ANGIOSCOPICALLY DIRECTED INTERVENTIONS IMPROVE ARM VEIN BYPASS GRAFTS

Purpose: Our purpose was to determine the incidence and segmental dist ribution of intraluminal disease in the arm veins of patients in whom saphenous vein was unavailable or inadequate for bypass, determine whe ther angioscopic evaluation and directed interventions can upgrade the quality of arm vein conduit and improve early graft patency, and desc ribe the angioscopic technique of in situ retrograde arm vein inspecti on. Methods. Retrospective review of 109 infrainguinal arm vein bypass grafts in 104 patients performed with intraoperative angioscopic vein preparation and monitoring between August 1989 and March 1992 was und ertaken. Four additional arm veins harvested were discarded because of diffuse disease. Results: IntraluminaI disease was noted in 71 (62.8% ) of 113 arm veins, ''webs'' in 61 (54%), vein sclerosis in 25 (22.1%) , localized stenosis in 11 (9.7%), and thrombus in 7 (6.2%). Intralumi nal disease was most common in the cephalic (forearm 49.2%; arm 35.1%) and median cubital (33.3%) veins and least common in the basilic vein (11.7%). Eighty-three angioscopically directed interventions in 68 of 71 abnormal arm veins resulted in upgraded vein conduit quality in 47 (66.1%) of 71. Primary patency (< 30 days) was 99 (90.8%) of the 109 grafts, 85 (95.5%) of 89 grafts with normal or upgraded quality condui ts, and 14 (70%) of 20 inferior-quality grafts (p = 0.0024). These dif ferences persisted through 1 year by life-table analysis, (p < 0.001). Conclusions: Not only is the routine use of the angioscope in arm vei n bypass grafting a sensitive technique to detect the intraluminal dis eases so prevalent in arm veins but it can also direct endoluminal and surgical interventions that upgrade the quality of the vein conduit a nd improve early graft patency.