Do Arterial Allografts Outperform Venous in Cryopreserved Bypass for Limb Salvage?: A Systematic Review and Meta-Analysis of Infrainguinal Revascularization Outcomes

Gianluca Buongiovanni; Alex K Murigu; Kitty H.F. Wong; Alberto Settembrini; Giovanni Nava; Luca Dainese; Piero Trabattoni; Robert J. Hinchliffe

doi:10.1016/j.avsg.2026.03.030

Do Arterial Allografts Outperform Venous in Cryopreserved Bypass for Limb Salvage? A Systematic Review and Meta-Analysis of Infrainguinal Revascularization Outcomes

Gianluca Buongiovanni, Alex K Murigu, Kitty H.F. Wong, Alberto Settembrini, Giovanni Nava, Luca Dainese, Piero Trabattoni, Robert J. Hinchliffe

Research output: Contribution to journal › Article (Academic Journal) › peer-review

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Abstract

Background

Cryopreserved allografts remain a viable option for infrainguinal revascularization in limb salvage when autologous veins are unavailable or prosthetic material is undesirable. Uncertainty persists regarding comparative outcomes by allograft type (arterial vs venous) and clinical indication (infectious vs non-infectious settings). This systematic review and meta-analysis summarizes outcomes and key evidence gaps.

Methods

A systematic search of studies reporting infrainguinal reconstructions with cryopreserved arterial or venous allografts was conducted according to PRISMA (PROSPERO: CRD42024579097). Primary outcomes were 1-year primary patency, overall survival, and cumulative major amputation. Random-effects single-arm meta-analyses were performed with subgroup analyses by graft type and infection status. Risk of bias was assessed using ROBINS-I and certainty of evidence using GRADE. Secondary outcomes, including reintervention and graft-related complications, were narratively summarized.

Results

Forty-two studies (2,237 patients; 2,170 limbs) were included: 25 were at serious risk of bias and 17 at moderate. Pooled 1-year primary patency was 51.1% (95% CI 40.9–61.4%), overall survival 85.0% (95% CI 81.1–88.9%), and cumulative major amputation 20.2% (95% CI 15.7–24.7%). Arterial grafts had higher patency (67.6%; 95% CI 54.3–80.9%) than venous (39.6%; 95% CI 30.2–49.0%). Reconstructions for infection had superior patency (70.4%; 95% CI 55.2–85.6%) compared with non-infectious indications (44.2%; 95% CI 32.8–55.5%). GRADE certainty was very low.

Conclusions

Cryopreserved allografts enable limb salvage in complex CLTI but show modest 1-year patency and substantial heterogeneity. Arterial conduit and use in infection were associated with superior early patency; robust comparative studies are required to optimize graft selection.

Original language	English
Pages (from-to)	129-146
Number of pages	18
Journal	Annals of Vascular Surgery
Volume	129
Early online date	26 Mar 2026
DOIs	https://doi.org/10.1016/j.avsg.2026.03.030
Publication status	E-pub ahead of print - 26 Mar 2026

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Publisher Copyright:
© 2026 Published by Elsevier Inc.

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Buongiovanni, G., Murigu, A. K., Wong, K. H. F., Settembrini, A., Nava, G., Dainese, L., Trabattoni, P., & Hinchliffe, R. J. (2026). Do Arterial Allografts Outperform Venous in Cryopreserved Bypass for Limb Salvage? A Systematic Review and Meta-Analysis of Infrainguinal Revascularization Outcomes. Annals of Vascular Surgery, 129, 129-146. Advance online publication. https://doi.org/10.1016/j.avsg.2026.03.030

