Management of aortic bypass graft thrombosis: Utility of thrombectomy (original) (raw)
Successful treatment of delayed aortobifemoral graft thrombosis with manual aspiration thrombectomy
Diagnostic and Interventional Radiology, 2011
S ymptomatic aortoiliac occlusions are regularly treated with aortofemoral bypass. Long-term patency of the bypass graft is very good. Early graft occlusions (within 30 days of surgery) occur in 1%-2% of patients in the postoperative period, usually because of technical difficulties with the bypass procedure. These problems are best treated with graft thrombectomy and correction of the underlying technical problem but can also be overcome by endovascular methods such as percutaneous mechanical thrombectomy with special devices and the infusion of thrombolytics. Late-graft occlusion occurs in 10%-15% of graft limbs, generally three to four years after the primary reconstruction. Late thrombosis is most commonly attributed to anastomotic intimal hyperplasia and/or progression of atherosclerotic disease in the outflow vessels (1). Surgical thrombectomy is the treatment of choice for acute or chronic thrombosis. Endovascular methods are quite effective at the acute stage of thrombosis and can be a good alternative to surgery. Chronic thrombosis of the bypass graft can be treated with surgery alone because endovascular methods are usually ineffective. As a novel alternative to surgical thrombectomy, we present the use of manual aspiration thrombectomy (MAT) for the successful recanalization of delayed occlusion of an aortobifemoral graft.
Surgical care of the arteriovenous graft: issues for the interventionalist
Techniques in Vascular and Interventional Radiology, 1999
The optimal treatment of arteriovenous (AV) grafts requires a multidisciplinary approach to the management of graft pathology. Open surgical and percutaneous methods must complement each other. Patient care can be enhanced if the indications, strengths, and weaknesses of a given technique are understood by all those involved in patient care. Continued study of the relative efficacy of the various techniques and clinical algorithms is indicated so that the most appropriate procedure is undertaken for a given pathology. This article reviews graft pathology treated via open surgical intervention. The interventionalist must have a thorough understanding of surgical treatment options so that an appropriate and timely referral can be made. The need for the interventionalist to evaluate a wide range of graft pathology and to decide on the most appropriate treatment is becoming more important, because in many institutions, the interventionalist has become the primary referral physician for AV graft dysfunction.
Diagnostic and Interventional Radiology, 2013
The purpose of this study was to present our experience with guiding catheters in manual aspiration thrombectomy of occluded infra-aortic bypass grafts. This material was designed as a guiding catheter but was also used for thrombus aspiration. Six consecutive patients (all male; mean age, 61.0±5.7 years; range, 54-68 years) who underwent manual aspiration thrombectomy at the discretion of the operator for infra-aortic bypass graft thrombosis between 2002 and 2010 were retrospectively reviewed. The angiographic success described as either stenosis or residual thrombus less than 30% was 67%. Primary patency was 50%, and secondary patency was 66.7%. Additional stents were needed in four lesions of three patients. Manual aspiration thrombectomy is intended to remove both soft acute blood clots and hard organized embolic and thrombotic obstructions. Manual aspiration thrombectomy appears to be a safe and effective method for treating delayed graft thrombosis. This method provides an alternative to surgical thrombectomy, especially for patients who are not good candidates for the surgery.
Patency Following Successful Thrombolysis of Occluded Vascular Grafts
European Journal of Vascular and Endovascular Surgery, 2001
Aim: to determine patency after successful lysis of occluded bypass grafts. Methods: data were collected from four centres with a wide experience of thrombolysis. Outcome following successful lysis was determined from prospectively collected data or case notes. Data from 75 patients, 53 men, were analysed. Results: median age at time of lysis was 68 years (range 33-88). Median age of graft was 12 months (range 1-120). Patency at 12 months was 33% (95% conf. interval: 21-44%). There were no differences in patency depending on whether the graft was above or below the inguinal ligament or whether an additional procedure eg. percutaneous or vein patch angioplasty was carried out. However in those 48 cases when lysis was deemed complete, i.e. there was restoration of graft patency and at least one vessel run off patency at 12 months was 39% compared with 17% if lysis was incomplete (p=0.04). Conclusions: at the present time it is difficult to justify routine thrombolysis of occluded grafts when patency, based on intention to treat, is approximately 20% at one year. Following successful graft lysis the role of anticoagulation and careful graft surveillance require further investigation.
