Graft Failure After Revascularization for Chronic Limb-Threatening Ischaemia (CLTI) Patients: The Role of Graft Surveillance (original) (raw)
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Implementation of a graft surveillance programme for infrainguinal bypass surgery
Malta Medical Journal
Aim: Patients undergoing bypass graft placement in the lower limb are often entered into a graft surveillance programme using duplex scanning. The aim of this programme is to identify stenoses in vein grafts before they become symptomatic and treat these by angioplasty or surgery, thus prolonging the patency of the graft. This paper aims at reporting on the progress and viability of this programme at Mater Dei Hospital, Malta. Method: Infrainguinal bypass grafts carried out between July 2007 and May 2009 were enrolled. Scanning starts during the patient's in-hospital stay at one week post-operation. It is then scheduled at 6 weeks, 3 months, 6 months, 12 months, 18 months, 24 months, and yearly afterwards. When a significant stenosis is encountered, the patient is referred for angioplasty. Surgery would be considered in cases when angioplasty is not an option. Results: During this period 56 patients were recruited. At one week post-op the patency rate was 100%. At 6 months the primary unassisted patency was 77.5% while the primary assisted patency was 87.5%. At 12 months the primary unassisted patency was 50% while the primary assisted patency was 77%. Secondary patency rates at 6 and 12 months were 95% and 82% respectively. Conclusion: The graft surveillance programme ensures that any problem detected in the post-operative period is dealt with as soon as possible. The study shows that this programme is being effective in that assisted rates (i.e. after angioplasty or surgery) are better than unassisted rates.
The value of vein graft surveillance in bypasses performed with small-diameter vein grafts
Annals of vascular surgery
We assessed the impact of preoperative diameter of the venous conduit on reintervention rate and outcome following infrainguinal vein graft bypass. Consecutive infrainguinal vein bypasses between January 2001 and December 2006 were reviewed. All patients underwent preoperative measurement of vein graft diameter (VGD). Grafts were classified into those with VGD <3.5 mm and those with VGD > or =3.5 mm. All patients were enrolled in a duplex surveillance program. The association between VGD and reintervention rate was assessed. Graft patency and amputation rates were compared. There were 377 bypasses followed up for a median of 23 months (range 8-67). VGD was <3.5 mm in 139 grafts (36.9%) and > or =3.5 mm in 238 grafts (63.1%). A higher proportion of smaller vein grafts (32.3%) required reintervention to maintain graft patency compared with larger conduits (20.2%) (chi(2) = 7.7, p < 0.001). VGD (odds ratio [OR] = 2.87, 95% confidence interval [CI] 1.63-3.81; p < 0.001...
European Journal of Vascular and Endovascular Surgery, 1996
Objectives: The objectives of this study were to assess the impact of Duplex surveillance on the results of infrainguinal vein grafts. A review has been performed comparing the outcome of vein grafts undergoing Duplex surveillance plus prophylactic treatment of stenoses to that of vein grafts followed clinically. Design, patients and methods; Only studies providing information on occlusion rates were included. Mortality and limb salvage rates were also analysed but were not available from all studies. Results; 2680 surveillance and 3969 non-surveillance vein grafts were analysed. There was no significant difference between the two groups with respect to presence of critical ischaemia (p = 0.3) and level of distal anastomosis (p > 0.5). Surveillance identified 493 stenoses in 469 (19%) grafts, 397 (16%) grafts were treated by surgery (24& 62%) and angioplasty (149; 38%). Ninety-eight (26%) grafts developed recurrent stenoses. Total number of deaths, total number of occluded grafts and number of occlusions after 30 days were significantly greater for the non-surveillance group (p < 0.001; p < 0.001; p < 0.01). Perioperative occlusion rates were not significantly different (p = 0.1). Few surveillance studies reported limb salvage rates (6 of 17). The numbers of amputations were not significantly different between the two groups (p > 0.5). Conclusions: The patency of infrainguinal vein grafts would appear to be improved as a result of surveillance. Howevel; no improvement in limb salvage has been demonstrated.
