Cephalic vein grafts for lower extremity revascularization

doi:10.1016/0741-5214(92)90194-D

Journal of Vascular Surgery

Volume 15, Issue 3, March 1992, Pages 543-549

https://doi.org/10.1016/0741-5214(92)90194-D Get rights and content

Abstract

From 1980 to 1989 infrainguinal revascularization was performed with cephalic vein grafts in a consecutive series of 34 patients (35 limbs) whose saphenous veins were either inadequate or already had been harvested for previous coronary (N = 16, 47%) or ipsilateral lower extremity bypass (N = 19, 56%). Surgical indications included ischemic rest pain or focal tissue necrosis in 25 limbs (71%), disabling claudication in six (17%), and popliteal aneurysms or prosthetic femoropopliteal graft infections each in two (6%). Preliminary arteriovenous fistulas were constructed in the arms of 23 patients (68%) to enhance the diameter of their cephalic veins, and 24 (69%) of the 35 infrainguinal procedures in this series were performed with use of cephalic vein alone. The distal popliteal artery was used for the outflow anastomosis in 10 limbs (29%), a tibial vessel was used in 12 (34%), and the peroneal artery was used in 13 (37%). Fourteen graft occlusions (400%) and six amputations (17%) have occurred during follow-up intervals of 1 to 107 months (mean, 28 months; median, 27 months). At 3 years the cumulative primary patency rate is 40%, the secondary patency rate is 46%, and the limb salvage rate is 82%. Despite their relative inconvenience, cephalic vein grafts appear to be preferable to prosthetic materials for infrainguinal revascularization below the knee. (J Vasc Surg 1992;15:543–9.)

Section snippets

Patient information

From 1980 through 1989, 926 distal popliteal or tibioperoneal bypass grafts were constructed at this center. Thirty-five (3.8%) of these required the use of the cephalic vein(s) alone (N = 23; 65%) or in conjunction with composite segments of saphenous vein (N = 9; 26%) or PTFE (N = 3; 9%). This cohort included 26 men (76%) and eight women (24%) with a mean age of 61 years (range, 33 to 81 years). Seventeen (50%) of these patients were hypertensive, and 10 (29%) had diabetes, eight of whom

Results

No postoperative deaths occurred in this series. Early thrombosis occurred in two grafts (6%), both of which were successfully revised. Another immediate reoperation was necessary to control bleeding from a cephalic vein branch. The mean Doppler ankle/brachial index for all 35 limbs improved from 0.38 before operation to 0.91 after revascularization.

Cumulative data concerning late survival, graft patency, and limb salvage are presented in Fig. 2 and in Table II.

. Cumulative 3-year survival,

Discussion

Countless reports have documented the consistently superior performance of saphenous vein grafts for below-knee femoropopliteal or femorotibial-peroneal bypass in comparison to a number of prosthetic materials that have been introduced during the past 30 years. The merit of an “all autogenous” policy for these procedures has been assumed to include the use of arm veins under circumstances in which the saphenous system is inadequate or no longer available. Several sources, however, suggest that

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There are more references available in the full text version of this article.

Cited by (41)

