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Thrombolysis of occluded infrainguinal vein grafts: predictors of outcome
G B Nackman1, D B Walsh, M F Fillinger
1Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH 03756, USA.
Insights
Thrombolysis of occluded infrainguinal vein grafts offers improved limb salvage but limited long-term patency. Successful lysis benefits patients without diabetes and with mature grafts, enhancing limb salvage rates.
Area of Science:
- Vascular Surgery
- Interventional Radiology
- Graft Patency Research
Background:
- Occluded infrainguinal vein grafts pose challenges for limb salvage.
- Thrombolysis is a potential treatment for graft occlusion.
Purpose of the Study:
- Identify factors influencing graft patency after thrombolysis.
- Determine factors affecting limb salvage rates post-thrombolysis.
Main Methods:
- Retrospective review of 44 patients undergoing thrombolysis for occluded infrainguinal vein grafts (1985-1995).
- Life table analysis for survival and patency.
- Univariate and multivariate analyses for outcome predictors.
Main Results:
- Thrombolysis achieved 75% initial success but required adjunctive procedures in 88% of cases.
- Overall 1-year primary patency was 25%, improving to 34% in successfully lysed grafts.
- Graft patency was better in non-diabetic patients and grafts >12 months old.
- Successful thrombolysis significantly improved limb salvage (63% at 2 years vs. 31%).
Conclusions:
- Vein graft thrombolysis yields suboptimal durable patency, even with adjunctive therapies.
- Successful thrombolysis significantly enhances limb salvage.
- Consider thrombolysis for non-diabetic patients with mature grafts lacking other revascularization options.
Purpose:
The purpose of this study was to identify factors that influence graft patency and limb salvage rates after thrombolysis of occluded infrainguinal vein grafts.
Methods:
The records of patients who underwent percutaneous catheter-directed thrombolysis of occluded infrainguinal vein bypass grafts at our institution between 1985 and 1995 were reviewed. Life table analysis was used to determine survival and patency differences. Univariate and multivariate analyses were used to identify the patient-specific factors that affected outcomes.
Results:
Forty-four patients with 44 thrombosed infrainguinal vein grafts underwent thrombolysis with urokinase. The thrombolysis-related mortality rate was 2%, and nonfatal complications occurred in 16%. Thrombolysis was unable to restore graft patency in 25% of grafts (11 of 44). Of the remaining 33 successfully lysed grafts, 88% required adjunctive surgery or percutaneous transluminal angioplasty after thrombolysis. Overall, the primary graft patency rate was 25% at 1 year and 19% at 2 years after thrombolysis. Considering only successfully lysed grafts, the primary patency rate improved to 34% at 1 year and 25% at 2 years. Multivariate analysis revealed that the graft patency rate was substantially better in patients without diabetes and in vein grafts that had been in place for longer than 12 months (p < 0.01). The limb salvage rate was significantly improved by successful thrombolysis (63% at 2 years vs 31% if lysis failed; p < 0.01). The patient survival rate was high-89% 2 years after thrombolysis.
Conclusions:
Even with adjunctive therapy, vein graft thrombolysis is unlikely to yield durable patency overall. However, successful thrombolysis improves limb salvage rates and may be beneficial in patients without diabetes who have mature vein grafts but who do not have options for other autogenous revascularization procedures.