Chapter 13 Evaluation of arterial bypass grafts and stents

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Presentation transcript:

Chapter 13 Evaluation of arterial bypass grafts and stents

Treatment of Lower Arterial Disease Conservative treatment cessation of smoking regular exercise lowering cholesterol and LDL Medications options: Trental, Pletal

Interventional Procedures Bypass graft Synthetic: Polytetrafluoroethylene (PTFE) , Dacron Autogenous vein grafts Reversed In situ Percutaneous angioplasty (PTA) Stents

Aorto-femoral grafts 1. 2. 3. Axillo-fem Fem-fem Aorto-iliac Fem -Fem

Femoral - distal graft In situ Vein Graft Uses greater saphenous vein (GSV) in native bed Valves leaflets are excised Perforators / tributaries are ligated Proximal and distal ends are anastomosed to artery

Valvulatome

Occluded SFA In situ vein graft CFV CFA PFA SFA GSV CFA GSV ligated Perforators Valves CFV CFA PFA SFA GSV CFA GSV ligated perforators

Reverse vein graft GSV harvested CFA SFA Vein graft GSV harvested Perforating veins and tributaries are ligated and cut Vein reversed and implanted as bypass Valves are not excised Small diameter proximally, large diameter distally is advantageous

PTFE Graft

In situ fem-tibial graft femoro-popliteal graft

Graft surveillance 20-30 % stenosis rate within 1 year if graft occludes, 20-50% patency rate after thrombectomy 60% of graft stenoses are ASX, due to limited ambulation - limb salvage

Bypass graft surveillance Identify graft type Perform ABI Map graft and record spectral waveforms prox, mid and distally Measure PSV

Graft evaluation Graft inflow and anastomosis entire graft wall irregularity partially excised valve leaflets A-V in non-ligated perforators (insitu only)

Graft evaluation Aneurysm P-aneurysm Distal anastomosis run-off Vein graft aneurysm

Distal anastomosis Stenosis has an abrupt increase in velocity High frequency Stenosis has an abrupt increase in velocity

Bypass graft surveillance 0.15 drop in ABI suggests graft stenosis Duplex is more sensitive than ABI for stenosis

> 50% graft stenosis Peak Velocities > 150cm/s Velocity ratio > 2.0 Post stenostic turbulence

Pt. Flint Recent In-situ femoro-popliteal. No increase post-op in ABI

Vein graft stenosis

Graft - valve stenosis Graft stenosis

Vein graft -pre stenosis PSV 39 cm/s

Vein graft, max stenosis PSV 504 cm/s

Graft- Post stenosis PSV 120cm/s

Distal vein graft PSV 49 cm/s

Graft surveillance Dennis Bandyk, MD, RVT

Graft surveillance Threshold for graft revision > 300 cm/s VR > 3.5 low velocity < 40-45 cm/s ABI Dennis Bandyk, MD, RVT

Reverse vein graft stenosis Valve cusp Transverse vein graft

Stents Palmaz - balloon deployed Wallstent - self expanding

Palmaz stent - nonexpanded Palmaz stent expanded on PTA balloon

Stent sites: peripheral vascular Aorta renals iliacs femoral - popliteal carotid

Stent deployment

Carotid stent

Graft waveform 1 week post op Hyperemia will usually occur in normal, patent grafts in the early post op period.

Endoluminal AAA repair with covered stent Fem-fem bypass