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PAPER

Factors Affecting Symptomatic vs Asymptomatic Vein Graft Stenoses in Lower Extremity Bypass Grafts
Gregory J. Landry, MD; Timothy K. Liem, MD; Erica L. Mitchell, MD; James M. Edwards, MD; Gregory L. Moneta, MD

Objective: To determine differences in patients undergoing lower extremity vein graft revisions presenting with and without recurrence of preoperative symptoms. Design: Retrospective case-control study of a prospec-

Results: Vein graft stenoses were asymptomatic in 125

tively maintained database.
Setting: University and veterans’ administration hos-

pitals
Patients: Two hundred nineteen lower extremity vein graft revisions were performed in 161 patients from January 1995 to January 2007. Patients were categorized as asymptomatic or symptomatic (recurrence of initial symptoms) at the time of revision. Main Outcome Measures: Univariate analysis was per-

cases (57%) and symptomatic in 94 cases (43%). Symptomatic recurrences were associated with a significantly greater drop in ankle brachial index than asymptomatic lesions (mean [SD], 0.21 [0.03] vs 0.11 [0.02]; P =.003). Distal graft or outflow lesions were significantly associated with symptom recurrence (P = .048). Multivariate analysis identified ankle brachial index decrease (odds ratio, 6.803; 95% confidence interval, 1.418-32.258; P =.02) and the use of alternate graft conduit (odds ratio, 2.633, 95% confidence interval, 1.243-5.578; P =.01) as independent predictors of recurrent symptoms. Overall 5-year patency was the same regardless of preoperative symptoms (82% symptomatic and 88% asymptomatic; P =.30).
Conclusions: Symptomatic recurrences are associated with larger decreases in ankle brachial index, distal lesions, and alternate conduit grafts. Duplex surveillance is necessary to identify asymptomatic vein graft stenoses. Because graft patency is independent of preoperative symptoms, surveillance consisting of clinical follow-up with ankle brachial index evaluation warrants further consideration.

formed to assess differences in patient demographics, details of initial operation, site of recurrent lesion, and follow-up surveillance data between symptomatic and asymptomatic patients. Independent predictors of symptomatic recurrence were identified with multivariate logistic regression. Primary assisted patency was compared between revisions performed for symptomatic and asymptomatic lesions.

Arch Surg. 2007;142(9):848-854 though the reasons for this are not known. This study was undertaken to assess differences in vein graft stenoses that present asymptomatically compared with those that present with recurrence of symptoms.
METHODS Patients (maintained in a prospective database) undergoing lower extremity vein graft revisions at the Oregon Health & Science University and Portland Veterans Administration Hospital from 1995 to 2007 were included in the study. Information in the database included patient demographics, operative indication, operative details (inflow, outflow, and conduit), vascular laboratory follow-up data, details of surgical revisions, and long-term follow-up data following revision. At the time of revision, it was recorded whether or not the pa-

Author Affiliations: Department of Surgery, Division of Vascular Surgery, Oregon Health & Science University (Drs Landry, Liem, Mitchell, and Moneta), and Department of Surgery, Portland VA Medical Center (Dr Edwards), Portland.

tremity vein grafts occasionally develop stenoses that threaten the patency of the graft. Approximately 20% to 30% of lower extremity vein grafts are treated for critical stenoses, either surgically or endovascularly.1-3 Most stenoses are found as part of a duplex surveillance program. Criteria for revision vary from center to center. In general, a focal peak systolic velocity (PSV) exceeding 300 cm/s or a prestenotic to intrastenotic systolic velocity ratio exceeding 3:4 are indications for either surgical or endovascular repair.4,5 One of the reasons for regular duplex surveillance is that not all vein graft stenoses are associated with symptoms. Asymptomatic vein graft stenosis is common,

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T IS RECOGNIZED THAT LOWER EX-

