AN ALTERNATIVE METHOD OF SALVAGING OCCLUDED SUPRAINGUINAL BYPASS GRAFTS WITH OPERATIVE ANGIOSCOPY AND ENDOVASCULAR INTERVENTION

Purpose: A study of technical feasibility was undertaken to determine whether angioscopy and parallel endovascular instrumentation could eff ectively evaluate and restore inflow into occluded suprainguinal graft s. Methods: Several endobronchial instruments were selected for adapta tion for use in clearing occluded grafts under angioscopic guidance. T hese instruments were used in the treatment of 12 thrombosed graft lim bs in 10 patients who were admitted 1 to 40 days after occlusion. The occluded suprainguinal graft Limbs were exposed just proximal to the f emoral anastomosis. Blind retrograde balloon thrombectomy and clot ext raction were performed. Graft limbs underwent angioscopy, and the pres ence of luminal defects were recorded. Endoluminal instruments were th en inserted parallel to the angioscope, and luminal defects were corre cted. After inflow was reestablished, the distal portion of the graft was thrombectomized, and any necessary distal revisions were performed . Results: Blind retrograde thrombectomy was successful in restoring i nflow deemed normal in (67%) eight of 12 graft limbs and present but d iminished in two (17%) graft limbs. Balloon thrombectomy was ineffecti ve in restoring graft flow in two (17%) graft limbs. Angioscopy reveal ed luminal defects in 10 (83%) graft limbs after blind retrograde thro mbectomy. Only 2 (17%) graft limbs had no luminal defects after thromb ectomy. Findings included pseudointimal flap in eight of 12 (67%), adh erent residual thrombus in 4 (33%), and kinked graft limbs in 2 (17%) graft limbs. Endovascular instrumentation was successful in resecting all luminal disease under angioscopic guidance. There were no deaths, no episodes of graft injury or distal embolization, and only one groin hematoma. During a mean follow-up period of 6 months (2 to 13 months) , there was one late reocclusion at 7 months. Conclusion: We conclude that angioscopically guided thrombectomy and endovascular graft revisi on is a useful approach to the treatment of the occluded suprainguinal graft. Enhanced luminal visualization permits refined diagnostic asse ssment and definitive therapy. This may prolong the benefit of suprain guinal reconstructions.