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Synergizing Antegrade Endoscopic with Bridging Vein Harvesting for Improvement of Great Saphenous Vein Graft Quality from the Lower Leg
Published on: November 19, 2019
Revision of vein bypass grafts: factors affecting durability of interventions
1Department of Surgery, University of Florida and the Malcom Randall VA Medical Center, Gainesville, FL 32610-0286, USA.
Insights
Choosing the best intervention for failing vein grafts is challenging due to limited data. Endovascular revision is reasonable for favorable lesions, while open surgery is better for complex cases like thrombosis.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Graft Patency Maintenance
Background:
- Clinical decisions for failing vein grafts are hindered by limited data from retrospective studies.
- Graft patency is crucial, necessitating appropriate interventions to prevent failure.
Purpose of the Study:
- To review and compare the effectiveness of open surgical versus endovascular revisions for failing vein grafts.
- To identify factors influencing the success of different intervention strategies.
Main Methods:
- Retrospective analysis of clinical data on vein graft interventions.
- Comparison of primary and secondary patency rates between open and endovascular approaches.
- Evaluation of periprocedural morbidity associated with each intervention type.
Main Results:
- Open surgical revisions may offer better primary patency but with higher morbidity.
- Endovascular revisions have higher initial failure rates but lesions are often amenable to reintervention.
- Secondary patency rates for both methods may be comparable.
- Longer lesions, multiple stenoses, early graft failure, or thrombosis are associated with poorer endovascular outcomes.
Conclusions:
- Endovascular intervention is a reasonable initial choice for favorable vein graft lesions.
- Open surgery is warranted for complex cases, including graft thrombosis or extensive lesions.
- Cutting balloons may offer a modest improvement over standard balloon angioplasty for percutaneous interventions.
Abstract:
Once the failing vein graft is identified and characterized, the clinician must choose the appropriate intervention to maintain graft patency. Limited by the single-institution, retrospective studies that are pervasive in this area, definitive data to guide these decisions are limited. In general, open surgical revisions appear to offer a modest benefit in primary patency, but likely at the cost of increased periprocedural morbidity. Although endovascular revisions are more prone to failure, these recurrent lesions are often amenable to reintervention so that the secondary patency rates for both endovascular and open interventions may be similar. Given this, endovascular intervention as an initial treatment modality seems a reasonable approach for favorable lesions. Factors associated with poor outcome for endovascular revision include longer lesions (stenosis >2 cm in length), multiple stenoses, lesions occurring within 3 months of graft placement, or interventions for graft thrombosis, where endovascular failures are high and open surgery as an initial approach is warranted. The optimum method for percutaneous intervention remains a shifting landscape. No techniques as of yet appear clearly superior to standard balloon angioplasty, but initial investigations would suggest that cutting balloons offer a modest improvement and are worthy of consideration.
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