RS01 - Adequacy and utilization of greater saphenous vein in patients undergoing preoperative vein mapping for chronic limb-threatening ischemia

Objectives: Single-segment greater saphenous vein (ssGSV) demonstrates superior outcomes in infrainguinal revascularization for CLTI, but the definition and prevalence of adequate ssGSV are not well established.

Methods: This is a single-center retrospective analysis of patients with CLTI who underwent preoperative vein mapping (VM) by duplex ultrasound (2015-2025). A standardized scoring system was applied to classify GSV suitability as a bypass conduit, measured from saphenofemoral junction to knee (GSV-K) and to mid-calf (GSV-MC) (A: ≥3mm, B: ≥2.5mm, C: >2mm, D: any portion ≤2mm, E: thrombosed, ablated, varicose, previously harvested). GSV quality, associated clinical factors, and interventions received were analyzed. Major adverse limb events (MALE) and limb-based patency were assessed as outcomes.

Results: Patients (n=351) had a median age of 71.1 years and 69% were male. Comorbidities included diabetes (64%), end-stage renal disease (13%), coronary revascularization (37%) and heart failure (38%). The best available GSV-K and GSV-MC from either extremity were adequate (A/B) in 66% and 46%, marginal (C) in 8.3% and 13% and inadequate (D/E) in 26% and 40%, respectively (Figure 1).
Among this VM cohort, 197 limbs underwent infrainguinal bypass (representing 61% of all infrainguinal bypasses performed for CLTI during the study period), using ssGSV (53%), alternate autogenous vein (23%; includes spliced GSV), prosthetic (6.1%), or cryopreserved vein (18%). Among GSV bypasses performed, 33% were femoro-popliteal, 19% infra-popliteal, and 48% femoro-distal. The GSV conduits used were classified by VM as GSV-K: 81% A/B, 7.8% C, 11% D/E; and GSV-MC: 57% A/B, 14% C, 29% D/E. Of limbs with A/B grade GSV-K that underwent bypass (n=132), 70% used ssGSV conduit; this utilization rose to 82% for A/B grade GSV-MC.
Major amputation, major reintervention, and MALE at one year after GSV bypass (ss or spliced) were 11%, 17%, and 22%, respectively. Use of grade D/E GSV-K conduit was associated with greater risk of major reintervention (p=0.048). Among ssGSV bypasses, preoperative grade A/B GSV-K was associated with superior primary limb-based patency (p=0.04, Figure 2). In a logistic multiple regression model, GSV-K grade D/E and spliced GSV use were independently associated with loss of primary patency, accounting for covariate interaction [HR 4.1 (1.6-10.8), p=0.005 for GSV-K D/E vs A/B; HR 2.2 (1.03-4.7), p=0.04 for spliced vs ssGSV].

Conclusions: Most CLTI patients undergoing preoperative VM had adequate GSV for use as a bypass conduit (66% GSV-K, 46% GSV-MC). More than half of infrainguinal bypasses received a ssGSV conduit, with outcomes consistent with those observed in the BEST-CLI trial.