Prospective randomized multicenter comparison of in situ and reversed vein infrapopliteal bypasses

doi:10.1016/0741-5214(91)90211-C

Journal of Vascular Surgery

Volume 13, Issue 2, February 1991, Pages 189-199

Presented at the Thirty-eighth Scientific Meeting of the North American Chapter, International Society for Cardiovascular Surgery, Los Angeles, Calif., June 4-6, 1990.

https://doi.org/10.1016/0741-5214(91)90211-C Get rights and content

Abstract

We have performed a prospective, randomized, multicenter study to compare in situ and reversed vein grafts for long limb salvage bypasses from the proximal thigh to an infrapopliteal artery. Three hundred eighty-four patients required an infrapopliteal bypass for critical lower extremity ischemia. Of these, 259 were excluded because a short vein bypass was performed or because the vein was considered inadequate. The remaining 125 patients had a randomized vein bypass, 63 reversed, 62 in situ. The two groups were similar with regard to risk factors, indications, graft dimensions, and outflow. Secondary patency at 30 months was similar for both techniques: reversed 67% ± 9% (±SE); in situ 69% ± 8%. For veins ≤3.0 mm in minimum distended diameter 24-month patency rates were 61% ± 22% for 12 in situ veins and 37% ± 29% for 10 reversed veins (p > 0.05). Angiographic evaluation of failing grafts revealed lesions similar in type and frequency in both types of grafts. These included focal (in situ, n = 4; reversed, n = 7 and diffuse vein hyperplasis (in situ, n = 2; reversed, n = 1), and inflow and outflow stenoses (in situ, n = 4; reversed, n = 3). The incidence of wound complications and the mortality rate were similar for the two groups. These data show no significant difference in overall patency rates for the two types of vein grafts at 2½ years. Because of the poor preliminary patency of reversed vein grafts ≤3.0 mm in minimum distended diameter, we suggest the in situ method be used preferentially when such small veins are encountered. Thirty percent of patients requiring a long infrapopliteal bypass had no vein suitable for an in situ graft, although an ectopic vein bypass was feasible. Thus surgeons performing these operations should be adept at both procedures. (J VASC SURG 1991;13:189-99.)

Section snippets

Methods

All three centers had considerable interest and experience in the performance of infrainguinal bypass procedures by use of both reversed and in situ vein grafts.3, 17, 23 All six participating surgeons were adept in the performance of both techniques, and all agreed to the following standard protocol for the evaluation, randomization, operative care, and postoperative follow-up of their patients undergoing infrapopliteal bypass. Appropriate approval of this protocol was obtained from the

Excluded or withdrawn patients

Seventy-four (37%) of the 199 candidates for randomization (Table I) were excluded before randomization or withdrawn after randomization because the vein was unsuitable for use because it was absent, too small (<2.5 mm in MDD), fibrotic, or had an intraluminal obstruction to the passage of a soft catheter. Fiftynine patients (30%) underwent a bypass with a contralateral saphenous or another ectopic vein, and 15 (7%) received a prosthetic polytetrafluoroethylene graft.

Clinical characteristics of patients and vein grafts in the randomized group

Characteristics of the

Discussion

Infrainguinal reconstructive arterial surgery for limb salvage is now widely accepted and practiced.1, 2 Operability rates and limb salvage rates have increased dramatically.³ In addition, as techniques for performing infrainguinal bypasses in general and infrapopliteal bypasses in particular have improved, the patency rates have increased. Important contributions to these improved results have been the introduction of fine instruments, meticulous techniques, and recognition of the frequent

