Impact of infra-inguinal bypass tunneling technique on patency and amputation free survival in patients with critical limb ischemia
Nallely Saldana-Ruiz, MD, MPH, Josefina Dominguez, MD, Sung W. Ham, MD, Vincent L. Rowe, MD, Gregory A. Magee, MD MSc, Fred A. Weaver, MD, Sukgu M. Han, MD, Kenneth Ziegler, MD.
University of Southern California, Los Angeles, CA, USA.
Objective: Critical limb ischemia (CLI) and its limb related complications consume a great deal of healthcare resources. While vein harvesting techniques and conduit selection in the treatment of CLI have been well studied, the difference in outcomes between subcutaneous and subfascial tunneling of infrainguinal vein bypass remains unknown. We aimed to evaluate the impact of tunneling technique on outcomes of vein graft patency and amputation-free survival for patients with CLI. Methods: We the used Vascular Quality Initiative national database to identify 7,486 infrainguinal bypass procedures (femoral to below knee popliteal/tibial arteries), using single-segment greater saphenous vein (SSGSV) conduit from 2008-2017. Outcomes were defined a priori as primary patency, primary-assisted patency and amputation-free survival. Multivariate logistic regression modeling was employed to adjust for differences in preoperative characteristics. Kaplan-Meier statistics were applied for outcomes of patency and amputation. Results: 3,904 subcutaneous and 3,582 subfascial bypasses were included in the analysis. Overall mean follow-up was 274 days and age 66 years. Univariate analyses showed age, race, graft-orientation, bypass targets, surgical site infection, ESRD, CHF, prior CABG, smoking, P2Y12anti-platelet medication, and CLI level were associated with tunneling (P<0.05). Multivariate logistic regression demonstrated tunneling was not to associated with primary patency (at discharge P=0.33), (follow-up P=0.18), primary-assisted patency (at discharge P= 0.34), (follow-up P=0.23), or amputation-free survival (P=0.18) after adjusting for preoperative characteristics. Preoperative risk factors for lower amputation-free survival at follow-up included ESRD, COPD, CHF, surgical site infection, level of CLI, while aspirin and P2Y12 inhibitors showed a protective effect(P<0.05). Kaplan-Meier survival analyses confirmed no difference in primary patency or amputation-free survival between tunneling methods (Logrank=0.80, Logrank=0.88). Conclusions: Tunneling choice for patients undergoing infrainguinal bypass with SSGSV for CLI, does not convey a clinical advantage for important surgical outcomes of primary patency, primary-assisted patency, or amputation-free survival at 1-year follow-up. 
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