- Email: [email protected]
21.8 Duplex graft surveillance, does it improve limb salvage?
23rd World Congress of the ISCVS at regular intervals. Over an eight year period, 220 grafts (141 above-knee popliteal, 69 below-knee popliteal, 10 tibial) were patent on discharge from hospital and entered the programme. A total of 560 duplex scans were performed: median two scans/graft (range: 1-8). Eleven grafts (5%) occluded prior to the first follow-up scan. An abnormal duplex scan was reported in relation to 56 grafts (25%) but for clinical reasons (no treatable lesion/no other bypass option/anticoagulated only/etc) no intervention was undertaken. Thirty-four grafts in this group occluded subsequently and 17 amputations resulted. Thirty-five grafts (16%) occluded despite apparently normal duplex scans, resulting in 18 amputations. A further 18 grafts (8%) with previous normal scan were found to be occluded unexpectedly on routine scanning, without any clinical deterioration. A further three amputations resulted. An intervention to maintain patency was carried out in 10 patients (4%): four for anastomotic hyperplasia and six for arterial disease progression. Primary and secondary graft patency rates at 36 months were 48% and 51%, respectively. If the aim of surveillance is to identify grafts at risk of occlusion, these data suggest that regular postoperative duplex scanning of infrainguinal PTFE grafts is not justified.
21.8 Duplex Graft Surveillance, Does it Improve Limb Salvage?
M .J. UCLARKE,A.S. BROWN, c.p. OATES, N.A.G. JONES, .I. CHAMBERLAIN and M.G. WYATT, Newcastle upon
Tyne, UK
Aims: Following
femoro-popliteal/distal (FPD) vein bypass, duplex surveillance is widely employed to detect graft related stenoses and allow intervention to prevent occlusion. The aim of this study was to determine whether such surveillance improves limb salvage rates. Methods: One hundred and nine FPD vein bypasses were performed between October 1993 and March 1996. Sixty-five (Group 1) were referred for duplex surveillance (1 month, 3 months, 6 months 9 months and 1 year) and 31 (Group 2) were followed up clinically. Thirteen patients suffered graft failure, amputation or died within 30 days (Group 3) and have been excluded from the surveillance analysis. Results: In Group 1, 18 grafts (28%) developed stenoses. Ten were revised, of which four restenosed and occluded. By comparison, three of the eight untreated grafts occluded (n.s., P = 0.37, Fisher’s exact test). In Group 2, four symptomatic grafts (13%) were successfully revised. In Group 3, five grafts occluded between 10 and 30 days. The table shows cumulative life table results at 1 year.
Primary
Group 1
Group 2
Logrank test
Patency Assisted primary patency Limb salvage Survival
71 87 98 91
64 76 96 87
P > 0.2 P > 0.1 P > 0.2 P > 0.2
Conclusions: In patients whose grafts remain functional beyond the first month, duplex surveillance has little effect on graft patency, limb salvage or patient survival. A significant
108
number of grafts fail in the first 30 days and intensive surveillance may be of benefit during this period. A randomized clinical trial of duplex surveillance is required to determine its most effective clinical utilization.
21.9 Three-year Results of the Epoxy-treated Vascular Bioprostheses Application for Femoro-popliteal and Femoro-tibia1 Bypass Grafting
L.S. BARBARASH, A.S. KRIKOVTSOV, S.V. IVANOV and I. Yu. ZHOURAVLZOVA, Kemerovo Russia Between 1993 and 1996 vascular bioprostheses from the bovine mammary artery were applied in 115 patients with chronic occlusive disease of lower extremities. Bioprotheses were produced using the original technique of biotissue treatment with 5% diglycidyl ether ethylene glycol. One hundred and forty-five prostheses were implanted in 126 lower extremities: 73 of them as femoro-popliteal bypass with the distal anastomosis above the knee joint (Group I), 48 grafts as femoro-popliteal bypasses below the knee joint (Group II) and 24 grafts femoro-tibia1 bypasses (Group III). Bioprosthetic primary actuarial patency rates under a 3 year period following surgery were 71.6%, 68.5% and 61.3% in Group I, II and III, respectively. Bioprosthetic infection was noted in four patients, two patients had ectasia. In patients of Group I, with good outflow tract, actuarial patency rate was
79.9%. In these cases diepoxy-treated bioprostheses may present the alternative to the autologic vein and be used as the bioprostheses of choice.
