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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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.

10. 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
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
% at 6 months
% at 12 months
% at 24 months
% at 6 months
83.2% at 12 months
78.9% at 24 months

11. 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%

12. 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

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

18. 63 years old male
hypertension, dyslipidemia
femuro-popliteal venous bilateral bypass
critical ischemia of left lower extremity after one year from bypass surgery

21. OTW balloon 4,0/100 mm

22. 61 years old female
smoking, dyslipidemia
bilateral femuro-popliteal venous bypass
critical ischemia of left lower extremity after 3 months from surgery

24. OTW balloon 6,0/120 mm

26. 77 years old male
hypertension, dyslipidemia, obesity
left femuro-popliteal venous bypass
critical ischemia after 8 months

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

32. 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

33. 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

34. 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