1
|
Mohapatra A, Lowenkamp MN, Avgerinos ED, Hager ES, Madigan MC. Open Surgical Secondary Interventions are More Durable than Endovascular Interventions for Lower Extremity Bypass Stenosis or Occlusion. Vasc Endovascular Surg 2021; 55:843-850. [PMID: 34261375 DOI: 10.1177/15385744211028749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: Lower extremity bypasses often require secondary interventions to maintain patency. Our objectives were to characterize effectiveness of secondary interventions to maintain or restore bypass graft patency, and to compare outcomes of open and endovascular interventions. Methods: We reviewed patients who underwent lower extremity bypass at our institution from 2007 to 2010. We recorded the index bypass and subsequent ipsilateral interventions performed through 2018 or until loss of secondary patency. Patient, procedure, and anatomic data were collected. Endovascular intervention was compared with open/hybrid intervention. For outcome analysis, patency measures were defined relative to the time of the secondary intervention rather than the time of the index bypass. Results: 174 secondary interventions (56 open/hybrid, 118 endovascular; 42 for graft occlusion, and 132 for stenosis) treating 228 lesions in 97 bypasses were available for study. The index bypass was most commonly performed for tissue loss (71.1%), utilized a tibial artery target (57.7%), and used single-segment great saphenous vein (59.8%) rather than alternative vein (32.0%) or prosthetic (8.2%). A higher portion of open/hybrid interventions (51.8%) were done for graft occlusion than endovascular interventions (11.0%, P < .001). Mean follow-up for secondary interventions was 3.5 years. A multivariate Cox proportional hazards model identified female gender, prior MI, anticoagulation, occlusion, and endovascular intervention as predictors of loss of primary patency. Intervention for occlusion predicted poorer primary and secondary patency. Endovascular intervention was associated with poorer primary patency as compared to open intervention and a trend toward poorer secondary patency. Conclusions: Both open and endovascular secondary interventions on lower extremity bypasses are low-risk procedures that offer acceptable patency. Although more commonly performed in the setting of graft occlusion, open surgical interventions show improved durability compared to endovascular interventions. Some patients, including those with occluded grafts, may benefit from more liberal use of open surgical intervention to restore bypass patency.
Collapse
Affiliation(s)
- Abhisekh Mohapatra
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mikayla N Lowenkamp
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Eric S Hager
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael C Madigan
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| |
Collapse
|
2
|
Botelho FE, Cacione DG, Leite JO, Baptista-Silva JC. Endoluminal interventions versus surgical interventions for stenosis in vein grafts following infrainguinal bypass. Cochrane Database Syst Rev 2021; 4:CD013702. [PMID: 33910264 PMCID: PMC8081584 DOI: 10.1002/14651858.cd013702.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bypass surgery using a large saphenous vein graft, or another autologous venous graft, is a well-recognised treatment option for managing peripheral arterial disease of the lower limb, including chronic limb-threatening ischaemia (CLTI) and intermittent claudication, peripheral limb aneurysms, and major limb arterial trauma. Bypass surgery has good results in terms of limb preservation rates and long-term graft patency but is limited by the possibility of vein graft failure due to stenoses of the graft. Detection of stenoses through clinical and ultrasonographic surveillance, followed by treatment, is used to avoid graft occlusion. The conventional approach to treatment of patients with graft stenosis following infrainguinal bypass consists of open surgical repair, which usually is performed under general anaesthesia. Endoluminal treatment with angioplasty is less invasive and uses local anaesthesia. Both methods aim to improve blood flow to the limb. OBJECTIVES To assess the effectiveness of endoluminal interventions versus surgical intervention for people with vein graft stenosis following infrainguinal bypass. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov to 25 August 2020. SELECTION CRITERIA We aimed to include all published and unpublished randomised controlled trials (RCTs) that compared endoluminal interventions versus surgical intervention for people with vein graft stenosis following infrainguinal bypass. DATA COLLECTION AND ANALYSIS Two review authors independently assessed all identified studies for potential inclusion in the review. We aimed to use standard methodological procedures in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. The main outcomes of interest were primary patency, primary assisted patency, and all-cause mortality. MAIN RESULTS We identified no RCTs that met the inclusion criteria for this review. AUTHORS' CONCLUSIONS We found no RCTs that compared endoluminal interventions versus surgical intervention for stenosis in vein grafts following infrainguinal bypass. Currently, there is no high-certainty evidence to support the use of one type of intervention over another. High-quality studies are needed to provide evidence on managing vein graft stenosis following infrainguinal bypass.