21.10 Does Intraoperative Resistance Measurement Predict Postoperative Graft Related Problems? K.G. MERCER, D.J.A. SCOm, M.J. WESTON and D.C. BERRIDGE, Leeds, UK Zntroduction: Autologous vein gives superior patency rates to synthetic graft materials in infrainguinal arterial reconstruction. Duplex graft surveillance uses a doubling of peak systolic velocity in the graft to identify at risk grafts for radiological or surgical intervention. Intraoperative measurement of out-flow resistance has been shown to correlate with early and intermediate graft patency. However, the value of intraoperative measurement in predicting graft related problems has not been demonstrated. Aim: To establish the value of intraoperative flow measurements as predictors of graft occlusion or a requirement for interventional procedure. Materials: Forty-five infrainguinal reconstructions (18 popliteal; 27 to trifurcation vessels) carried out in 43 patients (11 women, 32 men; median age 73 years; range 41-89) using autologous vein. Methods: Intraoperative measurements of flow rate, peak systolic velocity (PSV) and peripheral resistance after injection of 25 mg of papaverine were carried out on autologous vein grafts. These parameters were compared to the incidence of graft occlusion or radiological or surgical intervention (insti-
CARDIOVASCULAR SURGERY
S E P T E M B E R 1997
21.8 Duplex Graft Surveillance, Does it Improve Limb Salvage?
M .J. UCLARKE,A.S. BROWN, c.p. OATES, N.A.G. JONES, .I. CHAMBERLAIN and M.G. WYATT, Newcastle upon
Tyne, UK
Aims: Following
femoro-popliteal/distal (FPD) vein bypass, duplex surveillance is widely employed to detect graft related stenoses and allow intervention to prevent occlusion. The aim of this study was to determine whether such surveillance improves limb salvage rates. Methods: One hundred and nine FPD vein bypasses were performed between October 1993 and March 1996. Sixty-five (Group 1) were referred for duplex surveillance (1 month, 3 months, 6 months 9 months and 1 year) and 31 (Group 2) were followed up clinically. Thirteen patients suffered graft failure, amputation or died within 30 days (Group 3) and have been excluded from the surveillance analysis. Results: In Group 1, 18 grafts (28%) developed stenoses. Ten were revised, of which four restenosed and occluded. By comparison, three of the eight untreated grafts occluded (n.s., P = 0.37, Fisher’s exact test). In Group 2, four symptomatic grafts (13%) were successfully revised. In Group 3, five grafts occluded between 10 and 30 days. The table shows cumulative life table results at 1 year.
Primary
Group 1
Group 2
Logrank test
Patency Assisted primary patency Limb salvage Survival
71 87 98 91
64 76 96 87
P > 0.2 P > 0.1 P > 0.2 P > 0.2
Conclusions: In patients whose grafts remain functional beyond the first month, duplex surveillance has little effect on graft patency, limb salvage or patient survival. A significant
108
number of grafts fail in the first 30 days and intensive surveillance may be of benefit during this period. A randomized clinical trial of duplex surveillance is required to determine its most effective clinical utilization.
21.9 Three-year Results of the Epoxy-treated Vascular Bioprostheses Application for Femoro-popliteal and Femoro-tibia1 Bypass Grafting
L.S. BARBARASH, A.S. KRIKOVTSOV, S.V. IVANOV and I. Yu. ZHOURAVLZOVA, Kemerovo Russia Between 1993 and 1996 vascular bioprostheses from the bovine mammary artery were applied in 115 patients with chronic occlusive disease of lower extremities. Bioprotheses were produced using the original technique of biotissue treatment with 5% diglycidyl ether ethylene glycol. One hundred and forty-five prostheses were implanted in 126 lower extremities: 73 of them as femoro-popliteal bypass with the distal anastomosis above the knee joint (Group I), 48 grafts as femoro-popliteal bypasses below the knee joint (Group II) and 24 grafts femoro-tibia1 bypasses (Group III). Bioprosthetic primary actuarial patency rates under a 3 year period following surgery were 71.6%, 68.5% and 61.3% in Group I, II and III, respectively. Bioprosthetic infection was noted in four patients, two patients had ectasia. In patients of Group I, with good outflow tract, actuarial patency rate was
79.9%. In these cases diepoxy-treated bioprostheses may present the alternative to the autologic vein and be used as the bioprostheses of choice.
21.10 Does Intraoperative Resistance Measurement Predict Postoperative Graft Related Problems? K.G. MERCER, D.J.A. SCOm, M.J. WESTON and D.C. BERRIDGE, Leeds, UK Zntroduction: Autologous vein gives superior patency rates to synthetic graft materials in infrainguinal arterial reconstruction. Duplex graft surveillance uses a doubling of peak systolic velocity in the graft to identify at risk grafts for radiological or surgical intervention. Intraoperative measurement of out-flow resistance has been shown to correlate with early and intermediate graft patency. However, the value of intraoperative measurement in predicting graft related problems has not been demonstrated. Aim: To establish the value of intraoperative flow measurements as predictors of graft occlusion or a requirement for interventional procedure. Materials: Forty-five infrainguinal reconstructions (18 popliteal; 27 to trifurcation vessels) carried out in 43 patients (11 women, 32 men; median age 73 years; range 41-89) using autologous vein. Methods: Intraoperative measurements of flow rate, peak systolic velocity (PSV) and peripheral resistance after injection of 25 mg of papaverine were carried out on autologous vein grafts. These parameters were compared to the incidence of graft occlusion or radiological or surgical intervention (insti-
CARDIOVASCULAR SURGERY
S E P T E M B E R 1997