Limb salvage after aneurysmal degeneration of a cryopreserved vein allograft: Searching the autologous veins of the arm is worth the effort
2020, Morphologie
Citation Excerpt :
Limb salvage with autologous veins proved to superior to prosthetic grafts [3]. The dissection can be made easier after creation of an arteriovenous fistulas to increase the diameter of the cephalic vein [4]. In a retrospective analysis of 520 procedure performed in eight years, Faries et al., established that veins of the arm are an alternative of choice with excellent long-term patency and durability.
We hereby report a case of limb salvage involving a 64-year-old man who was hospitalized with ischemic foot ulcers for two months. Endarterectomy with patching and stenting of the left iliofemoral artery failed. A composite bypass of two segments of the endarterectomized superficial femoral artery and a cryopreserved saphenous vein graft was implanted one week later. On day 4 postoperatively, an infection (Staphylococcus epidermidis and Pseudomonas aeruginosa) was treated empirically with antibiotics. Four months later, the femoro-tibial bypass thrombosed and the patency was restored by thrombolysis. The aneurysmal cryopreserved vein was excised. Iterative complications followed and final success was attained after implantation of autologous cephalic and basilic veins. Four years later, this femoro-tibial is still patent.
After a gross observation, the explant was dissected and the most significant sections were processed for histology, followed by analyses in scanning electron microscopy, light microscopy and transmission electron microscopy.
The explanted specimen showed a smooth flow surface proximally but a severe distortion distally, with an accumulation of poorly organized mural thrombi. The wall of the arterialized vein was accompanied with an important inflammatory reaction. The degradation of the collagen structure was evidenced in TEM. The fibrils of collagen were still individualized but were fragmented and did not display parallelly. The regular banding was preserved. The presence of Pseudomonas aeruginosa was shown inside the wall of the homologous vein.
In case of sepsis, the most aggressive antibiotic treatments cannot fully eliminate the bacteremic colonizations within the wall of an alternative conduit. The cephalic and basilic autologous veins are proved to be preferable in absence of the autologous saphenous vein. The amputation was prevented and four years later the bypass is still patent. This is an outstanding result based upon the comorbidities of the patient. The most aggressive harvesting shall be recommended. This patient represented a considerable challenge and the clinical result is highly gratifying: the search for the autologous cephalic and basilic veins proved to be worth the effort.
Cette publication rapporte le cas d’un sauvetage de membre inférieur, chez un patient de 64 ans, qui était hospitalisé depuis deux mois et présentait une ischémie critique avec ulcères mixtes du membre inférieur gauche. L’endartériectomie de l’artère ilio-fémorale gauche avec pose d’un patch et déploiement d’un tuteur échoua. Un pontage composite, comportant deux segments de l’artère fémorale superficielle endarteriectomisée et une veine saphène cryopréservée, comme allogreffe veineuse, fut implanté une semaine plus tard. Quatre jours après cette intervention, une infection (Staphylocoques epidermidis et Pseudomonas aeruginosa) fut traitée de façon empirique aux antibiotiques. Quatre mois plus tard, le pontage fémorotibial thrombosa, et le débit sanguin fut rétabli par thrombolyse. La section anévrysmale de l’allogreffe veineuse fut ensuite excisée. Des complications itératives suivirent et le succès final fut obtenu par transplantation des veines céphalique et basilique autologues. Quatre années plus tard, le pontage est toujours perméable.
Après un examen macroscopique, l’explant a été disséqué afin de sélectionner les prélèvements requis pour les analyses histologiques en microscopie électronique à balayage, microscopie optique et microscopie électronique à transmission.
Le spécimen explanté présentait une surface luminale proximale sans atteinte pathologique, mais des distorsions considérables dans la partie distale avec une accumulation de thrombi pariétaux non organisés. La paroi de la veine artérialisée était endommagée et présentait une importante réaction inflammatoire. La dégradation du collagène fut mise en évidence par la microscopie électronique à transmission. Les fibrilles du collagène demeurèrent individualisées mais elles étaient fragmentées et n’étaient plus disposées parallèlement. La régularité des striations périodiques était cependant préservée. La présence de P. aeruginosa fut observée dans la paroi veineuse.
En cas d’infection, les traitements les plus agressifs aux antibiotiques se montrent incapables d’éradiquer complètement les colonisations bactériennes dans la paroi d’un conduit sanguin de substitution. Faute de veines saphénes autologues, les veines céphalique et basilique autologues doivent être sélectionnées et une dissection agressive est recommandée. Un tel cas représentait donc un défi considérable et ce résultat clinique est extrêmement gratifiant : les efforts concernant la dissection des veines du bras sont pleinement justifiés. L’amputation fut prévenue et le pontage demeure perméable quatre années plus tard ce qui constitue un résultat exceptionnel compte tenu des comorbidités du patient.
