title: The effect of graft configuration on 30-day failure of infrapopliteal bypasses.
abstract: BACKGROUND
  Despite advances in endovascular techniques, infrapopliteal bypasses are still required for limb salvage. Short-term graft patency is an important outcome parameter reflecting technical considerations and acute graft thrombosis. Both are important prerequisites for long-term patency. In this analysis, we compared the 30-day patency of all conduit configurations for infrapopliteal bypasses.
  
  
  METHODS
  All primary infrapopliteal bypasses from the American College of Surgeons-National Surgical Quality Improvement Program database between 2005 and 2010 were divided into six groups: (1) great saphenous vein (GSV); (2) prosthetic conduit (prosthetic); (3) prosthetic conduit with a distal anastomotic venous adjunct (ADJ), such as a cuff or patch (prosthetic + ADJ); (4) composite graft of prosthetic and a vein segment (composite); (5) spliced autogenous vein (spliced vein); and (6) arm vein. Thirty-day graft failure, patient demographics, and operative details were compared among groups. A multivariate model was used for statistical analysis.
  
  
  RESULTS
  A total of 5375 infrapopliteal bypasses were analyzed by conduit: GSV, 3983 (75%); prosthetic, 898 (17%); spliced vein, 160 (3%); prosthetic + ADJ, 112 (2%); arm vein, 93 (2%); and composite, 91 (2%). The difference among groups in demographics and comorbidities was not statistically significant. Perioperative mortality rates were similar among different conduits. After adjusting for sex, age, weight, race, and previous cardiac surgery, the bypass conduit had a significant independent association with 30-day graft patency (P = .006). The GSV failure rate was 7.5%. Composite had a significantly higher 30-day failure rate (15.4%, P = .006). There was no significant difference in 30-day failure rate of spliced vein (5.6%, P = .37) or arm vein (4.3%, P = .24) conduits compared with GSV. Prosthetic had significantly higher 30-day failure rate than GSV (10.5%, P = .004). The addition of adjuvant venous tissue at the distal anastomosis of prosthetic bypasses did not significantly improve their 30-day patency (failure rate of 9.8% for prosthetic + ADJ and 10.5% for prosthetic). There was no significant difference in graft patency between alternative venous conduits (arm vein/spliced vein) and prosthetic + ADJ.
  
  
  CONCLUSIONS
  Venous conduits (GSV, spliced vein, arm vein) deliver the best 30-day patency for infrapopliteal bypasses, and GSV remains the most commonly used graft. Prosthetic grafts had a higher 30-day failure rate. Composite grafts should be abandoned because their early patency is not better than pure prosthetic conduits. The addition of a distal venous adjunct did not seem to improve acute prosthetic graft patency, which may reflect lack of effect on thrombogenicity rather than the myointimal hyperplastic response that effects long-term failure of infrapopliteal bypass.
authors.affiliation: Department of Surgery, George Washington University, Washington, D.C.. Electronic address: bnnguyen@mfa.gwu.edu.
authors.forename: Bao-Ngoc
authors.initials: BN
authors.lastname: Nguyen
authors.affiliation: Department of Surgery, George Washington University, Washington, D.C.
authors.forename: Richard F
authors.initials: RF
authors.lastname: Neville
authors.affiliation: School of Medicine, George Washington University, Washington, D.C.
authors.forename: Mustafa
authors.initials: M
authors.lastname: Abugideiri
authors.affiliation: Department of Surgery, George Washington University, Washington, D.C.; Biostatistics Core, DC Veterans Administration Medical Center, Washington, D.C.
authors.forename: Richard
authors.initials: R
authors.lastname: Amdur
authors.affiliation: Department of Surgery, George Washington University, Washington, D.C.
authors.forename: Anton N
authors.initials: AN
authors.lastname: Sidawy
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001132:Arm / Q000098:blood supply*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000295:instrumentation* / Q000401:mortality; D016009:Chi-Square Distribution; D005260:Female; D006083:Graft Occlusion, Vascular / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality / Q000503:physiopathology; D006801:Humans; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D011150:Popliteal Artery / Q000503:physiopathology / Q000601:surgery*; D011474:Prosthesis Design; D011475:Prosthesis Failure; D012189:Retrospective Studies; D012307:Risk Factors; D012501:Saphenous Vein / Q000503:physiopathology / Q000637:transplantation*; D013997:Time Factors; D017211:Treatment Failure; D014654:Vascular Patency