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Revision of failed infrainguinal bypass graft: principles of management
Insights
Graft revision (GR) for infrainguinal bypass grafts (IIBPGs) offers improved patency, especially when performed before thrombosis. Secondary revisions and new bypass grafts show better outcomes than thrombectomy for failed IIBPGs.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Regenerative Medicine
Background:
- Infrainguinal bypass grafts (IIBPGs) are crucial for limb salvage but are prone to failure.
- Graft revision (GR) is an option for failed IIBPGs, but outcomes vary.
- Understanding factors influencing GR success is vital for optimizing patient care.
Purpose of the Study:
- To evaluate the cumulative patency rates (CPRs) after graft revision (GR) for failed infrainguinal bypass grafts (IIBPGs).
- To compare outcomes of early vs. late graft failure, primary vs. secondary revisions, and patent vs. thrombosed grafts.
- To assess the impact of distal arterial thrombus and surgical approach (revision vs. new bypass vs. thrombectomy) on graft patency.
Main Methods:
- Retrospective review of 112 patients with failed IIBPGs (>30 days post-insertion).
- Analysis of cumulative patency rates (CPRs) after graft revision (GR).
- Comparison of outcomes based on timing of failure, revision type, graft status (patent vs. thrombosed), and surgical intervention.
Main Results:
- Cumulative patency rates (CPRs) after graft revision (GR) were 71% at 6 months, decreasing to 46% at 48 months.
- Grafts failing >12 months post-insertion had better CPRs (60% at 36 months) than those failing earlier (36% at 36 months).
- Revision of patent grafts yielded significantly higher CPRs (89% at 12 months) than revision of thrombosed grafts (33% at 12 months).
- New bypass grafts showed superior CPRs (61% at 6 months) compared to thrombectomy/angioplasty (26% at 6 months).
- Presence of distal thrombus significantly worsened CPRs after GR.
Conclusions:
- Graft revision (GR) is a viable option for failed infrainguinal bypass grafts (IIBPGs), with better outcomes when performed before thrombosis.
- Early diagnosis and intervention for graft failure, particularly in patent grafts, significantly improve success rates.
- New bypass grafting offers superior patency compared to thrombectomy and angioplasty for failing IIBPGs.
Abstract:
Our experience with 112 patients whose infrainguinal bypass grafts (IIBPGs) failed more than 30 days after insertion was reviewed. Cumulative patency rates (CPRs) after graft revision (GR) were 71% at 6 months, 62% at 12 months, 57% at 24 months, 54% at 36 months, and 46% at 48 months. CPRs of IIBPGs that failed more than 12 months after insertion were higher than those of grafts that failed earlier (60% vs. 36% at 36 months (p less than 0.05). Failure of the initial GR did not preclude a successful secondary revision. The 3-year CPR of the initial GR was 31% compared with 49% for secondary GR (p = no significance). The results of GR are significantly better when graft failure is diagnosed before graft thrombosis. Revision of the 37 hemodynamically failed but patent grafts resulted in a CPR of 89% at 12 months and 77% at 36 months compared with a CPR of 33% at 12 months and 26% at 36 months after revision of the 75 thrombosed grafts (p less than 0.01). Hemodynamically failed but patent grafts occurred in 36 of 68 patients (53%) with failed autogenous veins but only 1 of 44 patients (2%) with a failed prosthetic graft had GR before thrombosis of the graft. There is a significant improvement in early CPR when a new bypass graft is inserted as compared with original graft thrombectomy and angioplasty. The CPR for new bypass grafts at 6 and 12 months was 61% and 41%, respectively, compared with a CPR of 26% and 20% for the same time intervals with graft thrombectomy and angioplasty (p less than 0.05). The presence of thrombus in the outflow artery at the site of GR is a contraindication to anastomosis at that site even if arterial thrombectomy reestablishes backflow. When distal arterial thrombus was not present, the CPR after GR was 62% at 6 months, 42% at 12 months, and 33% at 36 months. When distal arterial thrombectomy was necessary, the CPR after GR was only 14% at 6 months and zero at 12 months (p less than 0.05).