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Anticoagulation Does Not Improve Outcomes After Lower Extremity Cryopreserved Vein Bypasses
Thomas W. Cheng, M.D.1, Alik Farber, M.D., M.B.A.
2, Andrea Alonso, M.D.
2, Elizabeth G. King, M.D.
2, Jesse A. Columbo, M.D., M.S.
1, Caitlin W. Hicks, M.D., M.S.
3, Virendra I. Patel, M.D., M.P.H.
4, Karan Garg, M.D.
5, Lars Stangenberg, M.D., Ph.D.
6, Jeffrey J. Siracuse, M.D., M.B.A.
2.
1Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA,
2Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA,
3Johns Hopkins University School of Medicine, Baltimore, MD, USA,
4New York-Presbyterian Columbia University Medical Center, New York, NY, USA,
5New York University Langone Medical Center, New York, NY, USA,
6Beth Israel Deaconess Medical Center, Boston, MA, USA.
OBJECTIVES: Cryopreserved vein grafts are an alternative when autogenous vein is inadequate for an infrainguinal bypass. Anticoagulation has been advocated to improve outcomes, however the data is unclear. Our goal was to assess the association of anticoagulation on outcomes after infrainguinal bypass for chronic limb threatening ischemia (CLTI) with cryopreserved vein.
METHODS: The Vascular Quality Initiative was queried (2003-2022) for infrainguinal bypass with cryopreserved vein graft for CLTI. Baseline characteristics, procedural details, and outcomes between those discharged with or without anticoagulation were recorded. Univariable, Kaplan-Meier, and multivariable analyses were performed.
RESULTS: There were 2336 patients who underwent an infrainguinal bypass with cryopreserved vein conduit. The average age was 70.6 years and 63.5% were male sex. Bypass targets were femoral/popliteal (27.5%) and tibial (72.5%). Indications were for rest pain (25.7%) and tissue loss (74.3%). Patients were discharged with aspirin (80.1%), a P2Y12 antagonist (45.6%), and anticoagulation (47.3%). Patients discharged with postoperative anticoagulation more often had bypasses performed for rest pain (28.1% vs. 23.5%), have a tibial bypass target (78.4% vs. 67.2%), and less often underwent endarterectomy (27.8% vs. 34.2%) (all P<.05). Kaplan-Meier analysis at 1-year demonstrated that postoperative anticoagulation had similar freedom from loss of primary patency/death (28.9% vs. 34.3%), major amputation/death (62.3% vs. 63.8%), and reintervention/major amputation/death (50.6% vs. 53.8%) (all P>.05), but higher survival (85.1% vs. 81.7%, P=.03). Multivariable analysis at 1-year demonstrated that postoperative anticoagulation had a similar likelihood for loss of primary patency/death (HR .95, 95% CI .83.-1.09), major amputation/death (HR .88, 95% CI .74-1.05), and reintervention/major amputation/death (HR .93, 95% CI .79-1.08) (all P>.05), but lower likelihood for death (HR .59, 95% CI .46-.74, P<.001) compared to no anticoagulation. Postoperative aspirin was associated with decreased likelihood for amputation/death (HR .74, 95% CI .61-.91, P=.003) and reintervention/major amputation/death (HR .76, 95% CI .64-.9, P=.002). Postoperative P2Y12 antagonist was associated with decreased likelihood for amputation/death (HR .75, 95% CI .63-.9, P=.002) and reintervention/major amputation/death (HR .78, 95% CI .67-.91, P=.001). Results were similar when analyzing patients not on anticoagulation preoperatively.
CONCLUSIONS: Postoperative anticoagulation following infrainguinal bypass with cryopreserved vein graft did not affect patency or limb salvage. Antiplatelet agents were associated with improved outcomes. Overall patency and limb salvage rates at one year were poor and alternative revascularization options should be considered.
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