The Role of Interventional Treatment for The Failing Grafts Marin POSTU IECVD “C.C.Iliescu” Bucharest, ROMANIA

Patient with the most severe manifestations of lower extremity arterial occlusive disease often require peripheral bypass surgery for limb salvage and preservation of function 5 years failure rate (in good quality conditions) are 30-50% - unchanged for the past two decades The majority occur within the first year

The failing graft – the graft that has one or multiple hemodinamically significant stenosis that, if unrepaired, may lead to a failure. There are three distinct temporal phases of failure - early – within 30 days - mid-term – 3-24 months - late - > 2 years 5-10 % generally ascribed to technical complication ascribed to the development of intimal hyperplasia and progression of atherosclerotic degeneration in the native arterial tree

Anatomical classification of failing grafts  Lesion on native vessel    Lesion on anastomosis        Lesion on grafts          - Run in vessel - Run off vessel - Proximal anastomosis - Distal anastomosis

Reporting standards have recommended defining bypass graft endpoints into three categories Primary patency – uninterrupted patency with no procedure or intervention Primary assisted patency – is never lost but is maintained by prophylactic intervention endovascular or surgical Secondary patency – the time from implantation until the graft is occluded

The pooled weighted data for 1,3 and 5 years primary patency for femuro-distal bypass Venous bypass Prosthetic bypass 1 year 85% 3 years 80% 5 years 70% 1 year 70% 3 years 35% 5 years 25% * ESC guidelines

Recommendations for surgical revascularization in patient with lower extremity artery disease Class of recommendation I Level of evidence A When surgery is considered to revascularize infrailiac lesions, the autogenous saphenous vein is the bypass graft of choice * ESC guidelines

SURVEILLANCE There is no consensual protocol, but regular monitoring of revascularized limbs can permit a prompt prophylactic interventions and improve long term patency * Multicenter randomized trial included 594 pts. with vein graft found that a systematic duplex surveillance was not found to be beneficial in terms of short patency and limb survival rate and was less cost effective that clinical surveillance *. * ESC guidelines * Davies AV et al. study Circulation 2005

SURVEILLANCE ACC AHA Guidelines Recommendation Class. I, level of evidence B Long-term patency of infrainghinal bypass grafts should be evaluated in a surveillance program, which should include an interval vascular history , physical examination and a duplex ultrasound at regular intervals if a venous conduit has been used. The detection of a flow-limiting lesion has significant implication that permit improved maintenance of the long term patency of the instrumented native vessel or graft. As a result follow-up of autogenous vein bypass graft should be performed with duplex USG at intervals of 1,3,6,12,18 and 24 months and then annually.

Study Gregory A. Carlson et al. Iowa, USA, J.Vasc Surgery 2004 Retrospective study to evaluate the role of balloon angioplasty in the treatment of failing infrainguinal vein bypass grafts 1990-2001 Initial success 91.7% Cumulative primary patency Cumulative assisted patency CONCLUSION: This procedure should be considered as an initial option in failing infrainguinal vein bypass grafts - 74.2% at 6 months - 62.6% at 12 months - 58.2% at 24 months - 87.0% at 6 months 83.2% at 12 months 78.9% at 24 months

Angioplasty for Diabetic Patients with Failing Bypass Graft or Residual critical Ischemia after Bypass Graft, E. Faglia et al.,Eur. J. Vasc. Endovascular Surgery (2008) 36 Successful PTA was in 78.1% Follow up – 1.89±0.27 years find 28% restenosis After repeated angioplasty Conclusions : PTA is an elective method for revascularizing secondary obstructions in patients with graft failure - the cumulative primary patency was 72% - the assisted patency 92%

Balloon Angioplasty at the Primary Treatment for Failing Infra-inguinal Vein Grafts, R.Mofidi et al., European Journal of Vascular Endovascular Surgery 2009/37 411 grafts were followed up for a median 19 months 22.6% developed critical stenosis 76 patients underwent endovascular procedure Technical success – 78.9% Repeat angioplasty – technical success 75% No difference was observed in graft patency (p=0.08) or amputation rate (p=0.32) between the grafts requiring intervention to maintain patency and grafts which did not Conclusions: Balloon angioplasty of failing infra-inguinal vein bypass grafts is safe and can be performed with an acceptable medium term patency rate

Male, 62 years old smoking, diabetes, dyslipidemia critical ischemia of left lower extremity after 2 months from venous femuro-popliteal bypass

63 years old male hypertension, dyslipidemia femuro-popliteal venous bilateral bypass critical ischemia of left lower extremity after one year from bypass surgery

OTW balloon 4,0/100 mm

61 years old female smoking, dyslipidemia bilateral femuro-popliteal venous bypass critical ischemia of left lower extremity after 3 months from surgery

OTW balloon 6,0/120 mm

77 years old male hypertension, dyslipidemia, obesity left femuro-popliteal venous bypass critical ischemia after 8 months

after 2 years patient came back with critical ischemia of the left lower extremity

Conclusion Follow-up of bypass graft should be performed by clinical examination and if it possible with duplex USG for prevention of reoccurrence of symptoms Endovascular intervention should be considered as an initial option in failing infrainguinal vein bypass graft PTA is an elective method for revascularizing secondary obstructions in patients with graft failure

Discussion The high rate of restenosis after PTA may suggest that the use of pharmacologically active stents and balloons can increase primary patency after PTA

Failing Andie Brandt Describe your life in one word. Failure. I often find myself failing ………………………… But you see there's something I realized ………………………… ……with my survival There's something successful