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popliteal artery. A history of cerebrovascular disease was present in 38% of patients with symp- .38 .06 . Characteristics of the original operative procedure are presented in Table 2.9 [42. or continuous wave Doppler analysis at the discretion of the surgeon.0 (11.06).8) 69 31 82 45 47 40 49 26 10 28 Symptomatic Stenoses (n=94) 66. Median follow-up of all grafts was 30 months (mean. These factors. Illinois).4 (12.9) 10 90 33 28 36 3 3 32 63 2 68 32 21.17 Operative/Graft Characteristic Original operative indication. All patients underwent arteriography either prior to the vein graft revision or intraoperatively to confirm the presence and severity of stenosis. reverse saphenous vein graft.49 .67 . the details of the initial operation did not significantly predict symptomatic recurrences. In the univariate analysis. Assisted primary patency was assessed with Kaplan-Meier analysis. The validity of the logistic regression model was evaluated with the Hosmer-Lemeshow goodness-of-fit test.64 . There were some nonsignificant trends toward a greater number of symptomatic stenoses in patients whose initial operation was for critical limb ischemia (P =.06). There was a strong trend for symptomatic recurrence in patients with other manifestations of systemic atherosclerosis. were subsequently entered into the multivariate model. P = . which accounts for both continuous and categorical variables in the logistic regression model.0) 67. Ninety-four revisions (43%) were performed for symptomatic stenoses and 125 (57%) were performed for asymptomatic stenoses. Patient Demographics in Grafts With Asymptomatic and Symptomatic Stenoses a Asymptomatic Stenoses (n=125) 67.003).ARCHSURG. The types of surgical revision included vein patch angioplasty for focal (Ͻ 2 cm) lesions or vein interposition grafts for longer lesions or lesions that involved the native arterial inflow or outflow.8 (10. RESULTS Table 1. Symptomatic recurrences were defined as recurrence or worsening of intermittent claudication. no demographic characteristics were significantly different between patients with symptomatic or asymptomatic stenoses. y Sex M F Hypertension Active smoking Diabetes mellitus Hyperlipidemia Coronary artery disease Cerebrovascular disease Renal failure Anticoagulation P Value . Redmond. Criteria for considering vein graft revision included a focal PSV in the graft of greater than 300 cm/s.17) and in patients in whom alternate vein bypasses (arm vein and composite vein) were performed (P =. superficial femoral artery. Patient. y Mean age at revision (SD). PFA. Pop.06 . 9). All rights reserved. above-knee popliteal artery. ␹2 analysis for categorical variables. Symptomatic stenoses were significantly more frequent in revisions performed between 1 and 2 years (56%) and 2 years or longer (56%) after the initial operation than those within the first year (37%. or ischemic ulcerations. All statistical analyses were performed with SPSS.2 were entered into a stepwise logistic regression model to assess independent risk factors for symptomatic recurrence. common femoral artery.18) WWW.05 was considered significant in multivariate analysis. along with a history of hyperlipidemia (P =. a Values are percentages unless otherwise indicated.com/ by oceana mega on 05/10/2013 . Chicago. rest pain. tomatic stenoses vs 26% in patients with asymptomatic stenoses (P =. SEP 2007 849 ©2007 American Medical Association.1) .78 . A history of coronary artery disease was present in 62% of patients with symptomatic stenosis vs 49% in patients with asymptomatic stenoses (P = .38 Abbreviations: AKpop. Original graft inflow (P =.1) 68. Table 2. Continuous variables are presented as mean (SD) unless otherwise specified.06).5:1.4 (3. 43. or a change in clinical status. BKpop. Washington).tient had recurrence or worsening of symptoms or had an asymptomatic stenosis. One hundred forty-seven revisions (65%) were performed within 1 year of the initial operation. Differences in patency curves were assessed with log-rank analysis. and the Mann-Whitney test for ordinal variables. In univariate analysis. and surveillance characteristics for asymptomatic and symptomatic stenoses are presented in Table 1. SFA.9 (11. Odds ratios and 95% confidence intervals were recorded for significant variables.7] months). Intraoperative assessment of the revised graft included arteriography. RSVG. profunda femoral artery.15). 32 (15%) were performed between 1 and 2 years.26 a Values are percentage unless otherwise indicated.7) 66 34 84 48 54 50 62 38 9 35 Patient Characteristic Mean age at original operation (SD).69 . 219 lower extremity vein graft revisions were performed in 161 patients. version 15. and 45 (20%) were performed more than 2 years after. Claudication Critical limb ischemia Original graft inflow CFA SFA PFA Pop Original graft outflow AKpop BKpop Tibial Pedal Original graft conduit RSVG Alternate vein Mean interval between original operation and revision (SD). uniformly low PSVs throughout the graft (suggesting either inflow or outflow disease outside of the graft). below-knee popliteal artery.0 (SPSS Inc.18 During the study period.COM (REPRINTED) ARCH SURG/ VOL 142 (NO. Univariate analysis included independent samples t test for continuous variables. Downloaded From: http://archsurg. All data were stored in a password-protected Microsoft Access 2003 database (Microsoft Corp. mo . CFA.11 . Characteristics of the Original Graft a Asymptomatic Symptomatic Stenoses Stenoses P (n=125) (n=94) Value 16 84 40 35 24 1 8 34 53 6 79 21 17.jamanetwork. duplex scanning. The focus of this article is to determine differences in grafts and patients who presented with symptomatic vs asymptomatic recurrences. P Ͻ .11) and outflow (P =. All variables with a P value Ͻ . graft.15 .7 (2. a preintrastenotic to intrastenotic velocity ratio of greater than 3.30 .06 .