Collapse
Affiliation(s)
- Francesco E Botelho
- Department of Surgery, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
| | - Daniel G Cacione
- Division of Vascular and Endovascular Surgery, Department of Surgery, UNIFESP - Escola Paulista de Medicina, São Paulo, Brazil
| | - Jose Oyama Leite
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jose Cc Baptista-Silva
- Evidence Based Medicine, Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
| |
Collapse
|
3
|
Patel SD, Zymvragoudakis V, Sheehan L, Lea T, Padayachee S, Donati T, Katsanos K, Zayed H. The efficacy of salvage interventions on threatened distal bypass grafts. J Vasc Surg 2016; 63:126-32. [DOI: 10.1016/j.jvs.2015.07.093] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 07/24/2015] [Indexed: 10/22/2022]
|
4
|
Linni K, Ugurluoglu A, Aspalter M, Hitzl W, Hölzenbein T. Paclitaxel-coated versus plain balloon angioplasty in the treatment of infrainguinal vein bypass stenosis. J Vasc Surg 2015; 63:391-8. [PMID: 26492997 DOI: 10.1016/j.jvs.2015.08.081] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 08/17/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to compare the clinical and hemodynamic outcomes of plain vs paclitaxel-coated percutaneous transluminal angioplasty (PTA) in patients with infrainguinal vein bypass stenosis. METHODS A single-center retrospective analysis was conducted of consecutive patients treated by infrainguinal bypass PTA. Primary study end points were primary and assisted primary patency. Secondary end points were clinical and hemodynamic improvement, limb salvage, and survival. Society for Vascular Surgery reporting standards were applied. RESULTS From April 2008 to November 2014, 83 infrainguinal vein bypasses were treated for graft stenosis by plain (group A, n = 41) or by paclitaxel-coated PTA (group B, n = 42). The groups did not differ significantly in mean age (71.9 years for both groups; P = .99), hypertension (P = 1.0), hyperlipidemia (P = .5), diabetes (P = .6), coronary artery disease (P = 1.0), smoking (P = 1.0), preoperative ankle-brachial index (P = .08), or bypass characteristics (below-knee, P = .82). Technical success rate was 100% for both groups. Mean follow-up was 2.9 years for group A patients and 2.2 years for group B patients (P = .08). No patient was lost to follow-up. Primary patency rates were 88% vs 87% and 73% vs 75% (P = .19) and assisted primary patency rates were 88% vs 90% and 77% vs 84% (P = .76) for group A and B patients at 1 and 2 years, respectively. Repeat target lesion revascularization rates were 22% vs 14% (P = .17). At the last follow-up, there were eight vs seven bypass occlusions (P = .74) for group A and B patients, respectively. In univariate analysis, proximal in-graft stenosis (Cox F, P = .041), bypass failure <6 months after bypass surgery (Cox F, P = .013), more than one bypass stenosis per graft (Cox F, P = .047), and redo bypass procedure (Cox F, P = .0001) were significantly related to assisted primary bypass patency. Immediate hemodynamic and sustained clinical improvement rates were 88% vs 86% and 70% vs 73% for group A and B patients, respectively. There were three vs one major amputations (P = .36) and eight vs seven deaths (P = .78) in group A and B patients, respectively. CONCLUSIONS Paclitaxel-coated and plain angioplasty of significant infrainguinal vein bypass stenoses performed equally well in clinical and hemodynamic improvement and in primary and assisted primary bypass patency rates.
