Study supports routine vein mapping before CLTI revascularization

Many patients with chronic limb-threatening ischemia (CLTI) have suitable great saphenous vein (GSV) for bypass surgery, according to research published in the Journal of Vascular Surgery. The findings highlight the importance of routine vein mapping before revascularization. 

The study was designed to address an ongoing question that has emerged following the BEST-CLI trial. While that study demonstrated that patients with adequate single-segment GSV achieved better outcomes with bypass surgery than endovascular intervention, some clinicians have questioned how often suitable vein is still available in contemporary practice. 

“One of the criticisms of the BEST-CLI trial was that a lot of patients nowadays don’t have good vein,” said Jeffrey Siracuse, MD, senior author on the study. “A lot of people who are endovascular-first for everybody just say the vein isn’t good, so they don’t even check as much anymore before they do an intervention.” 

To better understand current vein availability, investigators conducted a single-center review of 223 patients with CLTI who underwent vein mapping before either open or endovascular intervention. The team evaluated GSV diameter using thresholds of at least 2.5 mm and 3 mm throughout the thigh and the entire leg, assessing both ipsilateral and contralateral veins. 

The study found that adequate vein remained available in a substantial proportion of patients, particularly when evaluating the thigh alone. Siracuse noted that while a full-length vein is ideal, many bypass procedures do not require the entire GSV because surgeons can use more distal inflow vessels, including the popliteal artery. “Even looking at the thigh alone, you can usually conserve a usable vein,” he said. “The vein quality was better than what a lot of people thought was out there.” 

Siracuse, professor of surgery and radiology at Boston University’s Chobanian and Avedisian School of Medicine, said the findings should encourage surgeons to perform vein mapping routinely before deciding on a revascularization strategy instead of assuming bypass is not an option. 

“I think surgeons shouldn't preemptively assume that a patient lacks adequate GSV,” he said. “Patients should have widespread vein mapping.” He added that vein mapping ideally should be performed before diagnostic angiography. Knowing whether suitable conduit is available beforehand allows surgeons to tailor treatment plans based on both anatomy and conduit availability. In some cases, he said an angiogram may remain purely diagnostic while plans are made for bypass surgery rather than proceeding directly with an endovascular intervention. 

“If you know whether they have a vein ahead of time, you can determine whether you're going to stop with a diagnostic angiogram and proceed with a bypass or do an endovascular intervention at that time,” said Siracuse. 

Although the study focused on conduit availability, Siracuse said it also raises important questions for future research. One area is understanding how preoperative ultrasound findings correlate with what surgeons ultimately encounter in the operating room, as vein quality can occasionally differ from preoperative imaging. 

Siracuse also said the long-term implications of the growing use of GSV ablation needs to be better understood. As more patients undergo procedures that eliminate or damage the vein earlier in life, he said surgeons may have fewer autogenous conduit options later. 

“With widespread vein ablations and destruction of great saphenous veins, we need to understand the long-term impact on patients who may later need that vein in the future for peripheral arterial interventions or coronary bypass grafts,” said Siracuse.