Primary revision of mid-vein stenoses in venous bypass conduits: venous patch versus interposition vein

Patients after infrainguinal vein bypasses are a group at risk of graft stenosis and occlusion. Revision of failing grafts has been shown to significantly improve bypass patency and limb salvage. Options for surgical revision of mid bypass stenosis includes either patch angioplasty (PA) or interposition grafting (IG). We reviewed our experience with surgical revision of vein bypass stenosis.

From April 1968 to March 2006, 7557 autogenous vein bypasses were performed at Albany Medical Center and its affiliated institutions, of these 316 required single or multiple revision of vein grafts with patch angioplasty or interposition vein grafting. Excluded were proximal and distal anastomotic revisions. Only 235 bypasses had single revisions as either patch angioplasty (n = 108) or interposition grafting (n = 127) and are the focus of this review. The initial bypass revisions in these two groups are analyzed for indications, clinical parameters, operative strategies, and long-term patencies and clinical outcomes.

There were no significant differences in mean age, gender, or frequency of comorbid conditions (coronary artery disease, pulmonary disease, hypertension, and diabetes) between the two patient groups. Secondary patency of patch angioplasty revision at 5 years was 79%. Patencies for interposition grafting revision at 5 years were equivalent to patch angioplasty group at 75%. When bypasses were evaluated on the basis of initial reconstructions (ie, in situ vs excised vein bypass), the results showed that in situ bypasses that required initial revision had similar 5-year patencies when interposition grafting was used as the first revision strategy vs patch angioplasty (80% vs 73%). Excised vein bypasses had similar patency when patch was their first revision strategy vs interposition grafting (4 year secondary patency 92% vs 75% respectively).

Autogenous vein bypasses are at risk for developing significant stenosis and occlusion with time. Bypass stenosis that develops in the main body of the graft can be effectively repaired using either patch angioplasty or interposition grafting. Depending on the host of other factors, such as availability of autogenous venous conduit, location of stenosis, accessibility for operative repair, and the patient's anatomic characteristics, either operative strategy is effective in prolonging the patency of the bypass.