Collapse
Affiliation(s)
- Klaus Linni
- Department of Vascular and Endovascular Surgery, Paracelus Medizinische Privatuniversität (PMU), Salzburg, Austria.
| | - Ara Ugurluoglu
- Department of Vascular and Endovascular Surgery, Paracelus Medizinische Privatuniversität (PMU), Salzburg, Austria
| | - Manuela Aspalter
- Department of Vascular and Endovascular Surgery, Paracelus Medizinische Privatuniversität (PMU), Salzburg, Austria
| | - Wolfgang Hitzl
- Department of Biostatistics, Research Office (Biostatistics), Paracelus Medizinische Privatuniversität (PMU), Salzburg, Austria
| | - Thomas Hölzenbein
- Department of Vascular and Endovascular Surgery, Paracelus Medizinische Privatuniversität (PMU), Salzburg, Austria
| |
Collapse
|
5
|
Open surgical revision provides a more durable repair than endovascular treatment for unfavorable vein graft lesions. J Vasc Surg 2015; 63:142-7. [PMID: 26483000 DOI: 10.1016/j.jvs.2015.08.065] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 08/13/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Lower extremity bypass grafts that develop stenoses are commonly treated with either open surgical or endovascular revision. Vein graft stenoses with unfavorable lesions (multiple lesions, lesions >2 cm in length, lesions in grafts <3 months old, lesions in grafts <3 mm in diameter) fare worse than those with favorable lesions when treated with endovascular therapy. However, it is not known if unfavorable lesions fare better with surgical revision than with endovascular treatment or than favorable lesions treated with surgery. METHODS We performed a retrospective review of 175 vein graft revisions performed at a single institution from 2000 to 2010. Characteristics of lesions treated with surgical and endovascular revision were identified. Cox proportional hazard models were used to identify predictors of revision failure (restenosis >75%, revision, or amputation). RESULTS Ninety-one failing vein grafts (52%) were treated with surgical revision and 84 with endovascular treatment (48%), with a median follow-up of 30 months. Favorable lesions fared better than unfavorable lesions after endovascular treatment, with 12-month freedom from failure of 59% vs 34% (P < .01), but not after surgical revision (66% vs 62%; P = .90). Unfavorable lesions had better freedom from failure after surgery than endovascular treatment (62% vs 34%; P < .01), and results in favorable lesions were similar (66% vs 59%; P = .57). CONCLUSIONS For the treatment of failing vein grafts, endovascular therapy appears adequate for favorable lesions and surgical revision is more durable for unfavorable lesions.
Collapse
|
6
|
Ali H, Elbadawy A, Saleh M, Hasaballah A. Balloon angioplasty for revision of failing lower extremity bypass grafts. J Vasc Surg 2015; 62:93-100. [PMID: 25769387 DOI: 10.1016/j.jvs.2015.01.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 01/14/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the efficacy and safety of balloon angioplasty as the primary method of intervention in patients with color duplex ultrasound documented failing bypass grafts and to determine factors that may affect the patency of lower extremity bypass grafts revised by percutaneous transluminal angioplasty (PTA). METHODS All consecutive patients who underwent lower extremity bypass grafts from January 2009 to December 2013 were enrolled in a graft surveillance program. Patients identified as having failing grafts underwent arteriography to confirm the diagnosis with a view to concomitant treatment of the lesion using balloon angioplasty. Procedural success was defined as <30% residual stenosis. Treatment failure was defined as target lesion restenosis or graft occlusion. Descriptive and life-table analyses were performed. RESULTS PTA was used to revise 96 failing grafts in 90 patients. Mean age was 65.8 years (range, 50-88 years), 64% were male, and 66% were symptomatic. Mean follow-up was 18.5 months (range, 3-24 months). Twenty-four grafts (25%) underwent repeat angioplasty for restenosis. Grafts with multiple lesions (P = .009) and grafts aged <6 months from the index operation (P = .004) were the only graft-related variables that showed a significant effect on the longevity of the endovascular revision. The PTA-revised grafts had primary, assisted primary, and secondary patency rates of 56.9%, 83.2%, and 90%, respectively, at 2 years. CONCLUSIONS Primary balloon angioplasty of failing lower extremity bypass grafts, notwithstanding the higher restenosis rate and the need for reintervention, appears to be safe and is associated with acceptable early and medium-term patency rates. Grafts with multiple lesions and those revised ≤6 months of the index operation showed a significant association with the need for a second revision at the same site.
