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Surgical Bypass Summit — Session 3:
When to use graft versus multi-segment spliced vein — Prof. Thomas Schmitz-Rixen

  • Video

Prof. Thomas Schmitz-Rixen

Despite advances in endovascular techniques, surgeons acknowledge that there is still a role for infrapopliteal bypasses for limb salvage. This is especially the case for patients with critical limb issues, when surgeons must get pulsatile blood flow down to the foot—regardless of which artery is available. Although the greater saphenous vein is the best replacement material, arm vein is considered the last autogenous option for infrainguinal bypass surgery, and several studies have evaluated the efficacy of long arm veins as an alternative conduit for treating critical limb ischemia (CLI).1-2 While the results have varied, bypass surgeries performed using arm vein are generally safe and result in favorable patency and high rates of limb salvage.3 Moreover, a direct comparison of arm vein versus prosthetic graft for infrapopliteal bypasses for CLI found that, even when spliced, arm vein conduits are superior to prosthetic grafts in terms of midterm-assisted primary patency, secondary patency, and leg salvage.4 Despite the documented superiority of arm veins to prosthetic grafts, there appears to be a role for the GORE® PROPATEN® Vascular Graft (Gore & Associates) for the treatment of claudication and noninfected CLI, particularly when the patient does not have an available vein.

Our group performed a retrospective analysis of patients who received surgical bypass as a treatment for peripheral artery disease (PAD) between January 2011 and July 2014. The GORE® PROPATEN® Vascular Graft was used for two different indications: Claudication (n = 8) and noninfected CLI (n = 67). Overall, 1-year patency was 69% and 2-year patency was 65%. Thus, most failures occurred in the first year. Patients who received alternative veins had an 81% patency rate in the first year and a 75% patency rate in the second year. Complication rates were low for both groups. There were no differences in wound- healing complications and cardiac complications between patients who received the GORE® PROPATEN® Vascular Graft and those who received spliced vein. However, there was one death in the GORE® PROPATEN® Vascular Graft group from an acute, infected graft. During the study period, there were 25 failed grafts in the below-knee popliteal artery and femorocrural groups, including three infected grafts that required explant. There were no problems with the other grafts. Graft failures resulted in 10 major amputations.

Summary

The treatment approach used at our facility appears to have delivered results that fall within the expected range. The next step is to extend the analysis of PAD treatment policy to a nation wide registry.

Prof. Thomas Schmitz-Rixen is Professor and Chairman of the Department of Vascular and Endovascular Surgery, Goethe-University-Hospital in Frankfurt, Germany. He has disclosed that he has received travel grants from Gore & Associates, has received compensation from Gore for participating in the Summit, and has received honoraria from Gore for writing this article. He can be reached at [email protected]

  1. Brochado Neto F, Sandri GA, Kalaf MJ, et al. Arm vein as an alternative autogenous conduit for infragenicular bypass in the treatment of critical limb ischaemia: a 15 year experience. Eur J Vasc Endovasc Surg. 2014;47:609-614.
  2. Nguyen BN, Neville RF, Abugideiri M, et al. The effect of graft configuration on 30-day failure of infrapopliteal bypasses. J Vasc Surg. 2014;59:1003-1008.
  3. Robinson DR, Varcoe RL, Chee W, et al. Long-term follow-up of last autogenous option arm vein bypass. ANZ J Surg. 2013;83:769-773.
  4. Arvela E, Soderstrom M, Alback A, et al. Arm vein conduit vs prosthetic graft in infrainguinal revascularization for critical leg ischemia. J Vasc Surg. 2010;52:616-623.