Long-term Outcomes of Reversed, In Situ, and Non-reversed Great Saphenous Vein Conduits for Chronic Limb-Threatening Ischemia: An Analysis of the Vascular Quality Initiative-Medicare-Linked Database.

Abstract

Single-segment great saphenous vein (GSV) grafts are the conduits of choice for infra-inguinal bypasses (IIB) performed for chronic limb-threatening ischemia (CLTI). GSV has been used in three different configurations: reversed, in situ, and non-reversed. In this large multi-institutional study, we aimed to compare outcomes of IIBs performed utilizing different GSV configurations in a real-world experience. We queried Vascular Quality Initiative (VQI)-Medicare-Linked database for all IIBs performed for occlusive disease presenting with CLTI between 2011 and 2019. All bypasses were performed with single-segment GSV. The primary outcome was amputation-free survival (AFS). The secondary outcomes included overall survival (OS), limb salvage (LS), and freedom from reintervention (FFR). LS was defined as freedom from major amputation. All outcomes were analyzed at one and five years. Kaplan-Meier survival estimates and Cox regression were used for the analyses. The study included three cohorts of IIBs including reversed (N=3,003, 53.0%), in situ (N=1,344, 23.7%), and non-reversed (N=1,322, 23.3%) GSV configurations. Five-year AFS was 39.8%, 39.5%, and 42.4%, in reversed, in situ, and non-reversed cohorts, respectively (P=0.126). After adjusting for potential confounders, in situ and non-reversed configurations were not associated with increased hazards of major amputation/death at one year compared with reversed configuration (adjusted Hazards Ratio [aHR]=0.96, 95% Confidence Interval [CI], 0.83-1.13; P=0.652 and aHR=0.94, 95% CI, 0.81-1.08; P=0.375, respectively). Additionally, in situ and non-reversed configurations were not associated with increased hazards of major amputation/death at five years compared with reversed (aHR=1.06, 95% CI, 0.96-1.17; P=0.255 and aHR=0.93, 95% CI, 0.84-1.02; P=0.129, respectively). Non-reversed configuration was associated with decreased hazards of death (aHR=0.82, 95% CI, 0.73-0.93; P=0.002) and major amputation/death (aHR=0.87, 95% CI, 0.78-0.97; P=0.016) compared with in situ configuration at five years. GSV configuration was not associated with reintervention. In this large multi-institutional study comparing three GSV configurations for lower extremity bypass, long-term limb-related outcomes were largely comparable across configurations. Although non-reversed configuration was associated with lower hazards of death and major amputation/death compared with in situ configuration at five years, this difference was primarily driven by mortality and may reflect differences in patient selection. Overall, all three GSV configurations represent acceptable and durable options for infrainguinal bypass, with conduit selection guided by surgeon preference, conduit availability, and patient anatomy.