Circulation, 1979
Early and late (range 5-73 months, average 2.5 years) postoperative arteriographic studies were performed in 85 patients after saphenous vein aortocoronary bypass surgery. In a prior study (< 2 weeks postoperative) of 570 patients with 1197 grafts, arteriography revealed 89.6% early patency of grafts. Late follow-up in 85 patients discharged with all grafts patent revealed 92.2% still patent, an annual mean graft attrition rate (percent of grafts closed/year) of 3.2%/year. This mean graft attrition rate was only slightly affected by regrouping patients according to the interval between the two postoperative studies; however, recurrent angina pectoris was influenced by vein graft attrition. Thus, in 36 patients restudied because of recurrent angina pectoris, the attrition rate was 6.1%/year, compared with 1.1%/year in 49 patients without angina. Progressive coronary artery disease (41% vs 18%), graft closure (22% vs 4%) and incomplete revascularization (39% vs 16%) were significantly more frequent in those with recurrent angina. The frequency of progressive coronary disease was directly related to the duration of follow-up (i.e., the longer the follow-up the higher the frequency of progressive disease). The mean annual rate of progressive coronary disease in arteries not grafted was 11.8%/year. Kinking or graft stenosis was observed in 3.1% of grafts in the early study, while late localized graft narrowing was observed in 8%. At late follow-up, most patent grafts were uniformly narrowed and foreshortened. The mean graft diameter decreased by 17% at late follow-up, and 25% of grafts had at least 25% reduction in mean diameter; however, the mean graft diameter/mean recipient artery diameter ratio exceeded 1.0 in all but one graft. The graft/artery diameter ratio at late follow-up was over 1.5 in 71% of the grafts. The mean graft blood flow determined by cinedensitometric methods revealed a 30% or more reduction in blood flow in 35% of grafts, compared with early postoperative measurements.
Annals of Vascular Surgery, 2009
consecutive patients (708 men, 114 women; mean age 63.8 years) underwent aortoiliac or aortofemoral reconstruction using a bifurcated ePTFE stretch graft. Preoperatively, all patients had ultrasonographic and arteriographic evaluations and were divided into groups according to the TASC II morphological stratification of iliac lesions. Seventy-seven patients (9.4%) had type B lesions, 314 (38.2%) had type C lesions, and 431 (52.4%) were classified as type D lesions. Endarterectomy of the aorta was required in 172 patients (21%); femoral arteries were endarterectomized in 222 (27%). Femoropopliteal bypass grafting was performed in 18 patients, aortorenal bypass in 12, and mesenteric artery grafting in one. One patient died perioperatively of a myocardial infarction. Perioperative morbidity included cardiac (2.2% of patients), respiratory (0.9%), and gastrointestinal (1.2%) complications, as well as acute renal insufficiency (1.3%). Seven patients had bleeding requiring surgical revision within the first 24 hr after surgery. There were four cases (0.5%) of immediate graft thrombosis and five (0.6%) of single-limb graft thrombosis. During a mean follow-up time of 72 months (range 28-170), 58 patients (7.1%) were lost to follow-up and 205 patients (24.9%) died. The primary and secondary graft-patency rates during the observation period were 90.6% and 97.9%, respectively. Twelve late graft occlusions resolved after thrombectomy alone. Eleven cases of single-limb late thrombosis resolved after thrombectomy and profundoplasty. The limb-salvage rate during the observation period in patients who underwent operation for critical limb ischemia was 84.5%. There were nine postoperative graft infections (1.1% infection rate) in the series. Our long-term experience with ePTFE stretch grafts in aortoiliac and aortofemoral reconstruction shows that these prostheses have a high rate of patency and a low rate of graft-related complications.
