurements might be a possible tool for the prediction of graft failure.

Autologous saphenous vein and heparin-bonded expanded polytetrafluoroethylene as graft materials for below-the-knee femoro-popliteal bypass in patients with critical limb ischemia: A propensity score-matched analysis

ObjectiveTo compare the outcomes of heparin bonded expanded polytetrafluoroethylene (HePTFE) and autologous saphenous vein (ASV) in patients undergoing below-knee (BK) femoro-popliteal bypass for critical limb ischemia (CLI). DesignRetrospective single-centre matched case–control study. MethodsFrom 2003 to 2019, 275 consecutive BK bypasses for CLI were performed, 109 with the ASV and 166 with a HePTFE graft. All the baseline characteristics that were reliably measured and were potentially relevant in the decision-making process were included as confounders in a logistic regression model and the factors that were significantly different between the two groups then used to perform a propensity matching analysis. Propensity score-based matching was performed in a 1:1 ratio to compare outcomes. Arterial hypertension, hyperlipemia, the need for tibial anastomosis at the distal level and the run-off status were the covariates included in the matching. Follow-up outcomes were estimated by Kaplan–Meier methods and compared with log rank test. ResultsAfter propensity matching, 101 HePTFE bypasses were matched with 101 ASV bypasses. The median duration of follow-up was 37 months (range 1–192). The 5-year survival rate was 67.5% (standard error (SE) 0.05) in the HePTFe group and 64.5% (SE 0.06) in the ASV group (p = 0.8, log rank 0.04). Primary patency rates were 38% (SE 0.06) in the HePTFE group and 41% (SE 0.06) in the ASV group (p = 0.7, log rank 0.3). Also assisted primary patency and secondary patency rates did not differ in the two groups. Amputation-free survival was 53% (SE 0.05) in the HePTFE group and 58% (SE 0.06) in the ASF group (p = 0.6, log rank 0.2). ConclusionsHePTFE provided 5-year similar results to those obtained with use of the ASV in equivalent patients with CLI undergoing below-knee or tibial bypass.

Impact Of Tibial Bypass Conduit On Long-term Patency And Survival In The Vascular Quality Initiative

Optimal conduit selection for tibial artery bypass in limited clinical situations remains controversial. We sought to characterize long-term patency and mortality of patients undergoing tibial bypass across conduit types in the VQI.

Ruptured True Common Femoral Artery Aneurysm and Operative Management

An 81-year-old male with past surgical history significant for right common femoral to posterior tibial artery bypass as well as aortic aneurysm repair using endograft presented with painful pulsatile right groin swelling. Ultrasound imaging revealed a fluid collection and concern for ruptured right common femoral artery aneurysm with expanding hematoma. The patient underwent prompt aneurysm excision with graft interposition complicated by wound dehiscence for which he subsequently underwent wound exploration, revision of proximal anastomosis and sartorius myoplasty. Our case illustrates a rare form of femoral artery rupture and operative management of a true common femoral artery aneurysm.

Resurrection of Chronically Occluded Prosthetic Bypass Grafts in a Single Stage with Suction Thrombectomy and Intervention

Peripheral arterial occlusive disease (PAOD) continues to be a vexing problem despite the advent of endovascular techniques augmenting traditional open repair. At our institution, we have found there is a growing number of patients with PAOD who are vein-challenged and have undergone prosthetic bypass previously for infrainguinal arterial reconstruction. When occluded, these grafts have been abandoned for a new bypass strategy or amputation. We present a novel technique of reestablishing flow through chronically occluded prosthetic bypass grafts. A retrospective review of a prospectively maintained database compiled at 2 institutions between 2016 and 2019 was performed. Six patients had previous prosthetic bypass grafts with 4 patients having femoral to popliteal grafts, 1 patient with a femoral to femoral graft, and 1 with a femoral to posterior tibial bypass graft. All patients had an attempted single-stage intervention to clear chronically occluded grafts. A total of 6 patients were included in the study. Indications for intervention were chronic, critical limb ischemia with tissue loss (3), severe claudication (2), and acute on chronic limb ischemia (1). Average time from bypass to suction thrombectomy was 29months (6-60months). Mean patency duration is 13months (1-28months). Adjunctive procedures include overnight lysis to improve outflow in 1 patient (16.6%), drug-coated balloon angioplasty (83.3%), or stents (83.3%). There were no embolic complications during these procedures. All (2) wounds healed and all are maintained on full-dose anticoagulation and/or antiplatelet therapy. Often, the timing of bypass graft occlusion is unknown, and the risk of embolism with lysis for chronically occluded bypass grafts is concerning with traditional peripheral intervention techniques. We report a new and unique minimally invasive approach to resurrect chronically occluded prosthetic bypass grafts often successful in just one stage. This tool offers an alternative technique for limb salvage in complex patients and as use increases, requires further interrogation.