Intensive Surveillance of Femoropopliteal-Tibial Autogenous Vein Bypasses Improves Long-Term Graft Patency and Limb Salvage

Abstract

ObjectiveThe authors determined the impact of an intensive surveillance program of autogenous vein bypasses on patency and limb salvage. Summary Background DataSurveillance protocols of vein bypasses can identify graft-threatening lesions to permit elective revisions before thrombosis. The authors compared follow-up based on clinically indicated procedures with intensive surveillance. MethodsFrom 1985 to 1994, 615 autogenous vein bypasses (454 in situ, 161 reversed/composite) to popliteal (n = 169) and tibial (n = 446) arteries were performed for critical limb ischemia (n = 507), claudication (n = 88), and popliteal aneurysm (n = 20). Intensive surveillance of autogenous vein bypasses consisted of ankle brachial index and duplex scan with graft velocities measured at 1 month, 3 months, 6 months, and every 6 months subsequently. After surgery 317 bypasses had intensive surveillance, 222 bypasses were clinically indicated for follow-up, and 76 bypasses were excluded because follow-up or patency was less than 31 days. ResultsPrimary patency at 5 years was similar for bypasses treated by intensive surveillance (56%) and those treated with clinically indicated procedures (67%). Secondary patency and limb salvage at 5 years was significantly improved (p < 0.02) for bypasses followed by intensive surveillance (80% and 94%) compared with clinically indicated procedures (67% and 73%). Revision of patent bypasses was higher (p < 0.000001) for bypasses treated by intensive surveillance (61 of 70, 87%) compared with those treated with clinically indicated procedures (9 of 34, 26%). Secondary patency at 2 years was significantly higher (p < 0.02) for revision of patent bypasses (79%) compared with thrombosed bypasses (55%). ConclusionsLong-term autogenous vein bypass patency and limb salvage is significantly improved by intensive surveillance, permifting identification and correction of graft threatening lesions before thrombosis. 507

Critical Assessment of the Outcome of Infrainguinal Vein Bypass

“…2 For example, the acceptance by many of the value of identifying graft stenosis and carrying out prompt corrective surgery leads to many patients undergoing further surgery. 2,3 The outcome of bypass surgery is traditionally reported in terms of patency (i.e., the percentage of grafts free from occlusion), 4 but this may give little information regarding the patient's quality of life after surgery. 5 Perioperative complications, repeated admissions to the hospital, and particularly further surgery all interfere with recovery from bypass surgery.…”

Outcomes of reinterventions after subintimal angioplasty

“…After confirmation of traversing the lesion with a catheter into the true lumen, balloon angioplasty was used to dilate the area of stenosis or the new subintimal channel. Other adjunctive devices utilized during reinterventions included mechanical atherectomy (3), mechanical thrombolysis (2), thrombolytic infusion (5), cryoplasty (3), cutting balloon (2), and laser atherectomy (7). Only one patient underwent a combination procedure of cuttingballoon, angiojet, and tPA infusion.…”

“…1 Surveillance with duplex ultrasound has been used to maintain patency and improve outcomes for lower extremity vein bypasses. 2,3 Reinterventions to preserve open autologous surgical bypass grafts have been shown to improve overall outcomes. 1,4 One of the limitations of endovascular interventions is its long-term durability, in which endoluminal restenosis or occlusions occur.…”

Management of Patients After Endovascular Interventions for Peripheral Artery Disease

“…Close clinical surveillance of surgical conduits can identify threatened grafts, allow revision before graft failure, and improve longterm graft patency. 34 However, the incremental benefit of ultrasonographic surveillance on short-term graft patency and clinical outcomes has been challenged in more recent randomized trials. 35 No randomized trials have assessed the clinical benefit and cost-effectiveness of various surveillance methods after endovascular interventions.…”