Endovascular Therapy is Effective Treatment for Focal Stenoses in Failing Infrapopliteal Vein Grafts

Abstract

Objective To evaluate the efficacy of endovascular therapy for maintaining patency and preserving limbs among patients with failing infrapopliteal bypass grafts. Methods We gathered data from a registry of catheter-based procedures for peripheral artery disease. Of 1554 arteriograms performed from 2006 to 2012, 30 patients had interventions for failing bypass vein grafts to infrapopliteal target vessels. The first intervention for each patient was used in this analysis. Duplex ultrasonography was used within 30 days after intervention and subsequently at 3-6 month intervals for graft surveillance. Results Interventions were performed for duplex ultrasonography surveillance findings in 21 patients and for symptoms of persistent or recurrent critical limb ischemia in 9 patients. Procedural techniques included cutting balloon angioplasty (83%), conventional balloon angioplasty (7%), and stent placement (10%). Procedural success was achieved in all cases. There were no procedure-related complications, amputations, or deaths within 30 days. By Kaplan-Meier analysis, 37% were free from graft restenosis at 12 months and 31% were at 24 months. Receiver operating characteristic analysis indicated that a lesion length of 1.75 cm best predicted freedom from restenosis (C statistic: 0.74). Residual stenosis (P=0.03), patency without reintervention (P=0.01), and assisted patency with secondary intervention (P=0.02) rates were superior for short lesions compared to long lesions. The cohort had acceptable rates of adverse clinical outcomes, with 96% of patients free from amputation at both 12 and 24 months; clinical outcomes were also better in patients with short lesions. Conclusions In this single-center experience with endovascular therapies to treat failing infrapopliteal bypass grafts, rates of limb preservation were high, but the majority of patients developed graft restenosis within 12 months. Grafts with longer stenoses fared poorly by comparison. These data suggest that endovascular interventions to restore or prolong graft patency may be associated with maintained graft patency and that close follow up with vascular laboratory surveillance is essential.

The efficacy of salvage interventions on threatened distal bypass grafts

“…The median interval from bypass to first endovascular intervention was 5 months (range, 1-46 months) and did not vary significantly when stratified by site of lesion (inflow lesions, 7 [range, [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]; proximal anastomosis lesions, 9 [range, 2-24]; vein graft lesions, 8.5 [range, 2-37]; distal anastomosis lesions, 6 [range, 1-47]; outflow lesions, 4 [range, 1-36]; P ¼ .37). Operative interventions occurred significantly earlier at a median of 1 months (range, 1-14 months) after bypass when compared with endovascular interventions (P ¼ .007).…”

“…Similarly, another study found that only 37% of the patients were free from graft restenosis at 12 months and 31% at 24 months after the first intervention, although again with good technical success and low overall morbidity. 16 As such, we feel that endovascular therapy should be considered the first-line treatment of threatened grafts if suitable. Surgical graft salvage remains an option in selected patients after failed endovascular interventions, although in our series this was necessary in only 11% of grafts.…”

Long Term Outcomes of Endovascular Therapy for Failing Distal Bypass Vein Grafts

“…Similar results have been reported by others. 7,9 To maintain patency of the failing grafts, multiple EVTs are required frequently. In this study, EVT was performed a median of two times and maximum of 11 times.…”

“…9 Westin et al reported that their first EVT was performed a median of 12 months after infrapopliteal bypass (range 4e45 months). 7 Such an early intervention indicates that some vein grafts fail early after distal bypass, and that early detection of the failing grafts leads to early EVT.…”

ESVM Guideline on peripheral arterial disease

“…There are now many new devices for the interventional therapy of vascular lesions causing CLI. The evidence is still not robust but in specialized institutions some of the devices are already an indispensable part of the interventional armamentarium, making therapies faster and safer than before [290,[358][359][360][361].…”