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IP193. Involvement of Hemodialysis to Graft Stenosis Development in Paramalleolar Bypasses Vein Graft
JOURNAL OF VASCULAR SURGERY June Supplement 2016
116S Abstracts
Table. Revascularization group
Age, years Male, No. (%) Rutherford, No. (%) 4 5 6 Ankle-brachial index Before After Major amputation, No. (%) Follow-up, months
Complete (n ¼ 38)
Incomplete (n ¼ 23)
P value
67.2 18 (47)
70.7 11 (48)
.11 .97
14 (37) 24 (63) 0 (0)
16 (70) 7 (30) 0 (0)
.027 .027 e
0.42 0.87 1 (2.6)
0.27 0.53 2 (8.7)
.046 .0001 .20
15.7
12.2
.40
(8.7%) than in the CR group (2.6%) but was not statistically significant (P ¼ .20). The mean follow-up months was similar between two groups: 15.7 months in the CR group and 12.2 months in the IR group (P ¼ .40). Conclusions: For patients with CLI caused by CFAinvolved complicated arterial lesions, complete revascularization by the hybrid procedure achieved a higher postoperative ABI and may have contributed to limb salvage. Author Disclosures: J. Matsumura: Abbott, Cook Medical, Covidien, Endologix, and W. L. Gore: contracted research; T. Takayama: Nothing to disclose. IP193. Involvement of Hemodialysis to Graft Stenosis Development in Paramalleolar Bypasses Vein Graft Shinsuke Kikuchi, MD1, Daiki Uchida, MD1, Atsuhiro Koya, MD1, Hisashi Uchida, MD2, Yukihiro Saito, MD, PhD3, Tadahiro Sasajima, MD, PhD4, Nobuyoshi Azuma, MD, PhD1. 1Asahikawa Medical University, Asahikawa, Japan; 2Sapporo kosei hospital, Sapporo, Japan; 3Asahikawa Medical University, Asahikawa, Japan; 4 Asahikawa Medical University, Tokyo, Japan Objectives: Paramalleolar or inframalleolar bypass (distal bypass [DB] as below) is one of important option for limb salvage in diabetes mellitus (DM) and hemodialysis (HD) patients with critical limb ischemia (CLI). Vein bypass grafting has crucial superiority regarding its long-term patency and durability compared to endovascular treatment, whereas the understanding of graft stenosis (mainly progressive intimal hyperplasia), which is the main cause of vein graft failure, is still not enough, especially in HD patients. Methods: This was a retrospective single-center study. Between 2000 and 2013, DB was performed for 401 consecutive CLI using autogenous vein in all cases, in which HD and non-HD (NHD) limbs were 242 (60.3%) and 159 (39.7%), respectively. Patients with grafts with early thrombosis that underwent successful revision surgery were ncluded in the analysis, and patients who had operative death, major amputation, or graft occlusion with 4 weeks after surgery were excluded. Single vein graft was placed in 68.2% of HD limbs and 74.8% of NHD limbs (P ¼ .15). There was no difference between the groups in poor quality graft (<3 mm; 23.1% vs 22.6%; P ¼ .91). In addition, arterial
Fig.
runoff score, based on the Rutherford resistance value, was significantly poorer in HD limbs than in NHD limbs (68.6% vs 42.1%; P < .01). The end point was graft stenosis development, which occurred from 4 weeks to 5 years after bypass surgery, and risk factors for graft stenosis were assessed by Cox proportional hazard model. Results: Five-year cumulative graft stenosis developed more in HD grafts compared to NHD grafts (38.2% vs 24.8%; P ¼ .035; Fig). Breakdown of graft stenosis was mainly long-segmental graft narrowing (36.4% vs 35.1%), distal anastomosis site (16.7% vs 18.9%), proximal anastomosis site (13.6% vs 13.5%), composite site (10.6% vs 10.8%), and valve site (6.6% vs 10.8%). Multivariate analysis identified the following risk factors for graft stenosis development in DBs: female gender (hazard ratio, 1.777; 95% confidence interval, 1.148-1.753); poor quality vein (2.438; 1.608-3.696; P < .01), spliced vein graft (3.181; 2.126-4.760; P < .01); poor arterial runoff (2.276; 1.466-3.531; P < .01), dropping HD out. Conclusions: Graft stenosis has continued developing for longer time in HD patients. The vein graft having one of the 4 factorsdspliced vein graft, poor quality vein, poor run-off, and female genderdshould be managed by a longer graft surveillance program. Although HD is not detected as the risk factors, it should be remembered that HD strongly reflects poor runoff in the patient’s background. Author Disclosures: N. Azuma: Nothing to disclose; S. Kikuchi: Nothing to disclose; A. Koya: Nothing to disclose; Y. Saito: Nothing to disclose; T. Sasajima: Nothing to disclose; D. Uchida: Nothing to disclose; H. Uchida: Nothing to disclose. IP195. Vascular Surgeons Play a Critical Role in the Perioperative Management of Patients With End-Stage Heart Failure Thomas M. Loh, MD, Cassidy Duran, MD, Barry Trachtenberg, MD, Jerry Estep, MD, Jean Bismuth, MD. Houston Methodist Hospital, Houston, Tex Objectives: Patients in end-stage heart failure are medically complex and often require invasive monitoring