Long-term outcome of revised lower-extremity bypass grafts*1
Journal of Vascular Surgery, 2002
Purpose: Reversed lower-extremity vein grafts (LEVGs) frequently require operative revisions to maintain patency. Identifying grafts that are at risk, however, requires an intensive duplex scanning-based surveillance program. Excellent 5-year graft patency and limb-salvage rates have previously been reported in patients undergoing graft revisions, but results beyond 5 years are essentially unknown, a factor that is of importance in an increasingly aging population. This study was performed to determine the results of surgical revisions of LEVGs after a follow-up as long as 10 years. Methods: All patients undergoing placement of a LEVG were observed in a program of duplex scanning-based surveillance as long as the patient remained a candidate for graft revision. Grafts were considered for revision on the basis of the presence of focal areas of increased velocity, a prestenotic to intrastenotic velocity ratio more than 3.0, or uniformly low velocities throughout the graft. All lesions were confirmed with preoperative arteriography before revision. Assisted primary patency, limb-salvage, and survival rates were determined by means of Kaplan-Meier analysis in all patients who underwent LEVG revision from January 1990 to December 2000. Results: A total of 1498 LEVG procedures were performed during the study period. A total of 330 surgical graft revisions were performed on 259 extremities in 245 patients. The median follow-up period was 38 months. The assisted primary patency rate of all grafts, the limb-salvage rate for patients undergoing surgery for limb-salvage indications, and the survival rate of all patients were 87.4%, 88.7%, and 72.4%, respectively, 5 years after the original bypass grafting procedure, 85.7%, 83.4%, and 67.8%, respectively, 7 years after the original bypass grafting procedure, and 80.4%, 75.4%, and 53.4%, respectively, 10 years after the original bypass grafting procedure. A total of 180 revisions (55%) were performed during the first year, 110 (33%) between the first year and the fifth year, and 40 revisions (12%) were performed on grafts older than 5 years. LEVGs revised within the first year after bypass grafting had lesions within the graft in 78%, in the native arterial inflow in 10%, and in the native arterial outflow in 12%. This differed significantly from the location of lesions in revisions performed between 1 and 5 years and after 5 years (graft, 63% and 62%; inflow, 20% and 19%; outflow, 17% and 19%; P > .05, Chi-square). Conclusion: Excellent assisted primary patency and limb-salvage rates can be achieved for as long as 10 years in LEVGs that require revision, with only a 7% drop in overall patency and limb-salvage rates between the fifth and 10th years. Although most revisions were required within the first year, 34% were performed between the first year and the fifth year, and 11% after 5 years. These data support the growing body of evidence that favors an aggressive regimen of duplex scanning surveillance of LEVGs for the life of the graft. Revised grafts have excellent patency through 10 years.
The Vein Graft Surveillance Trial: Rationale, Design and Methods
European Journal of Vascular and Endovascular Surgery, 1999
Objectives: to compare the amputation rates, quality of life and health care costs in patients receiving duplex ultrasound scanning against clinical surveillance following femoropopliteal and femorocrural vein bypass. Design: multi-centre, prospective, randomised controlled trial. Methods: 1200 patients with a patent vein graft at 30 days postoperatively will be randomised to either clinical or duplex follow-up. All patients are seen in an out-patient clinic at 6 weeks, then 3, 6, 9, 12 and 18 months postoperatively. At each appointment patients are examined clinically; palpable pulses in the graft and crural vessels, presenting symptoms and their ankle-branchial pressure indices (ABPIs) measured. In the duplex group only, the results of the scan are monitored. The incidence of radiological and/or surgical interventions throughout the follow-up period are also noted. Quality of life is measured using the SF-36 and EuroQol questionnaires at the 6 and 18 month appointments. Hospital stays and resource use are documented for health economic analysis. Results: the primary endpoint of this study is amputation or death from vascular causes; however, graft patency rates will also be compared between the groups. Quality of life and health economic data will be used to determine if there is any benefit in either arm in these outcomes between follow-up strategies. Conclusions: this large, randomised-controlled trial will hopefully provide direct evidence on the benefit of duplex surveillance for vein grafts in terms of limb salvage, quality of life of the patients and cost-benefit to the purchaser.
European Journal of Vascular and Endovascular Surgery, 2011
Objectives: Compare the outcome of distal (bypass to the crural arteries) versus ultradistal (bypass to the pedal arteries) bypasses in patients with critical leg ischaemia (CLI). Design: Retrospective analysis of prospectively collected data of patients with CLI undergoing infra-popliteal bypass surgery is performed. Materials and Methods: Patients undergoing infra-popliteal bypass at a single institution between 2004 and 2010 are included. Patency rates at 1-year and amputation-free survival at 12 and 48 months are analysed. Results: Two hundred and thirty bypasses were performed in 209 consecutive patients (156 men, median age; 76 years, range; 19e96 years). One hundred and seventy nine (78%) bypass were classified as distal and 51 (22%) as ultradistal. The incidence of diabetes mellitus was significantly higher in the ultradistal group (p Z 0.0025). At 1-year, the distal group primary, assisted-primary and secondary patency rates were 61.7%, 83.1% and 87.4% compared to 61.9%, 87.4% and 87.4% in the ultradistal group respectively. Amputation-free survival at 12 and 48 months was 82.9% and 61.5% in the distal group compared to 83.0% and 64.9% in the ultradistal group. Conclusions: This study show that both distal and ultradistal bypass have comparable outcome regardless of the co-morbidities. The authors believe that elderly patients should be offered ultradistal bypass if indicated to avoid major amputation.
