Outcomes of prosthetic and biological grafts compared to arm vein grafts in patients with chronic limb-threatening ischemia.

Objective: 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 (AVs), prosthetic grafts (PGs), or biologic grafts (BGs). 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 postoperative 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: AVs (cephalic, basilic), PGs (Dacron, polytetrafluoroethylene [PTFE]), and BGs (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, graft occlusion, prolonged length of stay >7 days, packed red blood cell transfusion >2 units, and infection. Cox regression was used to report 1-year outcomes: mortality, major amputation (above-ankle), and major adverse limb events (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%); and BG, 1228 (13.40%). Compared with AVs, patients receiving PGs had higher odds of infection (adjusted odds ratio [aOR], 2.89; P = .045) and higher hazard of 1-year mortality (adjusted hazard ratio [aHR], 1.51; P = .035). On the other hand, patients receiving BGs had higher risk of graft occlusion (aOR, 4.55; P = .040) and infection (aOR, 2.78; P = .046), as well as higher hazard of 1-year mortality (aHR, 1.53; P = .040), amputation (aHR, 1.72; P = .019), and amputation or death (aHR, 1.52; P = .005) compared with patients receiving AVs. After stratifying by bypass configuration, patients with AVs 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, AVs are found to be the most resistant to infections and are associated with the best overall survival and limb salvage outcomes compared with PGs and BGs, particularly in below-knee distal targets. In cases where no GSV is available, AVs and PGs are acceptable alternatives with comparable 1-year amputation-free survival and major adverse limb events-free survival rates. On the other hand, BGs are associated with higher risk of graft occlusion and lower freedom from major amputation and death compared with AVs.