Adequacy and utilization of greater saphenous vein in patients undergoing preoperative vein mapping for chronic limb-threatening ischemia.

Abstract

Infrainguinal bypass (IB) using single-segment greater saphenous vein (ssGSV) demonstrates superior outcomes for chronic limb-threatening ischemia (CLTI), but the definition and prevalence of adequate ssGSV are not well established. This is a single-center retrospective analysis of patients with CLTI who underwent preoperative vein mapping (VM) by duplex ultrasound (2015-2025). A standardized hierarchical scoring system was applied to classify GSV suitability as a bypass conduit, measured from the saphenofemoral junction to the knee (GSV-K) and to mid-calf (GSV-MC) (A: ≥3 mm, B: ≥2.5 mm, C: >2 mm, D: any portion ≤2 mm, and E: thrombosed, ablated, varicose, previously harvested). GSV quality, associated clinical factors, and interventions received were analyzed. Major adverse limb events (MALE) and patency were assessed as outcomes. Patients (n = 349) had a median age of 71.1 years, and 68% of the patients were male. Comorbidities included diabetes (67%), end-stage renal disease (13%), coronary revascularization (37%), heart failure (38%), and current tobacco use (22%). The best available GSV-K and GSV-MC were classified as adequate (A/B) in 67% and 46%, marginal (C) in 7.7% and 13%, and inadequate (D/E) in 25% and 40%, respectively. In this cohort, IB was performed on 197 limbs (representing 67% of all IB performed for CLTI during the study period), using ssGSV (53%), alternate autogenous vein (23%), prosthetic (6.1%), or cryopreserved vein (18%). Among GSV bypasses performed, 32% were femoropopliteal, 19% infrapopliteal, and 49% femorodistal. The GSV conduits used were classified by VM as GSV-K: 81% A/B, 7.8% C, and 11% D/E; and GSV-MC: 57% A/B, 14% C, and 29% D/E. Of limbs with grade A/B GSV-K that underwent bypass (n = 133), 69% used an ssGSV conduit; this utilization rose to 82% for grade A/B GSV-MC (n = 87). Major reintervention, major amputation, and MALEs at 1 year after GSV bypass (ss or spliced) were 17%, 10%, and 23%, respectively. Among GSV bypasses, preoperative grade A/B GSV-K was associated with superior primary patency (P < .001). In a Cox proportional hazards multiple regression model, GSV-K grade D/E and spliced GSV conduits were independently associated with loss of primary patency (hazard ratio, 3.8; 95% confidence interval, 1.8-7.8; P < .001 and hazard ratio, 2.1; 95% confidence interval, 1.2-3.8; P = .01, respectively). Most patients with CLTI undergoing preoperative VM had adequate GSV for use as a bypass conduit. More than half of IBs performed used an ssGSV conduit, with outcomes consistent with those observed in the Best Endovascular vs. Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) trial.