Long-term outcomes of reversed, in situ, and nonreversed great saphenous vein conduits for chronic limb-threatening ischemia: An analysis of the Vascular Quality Initiative-Medicare-linked database.

BACKGROUND

Single-segment great saphenous vein (GSV) grafts are the conduits of choice for infrainguinal bypass (IIB) performed for chronic limb-threatening ischemia. GSV has been used in three configurations: reversed, in situ, and nonreversed. In this large multi-institutional study, we aimed to compare the outcomes of IIB performed utilizing different GSV configurations in a real-world experience.

METHODS

We queried the Vascular Quality Initiative-Medicare-linked database for all IIB procedures performed for chronic limb-threatening ischemia due to occlusive disease between 2011 and 2019. All bypass procedures were performed with single-segment GSV. The primary outcome was amputation-free survival. The secondary outcomes included overall survival, limb salvage, and freedom from reintervention. Limb salvage was defined as freedom from major amputation. All the outcomes were analyzed at 1 and 5 years. Kaplan-Meier survival estimates and Cox regression were used for analyses.

RESULTS

This study included three cohorts of IIB, namely reversed (N = 3003, 53.0%), in situ (N = 1344, 23.7%), and nonreversed (N = 1322, 23.3%) GSV configurations. The 5-year amputation-free survival rates were 39.8%, 39.5%, and 42.4% in the reversed, in situ, and nonreversed cohorts, respectively (P = .126). After adjustment for potential confounders, the analysis revealed that the in situ and nonreversed configurations were not associated with increased hazard of major amputation/death at 1 year compared with the reversed configuration (adjusted hazard ratio [aHR], 0.96; 95% confidence interval [CI], 0.83-1.13; P = .652 and aHR, 0.94; 95% CI, 0.81-1.08; P = .375, respectively). Additionally, the in situ and nonreversed configurations were not associated with increased hazards of major amputation/death at 5 years compared with the reversed configuration (aHR, 1.06; 95% CI, 0.96-1.17; P = .255 and aHR, 0.93; 95% CI, 0.84-1.02; P = .129, respectively). The nonreversed configuration was associated with decreased hazards of death (aHR, 0.82; 95% CI, 0.73-0.93; P = .002) and major amputation/death (aHR, 0.87; 95% CI, 0.78-0.97; P = .016) at 5 years compared with the in situ configuration. GSV configurations were not associated with reintervention.

CONCLUSIONS

In this large multi-institutional study comparing three GSV configurations for lower extremity bypass, long-term limb-related outcomes were mainly comparable across the configurations. Although the nonreversed configuration was associated with lower hazards of death and major amputation/death at 5 years compared with the in situ configuration, this difference was primarily due to mortality and may reflect differences in patient selection. Overall, all three GSV configurations represent acceptable and durable options for IIB, with conduit selection guided by surgeon preference, conduit availability, and patient anatomy.