Collapse
Affiliation(s)
- Haitham Ali
- Vascular and Endovascular Surgery Department, Assiut University Hospitals, Assiut, Egypt.
| | - Ahmed Elbadawy
- Vascular and Endovascular Surgery Department, Assiut University Hospitals, Assiut, Egypt
| | - Mahmoud Saleh
- Vascular and Endovascular Surgery Department, Assiut University Hospitals, Assiut, Egypt
| | - Ayman Hasaballah
- Vascular and Endovascular Surgery Department, Assiut University Hospitals, Assiut, Egypt
| |
Collapse
|
7
|
van Oostenbrugge TJ, de Vries JPP, Berger P, Vos JA, Vonken EP, Moll FL, de Borst GJ. Outcome of endovascular reintervention for significant stenosis at infrainguinal bypass anastomoses. J Vasc Surg 2014; 60:696-701. [DOI: 10.1016/j.jvs.2014.03.289] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 03/31/2014] [Indexed: 11/15/2022]
|
8
|
Park KM, Park YJ, Yang SS, Kim DI, Kim YW. Treatment of failing vein grafts in patients who underwent lower extremity arterial bypass. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2012; 83:307-15. [PMID: 23166890 PMCID: PMC3491233 DOI: 10.4174/jkss.2012.83.5.307] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 08/10/2012] [Accepted: 08/23/2012] [Indexed: 11/30/2022]
Abstract
PURPOSE We attempted to determine risk factors for the development of failing vein graft and optimal treatment in patients with infrainguinal vein grafts. METHODS We retrospectively reviewed a database of patients who underwent infrainguinal bypass using autogenous vein grafts due to chronic atherosclerotic arterial occlusive disease of lower extremity (LE) at a single institute between September 2003 and December 2011. After reviewing demographic, clinical, and angiographic features of the patients with failing grafts, we analyzed those variables to determine risk factors for the development of failing grafts. To determine an optimal treatment for the failing vein grafts, we compared results of open surgical repair (OSR), endovascular treatment (EVT) and conservative treatment. RESULTS Two hundred and fifty-eight LE arterial bypasses using autogenous vein grafts in 242 patients were included in this study. During the follow-up period of 39 ± 25 months (range, 1 to 89 months), we found 166 (64%) patent grafts with no restenosis, 41 (15.9%) failing grafts, 39 (15.1%) graft occlusions, and 12 (4.7%) grafts lost in follow-up. In risk factor analysis for the development of a failing graft, no independent risk factors were identified. After 50 treatments of the 41 failing grafts (24 OSR, 18 EVT, 8 conservative management), graft occlusion was significantly more common in conservative treatment group and severe (>75%) restenosis was significantly more common following EVT than OSR (P = 0.001). Reintervention-free graft patency was also superior in the OSR group to that of the EVT group (87% vs. 42%, P = 0.015). CONCLUSION OSR of failing grafts has better outcomes than EVT or conservative management in treating failing grafts.
Collapse
Affiliation(s)
- Keun-Myoung Park
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | | | | | | | | |
Collapse
|
9
|
Baumann F, Engelberger RP, Makaloski V, Do DD, Baumgartner I, Diehm N. Single-center experience in endovascular treatment for infrainguinal bypass obstructions. J Vasc Interv Radiol 2012; 23:1055-62. [PMID: 22840804 DOI: 10.1016/j.jvir.2012.05.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Revised: 05/05/2012] [Accepted: 05/07/2012] [Indexed: 10/28/2022] Open
Abstract
PURPOSE To evaluate patency and clinical efficacy of endovascular therapy for infrainguinal bypass obstructions. MATERIALS AND METHODS Patients were categorized with regard to symptoms (asymptomatic/intermittent claudication [IC] vs critical limb ischemia [CLI]), bypass graft material used (autologous vs prosthetic graft), and localization of distal anastomoses (femoropopliteal vs femorodistal bypass). Primary patency was defined as absence of sonographically verified stenosis greater than 50%. Assisted primary patency was applied to secondary revisions to prevent impending occlusion. Secondary patency refers to repeat interventions aimed at restoring bypass patency after occlusion. Primary sustained clinical improvement in IC was defined as an upward shift of at least one category per Rutherford classification, accordingly to a level of claudication in patients with CLI. RESULTS A total of 54 patients (54 limbs, 12 with CLI) were included. At 1 year, primary patency rates were 74% in IC and 27% in CLI (P = .001), primary assisted patency rates were 85% in IC and 68% in CLI (P = .05), and secondary patency rates were 89% in IC and 100% in CLI (P = .32). Accordingly, primary sustained clinical improvement rates were 64% in IC and 25% in CLI (P = .018). After adjustment for confounding factors, CLI (hazard ratio [HR], 7.8; 95% CI, 2.3-26.32; P = .001) and impaired patent runoff (ie, less than three crural runoff vessels; HR, 0.16; 95% CI, 0.03-0.96; P = .045) were independently associated with impaired primary patency. CONCLUSIONS Endovascular revascularization is a reasonable treatment option to prevent impending bypass occlusion. Presence of CLI and impaired crural runoff are independent risk factors for lower patency rates.