116S Abstracts
Table. Revascularization group
Age, years Male, No. (%) Rutherford, No. (%) 4 5 6 Ankle-brachial index Before After Major amputation, No. (%) Follow-up, months
Complete (n ¼ 38)
Incomplete (n ¼ 23)
P value
67.2 18 (47)
70.7 11 (48)
.11 .97
14 (37) 24 (63) 0 (0)
16 (70) 7 (30) 0 (0)
.027 .027 e
0.42 0.87 1 (2.6)
0.27 0.53 2 (8.7)
.046 .0001 .20
15.7
12.2
.40
(8.7%) than in the CR group (2.6%) but was not statistically significant (P ¼ .20). The mean follow-up months was similar between two groups: 15.7 months in the CR group and 12.2 months in the IR group (P ¼ .40). Conclusions: For patients with CLI caused by CFAinvolved complicated arterial lesions, complete revascularization by the hybrid procedure achieved a higher postoperative ABI and may have contributed to limb salvage. Author Disclosures: J. Matsumura: Abbott, Cook Medical, Covidien, Endologix, and W. L. Gore: contracted research; T. Takayama: Nothing to disclose. IP193. Involvement of Hemodialysis to Graft Stenosis Development in Paramalleolar Bypasses Vein Graft Shinsuke Kikuchi, MD1, Daiki Uchida, MD1, Atsuhiro Koya, MD1, Hisashi Uchida, MD2, Yukihiro Saito, MD, PhD3, Tadahiro Sasajima, MD, PhD4, Nobuyoshi Azuma, MD, PhD1. 1Asahikawa Medical University, Asahikawa, Japan; 2Sapporo kosei hospital, Sapporo, Japan; 3Asahikawa Medical University, Asahikawa, Japan; 4 Asahikawa Medical University, Tokyo, Japan Objectives: Paramalleolar or inframalleolar bypass (distal bypass [DB] as below) is one of important option for limb salvage in diabetes mellitus (DM) and hemodialysis (HD) patients with critical limb ischemia (CLI). Vein bypass grafting has crucial superiority regarding its long-term patency and durability compared to endovascular treatment, whereas the understanding of graft stenosis (mainly progressive intimal hyperplasia), which is the main cause of vein graft failure, is still not enough, especially in HD patients. Methods: This was a retrospective single-center study. Between 2000 and 2013, DB was performed for 401 consecutive CLI using autogenous vein in all cases, in which HD and non-HD (NHD) limbs were 242 (60.3%) and 159 (39.7%), respectively. Patients with grafts with early thrombosis that underwent successful revision surgery were ncluded in the analysis, and patients who had operative death, major amputation, or graft occlusion with 4 weeks after surgery were excluded. Single vein graft was placed in 68.2% of HD limbs and 74.8% of NHD limbs (P ¼ .15). There was no difference between the groups in poor quality graft (<3 mm; 23.1% vs 22.6%; P ¼ .91). In addition, arterial
Fig.
runoff score, based on the Rutherford resistance value, was significantly poorer in HD limbs than in NHD limbs (68.6% vs 42.1%; P < .01). The end point was graft stenosis development, which occurred from 4 weeks to 5 years after bypass surgery, and risk factors for graft stenosis were assessed by Cox proportional hazard model. Results: Five-year cumulative graft stenosis developed more in HD grafts compared to NHD grafts (38.2% vs 24.8%; P ¼ .035; Fig). Breakdown of graft stenosis was mainly long-segmental graft narrowing (36.4% vs 35.1%), distal anastomosis site (16.7% vs 18.9%), proximal anastomosis site (13.6% vs 13.5%), composite site (10.6% vs 10.8%), and valve site (6.6% vs 10.8%). Multivariate analysis identified the following risk factors for graft stenosis development in DBs: female gender (hazard ratio, 1.777; 95% confidence interval, 1.148-1.753); poor quality vein (2.438; 1.608-3.696; P < .01), spliced vein graft (3.181; 2.126-4.760; P < .01); poor arterial runoff (2.276; 1.466-3.531; P < .01), dropping HD out. Conclusions: Graft stenosis has continued developing for longer time in HD patients. The vein graft having one of the 4 factorsdspliced vein graft, poor quality vein, poor run-off, and female genderdshould be managed by a longer graft surveillance program. Although HD is not detected as the risk factors, it should be remembered that HD strongly reflects poor runoff in the patient’s background. Author Disclosures: N. Azuma: Nothing to disclose; S. Kikuchi: Nothing to disclose; A. Koya: Nothing to disclose; Y. Saito: Nothing to disclose; T. Sasajima: Nothing to disclose; D. Uchida: Nothing to disclose; H. Uchida: Nothing to disclose. IP195. Vascular Surgeons Play a Critical Role in the Perioperative Management of Patients With End-Stage Heart Failure Thomas M. Loh, MD, Cassidy Duran, MD, Barry Trachtenberg, MD, Jerry Estep, MD, Jean Bismuth, MD. Houston Methodist Hospital, Houston, Tex Objectives: Patients in end-stage heart failure are medically complex and often require invasive monitoring