European Journal of Vascular and Endovascular Surgery, 2009
Objectives: To examine the incidence and risk factors of intraprosthetic thrombotic deposits in abdominal aortic endografts. Methods: The clinical records of 51 patients (44 males; mean age 76.3 years, range: 63e90 years) with abdominal aortic aneurysm treated with transfemoral implantation of bifurcated stent graft between the years 2002 and 2008 were retrospectively reviewed. Patients underwent three-phase helical computed tomographic (CT) examinations at 1-, 3-, 6-and 12-month intervals and then annually. The formation of intraprosthetic thrombus associated with use of anti-platelet, preoperative mural thrombus in the aneurysm, ratio of cross-sectional area between the mainbody and bilateral limb grafts and length of mainbody were evaluated. Results: Over a 10-month mean follow-up, intraluminal deposits of thrombotic material were observed in eight of 51 patients (15.6%, 95% confidence interval: 8.2e28). The first signs of thrombus formation occurred on average 9.8 months after endografting (range: 1e24 months). Intraprosthetic thrombotic deposits was not related to preoperative mural thrombus formation (p Z 0.38) or postoperative anti-platelet or anticoagulation medication (p Z 0.40). However, it was significantly related to the ratio of the cross-sectional area between the mainbody and the bilateral limb grafts and the length of mainbody (p Z 0.04 and p Z 0.01). There were three graft limbs occlusion owing to kinking with no intraprosthetic thrombus detected on CT scans taken prior to occlusion. One patient developed distal left proximal superior femoral artery embolisation 4 months after detectable intraprosthetic mainbody thrombus in a CT scan follow-up. In no case did the thrombotic deposits clear completely from the prosthesis lumen during follow-up. Conclusions: This short experience demonstrates that incidentally found thrombotic deposits in abdominal aortic endografts are common. The deposition of thrombus is mostly influenced
Journal of Vascular Surgery, 1991
infrainguinal revascularization procedures were performed. In 130 of these cases with patent bypasses, hemodynamic deterioration was suspected, and urgent arteriography was performed. Twenty additional patients with aortofemoral, fi:morofemoral, or axillofemoral bypasses demonstrated hemodynamic deterioration. In 93% of failing grafts the condition was suspected because of recurrent symptoms or changes in the pulse examination. Two hundred eighty-five high-grade stenotic or occlusive lesions were identified in inflow arteries, outflow arteries, within the graft, or at proximal or distal anastomoses associated with these 150 grafts. One hundred sixty-one (57%) of these lesions were in patients with failing vein grafts; 115 (40%) were in patients ,with failing polytetrafluoroethylene (PTFE) grafts; and 9 (3%) were associated with failing composite vein/PTFE grafts. Stenotic lesions < 5 cm in length were initially treated with percutaneous transluminal baUoon angioplasty (PTA). Occlusive lesions, stenoses > 5 cm in length, and PTA failures were treated surgically. The overall 6-year ctunulative secondary patency rate for failing grafts was 65%, and the limb salvage rate was 75%. The extended patency rate after the first intervention in the failing state was 56% at 5 years. The 5-year secondary patency rate for grafts initially treated with PTA (58%) was not significantly different (p = 0.25) from that for grafts treated initially with surgery (71%). Percutaneous translmninal angioplasty was effective for inflow stenoses of the iliac, femoral, and popliteal arteries and for some outflow lesions. The 24-month extended patency rate for lesions < 1.5 cm in length within vein grafts _> 3 mm in diameter treated by percutaneous transluminal angioplasty (93%) was significantly better than that of lesions that were multiple, _> 1.5 cm in length, or within grafts < 3 mm in diameter (54%) (p = 0.001). Frequent, careful surveillance can identify the failing state in both vein and PTFE arterial reconstructions. Percutaneous transhtminal angioplasty is effective in treating most short (< 5 cm) inflow or outflow lesions and graft stenoses < 1.5 cm. Surgical interventions are necessary to treat recurrent, long, diffuse, or occlusive lesions. Early detection of failing grafts and timely intervention are essential for the long-term maintenance of arterial bypass grafts. (J VASC SURG 1991;14:729-38.) Over the past 1,0 years, advances in vascular surgery and interventiional radiology have resulted in improved primary and secondary patency rates of From the Divisions of Vascular Surgery and Vascular Radiology,
