Infrainguinal Bypass Conduit: Autogenous or Synthetic - A National Perspective

Abstract

Numerous studies have compared autogenous versus synthetic grafts for infrainguinal bypasses. Synthetic grafts are associated with shorter operating times, comparable reimbursement, and despite inferior patency rates, remain in frequent use. Therefore, this study was undertaken in an effort to characterize, from a national perspective, the practice patterns and the drivers of practice variation in the use of synthetic grafts for infrainguinal bypass. Two data sets were obtained: 1) Medicare billings of infrainguinal bypasses in 49 states, years 1995 through 1997 (number of procedures, 254,677). Procedures were defined by nine CPT billing codes. 2) Hospitals over 150 beds in six states (CA, CO, CT, IA, MN, MS) were asked for volume statistics on the same CPT codes. Data were received from 27 institutions, comprising 1,063 procedures. Variations in graft use were analyzed by hospital type (teaching versus non-teaching) and correlated with the prevalence of diabetes mellitus and smoking. Nationwide, 41% of infrainguinal bypasses in 1997 were performed using synthetic grafts. Interstate synthetic conduit use ranged from 27% to 80%. These differences were similar for bypasses to popliteal or infrapopliteal vessels. Admission to a teaching hospital was associated with a lower use of synthetic grafts (21% vs 51%, odds ratio 0.26, p<0.0001). No correlation was seen between the prevalence of diabetes mellitus or smoking, and synthetic graft use. Synthetic graft use was significantly lower at teaching hospitals, and there was substantial interstate and intrastate variations. These findings suggest that there is wide variation in practice patterns. Further studies appear warranted to define the role of patient demographics and physician preference in explaining these differences.

Preoperative smoking is associated with early graft failure after infrainguinal bypass surgery

“…Inferior long-term outcomes associated with prosthetic graft use, especially for distal revascularization procedures, have been well described in the past. 27,28,33,34 The current results argue for cautious use of prosthetic grafts in active smokers regardless of level of bypass.…”

“…32 The presence of CLI, distal revascularization, prosthetic graft use, emergency surgery, thrombocytosis, renal insufficiency or failure, and dependent functional status are among modifiable factors that have been associated with increased graft failure rates. 10,[19][20][21][22]33 The assessment of comorbidities, presenting features, and intraoperative details did not reveal that active smokers in this patient population had higher rates of many of these known predictors of graft failure, except the use of prosthetic grafts. Inferior long-term outcomes associated with prosthetic graft use, especially for distal revascularization procedures, have been well described in the past.…”

Meta-analysis of femoropopliteal bypass grafts for lower extremity arterial insufficiency

“…AK-Vs and BK-Vs performed better than AK-Ps and should be used whenever possible to reduce the gap between the best practice and the true practice. 6 However, the absence of a suitable saphenous vein remains an acceptable indication for an AK-P, at least until the potentials of other alternatives are fully established.…”

“…4,5 It is interesting to note that AK-Ps remain in frequent use. 6,7 Femoropopliteal revascularization deserves re-evaluation for many reasons. First, four recent randomized trials 8 -11 have shown the superiority of AK-V over AK-P in the first 12 months of follow-up.…”

Development of a reinforced porcine elastin composite vascular scaffold

“…Currently available synthetic vascular bypass grafts display adequate performance in the peripheral vascular circulation, yet autologous vein, when available, remains the graft of choice 42. Although synthetic grafts are more readily available and easily implantable, it is widely believed that autologous veins display enhanced patency over the long term 43.…”