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

Date of Submission21-Sep-2022Date of Acceptance12-Oct-2022Date of Web Publication13-Jan-2023

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

How to cite this article:
Prasath S A, Viruthagiri A, Mandjini N. Outcomes following spliced vein graft and composite graft as conduit for infrainguinal bypass: An institutional experience. Indian J Vasc Endovasc Surg 2022;9:377-80
How to cite this URL:
Prasath S A, Viruthagiri A, Mandjini N. Outcomes following spliced vein graft and composite graft as conduit for infrainguinal bypass: An institutional experience. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2023 Jan 14];9:377-80. Available from: https://www.indjvascsurg.org/text.asp?2022/9/5/377/367727   Introduction 

Peripheral arterial disease affecting lower extremity may be clinically silent or symptomatic. Claudication which does not limit lifestyle usually does not warrant surgical intervention. Whereas patients with disabling claudication, rest pain and/or tissue loss require revascularization either by endovascular or open technique.

Open infrainguinal bypass is the most durable option for infrainguinal arterial disease[1] and a successful bypass requires good quality inflow, conduit, and outflow.

Kunlin was the first to describe the use of autogenous vein graft for femoropopliteal bypass[2],[3] and great saphenous vein (GSV) is considered the best and ideal conduit for peripheral bypass provided the quality and caliber is good.[4],[5]

In the absence of good quality GSV, splicing of leg/arm veins,[6] or synthetic graft with Miller's cuff[7] can serve as an alternate conduit with acceptable outcomes.

Aim

To compare the outcomes of infrainguinal bypass done for patients with symptomatic PAD in two groups of populationIn Group I, non spliced GSV was the conduit usedIn 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 centerTime interval – March 2019–June 2022Time duration – 40 months.

Inclusion criteria

All patients undergoing infrainguinal bypass for chronic limb-threatening ischemia.

Exclusion criteria

Patients with multi-segmental arterial occlusion undergoing aortic/iliac artery reconstruction with sequential infrainguinal bypass.

Patients who underwent infrainguinal revascularization by endovascular techniques.

Indication for surgery

All patients had chronic limb-threatening ischemia; there were no claudicants in our study.

Technique

All patients underwent preoperative duplex imaging of leg veins and arm veins if necessaryVein was considered to be of good caliber if its diameter was at least 3 mm, compressible throughout, nonphlebitic and nonvaricealVeins that were <3 mm and phlebitic were not preferred for bypass surgeryIpsilateral GSV was our preferred conduit. In the absence of ipsilateral GSV, our next choice was GSV of opposite legWhen both GSV were not suitable, splicing of leg veins and/or arm veins was doneVeins were used in reverse configurationSynthetic 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 surgeryIn this situation, a vein cuff was used at the distal anastomosis to prevent exposure of native endothelium to synthetic graft.

Surveillance

Postoperative follow-up was done at 1st month, every 3rd month for 1st year, and every 6 months for the next 1 yearSurveillance 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 periodAmong 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 GSVSplicing 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.   Discussion 

Around 29% of patients did not have good caliber GSV in our study. This is low compared to the study done by Taylor et al. where up to 45% of patients lacked good caliber GSV of adequate length.[4]

Subgroup analysis

Group I

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 outflowTwo patients had late graft thrombosis of which one patient ended up in below knee amputation.

Group II

Spliced vein graft (n-10)

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.

Composite graft (n-5)

Limbs were salvaged in all patientsThe 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 complicationOne patient (20%) had subacute graft thrombosis (2 months' postoperative) due to poor distal runoffAnother 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 bypassWhen 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 graftSynthetic graft provides acceptable limb salvage rate inspite of lower patency rate when combined with an adjunctive procedure like vein cuff for tibial bypass.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

  References 
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    4.Taylor LM Jr., Edwards JM, Porter JM. Present status of reversed vein bypass grafting: Five-year results of a modern series. J Vasc Surg 1990;11:193-205.  
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    9.Slim H, Tiwari A, Ritter JC, Rashid H. Outcome of infra-inguinal bypass grafts using vein conduit with less than 3 millimeters diameter in critical leg ischemia. J Vasc Surg 2011;53:421-5.  
    10.Chang BB, Darling RC 3rd, Bock DE, Shah DM, Leather RP. The use of spliced vein bypasses for infrainguinal arterial reconstruction. J Vasc Surg 1995;21:403-10.  
    11.Stonebridge PA, Prescott RJ, Ruckley CV. Randomized trial comparing infrainguinal polytetrafluoroethylene bypass grafting with and without vein interposition cuff at the distal anastomosis. The Joint Vascular Research Group. J Vasc Surg 1997;26:543-50.  
    12.Neville RF, Tempesta B, Sidway AN. Tibial bypass for limb salvage using polytetrafluoroethylene and a distal vein patch. J Vasc Surg 2001;33:266-71.  
    
  [Figure 1], [Figure 2], [Figure 3]
 
 
  [Table 1], [Table 2]