RS22 - Long-term Outcomes of Great Saphenous Vein Harvest Techniques for Infrainguinal Arterial Bypass in a Medicare-matched Registry Database

Objectives: Long term outcomes of infrainguinal arterial bypass using different great saphenous vein (GSV) harvest techniques remain largely unknown. Endoscopic GSV harvesting (EVH) has emerged as a less invasive alternative to conventional open techniques. Using the Vascular Quality initiative Vascular Implant Surveillance & Interventional Outcomes Network (VQI-VISION) database, we compared the long-term outcomes of infrainguinal arterial bypass using open and endoscopic GSV harvest techniques.

Methods: Patients who underwent infrainguinal GSV bypass between November 1st 2010 and December 31st 2019 were identified in the VQI-VISION Medicare linked database. Thirty-day readmission rates and long-term outcomes (mortality, major/minor amputations, and reinterventions) up to 9 years of follow-up were compared between continuous incisions, skip incision, and EVH, with continuous incisions being the reference group. Survival analysis using Kaplan-Meier curves and Cox-regression hazard models were utilized to compare outcomes between groups.

Results: Among the 8,915 patients included in the study, continuous and skip vein harvest techniques were used in 44.4% and 43.4% of cases each, while 12.3% utilized EVH (Table 1). EVH use remained relatively stable at around 12% throughout the study period. Compared to continuous incisions, EVH was associated with lower odds of 30-day readmission [EVH 22.6% vs. 27.0%, OR (95%CI): 0.84 (0.70-1.00), p=0.04]. Despite differences in 1 year mortality, reintervention, and major amputations between EVH and continuous incisions, these differences were not statistically significant on long-term follow-up and after adjusting for potential cofounders (Figure 1). Procedures using skip incision were associated with lower risk of mortality [HR (95%CI): 0.92(0.85-0.99), p=0.028] compared to continuous incisions. These findings were consistent across different vein types (reversed GSV, in-situ GSV, non-reversed transposed GSV) and whether a single or multisegmented GSV was used (p of interaction>0.05). When stratified by the level of bypass, EVH and skip incisions were associated with lower long-term mortality compared to continuous incisions in patients undergoing above-knee bypass [HR (95% CI): 0.58 (0.40, 0.84), p=0.004 and 0.62 (0.49, 0.80), p< 0.001, respectively]. Among surgeons performing EVH, similar readmission and long-term outcomes were observed regardless of low ( < 4 cases/year), medium (4-7 cases/year), or high procedural volumes (> 7 cases/year).

Conclusions: Using EVH for infrainguinal arterial bypass is associated with lower 30-day readmission rates, with no difference in long-term mortality, reinterventions, or major amputations compared to other harvesting techniques. These outcomes are not influenced by procedural volumes for EVH technique. The increased risk of long-term mortality with continuous incisions, mainly in above-knee arterial bypass surgeries, warrants further investigation.