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Article
Distal anastomotic vein adjunct usage in infrainguinal prosthetic bypasses
Surgery Publications and Presentations
  • James T. McPhee, Brigham and Women's Hospital
  • Philip P. Goodney, Dartmouth-Hitchcock Medical Center
  • Andres Schanzer, University of Massachusetts Medical School
  • Shimon Shaykevich, Harvard School of Public Health
  • Michael Belkin, Brigham and Women's Hospital
  • Matthew T. Menard, Brigham and Women's Hospital
UMMS Affiliation
Department of Surgery
Date
4-1-2013
Document Type
Article
Medical Subject Headings
Adult; Aged; Aged, 80 and over; Amputation; Blood Vessel Prosthesis Implantation; Chi-Square Distribution; Comorbidity; Disease-Free Survival; Female; Humans; Kaplan-Meier Estimate; Limb Salvage; Lower Extremity; Male; Middle Aged; Multivariate Analysis; New England; Peripheral Arterial Disease; Postoperative Complications; Propensity Score; Proportional Hazards Models; Registries; Reoperation; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; Veins
Disciplines
Abstract
OBJECTIVE: Single-segment saphenous vein remains the optimal conduit for infrainguinal revascularization. In its absence, prosthetic conduit may be used. Existing data regarding the significance of anastomotic distal vein adjunct (DVA) usage with prosthetic grafts are based on small series. METHODS: This is a retrospective cohort analysisderived from the regional Vascular Study Group of New England as well as the Brigham and Women's hospital database. A total of 1018 infrainguinal prosthetic bypass grafts were captured in the dataset from 73 surgeons at 15 participating institutions. Propensity scoring and 3:1 matching was performed to create similar exposure groups for analysis. Outcome measures of interest included: primary patency, freedom from major adverse limb events (MALEs), and amputation free survival at 1 year as a function of vein patch utilization. Time to event data were compared with the log-rank test; multivariable Cox proportional hazard models were used to evaluate the adjusted association between vein cuff usage and the primary end points. DVA was defined as a vein patch, cuff, or boot in any configuration. RESULTS: Of the 1018 bypass operations, 94 (9.2%) had a DVA whereas 924 (90.8%) did not (no DVA). After propensity score matching, 88 DVAs (25%) and 264 no DVAs (75%) were analyzed. On univariate analysis of the matched cohort, the DVA and no DVA groups were similar in terms of mean age (70.0 vs 69.0; P = .55), male sex (58.0% vs 58.3%; P > .99), and preoperative characteristics such as living at home (93.2% vs 94.3%; P = .79) and independent ambulatory status (72.7% vs 75.7%; P = .64). The DVA and no DVA groups had similar rates of major comorbidities such as hypertension chronic obstructive pulmonary disease, diabetes mellitus, coronary artery disease, and dialysis dependence (P > .05 for all). Likewise, they had similar rates of distal origin grafts (13.6% vs 12.5%; P = .85), critical limb ischemia indications (P = .53), and prior arterial bypass (58% vs 47%; P = .08). The DVA group had a higher rate of completion angiogram performed (55.7% vs 37.5%; P =.002) and were more likely to be discharged on coumadin (53.4% vs 37.1%; P =.01). By multivariable analysis, use of a distal DVA was protective against MALEs (hazard ratio, 0.36; 95% confidence interval, 0.14-0.90; P = .03). CONCLUSIONS: This contemporary multi-institutional propensity-matched study demonstrates that patients that receive distal anastomotic vein adjuncts as part of infrainguinal prosthetic bypass operations in general have more extreme comorbidities and more technically challenging operations based on level of target vessel and prior bypass attempts. After propensity-matched analysis, the use of a DVA may protect against MALEs in prosthetic bypass surgery and should be considered when feasible. rights reserved.
Comments

Citation: McPhee JT, Goodney PP, Schanzer A, Shaykevich S, Belkin M, Menard MT. Distal anastomotic vein adjunct usage in infrainguinal prosthetic bypasses. J Vasc Surg. 2013 Apr;57(4):982-9. doi:10.1016/j.jvs.2012.10.098. Link to article on publisher's site

Related Resources
Link to Article in PubMed
PubMed ID
23375606
Citation Information
James T. McPhee, Philip P. Goodney, Andres Schanzer, Shimon Shaykevich, et al.. "Distal anastomotic vein adjunct usage in infrainguinal prosthetic bypasses" Vol. 57 Iss. 4 (2013) ISSN: 0741-5214 (Linking)
Available at: http://works.bepress.com/andres_schanzer/61/