Contemporary Assessment of Great Saphenous Vein Adequacy in Patients with Chronic Limb Threatening Limb Ischemia.

Abstract

In patients with chronic limb threatening ischemia (CLTI), the Best Endovascular versus Best Surgical Therapy in Patients with CLTI (BEST-CLI) trial demonstrated a significant benefit of infrainguinal bypass with single segment great saphenous vein (GSV). Given the rise of venous ablation and the lack of consistent vein mapping, prevalence of adequate GSV is poorly defined in current patients with CLTI. Our goal was to assess the availability of adequate GSV in a contemporary CLTI population. We conducted a single center review of unique CLTI patients (2016-2025) who had vein mapping before an open or endovascular intervention was performed. Patients with a history of prior open infrainguinal revascularizations were excluded. Duplex ultrasound reports were evaluated for GSV diameter. Vein diameter was assessed for a minimum of 2.5 mm and 3 mm throughout the thigh alone and the entire leg (thigh and calf). Ipsilateral and contralateral measurements were recorded. Patient and anatomical details were compared and stratified by available GSV. We identified 223 patients. The patients had a mean age of 68.6 years; 64.1% were male, 50.2% were of Black race and 17.9% were of Hispanic ethnicity. The majority (69.1%) had diabetes mellitus and 35% were currently smoking. Of these patients, 16.6% had a history of deep vein thrombosis, 18.4% had chronic venous insufficiency, and 0.9% had a prior GSV ablation; 29.1% had a prior ipsilateral infrainguinal endovascular intervention. With respect to duplex based measurements, thigh GSV ≥ 2.5 mm alone was seen in 69.5% and 74% of the ipsilateral and either leg, respectively. Entire leg GSV ≥ 2.5 mm was observed in 42.9% and 46.6% of ipsilateral and either leg. Thigh GSV ≥ 3 mm alone was seen in 58.7% and 64.6% of ipsilateral and either leg. Entire leg GSV ≥ 3 mm was observed in 23.8% and 27.4% of ipsilateral and either leg. Overall, 102 patients (45.7%) underwent femoropopliteal intervention, including 46 endovascular (20.6%) and 56 bypass (25.1%) procedures. Among patients having femoropopliteal intervention, 153 (68.6%) had a thigh GSV diameter ≥2.5 mm and 133 (59.8%) had a diameter ≥3.0 mm. Male gender (OR 2.32, 95% CI 1.28 - 4.24, P = .006) and diabetes mellitus (OR 2.17, 95% CI 1.15 - 4.1, P=.02) were associated with >2.5 mm vein diameter on multivariable analysis. The majority of patients with CLTI had adequate thigh GSV with a high percentage having adequate GSV throughout the entire leg. These findings suggest that a significant number of patients fit for revascularization could be candidates for a single segment GSV bypass.