title: Endovascular-assisted versus conventional in situ saphenous vein bypass grafting: cumulative patency, limb salvage, and cost results in a 39-month multicenter study.
abstract: OBJECTIVE
  In this retrospective multicenter study, the results of a minimally invasive method of endovascular-assisted in situ bypass grafting (EISB) versus "open" conventional in situ bypass grafting (CISB) were evaluated with a comparison of primary and secondary patency, limb salvage, and cost.
  
  
  METHODS
  Enrolled in this study were 273 patients: 117 underwent CISB (42 femoropopliteal, 75 femorocrural) and 156 underwent EISB (41 femoropopliteal, 115 femorocrural). EISB was performed with an angioscopic Side Branch Occlusion system and an angioscopically guided valvulotome. All the patients underwent follow-up examination with serial color-flow ultrasound scanning.
  
  
  RESULTS
  Both groups had similar comorbid risk factors for diabetes mellitus, coronary artery heart disease, hypertension, and cigarette smoking. The primary patency rates (CISB, 78.2% +/- 5% [SE]; EISB, 70.5% +/- 5%; P =.156), the secondary patency rates (CISB, 84.1% +/- 4%; EISB, 82.9% +/- 5%; P =.26), and the limb salvage rates (CISB, 85.8%; EISB, 88.4%; P =.127) were statistically similar, with a follow-up period that extended to 39 months (mean, 16.6 months; range, 1 to 40 months). In veins that were less than 2.5 to 3.0 mm in diameter, the EISB grafts fared poorly, with an increased incidence of early (12-month) graft thromboses (CISB, 10 grafts, 8.5%; EISB, 24 grafts, 15.3%). However, wound complications (CISB, 23%; EISB, 4%; P =.003), mean hospital length of stay (CISB, 6.5 days +/- 4.83; EISB, 3.2 days +/- 3.19; P =.001), and mean hospital charges (CISB, $25,349 +/- $19,476; EISB, $18,096 +/- $14,573; P =.001) were all significantly reduced in the EISB group.
  
  
  CONCLUSIONS
  The CISB and EISB midterm primary and secondary patency and limb salvage rates were statistically similar. In smaller veins (< 2.5 to 3.0 mm in diameter), however, EISB is not appropriate because overly aggressive instrumentation may cause intimal trauma, with resultant early graft failure. With the avoidance of a long leg incision in the EISB group, wound complications and hospital length of stay were significantly reduced, which lowered hospital charges and justified the additional cost of the endovascular instruments. When in situ bypass grafting is contemplated, EISB in appropriate patients is a safe, minimally invasive, and cost-effective alternative to CISB.
authors.affiliation: Department of Vascular Surgery, Georgia Baptist Medical Center, and The Medical College of Georgia, USA.
authors.forename: D
authors.initials: D
authors.lastname: Rosenthal
authors.forename: E J
authors.initials: EJ
authors.lastname: Arous
authors.forename: S G
authors.initials: SG
authors.lastname: Friedman
authors.forename: M D
authors.initials: MD
authors.lastname: Ingegno
authors.forename: B L
authors.initials: BL
authors.lastname: Johnson
authors.forename: L W
authors.initials: LW
authors.lastname: Kraiss
authors.forename: J D
authors.initials: JD
authors.lastname: Martin
authors.forename: M W
authors.initials: MW
authors.lastname: Moritz
authors.forename: G
authors.initials: G
authors.lastname: Piano
authors.forename: E E
authors.initials: EE
authors.lastname: Rigdon
authors.forename: S B
authors.initials: SB
authors.lastname: Self
authors.forename: L L
authors.initials: LL
authors.lastname: Pallos
mesh_terms: D000368:Aged; D017546:Angioscopy / Q000191:economics* / Q000379:methods*; D001157:Arterial Occlusive Diseases / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D017073:Atherectomy / Q000191:economics* / Q000379:methods*; D003362:Cost-Benefit Analysis; D005260:Female; D017722:Hospital Charges / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay / Q000191:economics / Q000706:statistics & numerical data; D008297:Male; D012189:Retrospective Studies; D012307:Risk Factors; D016879:Salvage Therapy / Q000191:economics* / Q000379:methods*; D012501:Saphenous Vein / Q000637:transplantation*; D016896:Treatment Outcome; D014463:Ultrasonography; D014654:Vascular Patency