Long-Term Outcomes Of Autologous Vein Bypass For Repair Of Major Arterial Extremity Trauma
Alexandra M. Forsyth, BA, Daniel B. Alfson, MD, Fernando Brea, MD, Shaikh P. Shams, BS, Maha Haqqani, MD, Aaron Richman, MD, Tejal S. Brahmbhatt, MD, Jeffrey Siracuse, MD, Alik Farber, MD.
Boston University School of Medicine, Boston, MA, USA.
OBJECTIVES: Autologous vein is the preferred bypass conduit for repair of major arterial extremity trauma (AET) given lower infection risk and superior patency rates over synthetic grafts. This study examines short- and long-term outcomes of patients undergoing autologous vein bypass (AVB) for major AET.
METHODS: We identified all patients with traumatic axillary, brachial, femoral, or popliteal arterial injury treated using AVB at a Level 1 trauma center between 2001 and 2019. Patient demographics, injury characteristics, short- and long-term outcomes were collected and analyzed.
RESULTS: 107 patients (88% male, median age 28) underwent AVB for major AET; 51% were African American and 27% were smokers. There were 34 upper-extremity (91% brachial) and 73 lower-extremity (56% femoral) injuries. Injury mechanisms were penetrating in 77 patients (79% gunshot) and blunt in 23 patients (36% motorcycle crash). Median injury severity score (ISS) was 10 (range 4-41). There were 23 and 40 associated nerve and bone injuries, respectively. Bypass conduit included great saphenous vein in 103 patients and arm vein in 4 patients. Median length of index hospitalization was 11 days (range 2-60). Sixty were discharged on an antiplatelet agent, and 39 on an anticoagulant. Median follow-up was 3.6 years (range 15 days-16.7 years). Thirty-six patients (9 symptomatic) underwent late graft imaging. Patients without claudication/ALI symptoms were surveilled for a median of 249 days after AET (range 7 days-11.4 years). On long-term follow-up of patients treated with leg AVB, 6 developed claudication and 3 developed acute limb ischemia. Fifty-five patients had complete limb function return (full strength in arm and unassisted ambulation in leg). Forty-three of the 45 with limited limb function had concomitant nerve or bone injury. Table 1 summarizes immediate, early, and late outcomes after AVB.
| Intraoperative (n=107) | Early (n=107) | Late (n=100) | |
| Mortality (Median ISS) | 0 (n/a) | 1 (9) | 0 (n/a) |
| AVB Thrombosis | 7 | 9 | 4 |
| AVB Stenosis | 0 | 0 | 4 |
| AVB Reintervention | 10 | 11 | 8 |
| Major Amputation (Median ISS) | 0 (n/a) | 4 (22) | 1 (16) |
CONCLUSIONS: Repair of major AET with AVB is durable and requires infrequent reintervention. Most loss of limb function is associated with bone/nerve injury. Mortality and major amputation were associated with high ISS and were uncommon.
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