Late occlusion of aorto-bifemoral grafts. Causes and management

Late occlusion occurred in 52 limbs of 37 bifurcated aorto-femoral grafts (37 patients). These were analysed to determine causal factors and the efficacy of various surgical techniques of repair. There were two principle causes: intimal hyperplasia (n = 19) and progressive atherosclerosis (n = 18), and then miscellaneous causes (n = 15). Surgical techniques included: repair of inflow by thrombectomy (n = 30), new aorto-femoral graft (n = 6), cross-over femoro-femoral (n = 3), and axillo-bifemoral graft (n = 2); repair of out-flow by profundoplasty (n = 18), addition of a new length of graft (n = 10), and femoro-popliteal bypass (n = 13). There were no immediate post-operative deaths but four rethromboses (7.6%) occurred and there were five amputations (9.6%). During the follow-up period (mean 19 months), four patients died (11%), 5 limbs reoccluded (9.4%), and two were amputated (4.2%). Patency rate was 90% for thrombectomy and 83% for new aorto-bifemoral graft. It was 86% for repair of the profunda femoris artery and 77% for femoro-popliteal bypass. Although no statistical analysis can be applied on this small number of patients, the present study suggests that: intimal hyperplasia is a frequent and probably under-estimated cause of late thrombosis; whenever feasible thrombectomy and profundoplasty are the most simple and effective procedure of repair.