BACKGROUND: Alternative autologous veins can be used as a conduit when adequate great saphenous vein is unavailable. We analyzed the results of our infrainguinal bypasses after adopting upper extremity veins in our practice.
METHODS: This is a single-center observational study involving all patients whose infrainguinal bypass involved the use of upper extremity veins between April 2019, when we began using arm veins, and February 2023.
RESULTS: During the study period, 49 bypasses were done in 48 patients; mean age 68.1 ± 9.8; men 32 (66.7%); body mass index 28.0 ± 4.8; indications for surgery: chronic limb threatening ischemia 41 (83.7%); acute limb ischemia 3 (6.1%); complications of previous prosthetic 3 (6.1%), or autologous 2 (4.1%) bypass grafts. Vein splicing was used in 43 (87.8%) bypasses with 3-segment grafts being the most common (26; 53.1%). There were 24 (49.0%) femorotibial, 11 (22.4%) femoropopliteal, 9 (18.4%) femoropedal, and 5 (10.2%) extension jump bypass procedures. Eighteen (36.7%) operations were redo surgeries. Twenty-one (42.9%) bypasses were formed using only arm veins. The median follow-up was 12.9 months (4.5-24.2). Two bypasses occluded during the first 30 postoperative days (2/49; 4.1%). Overall 30-day, 1-year, and 2-year primary patency rates were 93.7% ± 3.5%, 84.8% ± 5.9%, and 80.6% ± 6.9%, and secondary patency (SP) rates were 95.8% ± 2.9%, 89.2% ± 5.3%, and 89.2% ± 5.3%. One-segment grafts had better patencies than 2-, 3-, and 4-segment grafts (1-year SP 100% ± 0% vs 87.6% ± 6.0%). Two-year amputation-free survival was 86.8% ± 6.5%; 2-year overall survival was 88.2% ± 6.6%.
CONCLUSIONS: Integration of arm vein grafts in infrainguinal bypass practice can be done safely with low incidences of perioperative graft failure. One-segment grafts had better patencies than spliced vein grafts. The achieved early patency and amputation-free survival rates strongly encourage their use. In the absence of a single-segment great saphenous vein, upper extremity vein grafts should be the preferred conduit choice.

OBJECTIVE: Both bypass surgery and endovascular treatment are well-recognized interventions for the treatment of peripheral artery disease; however, the effect of failed endovascular treatment on subsequent surgeries remains controversial. A systematic review was conducted to compare the outcomes of primary bypass and bypass surgery after endovascular treatment.
METHODS: Three academic databases (Embase, PubMed, and Scopus) were searched from their inception to August 2022. Two independent investigators searched for studies that reported the outcomes of primary bypass surgery and bypass surgery after endovascular treatment in patients with peripheral artery disease. Abstracts and full-text studies were screened independently using duplicate data abstraction. Dichotomous outcome measures were reported using a random-effects model to generate a summary odds ratio (OR) and 95% confidence interval (CI). The risk of bias was assessed using the Newcastle-Ottawa Scale.
RESULTS: Seventeen retrospective observational studies were selected from 3911 articles and included 8064 patients, 6252 of whom underwent primary bypass surgery and 1812 underwent bypass surgery after endovascular treatment. The mean age was 69.0 years and 61.2% (n = 4938) were male. For perioperative outcomes, the 30-day results showed no difference in mortality (OR, 0.76; 95% CI, 0.53-1.10), or amputation (OR, 0.89; 95% CI, 0.67-1.20). For short- to mid-term outcomes, primary patency did not differ at 6 months (OR, 0.98; 95% CI, 0.81-1.19), 1 year (OR, 1.12; 95% CI, 0.97-1.30), or 2 years (OR, 1.17; 95% CI, 0.85-1.61) follow-up. Amputation-free survival did not differ at 6 months (OR, 1.03; 95% CI, 0.82-1.30), 1 year (OR, 1.09; 95% CI, 0.89-1.32), 2 years (OR, 1.18; 95% CI, 0.93-1.50), or 3 years (OR, 1.09; 95% CI, 0.84-1.40) of follow-up. No significant difference was found in overall survival or second patency.
CONCLUSIONS: This meta-analysis of retrospective, nonrandomized, observational studies suggests that prior endovascular treatment of lower extremity arterial disease does not result in worse perioperative, short-term, or mid-term clinical outcomes of subsequent infrainguinal bypass surgery compared with patients without prior endovascular treatment.

