Factors Affecting Patency of In Situ Saphenous Vein Bypass: Two Year Results from LIMBSAVE (Treatment of critical Limb Ischaemia with infragenicular Bypass adopting in situ SAphenous VEin technique) Registry


      The aim was to demonstrate contemporary outcomes of in situ saphenous vein bypass using a valvulotome.


      Analysis of two year outcomes of a multicentre registry based on the treatment of critical Limb Ischaemia with infragenicular Bypass adopting in situ SAphenous VEin technique (LIMBSAVE). Between January 2018 and December 2019, 541 patients in 43 centres were enrolled. In all patients an innovative valvulotome was used. Early outcomes were assessed. Two year outcomes according to Kaplan–Meier curves in terms of patency and limb salvage were evaluated. Associations between patient and procedure variables were analysed with univariable and multivariable analyses.


      In all cases, a valvulotome was able to lyse the valves. Vein injury due to the in situ technique was 3.5%. Thirty day mortality and major amputation rates were 3% and 0.9%, respectively. Mean follow up was 12.1 months. Two year estimated primary patency, primary assisted patency, secondary patency, and limb salvage were 69.1%, 81.4%, 86.5%, and 94.5%, respectively. Multivariable analysis showed an association between pre-operative vein diameter < 3 mm and lower primary patency (hazard ration [HR] 14.3, p < .001), primary assisted patency (HR 9.4, p = .002), secondary patency (HR 7.2, p = .007), and limb salvage (HR 7.8, p = .005) rates. Distal anastomosis to a tibial or foot vessel was also associated with lower primary patency (HR 4.8, p = .033), and primary assisted patency (HR 6, p = .011) rates. Use of a suprafascial tributary collateral as a graft was associated with lower primary patency (HR 6.7, p = .013), and primary assisted patency (HR 4.2, p = .042) rates.


      Vein diameter < 3 mm, distal anastomosis on a tibial or foot vessel, and use of a suprafascial tributary collateral as a graft were significantly associated with loss of patency and limb loss during follow up.