Contemporary Outcomes for Open Infrainguinal Bypass in the Endovascular Era
2016, Annals of Vascular Surgery
The role of infrainguinal bypasses in this era of increasing endovascular interventions remains the subject of significant debate. In this study, we evaluate contemporary long-term outcomes of lower-extremity open revascularization for peripheral arterial disease (PAD).
We evaluated all patients who underwent infrainguinal bypass with autogenous vein conduits for claudication or critical limb ischemia in our institution between January 1st, 2007 and July 31st, 2014. Kaplan–Meier and Cox regression analyses were used to evaluate graft failure and identify its predictors. Outcomes were defined per the Society for Vascular Surgery standards.
There were 428 autogenous vein grafts (femoro–popliteal: 32%, femoro–tibial: 39%, popliteo-tibial: 27%, and tibio-tibial: 2%) placed in 368 patients (mean age of 67 ± 11.4 years). Most patients were male (59%), white (73%), and presented with critical limb ischemia (81%). Sixty-five cases (15%) were redo bypasses. Arm veins and spliced vein conduits were used in 15% and 14% of cases, respectively. Primary patency at 1, 3, and 5 years was 66%, 59%, and 55%, respectively. Primary-assisted patency was 78%, 69%, and 64% at 1, 3, and 5 years, respectively. Secondary patency was 88%, 84%, and 82% at 1, 3, and 5 years, respectively. Patency was higher for grafts harvested from the lower versus upper extremities and for proximal versus distal bypass (all P < 0.05). Limb salvage rate was 88% after a mean follow-up of 2 ± 1.8 years. Significant predictors of graft failure were younger age, diabetes mellitus, and hyperlipidemia (all P < 0.05).
In this contemporary cohort of patients, we have demonstrated that infrainguinal bypass for lower-extremity revascularization has good long-term outcomes in patients with symptomatic PAD. Patency and limb salvage rates are optimized with careful selection of autogenous conduits, close monitoring of high-risk groups and management of comorbidities.
Autologous alternative veins may not provide better outcomes than prosthetic conduits for below-knee bypass when great saphenous vein is unavailable
2015, Journal of Vascular Surgery
Citation Excerpt :
In the literature, there is a weak consensus on the superiority of AAV when GSV is unavailable for below-knee bypasses, and guidelines recommend the use of AAV preferentially over prosthetic grafts when GSV is unavailable (Level C recommendation).26 The reported 2-year primary, primary assisted, and secondary patencies of AAV conduits range widely between 19% and 85%, 33% and 96%, and 46% and 98%, respectively, and most conclude that the use of AAV is acceptable, particularly for infrapopliteal targets.5-10,12-17,19-23,27 Differences in patient cohorts, indications for surgery, target vessels, runoff scores, prosthetic graft types, use of anastomotic adjuncts, and postoperative anticoagulation make it difficult to evaluate the overall benefit of revascularization with AAV conduits.
There is a need to better define the role of alternative autologous vein (AAV) segments over contemporary prosthetic conduits in patients with critical limb ischemia when great saphenous vein (GSV) is not available for use as the bypass conduit.
Consecutive patients who underwent bypass to infrageniculate targets between 2007 and 2011 were categorized in three groups: GSV, AAV, and prosthetic. The primary outcome was graft patency. The secondary outcome was limb salvage. Cox proportional hazards regression was used to adjust for baseline confounding variables.
A total of 407 infrainguinal bypasses to below-knee targets were analyzed; 255 patients (63%) received a single-segment GSV, 106 patients (26%) received an AAV, and 46 patients (11%) received a prosthetic conduit. Baseline characteristics were similar among groups, with the exception of popliteal targets and anticoagulation use being more frequent in the prosthetic group. Primary patency at 2 and 5 years was estimated at 47% and 32%, respectively, for the GSV group; 24% and 23% for the AAV group; and 43% and 38% for the prosthetic group. Primary assisted patency at 2 and 5 years was estimated at 71% and 55%, respectively, for the GSV group; 53% and 51% for the AAV group; and 45% and 40% for the prosthetic group. Secondary patency at 2 and 5 years was estimated at 75% and 60%, respectively, for the GSV group; 57% and 55% for the AAV group; and 46% and 41% for the prosthetic group. In Cox analysis, primary patency (hazard ratio [HR], 0.55; P < .001; 95% confidence interval [CI], 0.404-0.758), primary assisted patency (HR, 0.57; P = .004; 95% CI, 0.388-0.831), and secondary patency (HR, 0.56; P = .005; 95% CI, 0.372-0.840) were predicted by GSV compared with AAV, but there was no difference between AAV and prosthetic grafts except for the primary patency, for which prosthetic was protective (HR, 0.38; P < .001; 95% CI, 0.224-0.629). Limb salvage was similar among groups.
