Adjunctive procedures have been described in Literature as methods to improve the patency of prosthetic grafts. Similar techniques have not been reported when a good autologous vein is available. Bifurcated vein grafts named "Y-shaped" have been described in reconstructive microsurgery. Likewise, the possibility to transfer the bypass flow to two run-off vessels should improve the overall foot perfusion. Recently, the technique of "bifurcated" saphenous vein graft has been described to treat patients with critical limb-threatening ischemia (CLTI). No comparative studies have been yet published. The aim of this study was to compare the time to healing and the overall 2-year outcomes obtained with non-reversed bifurcated vs. single vein graft in patients with CLTI and ischemic wounds undergoing lower limb infrapopliteal bypass.
Between January 2015 and December 2021 193 patients with lower limb ischemic lesions have been treated at our Center with vein bypass and distal anastomosis performed on one or more tibial/foot vessels. In all cases a valvulotome was used to lyse the valves and to obtain the pulsatility of the vein in a non-reversed configuration. One-hundred-thirty-seven patients (71%) received a single graft (Group SIN), and 56 patients (29%) had a bifurcated bypass (Group BIF). Primary outcomes measures were time to healing, primary patency, primary assisted patency, secondary patency, and limb salvage. Two-year outcomes according to Kaplan-Meier curves were evaluated and compared.
Both groups were homogeneous in terms of demographic data, preoperative risk factors, and clinical presentation but for an elderly age in Group BIF (77.5 vs. 71.5 years; p < .001). Intraoperative technical success was achieved in all patients. The mean operation time was higher in Group BIF patients (306.3 ± 67.3 min vs. 250.4 ± 49.7 min; p = .03). At the 30-day follow-up period, the overall mortality was 4.4% in Group SIN and 3.6% in Group BIF (p = .43). Furthermore, no differences were found in the 30-day major amputation rate (2.9% in Group SIN vs. 1.8% in Group BIF; p = .37). Overall median duration of follow-up was 19 months (interquartile range 9-36). Wound healing did not differ between the two groups (77.4% Group SIN vs. 73.2% Group BIF; p = .33). Mean time to healing was faster in Group BIF (2.4 vs. 6.8 months; p < .001). At 2-year follow-up there were no differences between the two groups in terms of primary patency (71.4% Group SIN vs. 54% Group BIF; p = .10), primary assisted patency (81.7% Group SIN vs. 76.4% Group BIF; p = .53), secondary patency (85.1% Group SIN vs. 80.9% Group BIF; p = .79), and limb salvage (92.3% Group SIN vs. 87.2% Group BIF; p = .64) (Fig. 1).
Non-reversed bifurcated vein graft is a complex surgical technique to guarantee adequate blood flow to the foot in patients with ischemic foot wounds. In comparison with single vein grafts, bifurcated ones improve time to healing even if they do not increase the overall wound healing rate. Finally, mid-term outcomes in terms of overall patencies and limb salvage rates do not differ accordingly to vein graft configuration (single vs. bifurcated).
1. Orfaniotis G, Maruccia M, Sacak B, Ciudad P, Lima A, Chen HC. Expanding the applications of "Y-shaped" vein grafts in microsurgery. Microsurgery 2015; 35: 498-499.
2. Adami D, Marconi M, Piaggesi A, Mocellin DM, Berchiolli RN, Ferrari M. Bifurcated bypass in severe chronic limb threatening ischaemia. Vascular 2021; in press. doi: 10.1177/1708538121999856.
3. Lawson JA, Tangelder MJ, Algra A, Eikelboom BC. The myth of the in situ graft: superiority in infrainguinal bypass surgery? Eur J Vasc Endovasc Surg 1999; 18: 149-157.
4. Troisi N, De Blasis G, Salvini M, Michelagnoli S, Setacci C; LIMBSAVE Registry Collaborative Group. Preliminary six-month outcomes of LIMBSAVE (treatment of critical Limb IscheMia with infragenicular Bypass adopting in situ SAphenous VEin technique) registry. Vascular 2021; 29: 589-596.