SURGICAL-TREATMENT OF THREATENED REVERSED INFRAINGUINAL VEIN GRAFTS

Purpose: Current information concerning the results of surgical revisi on of threatened infrainguinal vein grafts is largely limited to in si tu conduits. Infrainguinal grafts may be threatened by intrinsic graft lesions or significant stenosis in the adjacent inflow or outflow art eries. To assess the results of operative revision of infrainguinal re versed vein grafts, we reviewed our experience with surgical revision of threatened infrainguinal reversed vein grafts identified through a program of postoperative clinical and vascular laboratory graft survei llance. Methods: All patients who underwent surgical revision of a thr eatened but patent infrainguinal reversed vein graft from January 1987 through April 1993 were identified through review of our vascular reg istry. Data mere analyzed for type of vein used, date of original reve rsed vein graft, clinical and vascular laboratory findings leading to reversed vein graft revision, results of preoperative angiography, pat ient risk factors, operative techniques and complications, and long-te rm assisted primary graft patency and limb salvage. Results: Ninety-si x patients with 100 infrainguinal reversed vein grafts (69) femoral-po pliteal, 31 femoral-tibial) underwent 117 surgical vein graft revision s or inflow procedures during the study period Eighty-one percent of t he original reversed vein grafts consisted of a single segment of grea ter saphenous vein. All revised grafts had at least a 50% stenosis in the graft itself or the proximal or distal artery. A single revision w as performed in 85 grafts, two revisions in 13 grafts, and three revis ions in two grafts. There were nine (8%) isolated inflow procedures, e ight (7%) vein patch angioplasties, 62 (53%) interposition vein grafts , and 29 (25%) vein graft extensions to a new distal anastomotic site. The remaining nine (8%) procedures consisted of combinations of the a bove. Median time to primary graft revision after initial graft implan tation was 15 months (range 2 days to 316 months). Mean time to second ary revision after primary revision was 21 months. Operative mortality was 0.9%. Cumulative assisted primary patency of the original grafts revised for stenotic lesions was 99%, 96%, and 92% at 1, 3, and 5 year s, respectively. Limb salvage was 99%, 97%, and 97% at 1, 3, and 5 yea rs, respectively. Conclusions: Although surgical revision of reversed vein graft requires much use of alternative vein sources, these proced ures can be performed with minimum mortality and provide excellent ass isted primary graft patency and limb salvage.