Outcomes of Prosthetic and Biological Grafts Compared to Arm Vein Grafts in Patients with Chronic Limb Threatening Ischemia.

Objectives: The optimal conduit for infrainguinal bypass (IIB) is single segment great saphenous vein (GSV). Unfortunately, GSV is not always available in patients with chronic limb threatening ischemia (CLTI). Other graft choices include arm vein grafts (AV), prosthetic grafts (PG) or biologic grafts (BG). Current data regarding the durability and limb salvage rates of those options is scarce, hence we aimed to investigate the impact of alternative graft types on post-operative and long-term outcomes on IIB in patients with CLTI.

Methods: The Vascular Quality Initiative (VQI) database was queried for patients undergoing IIB from January 2003 to April 2024. Patients were stratified into three groups: arm vein (cephalic, basilic), prosthetic grafts [Dacron, polytetrafluoroethylene (PTFE)], and biologic grafts (cadaveric, homograft, or xenograft). Saphenous vein grafts (greater and lesser saphenous) were excluded. Multivariate logistic regression analyzed postoperative outcomes: 30-day mortality, major adverse cardiovascular events (MACE), graft occlusion, prolonged length of stay >7days (PLOS), packed red blood cell (pRBC) transfusion >2 units, and infection. Cox Regression was used to report one-year outcomes: mortality, major amputation (above-ankle), and major adverse limb events (MALE defined as major amputation, thrombectomy or reintervention).

Results: A total of 9165 IIB procedures have been analyzed: AV 417 (4.55%); PG 7520 (82.05%); BG 1228 (13.40%). Compared to AV, patients receiving PG had higher odds of infection (aOR 2.89, p=0.045) and higher hazard of one-year mortality (aHR 1.51, p=0.035). On the other hand, patients receiving BG had higher risk of graft occlusion (aOR 4.55, p=0.040) and infection (aOR 2.78, p=0.046) as well higher hazard of one-year mortality (aHR 1.53, p=0.040), amputation (aHR 1.72, p=0.019) and amputation or death (aHR 1.52, p=0.005) compared to AV. After stratifying by bypass configuration, AV had the highest overall survival and amputation-free survival among the three alternative conduits in below-knee popliteal and tibial bypass targets.

Conclusions: In this large multi-institutional study investigating alternative conduits to GSV, AV are found to be the most resistant to infections and are associated with the best overall survival and limb salvage outcomes compared to PG and BG particularly in below-knee distal targets. In cases where no GSV is available, AV and PG are acceptable alternatives with comparable one-year amputation-free survival and MALE-free survival rates. On the other hand, BG are associated with higher risk of graft occlusion and lower freedom from major amputation and death compared to AV.