Factors affecting patency of in situ saphenous vein bypass: 2-year results from LIMBSAVE (Treatment of critical Limb IscheMia with infragenicular Bypass adopting in situ SAphenous VEin technique) registry

OBJECTIVES

Aim is to demonstrate contemporary outcomes of in situ saphenous vein bypass with the use of a valvulotome.

DESIGN

Analysis of two-year outcomes of a multicenter registry based on the treatment of critical Limb IscheMia with infragenicular Bypass adopting in situ SAphenous VEin technique (LIMBSAVE).

MATERIALS

Between January 2018 and December 2019 541 patients in 43 centers have been enrolled. In all patients an innovative valvulotome was used.

METHODS

Early outcomes were assessed. Two-year outcomes according to Kaplan-Meier curves in terms of patencies, and limb salvage were evaluated. Associations of patient and procedure variables were analysed with univariate and multivariate analyses.

RESULTS

In all cases valvulotome was able to lyse the valves. Vein injuries due to the in situ technique was 3.5%. Thirty-day mortality and major amputation rates were 3% and 0.9%, respectively. Mean follow-up was 12.1 months. Two-year estimated primary patency, primary assisted patency, secondary patency, and limb salvage were 69.1%, 81.4%, 86.5%, and 94.5%, respectively. Multivariate analysis showed association of preoperative vein diameter < 3 mm with lower primary patency (HR 14.3, p < .001), primary assisted patency (HR 9.4, p = .002), secondary patency (HR 7.2, p = .007), and limb salvage (HR 7.8, p = .005) rates. Distal anastomosis on a tibial/foot vessel also had association with lower primary patency (HR 4.8, p = .033), and primary assisted patency (HR 6, p = .011) rates. Use of a suprafascial tributary collateral as a graft confirmed association with lower primary patency (HR 6.7, p = .013), and primary assisted patency (HR 4.2, p = .042) rates.

CONCLUSIONS

Vein diameter < 3 mm, distal anastomosis on a tibial/foot vessel, and use of a suprafascial tributary collateral as a graft were significantly associated with loss of patency and limb loss during follow-up.

Comparison of long occlusive femoro-popliteal de novo vs. previous endovascularly treated lesions managed with in situ saphenous bypass

BACKGROUND

The aim of this study was to compare two-year outcomes of de novo vs. post-endovascular lesion treatment of femoro-popliteal occlusions included in a national, multicenter, observational, prospective registry based on the treatment of critical Limb-threatening IschaeMia with infragenicular Bypass adopting in situ SAphenous VEin technique (LIMBSAVE).

METHODS

From January 2018 until December 2019, 541 patients from 43 centers have been enrolled in the LIMBSAVE registry. Of these patients, 460 were included in the present study: 341 (74.1%) with de novo lesions (Group DN) and 119 (25.9%) with post-endovascular treatment lesions (Group PE). Initial outcome measures were assessed at 30 days post-treatment. Furthermore, at 2-year follow-up, estimated outcomes of primary patency, primary assisted patency, secondary patency, and limb salvage were analyzed with Kaplan-Meier curves and compared between groups with the log-rank test.

RESULTS

Both groups were homogeneous in terms of demographic data, preoperative risk factors, and clinical presentation. However, compared to Group DN, more patients in Group PE had a great saphenous vein diameter of < 3 mm (11.1% vs. 21%; P=0.007). Intraoperatively, both groups showed similar distal anastomosis sites: below-the-knee popliteal artery (63% Group DN, 66.4% Group PE) and tibial vessel (37% Group DN, 33.6% Group PE) (P=0.3). Overall mean duration of follow-up was 11.6 months (range 1-24). At 2-year follow-up there were no differences between the two groups in terms of primary patency (66.3% Group DN vs. 74.1% Group PE, P=0.9), primary assisted patency (78.2% Group DN vs. 79.5% Group PE, P=0.2), secondary patency (85.1% Group DN vs. 91.4% Group PE, P=0.2), and limb salvage (95.2% Group DN vs. 95.1% Group PE, P=0.9).

CONCLUSIONS

The LIMBSAVE registry did not show a worsening of overall patency and limb salvages rates at the 2-year follow-up in patients undergoing in situ saphenous bypass after a failed endovascular approach for long femoro-popliteal occlusive disease. This is in contrast to what has been published in literature.

Preliminary six-month outcomes of LIMBSAVE (treatment of critical Limb IscheMia with infragenicular Bypass adopting in situ SAphenous VEin technique) registry

OBJECTIVES

Guidelines recommend open bypass surgery for long occlusions of infrainguinal arteries. In situ saphenous vein bypass is a standardized technique. The aim of this study was to report preliminary six-month outcomes of a national, multicenter, observational, prospective registry based on the examination of treatment of critical Limb IscheMia with infragenicular Bypass adopting the in situ SAphenous VEin technique (LIMBSAVE).

METHODS

From January 2018 until October 2019, 428 patients from 41 centers were enrolled in the LIMBSAVE registry. Data were prospectively collected in a dedicated database, including demographics, preoperative risk factors, clinical and diagnostic preoperative assessments, intraoperative measures (including safety and effectiveness of the valvulotome during the surgical procedures), and 30-day follow-up data. Furthermore, estimated six-month outcomes according to Kaplan-Meier curves in terms of primary patency, primary assisted patency, secondary patency, and limb salvage were evaluated.

RESULTS

Patients were predominantly male (n = 332, 77.6%) with a mean age of 73.3 years (range 39-95). Technical success, defined as bypass pulse after use of the valvulotome, was obtained in all cases. The proximal anastomosis could be reached by the valvulotome in all cases. The mean number of valvulotome uses was 2.5 (range 1-5). No vein perforation was reported. In nine cases (2.1%), a vein lesion with intramural hemorrhage occurred. The mean length of hospital stay was 11.1 days (range 1-60). At 30-day follow-up, the overall bypass patency rate was 97.4%, and the rate of open or endo reinterventions for failing bypass was 5.4%. At six-month follow-up, the estimated primary patency, primary assisted patency, secondary patency, and limb salvage were 78.1%, 86.2%, 92.1%, and 94.7%, respectively.

CONCLUSIONS

Preliminary intraprocedural outcomes of the LIMBSAVE registry show that the in situ technique with the valvulotome is safe and effective in disrupting valves and obtaining pulsatility in the saphenous vein. The complication rate related to the use of the valvulotome is low. The six-month preliminary outcomes in terms of overall patency and limb salvage are promising. Further examinations and continuous follow-up are needed to evaluate long-term outcomes.