@article{3fd214decc114ead8f236cef4194e976,

title = "Do Arterial Allografts Outperform Venous in Cryopreserved Bypass for Limb Salvage?: A Systematic Review and Meta-Analysis of Infrainguinal Revascularization Outcomes",

abstract = "BackgroundCryopreserved allografts remain a viable option for infrainguinal revascularization in limb salvage when autologous veins are unavailable or prosthetic material is undesirable. Uncertainty persists regarding comparative outcomes by allograft type (arterial vs venous) and clinical indication (infectious vs non-infectious settings). This systematic review and meta-analysis summarizes outcomes and key evidence gaps. MethodsA systematic search of studies reporting infrainguinal reconstructions with cryopreserved arterial or venous allografts was conducted according to PRISMA (PROSPERO: CRD42024579097). Primary outcomes were 1-year primary patency, overall survival, and cumulative major amputation. Random-effects single-arm meta-analyses were performed with subgroup analyses by graft type and infection status. Risk of bias was assessed using ROBINS-I and certainty of evidence using GRADE. Secondary outcomes, including reintervention and graft-related complications, were narratively summarized. ResultsForty-two studies (2,237 patients; 2,170 limbs) were included: 25 were at serious risk of bias and 17 at moderate. Pooled 1-year primary patency was 51.1\% (95\% CI 40.9–61.4\%), overall survival 85.0\% (95\% CI 81.1–88.9\%), and cumulative major amputation 20.2\% (95\% CI 15.7–24.7\%). Arterial grafts had higher patency (67.6\%; 95\% CI 54.3–80.9\%) than venous (39.6\%; 95\% CI 30.2–49.0\%). Reconstructions for infection had superior patency (70.4\%; 95\% CI 55.2–85.6\%) compared with non-infectious indications (44.2\%; 95\% CI 32.8–55.5\%). GRADE certainty was very low. ConclusionsCryopreserved allografts enable limb salvage in complex CLTI but show modest 1-year patency and substantial heterogeneity. Arterial conduit and use in infection were associated with superior early patency; robust comparative studies are required to optimize graft selection.",

author = "Gianluca Buongiovanni and Murigu, \{Alex K\} and Wong, \{Kitty H.F.\} and Alberto Settembrini and Giovanni Nava and Luca Dainese and Piero Trabattoni and Hinchliffe, \{Robert J.\}",

note = "Publisher Copyright: {\textcopyright} 2026 Published by Elsevier Inc.",

year = "2026",

month = mar,

day = "26",

doi = "10.1016/j.avsg.2026.03.030",

language = "English",

volume = "129",

pages = "129--146",

journal = "Annals of Vascular Surgery",

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Buongiovanni, G, Murigu, AK, Wong, KHF, Settembrini, A, Nava, G, Dainese, L, Trabattoni, P & Hinchliffe, RJ 2026, 'Do Arterial Allografts Outperform Venous in Cryopreserved Bypass for Limb Salvage? A Systematic Review and Meta-Analysis of Infrainguinal Revascularization Outcomes', Annals of Vascular Surgery, vol. 129, pp. 129-146. https://doi.org/10.1016/j.avsg.2026.03.030

Do Arterial Allografts Outperform Venous in Cryopreserved Bypass for Limb Salvage? A Systematic Review and Meta-Analysis of Infrainguinal Revascularization Outcomes. / Buongiovanni, Gianluca; Murigu, Alex K; Wong, Kitty H.F. et al.
In: Annals of Vascular Surgery, Vol. 129, 01.08.2026, p. 129-146.

Research output: Contribution to journal › Article (Academic Journal) › peer-review

TY - JOUR

T1 - Do Arterial Allografts Outperform Venous in Cryopreserved Bypass for Limb Salvage?

T2 - A Systematic Review and Meta-Analysis of Infrainguinal Revascularization Outcomes

AU - Buongiovanni, Gianluca

AU - Murigu, Alex K

AU - Wong, Kitty H.F.

AU - Settembrini, Alberto

AU - Nava, Giovanni

AU - Dainese, Luca

AU - Trabattoni, Piero

AU - Hinchliffe, Robert J.

