Selection of the Optimal Femoropopliteal Bypass Strategy According to Autologous Vein Availability and Graft Thrombosis Risk

Background: Femoropopliteal bypass remains a priority surgical method for treating extensive atherosclerosis of the lower limb arteries. Selecting the optimal intervention strategy is challenging even for experienced vascular surgeons, which highlights the relevance of this study.

Objective: To identify the optimal method for femoropopliteal bypass in patients with extensive lower limb arterial lesions, depending on the availability of the autologous vein and the risk of graft thrombosis.

Materials and methods: The retrospective study was conducted involving 490 patients who underwent inpatient treatment from 2016 to 2020. Various bypass techniques were performed: reversed autologous vein grafts were used in 266 patients; in situ technique in 59 patients, ex situ technique with orthotopic placement of autologous vein in 66 patients, with upper limb veins in 73 patients, arterialized small diameter great saphenous veins in 17 patients, and synthetic graft in 9 patients. For the final analysis, patients were divided into two groups: Group 1 included patients with great saphenous vein of adequate length and diameter, who underwent bypass grafting using a reversed great saphenous vein (n=246), in situ (n=54), or ex situ (n=62) techniques; Group 2 included patients with a small diameter great saphenous vein who underwent bypass using upper extremity veins (n=61), a previously arterialized great saphenous vein (n=17), or synthetic prosthesis (n=9). Clinical observation was carried out during the hospitalization and the subsequent period (47.6±12.3 months). Statistical analysis was performed using IBM SPSS version 26 (IBM Corporation, USA).

Results: In Group 1, the best outcomes in terms of graft thrombosis prevention were demonstrated with the use of a reversed autologous vein above the knee joint (OR 0.503, 95% CI 0.293-0.865, p=0.013). The use of in situ and ex situ techniques for bypass grafting below the knee joint was associated with a significantly increased risk of thrombosis (OR 1.256, 95% CI 1.001-1.577, p=0.049 and OR 1.174, 95% CI 1.023-1.348, p=0.023, respectively). In Group 2, a significantly increased risk of thrombosis was observed only with the use of synthetic graft (OR 9.583, 95% CI 2.166-42.395, p=0.003).

Conclusions: For patients with available great saphenous veins of suitable size, the optimal approach is femoropopliteal bypass using a reversed autologous vein, which minimizes the risk of thrombosis. In cases where a suitable great saphenous vein is not available, the use of synthetic grafts is recommended to be avoided due to the increased risk of thrombosis, with preference given to other available materials such as upper limb veins or arterialized small great saphenous veins. 

1. Zakeryaev AB, Vinogradov RA, Sukhoruchkin PV, Butaev SR. Femoropopliteal bypass surgery. Russian Journal of Cardiology and Cardiovascular Surgery. 2023;16(3):272‑282. (In Russ.) https://doi.org/10.17116/kardio202316031272

2. Sterpetti AV, Sapienza P, Cavallaro A. Distal runoff and the development of degenerative changes in autologous reversed saphenous vein femoropopliteal bypass. Ann Vasc Surg. 2011;25(6):766- 769. PMID: 21514108. https://doi.org/10.1016/j.avsg.2011.01.006

3. Troisi N, 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(4):589-596. PMID: 33090947. https://doi.org/10.1177/1708538120966126

4. Zakeryaev AB, Vinogradov RA, Sukhoruchkin PV, et al. Hospital results of a new method of femoral-popliteal bypass surgery with preparation of a large subcutaneous autovein by the ex situ method and its orthotopic implantation. Grudnaya i SerdechnoSosudistaya Khirurgiya. 2022; 64 (1): 78–85 (In Russ.). https://doi.org/10.24022/0236-2791-2022-64-1-78-85

5. Lumsden AB, Morrissey NJ. Comparison of Safety and Primary Patency Between the FUSION BIOLINE Heparin-Coated Vascular Graft and EXXCEL Soft ePTFE (FINEST) Trial Co-investigators. Randomized controlled trial comparing the safety and efficacy between the FUSION BIOLINE heparin-coated vascular graft and the standard expanded polytetrafluoroethylene graft for femoropopliteal bypass. J Vasc Surg. 2015;61(3):703-12.e1. PMID: 25720929. https://doi.org/10.1016/j.jvs.2014.10.008

6. Enzmann FK, Metzger P, Martin JES, et al. The Upper-Arm Basilic-Cephalic Loop: A Valueable Alternative for Below-Knee Arterial Reconstruction. Vasc Endovascular Surg. 2021;55(4):348-354. PMID: 33478360. https://doi.org/10.1177/1538574420980610.

7. Bossi M, Tozzi M, Franchin M, et al. Cryopreserved Human Allografts for the Reconstruction of Aortic and Peripheral Prosthetic Graft Infection. Ann Vasc Dis. 2017;10(4):391-397. PMID: 29515701. PMCID: PMC5835436. https://doi.org/10.3400/avd.oa.17-00068

8. Krepkogorskiy NV, Bredikhin RA. Modern methods of preparing autologous vein for bypass surgery (non-systematic review). IP Pavlov Russian Medical Biological Herald. 2024;32(4):669–80. (In Russ.) https://doi.org/10.17816/pavlovj321630

9. Zakeryaev AB, Vinogradov RA, Matusevich VV, Butaev SR, Suhoruchkin PV, Baryshev AG, et al. FEMORAL-POPLITEAL BYPASS SURGERY: FROM ITS ORIGINS TO THE PRESENT DAY. Bulletin of Pirogov National Medical and Surgical Center. 2021;16(3):57–60. (In Russ.) https://doi.org/10.25881/20728255_2021_16_3_57

10. Krepkogorskiy NV, Bulatov DG. Results of in situ femoropopliteal (tibial) bypass in patients with extended lower limbs arterial bed lesion and critical ischemia. Kazan medical journal. 2015;96(6):942– 9. (In Russ.) https://doi.org/10.17750/kmj2015-942

11. Biroš E, Staffa R, Krejčí M, Novotný T, Skotáková M, Bobák R. Autologous Alternative Vein Grafts for Infrainguinal Bypass in the Absence of Single-Segment Great Saphenous Vein: A Single-Center Study. Ann Vasc Surg. 2024;103:133-140. PMID: 38428452. https://doi.org/10.1016/j.avsg.2023.12.067

12. Maksimov AV, Khizriev SM. PTFE-grafts in femoropopliteal reconstructive surgery in patients with critical limb ischemia. Strategies for use and results. Prakticheskaya meditsina. 2025; 4(89): 101-104. (In Russ.).