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Outcome of Prosthetic versus Vein Grafts for Below-Knee Bypass in Real World Practice
Bjoern D. Suckow, MD1, Larry W. Kraiss, MD1, David H. Stone, MD2, Andres Schanzer, MD3, Daniel J. Bertges, MD4, Jack L. Cronenwett, MD2, Philip P. Goodney, MD2.
1University of Utah, Salt Lake City, UT, USA, 2Dartmouth Medical School, Hanover, NH, USA, 3University of Massachusetts School of Medicine, Worcester, MA, USA, 4University of Vermont College of Medicine, Burlington, VT, USA.
Objectives: Native venous conduit is
preferred in below-knee vascular reconstructions. However, many argue that
prosthetic grafts can perform well in crural bypass with adjunctive
antithrombotic therapy. We therefore compared outcomes of below-knee bypass
grafts using prosthetic conduit with adjunctive antithrombotic therapy to those
using autologous vein.
Methods: Utilizing the Vascular Study
Group of New England registry (2003 - 2009), we studied 308 patients with a
prosthetic graft to the below-knee popliteal artery (76%) or more distal target
(24%). We used propensity matching to identify a patient cohort who received
single-segment saphenous vein (GSV) yet remained similar to the prosthetic cohort
in terms of patient characteristics, graft origin/target and antithrombotic regimen
(Table 1). Main outcome measures were
graft patency and major adverse limb events (MALE = ipsilateral amputation,
graft revision or thrombectomy/thrombolysis) within one year. Secondary
outcomes were bleeding complications (re-operation or transfusion) and
mortality. We performed comparisons by conduit type and by antithrombotic
therapy.
Results: Patients receiving prosthetic
conduit were more likely to be treated with warfarin than those with GSV (51%
versus 22%, p<0.001). Prosthetic grafts with tibial targets received the
most aggressive antithrombotic combination (aspirin+clopidogrel+warfarin) more
commonly than popliteal targets (26% versus 9%, p<0.001). At one year, we
found no significant difference in primary or secondary outcomes by conduit
type (Table 2). While 1-year prosthetic graft patency rates varied from 68% (aspirin+clopidogrel+warfarin)
to 82% (aspirin), no significant differences were seen in primary patency or
MALE by antithrombotic therapy (p=0.32 and 0.8, respectively). Further, the
incidence of bleeding complications and 1-year mortality in prosthetic graft
patients was similar among antithrombotic regimens.
Conclusions: While limited in size, our study
demonstrates that, with appropriate patient selection and antithrombotic
therapy, 1-year outcomes for below-knee prosthetic grafts can be comparable to greater
saphenous vein conduit.
Table 1 - Comparison of Native and Propensity-Matched Cohorts | Native Cohort | Propensity-Matched Cohort | | Variable | Prosthetic(n=308) | Greater Saphenous Vein(n=1,356) | p-value | Prosthetic(n=287) | Greater Saphenous Vein(n=287) | p-value | | Male Gender | 64% | 73% | 0.002 | 67% | 68% | 0.65 | | Coronary Artery Disease | 49% | 34% | <0.001 | 48% | 49% | 0.87 | | Previous Arterial Bypass | 46% | 25% | <0.001 | 46% | 46% | 1 | | Below-Knee Popliteal Target | 76% | 52% | <0.001 | 75% | 77% | 0.49 | | Aspirin only | 34% | 59% | <0.001 | 37% | 41% | 0.43 | | Aspirin + Clopidogrel | 15% | 20% | 0.04 | 16% | 15% | 0.82 | | Aspirin + Warfarin | 39% | 17% | <0.001 | 36% | 33% | 0.53 | | Aspirin + Clopidogrel + Warfarin | 12% | 5% | <0.001 | 11% | 11% | 1 |
Table 2 - Comparison of Outcomes in the Propensity-Matched Cohort| Variable | Prosthetic(n=287) | Greater Saphenous Vein (n=287) | p-value | | Primary Graft Patency at 1 Year | 80% | 81% | 0.44 | | Incidence of MALE at 1 Year | 20% | 17% | 0.25 | | Patient Survival at 1 Year | 87% | 89% | 0.5 | | Bleeding Complications | 10% | 11% | 0.79 |
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