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Technical Factors Affecting Autogenous Vein Graft Failure: Observations From A Large Multi-Center Trial

Andres Schanzer¹, Nathanael Hevelone¹, Christopher D Owens¹, Michael Belkin¹, Dennis F Bandyk², Alexander W Clowes³, Gregory L Moneta³, Michael S Conte^.1
1Brigham and Women's Hospital, Boston, MA; ²University of South Florida, Tampa, FL; ³Oregon Health Sciences University, Portland, OR.

OBJECTIVES: The effects of operator-dependent variables on lower extremity bypass (LEB) surgery have primarily been reported in single-institution, retrospective studies. We utilized data from a prospective, multicenter, randomized trial to identify technical variables that significantly impact outcomes after autogenous LEB for limb salvage.

METHODS: The PREVENT III trial database includes 1404 North American patients with critical limb ischemia who underwent all-autogenous LEB. Technical factors analyzed included vein diameter, conduit type, graft length, vein orientation, location of proximal and distal anastomoses, and performance of completion imaging. Univariate analysis was used to determine the effect of these factors on 30 day and 1 year outcomes. Multivariate Cox regression models evaluated the influence of these factors at 1 year while adjusting for age, sex, race, tobacco, diabetes, dialysis-dependency, and study drug (edifoligide) administration. The primary outcomes were primary patency (PP), primary assisted patency (PAP), and secondary patency (SP) assessed by Kaplan-Meier method.

RESULTS: Univariate analysis revealed that vein diameter <3.5 mm and composite graft type were significantly associated with 30 day graft failure. At 1 year, multivariate analysis (Table) revealed that inferior patency rates were associated with diameter < 3.5 mm (PP, SP), non-GSV type (PP, SP), and graft lengths > 50 cm (PP only). Limb salvage and survival at 1 year were not significantly impacted by technical variables. Employing a trial-specific definition of high risk conduits (diameter <3mm or non-GSV; 24% of cohort) revealed that use of such conduits was associated with a 2.5-fold increased risk of 30 day graft failure (p<.05), as well as reduced PP and SP at 1 year. Use of a high risk conduit was associated with an increased index length of stay (9.37 vs. 8.71 days, p=.03) and mean number of reinterventions (0.67 vs. 0.42, p<.0001) over the ensuing year.

CONCLUSIONS: In this large cohort of patients undergoing LEB for critical limb ischemia, vein diameter and conduit type were the primary technical determinants of early and late graft failure. High-risk conduits and longer grafts may benefit from aggressive postoperative graft surveillance.