Surgical and endovascular intervention for infrainguinal vein graft stenosis

Purpose: The purpose of this study was to evaluate the stenosis-free patenc y of open repair (vein-patch angioplasty, interposition, jump grafting) and percutaneous transluminal balloon angioplasty (PTA) of 144 vein graft sten oses that were detected during duplex scan surveillance after infrainguinal vein bypass grafting. Methods: Patients who underwent revision of an infrainguinal vein bypass gr aft were analyzed for type of vein conduit, vascular laboratory findings le ading to revision, repair techniques, assisted graft patency rate, procedur e mortality rate, and restenosis of the repair site. Results: The time of postoperative revision ranged from 1 day to 133 months (mean, 13 months). One hundred eighteen primary and 26 recurrent stenoses (peak systolic velocity >300 cm/s) in 52 tibial and 35 popliteal rein bypas s grafts were identified by means of duplex scanning. The repairs consisted of 77 open procedures (vein-patch angioplasty 28; vein interposition, 33; jump graft, 9; primary repair, 3) and 67 PTAs. No patient died as a result of intervention. Cumulative assisted graft patency rate (life-table analysi s) was 91% at 1 year and 80% at 3 years. At 2 years, cumulative assisted gr aft patency rate was comparable for saphenous vein grafts (reversed, 94%; i n situ, 88%; nonreversed, 63%) and alternative vein grafts (89%). Stenosis- free patency rate at 2 years was identical (P =.55) for surgical interventi on (63%) and endovascular intervention (63%) but varied with type of surgic al revision (P =.04) and time of intervention (<4 months, 45%; >4 months, 7 1%; P =.006). The use of duplex scan-monitored PTA to treat focal stenoses (<2 cm) and fate-appearing stenoses (>3 months) was associated with a steno sis-free patency rate that was 89% at 1 year. After intervention, the alter native vein bypass grafts necessitated twice the reinterventions per month of graft survival (P =.01). Bypass graft to the popliteal versus infragenic ulate arteries, site of graft stenosis (vein conduit, anastomotic region), and repair of a primary versus a recurrent stenosis did not influence the o utcome after intervention. Conclusion: The revision of duplex scan-detected vein graft stenosis with s urgical or endovascular techniques was associated with an excellent patency rate, including when intervention on alternative vein conduits or treatmen t of restenosis was neccssary. When PTA was selected on the basis of clinic al and duplex scan selection criteria, the endovascular treatment of focal vein graft stenosis was effective, durable, and comparable with the surgica l revision of more extensive lesions.