European Journal of Vascular and Endovascular Surgery, 2005
Objective. To compare the consequences of occlusion of infrainguinal venous and prosthetic grafts. Methods. In total, 2690 patients were included in the Dutch BOA study, a multicenter randomised trial that compared the effectiveness of oral anticoagulants with aspirin in the prevention of infrainguinal bypass graft occlusion. Two thousand four hundred and four patients received a femoropopliteal or femorodistal bypass with a venous (64%) or prosthetic (36%) graft. The incidence of occlusion and amputation was calculated according to graft material and the incidence of amputation after occlusion was compared with Cox regression to adjust for differences in prognostic factors. Results. The indication for operation was claudication in 51%, rest pain in 20% and tissue loss in 28% of patients. The mean follow up was 21 months. After venous bypass grafting 171 (15%) femoropopliteal and 96 (24%) femorodistal grafts occluded. After prosthetic bypass grafting 234 (30%) femoropopliteal and 25 (38%) femorodistal grafts occluded. Patients with occlusions in the venous group had more severe ischemia, less runoff vessels and were older than the patients with prosthetic grafts. In the venous occlusion group 54 (20%) amputations were performed compared to 42 (16%) in the prosthetic occlusion group; crude hazard ratio 1.17 (95% CI 0.78-1.75). After adjustment for above mentioned differences in patient characteristics the hazard ratio was 0.86 (95% CI 0.56-1.32). Conclusion. The need for amputation after occlusion is not influenced by graft material in infrainguinal bypass surgery.
European Journal of Vascular and Endovascular Surgery, 2012
Introduction and objectives: Infrainguinal bypass surgery (BPG) is accompanied by significant 30-day mortality and morbidity, including early graft failure. The goal of this study is to identify patient-and procedure-specific factors which predict the rate of early graft failure in contemporary practice. Methods: Data was obtained from the private sector National Surgical Quality Improvement Program, a prospective, validated database collected between 2005 and 2008 from 211 hospitals, using primary and modifier Current Procedural Terminology codes for BPG. The primary endpoint was graft failure at 30 days. Procedural parameters, patient demographics and clinical variables were analyzed by univariate and multivariate methods. Results: There were 9217 BPG procedures (limb salvage, 49%; infrapopliteal distal anastomosis, 43%; prosthetic 32%) with patient variables: age 67 AE 12 years, male 64%, diabetes 44%, dialysis 7.4%. Mortality was 2.4%, major morbidity was 17.3%, and graft failure rate was 6.3% at 30 days. Multivariate predictors of graft failure demonstrated correlation (p-value, OR) with female gender (p ¼ 0.0054, 1.29), limb salvage indication (p < 0.0001, 1.60), infrapopliteal anastomosis (p < 0.0001, 2.15), composite graft (p ¼ 0.0436, 1.82), current smoking (p ¼ 0.0007, 1.36), impaired sensorium (p ¼ 0.0075, 2.13), emergency procedure (p < 0.0001, 2.03), previous vascular procedure (p ¼ 0.0005, 1.39), and platelets >400K (p ¼ 0.0019, 1.49). High-risk composite constructs utilizing these significant predictive factors can identify cohorts of patients with up to a 98-fold increase in odds of early graft failure. Conclusions: These results describe common risk factors that correlate with early graft thrombosis including the unique description of its association with thrombocytosis. Additional risk factors thus identify a subset of patients who are at highest risk for early BPG failure. This data may be used to refine patient selection.
The effect of a surveillance programme on the patency of synthetic infrainguinal bypass grafts
European Journal of Vascular and Endovascular Surgery, 1996
The aim of this study was to examine the effect of a surveillance programme on the patency of synthetic infrainguinal bypass grafts. Design: A prospective study of 69 consecutive prosthetic bypass grafts was undertaken over a 3 year period. Methods: Patients were seen at 3 monthly intervals after surgery and underwent measurement of ankle brachiaI pressure indkes and a colour Duplex scan of the graft. Results; The surveillance programme was able to detect treatable lesions in five grafts and in the runoff vessels of two other grafts prior to occlusion. Hozoever 14 grafts failed after the first 30 days, 12 of which were not predicted by the surveillance programme. Conclusions; Surveillance appears to be of limited benefit in the maintenance of patency of synthetic infrainguinal bypass grafts.