Long-Term Outcomes of Autologous Vein Bypass for Repair of Upper and Lower Extremity Major Arterial Trauma.

Autologous vein is the preferred bypass conduit for extremity arterial injuries due to superior patency and low infection risk; however, long-term data on outcomes in civilians is limited. Our goal was to assess short- and long-term outcomes of autologous vein bypass for upper and lower extremity arterial trauma. A retrospective review was performed of patients with major extremity arterial injuries (2001-2019) at a Level I Trauma Center. Demographics, injury and intervention details, and outcomes were recorded. Primary outcomes were primary patency at 1-year and 3-years. Secondary outcomes were limb function at 6 months, major amputation, and mortality. Multivariable analysis determined risk factors for functional impairment. There were 107 extremity (31.8% upper and 68.2% lower) arterial injuries treated with autologous vein bypass. Mechanism was penetrating in 77% of cases, of which 79.3% were due to firearms. The most frequently injured vessels were the common and superficial femoral (38%), popliteal (30%), and brachial arteries (29%). For upper extremity trauma, concomitant nerve and orthopedic injuries were found in 15 (44.1%) and 11 (32.4%) of cases respectively. For lower extremities, concomitant nerve injuries were found in 10 (13.7%) cases, and orthopedic injuries in 31 (42.5%). Great saphenous vein was the conduit in 96% of cases. Immediate intraoperative bypass revision occurred in 9.3% of patients, most commonly for graft thrombosis. In-hospital return to operating room rate was 15.9%, with graft thrombosis (47.1%) and wound infections (23.5%) being the most common reasons. Median follow-up was 3.6 years. Kaplan-Meier analysis showed 92% primary patency at 1-year and 90% at 3-years. At 6 months, 36.1% of patients had functional impairment. Of patients with functional impairment at 6 months, 62.9% had concomitant nerve and 60% concomitant orthopedic injuries. Of those with nerve injury, 91.7% had functional impairment, compared to 17.8% without nerve injury (P < 0.001). Of patients with orthopedic injuries, 51.2% had functional impairment, versus 25% of those without orthopedic injuries (P=0.01). On multivariable analysis, concomitant nerve injury (OR 127.4, 95% CI 17-957, P <0.001) and immediate intraoperative revision (OR 11.03, 95% CI 1.27-95.55, P=0.029) were associated with functional impairment. Autologous vein bypass for major extremity arterial trauma is durable; however, many patients have long-term limb dysfunction associated with concomitant nerve injury and immediate intraoperative bypass revision. These factors may allow clinicians to identify patients at higher risk for functional impairment, in order to outline patient expectations and direct rehabilitation efforts towards improving functional outcomes.

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