Collapse
Affiliation(s)
- Frederic Baumann
- Department of General Internal Medicine, Inselspital, University Hospital of Bern, Freiburgstrasse, Bern, Switzerland
| | | | | | | | | | | |
Collapse
|
10
|
Schmieder GC, Richardson AI, Scott EC, Stokes GK, Meier GH, Panneton JM. Outcomes of reinterventions after subintimal angioplasty. J Vasc Surg 2010; 52:375-82. [PMID: 20541345 DOI: 10.1016/j.jvs.2010.03.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2009] [Revised: 03/01/2010] [Accepted: 03/04/2010] [Indexed: 11/18/2022]
Affiliation(s)
- Gregory C Schmieder
- Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, Va, USA
| | | | | | | | | | | |
Collapse
|
11
|
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.
Collapse
Affiliation(s)
- Scott A Berceli
- Department of Surgery, University of Florida and the Malcom Randall VA Medical Center, Gainesville, FL 32610-0286, USA
| |
Collapse
|
12
|
Mofidi R, Flett M, Nagy J, Ross R, Griffiths G, Chakraverty S, Stonebridge P. Balloon Angioplasty as the Primary Treatment for Failing Infra-inguinal Vein Grafts. Eur J Vasc Endovasc Surg 2009; 37:198-205. [DOI: 10.1016/j.ejvs.2008.10.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2008] [Accepted: 10/28/2008] [Indexed: 10/21/2022]
|
13
|
Predictors of failure after angioplasty of infrainguinal vein bypass grafts. J Vasc Surg 2008; 49:117-21. [PMID: 19028063 DOI: 10.1016/j.jvs.2008.08.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2007] [Revised: 08/07/2008] [Accepted: 08/09/2008] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Percutaneous transluminal angioplasty (PTA) has had an expanding role as primary therapy for vein graft stenosis with variable results. The aim of this study is to identify patient and graft characteristics predictive of failure after PTA of infrainguinal vein grafts. METHODS Retrospective review from Jan 2004 to Mar 2007 of patients undergoing angioplasty for failing grafts. Demographics, comorbidities, procedural data, and follow-up information were recorded. PTA failure was defined as first significant event including restenosis by duplex scan (>3.5 x velocity ratio), occlusion, redo-PTA, surgical revision, or amputation. Descriptive, logistic regression and life-table analyses were performed. RESULTS Eighty-seven grafts in 79 patients underwent PTA. Mean age was 70 years (median 70; range, 39-89 years), 71% were male and 52% were symptomatic (40% with limb-threat). Mean follow-up was 17 months (median 17.4; range, 0.03-39.8 months). Freedom from PTA failure was 58% (standard error [SE] 0.0574) at 12 months. Predictors of PTA failure by multivariate analysis were: time from bypass <3 months (hazard ratio [HR] 5.8; 95% confidence interval [CI] 1.91-18.0; P = .002), stenosis length >2 cm (HR 2.7; 95% CI 1.33-5.83; P = .007) and multiple stenoses (HR 2.5; 95% CI 1.29-5.1; P = .007). PTA patency for grafts with favorable lesions (single, less than 2 cm lesions in grafts older than 3 months) was 71% vs 35% for unfavorable lesions at 12 months. Limb-salvage was 95% and 90% and overall survival was 92% and 81% at 12 and 24 months, respectively. CONCLUSION PTA of failing infrainguinal vein grafts is a reasonable primary therapy for favorable lesions. Early graft stenosis, long, and multiple stenoses are markers for procedural failure and are better served with surgical revision.