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        • Aboyans V.
        • Ricco J.B.
        • Bartelink M.E.
        • Björck M.
        • Brodmann M.
        • Cohnert T.
        • et al.
        2017 ESC Guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS).
        Eur J Vasc Endovasc Surg. 2018; 55: 305-368
        • Conte M.S.
        • Bradbury A.W.
        • Kolh P.
        • White J.V.
        • Dick F.
        • Fitridge R.
        • et al.
        Global vascular guideline for the management of chronic limb-threatening ischemia.
        J Vasc Surg. 2019; 69: 3S-125S
        • Ambler G.K.
        • Twine C.P.
        Graft type for femoro-popliteal bypass surgery.
        Cochrane Database Syst Rev. 2018;11; 2: CD001487
        • Almasri J.
        • Adusumalli J.
        • Asi N.
        • Lakis S.
        • Alsawas M.
        • Prokop L.J.
        • et al.
        A systematic review and meta-analysis of revascularization outcomes of infrainguinal chronic limb-threatening ischemia.
        J Vasc Surg. 2019; 69: 126S-136S
        • Connolly J.E.
        The history of the in situ saphenous vein bypass.
        J Vasc Surg. 2011; 53: 241-244
        • Shah D.M.
        • Darling 3rd, R.C.
        • Chang B.B.
        • Fitzgerald K.M.
        • Paty P.S.
        • Leather R.P.
        Long-term results of in situ saphenous vein bypass. Analysis of 2058 cases.
        Ann Surg. 1995; 222: 438-446
        • Calligaro K.D.
        • Friedell M.L.
        • Rollins D.L.
        • Semrow C.M.
        • Buchbinder D.
        A comparative review of in situ versus reversed vein grafts in the 1980s.
        Surg Gynecol Obstet. 1991; 172: 247-252
        • Bergmark C.
        • Johansson G.
        • Olofsson P.
        • Swedenborg J.
        Femoro-popliteal and femoro-distal bypass: a comparison between in situ and reversed technique.
        J Cardiovasc Surg. 1991; 32: 117-120
        • Moody A.P.
        • Edwards P.R.
        • Harris P.L.
        In situ versus reversed femoropopliteal vein grafts: long-term follow-up of a prospective, randomized trial.
        Br J Surg. 1992; 79: 750-752
        • Harris P.L.
        • Veith F.J.
        • Shanik G.D.
        • Nott D.
        • Wengerter K.R.
        • Moore D.J.
        Prospective randomized comparison of in situ and reversed infrapopliteal vein grafts.
        Br J Surg. 1993; 80: 173-176
        • Watelet J.
        • Soury P.
        • Menard J.F.
        • Plissonnier D.
        • Peillon C.
        • Lestrat J.P.
        • et al.
        Femoropopliteal bypass: in situ or reversed vein grafts? Ten-year results of a randomized prospective study.
        Ann Vasc Surg. 1997; 11: 510-519
        • Lawson J.A.
        • Tangelder M.J.
        • Algra A.
        • Eikelboom B.C.
        The myth of the in situ graft: superiority in infrainguinal bypass surgery?.
        Eur J Vasc Endovasc Surg. 1999; 18: 149-157
        • Davidovic L.B.
        • Markovic D.M.
        • Vojnovic B.R.
        • Lotina S.I.
        • Kostic D.M.
        • Cinara I.S.
        • et al.
        Femoro-popliteal reconstructions: 'in situ' versus 'reversed' technique.
        Cardiovasc Surg. 2001; 9: 356-361
        • Troisi N.
        • De Blasis G.
        • Salvini M.
        • Michelagnoli S.
        • LIMBSAVE registry Collaborative Group
        Safety and effectiveness of a new valvulotome: insights from the LIMBSAVE registry.
        Int Angiol. 2019; 8: 299-304
        • Troisi N.
        • De Blasis G.
        • Salvini M.
        • Michelagnoli S.
        • LIMBSAVE registry Collaborative Group
        Treatment of critical limb ischemia with infragenicular bypass adopting the in-situ saphenous vein technique: protocol for a national, multicentre, observational, prospective registry (LIMBSAVE).
        Ital J Vasc Endovasc Surg. 2019; 26: 59-62
        • Bradbury A.W.
        • Adam D.J.
        • Bell J.
        • Forbes J.F.
        • Fowkes F.G.
        • Gillespie I.
        • et al.
        Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: a survival prediction model to facilitate clinical decision making.
        J Vasc Surg. 2010; 51: 52s-68s
        • Lawaetz M.
        • Fisker L.
        • Lonn L.
        • Sillesen H.
        • Eiberg J.
        In situ vein bypass is superior to endovascular treatment of femoropopliteal lesions in chronic limb-threatening ischemia.
        Ann Vasc Surg. 2020; 67: 437-447
        • van Mierlo P.A.
        • Bekkers W.J.
        • van 't Land F.R.
        • van Mierlo A.G.
        • de Smet A.A.
        • Fioole B.
