Arm Veins in Bypass for Chronic Lower Limb Ischemia Provide Durable Late Results

Introduction: Although endovascular treatment has gained popularity for treatment of leg ischemia bypass is still necessary in case of extensive disease or failed endovascular treatment. Autologous saphenous vein provides durable long term results. Arm veins represent an alternative to small calibre prosthetic conduits in case of insufficient saphenous vein. Methods: Arm veins were chosen in case of limited availability of greater saphenous vein for bypass, repair or extension of a preexisting graft. They were used as a single length vein or combined with other autologous veins. Only when too short vein segments were available they were combined with a prosthesis as the distal part of the construction. Grafts were followed after 3, 6, 12, 18, 24 months and yearly thereafter. Secondary interventional or operative procedures were added if necessary. Graft patency and limb salvage were analysed. Results: From 01/10 until 01/19 382 operations in 354 lower limbs were performed with arm vein for atherosclerotic chronic lower limb ischemia in 333 patients (209 men and 124 women, 75+-9 years, 51% diabetic). Critical limb ischemia was present in 86,7% and severe claudication in 13,3%. In 71% of cases previous endovascular or surgical revascularisations of the limb had been performed. By combining arm vein with other vein segments a complete autologous reconstruction could be achieved in 80% of cases. Spliced vein was used in 71% and three or more vein segments were combined in 29%. The composite technique became necessary in 20%. The most distal bypass anastomosis was constructed at the crural or pedal level in 84% and at the popliteal artery in 16%. In 12% arm vein was used for repair or extension of a patent bypass. 30 day mortality was 6,2% and early major amputation became necessary in critical ischemia in 3,6%. Mean follow-up was 31 +- 25 months. Primary, primary assisted and secondary patency was 45%, 66% and 70% for autologous bypasses and 35%, 43% and 43% for composite bypasses after 5 years. The 5-year limb salvage rate was 86% for CLI. There was no amputation after operation for claudication. Secondary patency and limb salvage were not influenced by diabetes (p .179 and p .083). Secondary patency (70% versus 42%, p .001) and limb salvage (91% versus 77%, p .000) was significantly higher for complete autologous grafts. Amputation free survival was significantly better for autologous grafts (57% versus 16%, p .000) and claudication (87% versus 41%, p .000) as was overall 5-year patient survival with a superior outcome for autogenous grafts (56% versus 23%, p .000) and claudication (85% versus 43%, p .000). Conclusion: The use of arm veins in peripheral bypass for chronic ischemia allows the construction of a complete autologous construction in most cases with a good late outcome. A composite bypass may be regarded in case of limited vein length and acceptable long term outcome may be expected. The complete autologous reconstruction is associated with good graft patency, limb salvage, amputation free survival and patient survival. Arm veins should be routine in peripheral bypass for chronic ischemia. Disclosure: Nothing to disclose