Collapse
|
14
|
Schneider PA, Caps MT, Nelken N. Infrainguinal vein graft stenosis: Cutting balloon angioplasty as the first-line treatment of choice. J Vasc Surg 2008; 47:960-6; discussion 966. [DOI: 10.1016/j.jvs.2007.12.035] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2007] [Revised: 12/01/2007] [Accepted: 12/13/2007] [Indexed: 11/17/2022]
|
15
|
Hagino RT, Sheehan MK, Jung I, Canby ED, Suri R, Toursarkissian B. Target lesion characteristics in failing vein grafts predict the success of endovascular and open revision. J Vasc Surg 2007; 46:1167-72; discussion 1172. [DOI: 10.1016/j.jvs.2007.08.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2007] [Revised: 08/03/2007] [Accepted: 08/06/2007] [Indexed: 11/30/2022]
|
16
|
Berceli SA, Hevelone ND, Lipsitz SR, Bandyk DF, Clowes AW, Moneta GL, Conte MS. Surgical and endovascular revision of infrainguinal vein bypass grafts: analysis of midterm outcomes from the PREVENT III trial. J Vasc Surg 2007; 46:1173-1179. [PMID: 17950564 DOI: 10.1016/j.jvs.2007.07.049] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2007] [Revised: 07/19/2007] [Accepted: 07/25/2007] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Data supporting the utility of percutaneous treatment to maintain vein graft patency have been limited to a collection of single-institution, retrospective analyses. Using the prospective, multi-institutional PREVENT III database, we sought to define the outcomes for endovascular vs surgical vein bypass graft revision and to define predictors for the success or failure of these interventions. METHODS A nested cohort study of 1404 patients in the PREVENT III trial who underwent infrainguinal vein bypass grafting for critical limb ischemia was performed to identify those patients who underwent either open surgical or endovascular graft revision. All patients in PREVENT III were followed up for 1 year from the initial bypass operation. The following were modeled as end points from the time of the initial open surgical or endovascular revision: freedom from graft reintervention, occlusion, amputation, and death. RESULTS A total of 156 open surgical and 134 endovascular reinterventions were performed, with a mean follow-up after revision of 193 and 151 days, respectively. Although the demographics for each group were similar, the choice of repair was influenced by the interval between the index graft placement and the initial revision, with a high percentage of the early graft revisions treated with an open surgical procedure (0-1 months: 84% open surgical vs 16% endovascular; P < .001). The primary end point (ie, failure resulting in repeat graft revision, graft occlusion, or major amputation) was reached in 30.2% of the endovascular and 26.2% of the open surgical individuals, with significant improvements in the durability of graft revisions noted in the open surgical group (12-month amputation-/revision-free survival of 75% for the open surgical and 56% for the endovascular group; hazard ratio, 2.2; 95% confidence interval, 0.92-5.26; P = .043). Furthermore, subgroup analysis revealed this benefit to be most profound within the subset of thrombosed grafts undergoing salvage (P = .006). For revisions performed to treat graft stenosis, early outcomes were similar, with a trend favoring the open surgical group developing beyond 6 months. Although 80% of open surgical and 64% of endovascular-revised grafts required no further intervention, endovascular revisions necessitated significantly more reinterventions to maintain patency. The mean hospital lengths of stay (open surgical, 2.1 days; endovascular, 1.7 days) and quality of life at completion of the study (VascuQoL: open surgical, 4.72; endovascular, 4.76) were similar between the groups. CONCLUSIONS Open surgical revision of infrainguinal vein grafts provides an increased freedom from further reinterventions or major amputation, but early success rates for endovascular procedures were similar, particularly for nonoccluded grafts. With time, endovascular revisions necessitate an increasing number of reinterventions and manifest higher rates of failure.
Collapse
Affiliation(s)
- Scott A Berceli
- University of Florida and the Malcom Randall VAMC, Gainesville, FL, USA.
| | | | | | | | | | | | | |
Collapse
|