1. Division of Endovascular Interventions
Mount Sinai Hospital
New York
11/20/2018

2. Case presentation
69 y.o. male presenting with (+) family history of heart disease, former smoker, PMH of Arthritis, Hep C, DM, HTN, HLD
PAD :
s/p multiple peripheral interventions
s/p right fem-tibial bypass with right endartectomy in January 2018
Recent Primary mech thrombectomy and DCB of LSFA ISR, PTA with DES of mid & distal Left SFA, DCB on Left popliteal artery & PTA with DES of Proximal LPT done in the setting of CLI
B-mode and spectral analysis is consistent with a 50-99% stenosis in the mid posterior tibial artery (PSV 469 cm/sec) just distal to the graft anastomosis.
Medications: Lisinopril, Glucophage, Xeralto, Plavix, Zocor, Carvedilol, Pletal, Gabapentin
Hb- 12.0, INR- 1.0, Creatinine- 1.0

3. Duplex surveillance- Marked spectral broadending and elevated velocities(460cm/s)

4. PSV ratio=10

5. Iliac angiogram

6. Run off of the RLE

7. DSA of Right common femoral to posterior tibial artery bypass touch down

8. BTN run off

9. Strategy L access, 6 Fr up and over sheath, Angiomax 0.014 wire
PTA/Atherotomy+/-stenting

10. Types of lower Extremity bypass grafts
Aortoiliac Disease
Direct Aortoiliac Revascularization
Aortobifemoral Bypass
Iliofemoral Bypass
Extra-Anatomic Bypass
Femorofemoral Bypass
Axillobifemoral Bypass
Femoropopliteal Disease
Femoral–popliteal bypass
Femoro-distal/femoro-tibial/peroneal/pedal bypass (CLI-inline flow)

11. Graft composition/conduit choice
Autogenous Grafts
Soft compressible vein, ideally at least 3mm in diameter and not calcified or sclerotic, without thrombosis or valve incompetence.
GSV (Ipsi- PREFERRED)> GSV (contra unless ABI <0.6 on that side)
SSV> femoral veins
Arm veins(basilic and cephalic)
Cryopreserved veins
Prosthetic grafts
Dacron
Heparin-bonded dacron
PTFE with and without a distal cuff (esp for bypasses BTK vein cuffs has superior patency and improve limb salvage)

12. Graft patency- AI disease
(Circ Res. 2015;116: DOI: /
CIRCRESAHA )

13. Graft patency- (Circ Res. 2015;116:1614-1628. DOI: 10.1161/
CIRCRESAHA )

14. BASIL study

15. BASIL Trial

16. BASIL trial- summary
Randomized trial of open vs endo revascularization for CLI
Early results with the two therapies were broadly similar
For patients who received a bypass and survived 2 years had a greater OS and AFS than those who went to have endo first
Bypass after failed endo intervention also fared poorly than those who went to bypass first
Outcome of vein bypass was better for AFS (P = 0.003) but not OS (P = 0.38, log-rank tests) than prosthetic BSX

18. Meta-analysis C of primary and secondary patencies

19. Meta-analysis CI of primary and secondary patencies

20. Graft failure
Vein graft stenosis is common (as high as 20% within 2 years)
Graft failure is divided into three phases
early (0 to 30 days)- technical failure
intermediate (30 days to 2 years)- usually intimal hyperplasia, young age, hypercoagulable state, redo bypass, critical limb ischemia, smoking, or inflammation
late (2 or more years)- related to progression of atherosclerosis, including natural progression of compromised in-flow of distal run-off vessels

21. Definition of patency
Primary Patency: defined as exempt from restenosis of the target lesion during follow-up.
Assisted primary patency: is defined as patency of the target lesion following endovascular re-intervention at the target vessel site in case of symptomatic restenosis.
Assisted primary patency: reports patency of the target lesion after treatment of a (re)occlusion of the index lesion.

22. Surveillance
Focused examination with color flow duplex ultrasound at 0, 1, 3, 6, 12, and 18 months with respect to surgery and then annually there after
Identification and repair of critical stenosis (PSV> 300 cm/s, PSVR>3.5 graft flow velocity <45 and change in ABI >0.15)

25. Treatment of failed grafts

26. KM analysis of patency

28. Comparison of treatment modalities

29. Supporting literature..
Avino et al demonstrated that the stenosis-free patency rate at 2 years was the same for both OS and PTA (63%) when patients were carefully selected for an endovascular approach. Graft stenoses selected for PTA were focal, short (2 cm), single lesions in grafts that were 3.5 mm in diameter and had been in place for 3 months.
Nguyen et al used PTA for focal, short (1.5 cm) lesions in the body of the graft and achieved 48% patency at 5 years.
Tong et al used PTA to treat all-comers with vein graft stenosis, and this resulted in patencies of 54% at 3 years and 45% at 5 years.