European Journal of Vascular and Endovascular Surgery, 2020
WHAT THIS PAPER ADDS Evidence regarding the management of thrombosed haemodialysis grafts (arteriovenous grafts [AVGs]) is limited to outcomes after open surgery or purely endovascular techniques. Hybrid interventions combining open surgical thrombectomy and endoluminal angioplasty and stenting of the venous anastomotic lesion have been investigated only minimally. This single centre retrospective study aimed to describe outcomes after hybrid treatment of thrombosed AVGs. Technical success and patency were compared with that of open surgery (thrombectomy and revision of venous anastomosis). No differences were identified. Objective: Arteriovenous graft (AVG) failures are typically associated with venous anastomotic (VA) stenosis. Current evidence regarding AVG thrombosis management compares surgical with purely endovascular techniques; few studies have investigated the "hybrid" intervention that combines surgical balloon thrombectomy and endovascular angioplasty and/or stenting to address VA obstruction. This study aimed to describe outcomes after hybrid intervention compared with open revision (patch venoplasty or jump bypass) of the VA in thrombosed AVGs. Methods: Retrospective cohort study. Consecutive patients with a thrombosed AVG who underwent thrombectomy between January 2014 and July 2018 were divided into open and hybrid groups based on VA intervention; patients who underwent purely endovascular thrombectomy were excluded. Patient demographics, previous access history, central vein patency, AVG anatomy, type of intervention, and follow up data were recorded. KaplaneMeier curves were used to analyse time from thrombectomy to first reintervention (primary patency) and time to abandonment (secondary patency). Cox regression analysis was performed to evaluate predictors of failure. Results: This study included 97 patients (54 females) with 39 forearm, 47 upper arm, and 11 lower extremity AVGs. There were 34 open revisions (25 patches, nine jump bypasses) and 63 hybrid interventions, which included balloon angioplasty AE adjunctive procedures (15 stents, five cutting balloons). Technique selection was based on physician preference. Primary patency for the open and hybrid groups was 27.8% and 34.2%, respectively, at six months and 17.5% and 12.9%, respectively, at 12 months (p ¼ .71). Secondary patency was 45.1% and 38.5% for open and hybrid treatment, respectively, at 12 months (p ¼ .87). An existing VA stent was predictive of graft abandonment (hazard ratio 4.4, 95% confidence interval 1.2e16.0; p ¼ .024). Open vs. hybrid intervention was not predictive of failure or abandonment. Conclusion: Hybrid interventions for thrombosed AVGs are not associated with worse patency at six and 12 months compared with open revision.
Journal of Endovascular Therapy, 2013
urpose: To evaluate the efficacy and outcome of thrombolysis and thrombectomy for thrombosed polytetrafluoroethylene stent-grafts inserted in the superficial femoral artery (SFA) for occlusive disease. Methods: A retrospective review was conducted of 79 consecutive patients with a thrombosed SFA endograft between November 2001 and December 2011. Of these, 46 (58%) were treated with thrombolysis (n¼40, 87%) or thrombectomy (n¼6, 13%) and form the study group (33 men; median age 66.8 years, range 30-80). Median time from stentgraft insertion to thrombosis was 3 months (range 0-53). Results: Thrombolysis was successful in 38 (95%) patients over a mean 24 hours (range 3-48); one patient had failed lysis and another died during lytic treatment. Thrombectomy was successful in all 6 patients. Thrombosis without a causal lesion was significantly more common in occlusions that presented ,30 days after insertion (p¼0.01). Over a median follow-up of 14 months (range 1-69), reinterventions were performed for restenosis in 12 patients and reocclusion in 14 patients, all within 18 months after thrombolytic treatment. More than a third of patients (16/45) had definitive failures (2/6 from the thrombectomy group); 4 were treated conservatively (no/minor symptoms) and 12 had bypass grafts. Three (7%) patients eventually required a major amputation. The primary, assisted primary, and secondary patency rates of thrombolysis at 6 months were 56%, 56%, and 68%, respectively. Secondary patency for the entire cohort was 58% at 1 year. Conclusion: Thrombolysis and thrombectomy of thrombosed endografts in the SFA is effective and safe. Patency rates after treatment are moderate, but prolonged secondary patency can be achieved.
