What is the management approach for patients with severe Peripheral Artery Disease (PAD) using artery bypass surgery with cryopreserved vein (cryovein) grafts?

Management of Severe Peripheral Artery Disease Using Artery Bypass with Cryopreserved Vein Grafts

For patients with severe Peripheral Artery Disease (PAD) requiring bypass surgery, autogenous vein grafts should be used as the primary conduit choice whenever possible, with cryopreserved vein grafts reserved only for cases where no autogenous vein is available and amputation is imminent. 1

Patient Selection and Preoperative Evaluation

• A comprehensive preoperative cardiovascular risk evaluation is mandatory for all patients with PAD undergoing major vascular surgical intervention 1
• Surgical intervention is indicated for patients with:
  • Significant functional disability affecting vocation or lifestyle
  • Failure to respond to exercise or pharmacotherapy
  • Reasonable likelihood of symptomatic improvement 1
  • Critical limb ischemia (CLI) with rest pain, tissue loss, or gangrene

Conduit Selection Algorithm

1. First choice: Autogenous saphenous vein

   • Ipsilateral greater saphenous vein is the gold standard 1
   • Strong evidence (Level A) supports using autogenous vein for both above-knee and below-knee popliteal artery bypasses 1

2. Alternative autogenous sources when saphenous vein unavailable:

   • Contralateral saphenous vein
   • Arm veins
   • Composite sequential bypasses 1

3. Cryopreserved vein consideration:

   • Only when no autogenous vein is available from any source
   • When amputation is imminent 1
   • Should be considered before using prosthetic grafts for below-knee bypasses

Surgical Approach Based on Disease Location

Inflow Procedures (Aortoiliac Disease)

• Aortobifemoral bypass is recommended for patients with symptomatic, hemodynamically significant aortoiliac disease 1
• Iliac endarterectomy or aortoiliac/iliofemoral bypass should be used for unilateral disease 1

Outflow Procedures (Infrainguinal Disease)

• The most distal artery with continuous flow and without significant stenosis should be used as the origin point for distal bypass 1
• The tibial or pedal artery providing continuous outflow to the foot should be the site of distal anastomosis 1
• For femoral-tibial artery bypasses, autogenous vein is strongly recommended 1

Special Considerations with Cryopreserved Vein Grafts

• Higher failure rates compared to autogenous vein
• Should be used primarily in limb-threatening situations when no autogenous conduit is available
• May require adjunctive procedures (such as arteriovenous fistula) to improve patency
• More intensive surveillance recommended due to higher risk of failure

Postoperative Management

• All patients should receive antiplatelet therapy indefinitely unless contraindicated (Level A evidence) 1
• Regular follow-up should include:
  • Assessment of recurrent symptoms
  • Pulse examination of proximal, graft, and outflow vessels
  • Ankle-brachial index (ABI) measurements 1
  • For cryopreserved vein grafts: more frequent duplex ultrasound surveillance is recommended

Pitfalls and Caveats

1. Do not use cryopreserved or prosthetic grafts as first choice: Autogenous vein has significantly better patency rates and should always be exhausted first 1

2. Avoid using cryopreserved or prosthetic grafts for claudication alone: These should be reserved for limb-threatening ischemia 1

3. Do not perform prophylactic revascularization: Surgical intervention is not indicated to prevent progression to limb-threatening ischemia in patients with intermittent claudication 1

4. Recognize high-risk patients: Patients younger than 50 years often have more aggressive atherosclerotic disease and may have less durable results from surgical intervention 1

5. Address inflow lesions first: For patients with combined inflow and outflow disease, inflow lesions should be addressed before outflow procedures 1

The multidisciplinary approach to PAD management has shown improved outcomes 2, but the surgical principles regarding conduit selection remain clear - autogenous vein first, with alternatives like cryopreserved vein only when necessary to prevent limb loss.