        The role of infragenicular spliced vein bypass surgery in patients with chronic limb-threatening ischemia: single center long-term results.
        J Cardiovasc Surg. 2019; 60: 686-692
        • Brochado Neto F.
        • Sandri G.A.
        • Kalaf M.J.
        • Matielo M.F.
        • Casella I.B.
        • Godoy M.R.
        • et al.
        Arm vein as an alternative autogenous conduit for infragenicular bypass in the treatment of critical limb ischaemia: a 15 year experience.
        Eur J Vasc Endovasc Surg. 2014; 47: 609-614
        • Nguyen B.N.
        • Neville R.F.
        • Abugideiri M.
        • Amdur R.
        • Sidawy A.N.
        The effect of graft configuration on 30-day failure of infrapopliteal bypasses.
        J Vasc Surg. 2014; 59: 1003-1008
        • Bolíbar I.
        • Gich I.
        • Anglès A.
        • Romero J.M.
        • Escudero J.R.
        Variability of revascularization techniques among Catalan hospitals and impact on leg salvage inpatients with peripheral arterial disease.
        Int Angiol. 2019; 38: 54-61
        • Adami D.
        • Marconi M.
        • Piaggesi A.
        • Mocellin D.M.
        • Berchiolli R.N.
        • Ferrari M.
        Bifurcated bypass in severe chronic limb threatening ischaemia.
        Vascular. 2021; 30: 63-71
        • Troisi N.
        • Masciello F.
        • Michelagnoli S.
        • Chisci E.
        Outcomes of popliteal artery aneurysms treated by ligation and in situ saphenous vein bypass.
        Int Angiol. 2021; 40: 435-441
        • Troisi N.
        • De Blasis G.
        • Salvini M.
        • Michelagnoli S.
        • Setacci C.
        • LIMBSAVE Registry Collaborative Group
        Preliminary six-month outcomes of LIMBSAVE (treatment of critical Limb IscheMia with infragenicular Bypass adopting in situ SAphenous VEin technique) registry.
        Vascular. 2021; 29: 589-596
        • Norgren L.
        • Hiatt W.R.
        • Dormandy J.A.
        • Nehler M.R.
        • Harris K.A.
        • Fowkes F.G.
        • et al.
        Inter-society consensus for the management of peripheral arterial disease (TASC II).
        J Vasc Surg. 2007; 45 (S5–67)
        • Steering Committee T.A.S.C.
        • Jaff M.R.
        • White C.J.
        • Hiatt W.R.
        • Fowkes G.R.
        • Dormandy J.
        • et al.
        An update on methods for revascularization and expansion of the TASC lesion classification to include below-the-knee arteries: a supplement to the inter-society consensus for the management of peripheral arterial disease (TASC II).
        J Endovasc Ther. 2015; 22: 663-677
        • Sasajima T.
        • Kubo Y.
        • Kokubo M.
        • Izumi Y.
        • Inaba M.
        Comparison of reversed and in situ saphenous vein grafts for infragenicular bypass: experience of two surgeons.
        Cardiovasc Surg. 1993; 1: 38-43
        • Nowygrod R.
        • Egorova N.
        • Greco G.
        • Anderson P.
        • Gelijns A.
        • Moskowitz A.
        • et al.
        Trends, complications, and mortality in peripheral vascular surgery.
        J Vasc Surg. 2006; 43: 205-216
        • Budd J.S.
        • Brennan J.
        • Beard J.D.
        • Warren H.
        • Burton P.R.
        • Bell P.R.
        Infrainguinal bypass surgery: factors determining late graft patency.
        Br J Surg. 1990; 77: 1382-1387
        • Rutherford R.B.
        • Jones D.N.
        • Bergentz S.E.
        • Bergqvist D.
        • Comerota A.J.
        • Dardik H.
        • et al.
        Factors affecting the patency of infrainguinal bypass.
        J Vasc Surg. 1988; 8 (236–6)
        • Golledge J.
        • Beattie D.K.
        • Greenhalgh R.M.
        • Davies A.H.
        Have the results of infrainguinal bypass improved with the widespread utilisation of postoperative surveillance?.
        Eur J Vasc Endovasc Surg. 1996; 11: 388-392
        • Fisker L.
        • Eiberg J.
        • Sillesen H.
        • Lawaetz M.
        The role of routine ultrasound surveillance after in situ infrainguinal peripheral vein bypass for critical limb-threatening ischemia.
        Ann Vasc Surg. 2020; 66: 529-536
        • Idu M.M.
        • Buth J.
        • Hop W.C.
        • Cuypers P.
        • van de Pavoordt E.D.
        • Tordoir J.M.
        Factors influencing the development of vein-graft stenosis and their significance for clinical management.
        Eur J Vasc Endovasc Surg. 1999; 17: 15-21
        • Jongsma H.
        • Bekken J.A.
        • van Buchem F.
        • Bekkers W.J.J.
        • Azizi F.
        • Fioole B.
        Secondary interventions in patients with autologous infrainguinal bypass grafts strongly improve patency rates.
        J Vasc Surg. 2016; 63: 385-390