THROMBOLYSIS COMBINED WITH ANGIOPLASTY FOR FAILED FEMORODISTAL ARTERIAL GRAFTS

This study examines the long-term clinical success and complications o f thrombolysis-angioplasty (TLA) of failed arterial grafts performed i n 17 patients (group 1) and matched with 21 patients (groups 2) who ha d intra-arterial thrombolysis (IAT) followed by graft revision. TLA co nsists of alternating thrombolysis with percutaneous transluminal angi oplasty (PTA) in the treatment of occlusive arterial disease. Failed g rafts consisted of 21 vein grafts, 6 ovine collagen grafts, 6 polytetr afluorethylene (PTFE) prostheses, 3 human umbilical veins and 2 polyur ethane vascular grafts. All bypasses were below the knee, of which 13 were to the tibial level. Thrombolytic agents used were urokinase in 2 1 cases, tissue plasminogen activator in 13 cases and streptokinase in 4 cases. Following successful thrombolysis, PTA was performed with a 3 mm to 5 mm balloon catheters. Nine tandem lesions were corrected. In all 24 stenoses were treated: 14 anastomotic stenoses, 4 graft strict ures and 5 peripheral stenotic lesions. The combined cumulative patenc y rate of both groups was 36% (SE 10.8%) at 3 years. The initial techn ical success rate in group 1 was 70% (12 of 17 grafts). The cumulative patency rate, as revealed by life-table analysis, was 35.6% (SE 10.2% ) at one year and 21.3% (SE 9.6%) at 2 years. In all, 10 grafts failed at follow-up and in 6 of these cases secondary intervention was unsuc cessful. Mid-graft and isolated lesions responded better than did anas tomotic and tandem lesions. In group 2 the cumulative patency rate was 60.4% (SE 5.7%) at one year and 50.3% (SE 12.9%) at 2 years. Because of the small number of cases statistical significance was not achieved x(2)= 1.910. The results suggest that thrombolysis of failed distal g rafts has poor long-term clinical success. Results of balloon angiopla sty are inferior to graft revision. Emphasis should be placed on early detection and repeated autogenous vein graft bypass.