REVISION OF REVERSED INFRAINGUINAL BYPASS GRAFTS WITHOUT PREOPERATIVEARTERIOGRAPHY

Purpose: To determine whether graft revision on the basis of a duplex scan alone without an arteriogram is effective in identifying graft st enosis and allowing for repair to preserve bypass graft patency. Metho ds: From 1994 to 1997, all patients in whom infrainguinal grafts were placed at a University-affiliated teaching hospital were entered into a prospective protocol using duplex scanning to detect stenotic lesion s, Studies were performed after the operation, at 1 month, at 3 months , and every 3 months thereafter. All grafts were composed of reversed autogenous vein and were placed subcutaneously to allow for easier mon itoring and correction. Patients who had failing grafts underwent oper ative correct-ion without preoperative arteriography. Results: During this interval, 48 lesions in 31 grafts were repaired. The indication f or repair was a velocity ratio greater than 2.5 in ail patients and gr eater than 3.0 for 43 lesions. Forty-four lesions had a peak systolic velocity greater than 250 cm/sec. Twenty-nine lesions reduced the dist al graft velocity to less than 45 cm/sec, Sixteen lesions involved the proximal anastomsis, 26 the body of the graft, three the distal anast omosis, two involved inflow arteries, and one affected the outflow ves sel. Repair included patch angioplasty for 39 lesions, resection with interposition graft-for five, a proximal jump graft for three, and a d istal extension graft for one. The severity and location of the stenos is was confirmed at operation in all cases. Twenty-eight of the 31 pat ients (90%) are currently alive, and follow-up on these patients has r anged from 5 to 36 months (mean, 19 months). Twenty-nine of the 31 gra fts (94%) remained patent, with a 92% patency rate by life table analy sis at 3 years. Follow-up duplex scans found improvement in the ankle- brachial index (mean increase, 0.33) and distal graft velocity (mean i ncrease, 43 cm/sec) in all patients. After repair, 27 patients had a d istal graft velocity greater than 45 cm/sec and no patient had a veloc ity ratio greater than 1.5. Complications included wound infection in two patients and bleeding that required reoperation in one. All sympto matic patients had clinical improvement, and none required early reexp loration for residual stenosis. Conclusions: Graft repair map be safel y performed on the basis of duplex scanning alone with preservation of bypass patency and correction of hemodynamic deterioration. Duplex sc anning can detect inflow or outflow disease in addition to intrinsic g raft stenoses and can identify sequential lesions, eliminating the nee d for, expense of, and risk of arteriography.