PY - 2026/3/26

Y1 - 2026/3/26

N2 - BackgroundCryopreserved allografts remain a viable option for infrainguinal revascularization in limb salvage when autologous veins are unavailable or prosthetic material is undesirable. Uncertainty persists regarding comparative outcomes by allograft type (arterial vs venous) and clinical indication (infectious vs non-infectious settings). This systematic review and meta-analysis summarizes outcomes and key evidence gaps. MethodsA systematic search of studies reporting infrainguinal reconstructions with cryopreserved arterial or venous allografts was conducted according to PRISMA (PROSPERO: CRD42024579097). Primary outcomes were 1-year primary patency, overall survival, and cumulative major amputation. Random-effects single-arm meta-analyses were performed with subgroup analyses by graft type and infection status. Risk of bias was assessed using ROBINS-I and certainty of evidence using GRADE. Secondary outcomes, including reintervention and graft-related complications, were narratively summarized. ResultsForty-two studies (2,237 patients; 2,170 limbs) were included: 25 were at serious risk of bias and 17 at moderate. Pooled 1-year primary patency was 51.1% (95% CI 40.9–61.4%), overall survival 85.0% (95% CI 81.1–88.9%), and cumulative major amputation 20.2% (95% CI 15.7–24.7%). Arterial grafts had higher patency (67.6%; 95% CI 54.3–80.9%) than venous (39.6%; 95% CI 30.2–49.0%). Reconstructions for infection had superior patency (70.4%; 95% CI 55.2–85.6%) compared with non-infectious indications (44.2%; 95% CI 32.8–55.5%). GRADE certainty was very low. ConclusionsCryopreserved allografts enable limb salvage in complex CLTI but show modest 1-year patency and substantial heterogeneity. Arterial conduit and use in infection were associated with superior early patency; robust comparative studies are required to optimize graft selection.

AB - BackgroundCryopreserved allografts remain a viable option for infrainguinal revascularization in limb salvage when autologous veins are unavailable or prosthetic material is undesirable. Uncertainty persists regarding comparative outcomes by allograft type (arterial vs venous) and clinical indication (infectious vs non-infectious settings). This systematic review and meta-analysis summarizes outcomes and key evidence gaps. MethodsA systematic search of studies reporting infrainguinal reconstructions with cryopreserved arterial or venous allografts was conducted according to PRISMA (PROSPERO: CRD42024579097). Primary outcomes were 1-year primary patency, overall survival, and cumulative major amputation. Random-effects single-arm meta-analyses were performed with subgroup analyses by graft type and infection status. Risk of bias was assessed using ROBINS-I and certainty of evidence using GRADE. Secondary outcomes, including reintervention and graft-related complications, were narratively summarized. ResultsForty-two studies (2,237 patients; 2,170 limbs) were included: 25 were at serious risk of bias and 17 at moderate. Pooled 1-year primary patency was 51.1% (95% CI 40.9–61.4%), overall survival 85.0% (95% CI 81.1–88.9%), and cumulative major amputation 20.2% (95% CI 15.7–24.7%). Arterial grafts had higher patency (67.6%; 95% CI 54.3–80.9%) than venous (39.6%; 95% CI 30.2–49.0%). Reconstructions for infection had superior patency (70.4%; 95% CI 55.2–85.6%) compared with non-infectious indications (44.2%; 95% CI 32.8–55.5%). GRADE certainty was very low. ConclusionsCryopreserved allografts enable limb salvage in complex CLTI but show modest 1-year patency and substantial heterogeneity. Arterial conduit and use in infection were associated with superior early patency; robust comparative studies are required to optimize graft selection.

U2 - 10.1016/j.avsg.2026.03.030

DO - 10.1016/j.avsg.2026.03.030

M3 - Article (Academic Journal)

C2 - 41903844

SN - 0890-5096

VL - 129

SP - 129

EP - 146

JO - Annals of Vascular Surgery

JF - Annals of Vascular Surgery

ER -