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Endovascular treatment of an aneurysmal vein graft twenty-six years after infrainguinal revascularization
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Open surgical bypass with single-segment greater saphenous vein remains the most durable revascularization option in symptomatic peripheral arterial disease. Aneurysmal degeneration of autologous conduit is quite rare. Herein is reported a case of a 78-year-old man who presented with a pulsatile medial thigh mass twenty-six years after ipsilateral infrainguinal autologous vein bypass grafting for lifestyle-limiting intermittent claudication. This was found to represent aneurysmal degeneration of the proximal vein graft with mural thrombus. He underwent an uneventful percutaneous endovascular venous aneurysm repair with implantation of a covered self-expanding endoprosthesis and preservation of his patent bypass.
Non-reversed and Reversed Great Saphenous Vein Graft Configurations Offer Comparable Early Outcomes in Patients Undergoing Infrainguinal Bypass
2022, European Journal of Vascular and Endovascular Surgery
Citation Excerpt :
The reversed vein bypass uses mobilisation of the entire length of the GSV, which is subsequently reversed in configuration to allow the passage of flow through valves. Many studies have evaluated outcomes of in situ and reversed vein bypasses with mixed results regarding the superiority of either technique.8–15 First described by Batson and Sottiurai in 1985, the non-reversed, transposed vein bypass combines two important attributes of both reversed and in situ techniques.16
Data on the efficacy of non-reversed and reversed great saphenous vein bypass (NRGSV and RGSV) techniques are lacking. The aim of the study was to compare the outcomes of patients undergoing open infrainguinal revascularisation using NRGSV and RGSV from a multi-institutional database.
The Vascular Quality Initiative database was queried for patients undergoing infrainguinal bypasses using NRGSV and RGSV for symptomatic occlusive disease from January 2003 to February 2021. The primary outcome measures included primary and secondary patency at discharge and one year. Secondary outcomes were re-interventions at discharge and one year. Cox proportional hazards models were used to evaluate the impact of graft configuration on outcomes of interest.
Of 7 123 patients, 4 662 and 2 461 patients underwent RGSV and NRGSV, respectively. At one year, the rates of primary patency (78% vs. 78%; p = .83), secondary patency (90% vs. 89%; p = .26), and re-intervention (16% vs. 16%; p = .95) were similar between the RGSV and NRGSV cohorts, respectively. Subgroup analysis based on outflow bypass target and indication for revascularisation did not show differences in primary and secondary outcomes between the two groups. Multivariable analysis confirmed that RGSV (NRGSV as the reference) configuration was not independently associated with increased risk of primary patency loss (hazard ratio [HR] 1.01; 95% confidence interval [CI] 0.91 – 1.13; p = .80), secondary patency loss (HR 0.94; 95% CI 0.81 – 1.10; p = .44), and re-intervention (HR 1.03; 95% CI 0.91 – 1.16; p = .67) at follow up.
The study shows that RGSV and NRGSV grafting techniques have comparable peri-operative and one year primary and secondary patency and re-intervention rates. This effect persisted when stratified by outflow targets and indication for revascularisation. Therefore, optimal selection of vein grafting technique should be guided by the patient’s anatomy, vein conduit availability, and surgeon’s experience.
Systematic review and meta-analysis of saphenous vein harvesting and grafting for lower extremity arterial bypass
2021, Journal of Vascular Surgery
Citation Excerpt :
These studies reported no significant differences in the patency of LEAB between continuous incision harvesting and skip incision harvesting (Peto OR, 0.93; 95% CI, 0.83-1.04; P = .20; I2 = 94%). A total of 20 studies reported data on reversed vs in situ bypass grafting (Table III).13,14,37,40-55 We did not find evidence of a difference between reversed and in situ grafting in the mortality rate (RR, 0.91; 95% CI, 0.45-1.87; P = .80; I2 = 0%) or wound complications (RR, 0.91; 95% CI, 0.45-1.82; P = .80; I2 = 65%).
In the present systematic review and meta-analysis, we compared the short- and long-term outcomes of different harvesting and grafting techniques in patients undergoing lower extremity arterial bypass.
We searched multiple electronic databases (up to December 1, 2019) for comparative trials investigating different harvesting and bypass grafting techniques.
We identified a total of 37 studies for our review. Skip incision harvesting showed a similar high primary patency rate (Peto odds ratio [OR], 0.93; 95% confidence interval [CI], 0.83-1.04; P = .20) with continuous incision harvesting and comparable low wound complication rates (relative risk, 1.55; 95% CI, 0.91-2.66; P = .11) with endoscopic harvesting. In situ bypass grafting a long-term patency similar to that of reversed grafting (Peto OR, 1.01; 95% CI, 0.75-1.37; P = .93). However, for femoropopliteal bypass, the reversed bypass grafting group had significantly lower 2-year (Peto OR, 0.63; 95% CI, 0.52-0.78; P < .001) and 5-year (Peto OR, 0.70; 95% CI, 0.50-0.98; P = .04) failure rates compared with the in situ bypass grafting group. For infrapopliteal bypass, the in situ bypass grafting group had significantly lower 1-year (Peto OR, 1.54; 95% CI, 1.04-2.28; P = .03), 2-year (Peto OR, 1.52; 95% CI, 1.15-2.02; P = .003), and 3-year (Peto OR, 2.14; 95% CI, 1.13-4.05; P = .02) failure rates.
Skip incision harvesting can be considered the first-line harvesting strategy. For patients undergoing femoropopliteal bypass, reversed bypass grafting seems to result in better long-term patency. In contrast, for those undergoing infrapopliteal bypass, in situ bypass grafting resulted in superior long-term patency.
Peripheral arterial disease and bypass surgery in the diabetic lower limb
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Basic data related to surgical infrainguinal revascularization procedures: A twenty year update
2011, Annals of Vascular Surgery
In 1990, Dalman and Taylor published a compilation of reported data that were identified by them as related to infrainguinal revascularization procedures in peripheral vascular surgery during the decade of the 1980s. The intervening 20 years has seen revolutionary advances in the field of peripheral vascular surgery, especially in the adoption of endovascular techniques, and an explosion of data related to emerging technologies in the field of infrainguinal revascularization. The tables in this manuscript reflect the evolution of our surgical knowledge during the turn of the 21st century. The superior patency of autologous saphenous vein in all positions is reaffirmed.

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^☆: Supported in part by the Manning Foundation, the Anna S. Brown Trust, the Hunter Surgical Research Fund, and the New York Institute for Vascular Studies.

^☆☆: Reprint requests: Frank J. Veith, MD, 111 E 210 St., New York, NY 10467.

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Original Articles from the International Society for Cardiovascular Surgery, North American ChapterProspective randomized multicenter comparison of in situ and reversed vein infrapopliteal bypasses☆,☆☆

Abstract

Section snippets

Methods

Excluded or withdrawn patients

Clinical characteristics of patients and vein grafts in the randomized group

Discussion

J Vasc Surg

J Vasc Surg

Am J Surg

J Vasc Surg

J Vasc Surg

J Vasc Surg

J Vasc Surg

J Vasc Surg

J Vasc Surg

J Vasc Surg

J Vasc Surg

J Vasc Surg

J Surg Res

J Thorac Cardiovasc Surg

Effect of arterial reconstruction on limb salvage: a ten-year appraisal

Arch Surg

Progress in limb salvage by reconstructive arterial surgery combined with new or improved adjunctive procedures

Ann Surg

Original Articles from the International Society for Cardiovascular Surgery, North American Chapter
Prospective randomized multicenter comparison of in situ and reversed vein infrapopliteal bypasses☆,☆☆