The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based suggestions for coordinated perioperative care for patients undergoing infrainguinal bypass surgery for peripheral artery disease. Structured around the ERAS core elements, 26 suggestions were made and organized into preadmission, preoperative, intraoperative, and postoperative sections.

BACKGROUND: The great saphenous vein (GSV) is commonly used as a conduit during infrainguinal bypass (IIB) and is usually well seen on computed tomography angiography (CTA) which is frequently performed for preoperative planning. In this study, we asked whether CTA could replace ultrasonography (US) as the primary mode of conduit assessment, by comparing GSV measurements for patients who underwent both CTA and US vein mapping prior to IIB.
METHODS: All IIB that were completed in the six-and-a-half-year period from January 1, 2012, to July 31, 2018, at the authors\' institution were examined. Great saphenous vein measurements were analyzed for patients who had undergone both CTA and US vein mapping. Correlation between the measurements was calculated with the Pearson correlation coefficient. Data were then examined using Bland-Altman plots. Then categorical analysis was used to determine the adequacy of GSV for use as a bypass conduit.
RESULTS: There were 302 patients who underwent IIB, with 73 legs, in 47 patients, examined with CTA and US. Computed tomography angiography and US measurements were moderately correlated (r = 0.531) across all measurement locations. Correlation progressively reduced distally (proximal thigh r = 0.534, midthigh r = 0.536, knee r = 0.35, midcalf r = 0.185, P = .074, ankle r = 0.078, P = .485). Bland-Altman plots of the pooled location data demonstrated no systematic bias. However, the upper and lower limits of agreement were wide, between -2.02 and +2.37 mm, demonstrating a lack of agreement between CTA and US. Analysis of each location revealed similar findings. A receiver operator characteristic curve was constructed based on a minimum US GSV diameter for adequate bypass conduit of 3 mm. The CTA value that maximized the Youden index was 3.8 mm.
CONCLUSIONS: The level of error between CTA and US measurements, demonstrated by the large limits of agreement on Bland-Altman plots, would not be clinically acceptable. However, if a larger threshold is accepted, CTA has the potential to replace preoperative US vein mapping of GSV.

Perioperative adjuncts are utilized across surgical specialities with the goal of improving patient outcomes. High-dose oxygen and extended warming are shown to increase wound collagen deposition during abdominal surgery. Prostacyclin is shown to improve limb salvage and patency rate in infrainguinal bypass (IIB) surgery. This study evaluated the impact of these adjuncts on healing and perfusion post IIB surgery.
This randomized controlled study allocated patients undergoing IIB surgery into three treatment arms (perioperative high-dose oxygen, extended warming, and a synthetic prostacyclin) or a control group. The primary outcome was accumulation of hydroxyproline (OHP, collagen surrogate marker) as collected in polytetrafluoroethylene implants on day 5. Secondary outcomes included levels of growth factors and cytokines, and tissue oxygenation of the wound and foot as measured by hyperspectral technology and ankle-brachial pressure index. Clinical outcomes were observed to day 30, with long-term follow-up of 12 mo.
Seventy-one patients completed the study. Comparing treatment groups with the control at day 5, there were no differences in OHP, growth factors or cytokines levels, or improvement in tissue oxygenation at the surgical incision. However, there was more flow to the foot (HT-SUM (%) change) in the Ilomedin group compared to control (0% versus -14.6%, P = 0.045). HT-deoxy was higher at the peripheries in the oxygen and temperature groups, suggesting decreased tissue oxygenation.
The perioperative treatments did not dramatically improve oxygenation or healing of the surgical wound in IIB surgery; however, Ilomedin may result in greater flow to the peripheries.