AAV conduits may not offer a significant patency advantage in midterm follow-up over prosthetic bypasses.
Spliced arm vein grafts are a durable conduit for lower extremity bypass
2015, Annals of Vascular Surgery
Citation Excerpt :
Despite the above evidence supporting the safety and efficacy of arm vein in patients with lower extremity ischemia, it remains an infrequently used technique because of concerns over the need to splice several segments of vein in some patients to achieve adequate length. This has been considered a limitation to the use of arm vein bypasses as the number of veno-venostomies has been shown to negatively affect the patency of these bypasses12–14 Our series does not support this conclusion. In our experience, the number of veno-venostomies did not affect patency or limb salvage rates.
Many patients with peripheral vascular disease (PAD) requiring revascularization do not have adequate ipsilateral great saphenous vein (GSV) for constructing a bypass because of intrinsic vein disease or prior harvesting for limb or coronary bypass. Prosthetic conduits have poor long-term patency, especially for distal bypass. With advancing endovascular sophistication, tibial angioplasty may be a good revascularization option, but we hypothesize that using spliced arm vein for distal lower extremity bypass is still a well-tolerated and more durable solution.
A retrospective chart review was conducted of all PAD patients undergoing lower extremity bypass or tibial angioplasty for lifestyle-limiting claudication or critical limb ischemia at a single institution over a 7-year period. Statistical analysis was conducted by Kaplan–Meier survival analysis and Cox proportional hazards model. Statistical significance was set at P = 0.05.
From 2005 to 2012, there were 120 patients who underwent infrageniculate revascularization with conduit other than GSV. Over half of the patients (66 patients, 71.2% male, mean age 62 years) underwent bypass operations using arm vein conduit, and 88% of those bypasses were to tibial vessels. Patency was 100% at 1 year and 85% at 2 years. There was no impact on patency or amputation rate based on the source of vein or the number of splices. Forty-three patients underwent tibial angioplasty and patency was 70% at 1 year and 50% at 2 years.
When GSV is not available, spliced arm vein grafts provide durable lower extremity revascularization with favorable patency and limb preservation rates. Spliced arm vein grafts should be considered over prosthetic grafts and angioplasty alone in patients with distal occlusive disease.
Arm vein as an alternative autogenous conduit for infragenicular bypass in the treatment of critical limb ischaemia: A 15 year experience
2014, European Journal of Vascular and Endovascular Surgery
The value of alternative autogenous venous conduits for treating critical limb ischaemia (CLI) with infragenicular bypass surgery is well established. In this study, the results of using arm veins as alternative conduits for treating CLI over a 15-year period have been evaluated.
This was a retrospective study. Between 1991 and 2005. 120 infragenicular bypasses using arm vein conduits (AVCs) were performed in 120 patients. CLI was the main indication (87.5%) for the procedures. The indications for using arm veins were inadequacy or absence of the ipsilateral greater saphenous vein (GSV). Survival, limb salvage, and patency rates were calculated using the Kaplan–Meier method.
There was a predominance of male gender (65%), and the group mean age was 68.1 ± 8.3 years. The mean follow-up period was 29.6 ± 26.3 months. The operative mortality (30 days) rate was 7.5%. The main alternative conduit was non-spliced cephalic vein (37.5%). Composite grafts included GSV + AVC (45.2%), AVC + AVC (43.3%) and small saphenous vein + AVC (11.5%). The 5-year primary and secondary patency (SP) rates were 45.2 ± 5.6% and 56.5 ± 5.0%, respectively. The 5-year SP rate was greatest when using non-spliced cephalic vein (65.8 ± 7.6%), but there was no difference in cumulative patency between spliced and non-spliced veins (49.5 ± 8.0% vs. 61.2 ± 6.4%; p = 0.501). The 5-year limb salvage and survival rates were 70.6 ± 5.9% and 59.6 ± 5.8%, respectively.
The favourable long term results of secondary patency and limb salvage rates encourage the use of arm veins as alternative conduits for infragenicular bypass surgery.
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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^*: Reprint requests: Norman R. Hertzer, MD, Department of Vascular Surgery, The Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195-5272.

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Original ArticlesCephalic vein grafts for lower extremity revascularization*

Abstract

Section snippets

Patient information

Results

Discussion

Ann Vasc Surg

J Vasc Surg

J Chron Dis

J Vasc Surg

J Vasc Surg

The cephalic vein as a peripheral vascular graft

Surg Gynecol Obstet

The use of the cephalic and basilic veins as peripheral vascular grafts

Aust N Z J Surg

Original Articles
Cephalic vein grafts for lower extremity revascularization*