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Recognition and management of impending vein-graft failure. Importance for long-term patency
Insights
Early Doppler ankle/brachial index (ABI) monitoring can detect stenosis in femoro-distal vein grafts. Patch angioplasty for stenosis offers better long-term patency than percutaneous transluminal angioplasty or thrombectomy.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Radiology
Background:
- Femoro-distal vein grafts have shown poor long-term patency, especially after thrombectomy for stenosis.
- Early detection of graft failure is crucial to improve outcomes.
Purpose of the Study:
- To evaluate the effectiveness of Doppler ankle/brachial index (ABI) monitoring for early detection of femoro-distal vein graft stenosis.
- To compare the long-term patency rates of different treatment modalities for stenotic vein grafts.
Main Methods:
- Prospective follow-up of 322 femoro-distal vein grafts using serial Doppler ABI measurements.
- Arteriography to confirm stenosis in grafts with diminished ABI.
- Comparison of five-year patency rates for patch angioplasty (n=22), percutaneous transluminal angioplasty (n=7), and thrombectomy followed by patch angioplasty (n=25).
Main Results:
- Twenty-nine grafts (9%) developed stenosis identified by Doppler ABI.
- Patch angioplasty for stenosis yielded an 82% five-year patency rate.
- Percutaneous transluminal angioplasty resulted in a 43% five-year patency rate, while thrombectomy followed by patch angioplasty had a 28% patency rate.
Conclusions:
- Frequent Doppler ABI monitoring in the early postoperative period is essential for identifying femoro-distal vein graft stenosis.
- Aggressive evaluation and treatment with patch angioplasty for identified stenosis can significantly improve long-term graft patency.
- Patch angioplasty is superior to percutaneous transluminal angioplasty or thrombectomy for managing stenotic femoro-distal vein grafts.
Abstract:
A previous report from this group indicated a very poor long-term patency rate (19%) for occluded femoro-distal vein grafts that require initial thrombectomy prior to patch angioplasty for documented stenosis. Patients with vein grafts were therefore followed up by Doppler pressure determinations of the ankle/brachial index (ABI) postoperatively at three weeks, six weeks, and every four months thereafter for two years in an effort to identify vein-graft failure prior to actual thrombosis. During the past six years we performed 322 vein grafts of which 29 grafts were identified by diminished Doppler ABI and were found to have stenotic segments on subsequent arteriography. Twenty-two of these patients (group 1) underwent reconstruction with patch angioplasty resulting in a five-year cumulative patency rate of 82%. The remaining seven patients (group 2) underwent percutaneous transluminal angioplasty of their stenotic segments yielding a significantly lower five-year patency rate of 43%. These two groups were compared with a third group fo 25 patients with thrombosed grafts mandating initial thrombectomy prior to patch angioplasty. The thrombectomized group 3 patients demonstrated a significantly lower five-year cumulative patency rate of 28%. These data suggest that patients with femoro-distal bypass vein grafts be followed up at frequent intervals early in their postoperative course with determinations of Doppler ABI measurements. Any significant reduction in Doppler ABI compared with the highest postoperative Doppler determination should be aggressively evaluated with digital-subtraction or routine angiography in an effort to locate a stenotic lesion prior to graft thrombosis. Patients found to have such a graft stenosis are then ultimately treated with patch angioplasty in anticipation of satisfactory long-term patency rates.