Predicting the Development of Thrombosis of the Femoral-Popliteal Bypass in the Long-Term Follow-Up Period

Abstract

Aim of study. The development of a program for predicting thrombosis with subsequent amputation of a limb in the long-term period after femoral-popliteal bypass (FPB).Material and methods. This is a retrospective open comparative study performed from January 10, 2016 to December 25, 2019 at Research Institute – Professor S.V. Ochapovsky Regional Clinical Hospital No. 1 of the Ministry of Health of the Krasnodar Territory, Krasnodar, which included 473 patients who underwent FPB. Depending on the type of bypass, five groups were formed: Group 1 (n=266), reversed vein (great saphenous vein (GSV); Group 2 (n=59), autovenous vein (GSV), prepared in situ; Group 3 (n=66), autovenous vein (GSV), prepared ex situ; Group 4 (n=9) synthetic graft (Jotec, Germany); Group 5 (n=73), veins of the upper limb (forearm and shoulder). In all cases of observation, multislice computed tomography with angiography revealed an extensive (25 cm or more) atherosclerotic occlusive lesion of the superficial femoral artery, corresponding to type D according to the transatlantic consensus (TASC II). The long-term followup period was 16.6±10.3 months.Results. During the hospital postoperative period, all complications developed in groups 1, 2, 3 and 5. However, no significant intergroup statistical differences were found. In the long-term follow-up period, according to the mortality rate (group 1: 4.6%; group 2: 1.7%; group 3: 4.6%; group 4: 0%; group 5: 2.8%; p=0.78), myocardial infarction (group 1: 1.9%; group 2: 0%; group 3: 1.5%; group 4: 0%; group 5: 0%; p=0.62), ischemic stroke (group 1: 0.8%; group 2: 1.7%; group 3: 1.5%; group 4: 0%; group 5: 0%; p=0.8) and bybass thrombosis (group 1: 14.5%; group 2: 19.3%; group 3: 18.5%; group 4: 44.4%; group 5: 19.7%; p=0.16), no significant intergroup differences were identified. However, the largest number of limb amputations (group 1: 4.2%; group 2: 5.3%; group 3: 9.2%; group 4: 22.2%; group 5: 1.4%; p=0.03) and the maximum composite endpoint (sum of all complications) (group 1: 26.0%; group 2: 28.1%; group 3: 35.4%; group 4: 66.7%; group 5: 23 .9%; p=0.05) were observed after the use of a synthetic graft. Using “random forest” analysis, a model and computer program was created that allows, the risk (low, medium, high) of developing bypass thrombosis to be assessed interactively, based on clinical, anamnestic, demographic and perioperative data, with subsequent amputation after FPB in the long-term follow-up period.Conclusions. Revascularization strategy for patients with extended atherosclerotic lesions of the femoropopliteal segment should be determined individually and only by a multidisciplinary council. The conduit of choice for femoral-popliteal bypass surgery is an autovenous graft. Synthetic prostheses can only be used in the absence of the latter. To identify a group of patients with a high risk of thrombosis of the femoral-popliteal bypass and limb amputation in the long-term follow-up period, the created risk stratification program for the development of these complications can be used. Precision supervision of these patients in the postoperative period will make it possible to prevent these adverse events in time.

Keywords

• femoral-popliteal bypass
• reverse autovein
• autovein “in situ”
• autovein “ex situ”
• autovein of the upper limb
• synthetic graft
• jotec
• risk stratification
• bypass thrombosis
• amputation