Applicability of distal protection for aortocoronary vein graft interventions in clinical practice
Catheterization and Cardiovascular Interventions, 2004
Percutaneous revascularization of diseased saphenous vein grafts is associated with increased risk of adverse events, although the use of distal protection mitigates this to a significant extent. However, anatomic characteristics may preclude the use of such devices in a proportion of vein grafts intended for percutaneous treatment. We reviewed our consecutive experience of saphenous vein graft interventions from 1 May 2001 through 30 April 2002 to determine suitability for distal protection. Relevant angiographic characteristics included lesion within 5 mm of the ostium; lesion < 20 mm from the distal anastomosis; planned distal landing site of the occlusion balloon < 3 mm or > 6 mm in diameter; total occlusion of the vein graft; or lesion in a sequential vein graft distal to the first anastomosis. One hundred twenty-seven patients (140 procedures, 147 vein grafts) were treated. One or more of the angiographic exclusion criteria for a balloon occlusion protection system existed in 57% of grafts, while 42% had exclusions for a filter device. A large number of patients with vein graft disease intended for percutaneous treatment have anatomic exclusions to available distal protection technology.
Endovascular Management of Delayed Complete Graft Thrombosis After Endovascular Aneurysm Repair
CardioVascular and Interventional Radiology, 2010
Graft thrombosis rates after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms vary widely in published series. When thrombosis does occur, it usually involves a single limb and occurs within 3 months of stent-graft insertion. If the entire endoprosthesis is thrombosed, treatment may be challenging because femoro-femoral crossover graft insertion is not an option and a greater volume of thrombus is present, thus making thrombolysis more difficult. We present two cases of delayed thrombosis after EVAR involving the entire stent-graft. These were successfully treated by a combined surgical and endovascular technique, and patency has been maintained in both cases to date.
Twenty-Year follow-up of saphenous vein aortocoronary artery bypass grafting
The Annals of Thoracic Surgery, 1992
The clinical records of our first 100 patients to undergo saphenous vein aortocoronary bypass grafting were reviewed. The procedures were performed between March 19, 1970, and March 30, 1972. The patient population included 84 men, and the mean age was 51.4 years. There were 12 patients with single-vessel disease, 36 with double-vessel disease, and 52 with triple-vessel disease, for an average of 2.4 involved vessels per patient. Fortyeight patients were judged to have diffuse atherosclerotic disease. Twelve patients had left main coronary artery stenoses. Each patient received an average of 1.8 saphenous vein grafts. Thirty-six patients underwent repeat coronary artery bypass grafting after an average of 132.8 months and received an average of 3.5 grafts. This resulted in cumulative reoperative rates of 5%, 14%, 27%, and 36% at 5, 10, 15, and 20 years, respectively. The 5-, lo-, 15-, and 20-year survival rates were 89.8%, 68.4%, 53.1%, and 40.8%, respectively. Survival was not significantly related to the cause of death, cardiac-related causes being predominant. There were no significant ince the initial report by Favaloro [l], aortocoronary S artery bypass grafting (CABG) has become commonplace. A vast body of literature is available regarding the risks, benefits, and long-term survival. Much has changed since the early days of this operation with improvements in surgical technique, lighting, magnification, suture material, cardiopulmonary bypass techniques, and myocardial protection. The use of arterial conduits, such as the internal mammary artery [2, 31 and more recently the right gastroepiploic artery [4], has been shown to improve graft patency rates. In contrast to the 40% to 60% patency rate for vein grafts at 10 to 12 years postoperatively, arterial graft patency exceeds 90% [2]. Several articles have been published regarding the 5-year [>lo], 10-year [3, 5-14], and even 15-year [15, 161 survival rates after CABG. Factors determining survival are controversial. Age (8
Upper extremity thromboembolism caused by occlusion of axillofemoral grafts
The American Journal of Surgery, 1995
Oregon P rosthetic bypass grafting from the axillary artery to the femoral arteries was first performed by Louw' and by Hall and Blaisdel12 in 1962. Axillofemoral bypass has become the treatment of choice for infected aortic prostheses, as well as aortoiliac occlusive disease in high-risk pa-