patients with asymptomatic recurrence were more likely to have a midgraft lesion (26% vs 15%. change in ABI Ն0. proximal anastomosis. the recurrent symptoms closely correlated with their symptoms prior to the initial operation. change in ABI = 0.03 .20 ∗ Symptomatic Asymptomatic Stenoses Figure 1.38) 0.4). Table 3 details the sites of stenoses in both symptomatic and asymptomatic grafts. with claudication in 14% and rest pain in 24% of cases. category 3. % P (n=125) (n=94) Value 17 25 38 58 26 9 8 14 18 19 19 34 52 15 16 12 30 30 . As seen in Figure 3.65 .03) P Value Ͻ . P =.2. only change in ABI was entered into the multivariate model.006 . all recurrent symptoms were also claudication. and ulcers or gangrene in 14%. Abbreviation: ABI.20 0. and graft inflow and outflow were all entered into the multivariate model.COM Change in ABI (REPRINTED) ARCH SURG/ VOL 142 (NO. In contrast. or outflow) 1. When the initial operation was performed for claudication. There was a strong linear correlation between ABI at the time of revision and change in ABI (R2 = 0.80 0.11 .003 Figure 2.Table 3.26) 0.83 (0. to prevent confounding. Boxplot demonstrating differences in ankle brachial index (ABI) change in patients with symptomatic vs asymptomatic stenoses. category 1.40 0.com/ by oceana mega on 05/10/2013 . Ͼ 200 cm/s) ABI Change in ABI Asymptomatic Stenoses (n=125) 385 (143) 413 (115) 0.21 (0. conduit. The effect of follow-up surveillance data on symptomatic recurrences is listed in Table 4.69 (0.80 0. Scatterplot with regression line demonstrating linear correlation between ankle brachial index (ABI) at time of revision and change in ABI from prior surveillance examination.25 0.00 0. Lesions involving the inflow proximal to the graft or involving the proximal graft did not predict the nature of symptomatic recurrence in univariate analysis. Change in ABI was also examined as an ordinal variable (category 0. recurrent symptoms were rest pain in 64% of cases.05 .00 0. P =.20 0. When the initial operation was performed for ischemic ulcers or gangrene.578 Site of Vein Graft Stenosis Inflow Proximal anastomosis Proximal graft Any proximal lesion (inflow. Both midgraft lesions and distal lesions were entered into the multivariate model.36 . recurrent ulcers or gangrene was present in 62% of symptomatic recurrence.4. P Ͻ . were also nonsignificant predictors of symptomatic recurrence. Downloaded From: http://archsurg. Indication.25 ABI Table 4.578.0-0.36 . Duplex and Clinical Surveillance Data for Asymptomatic and Symptomatic Stenoses Mean (SD) Duplex and Clinical Surveillance Data Peak systolic velocity. claudication in 22%.20 0.048 Change in ABI 1.59 .00 – 0.05). as including both terms would not beneficially add to the parsimony of the multivariate model.00 – 0. change in ABI Յ 0. Patients with recurrent symptoms had a lower ankle brachial index (ABI) at the time of revision and a larger drop in ABI from the time of prior surveillance (Figure 1). all cases Peak systolic velocity (minimum. SEP 2007 850 ©2007 American Medical Association. while patients with symptomatic recurrences were more likely to have a lesion involving the distal part of the graft or native arterial outflow (30% vs 18%. The time interval between the initial operation and revision did not influence the nature of symptoms at the time of recurrence.60 0.32 . there WWW. % Stenoses.50 0.ARCHSURG. When patients did have a symptomatic lesion. All rights reserved.001 . or graft) Midgraft Distal graft Distal anastomosis Outflow Distal lesion (distal graft.60 0. Sites of Asymptomatic and Symptomatic Vein Graft Stenoses Asymptomatic Symptomatic Stenoses. 1.048).02) Symptomatic Stenoses (n=94) 279 (158) 369 (105) 0. with a higher percentage of symptomatic recurrences arising from the profunda femoral artery (36% vs 24%) and anastomosed distally to a tibial artery (63% vs 53%).75 1. 9). When rest pain was the initial operative indication.00 0.40 0. change in ABI = 0.jamanetwork.20 1.003 .11 (0. ankle brachial index.00 Observed Linear Fit line for total R 2 linear = 0.001) (Figure 2).2-0. anastomosis.20 1. The change in ABI is a more relevant clinical marker in a duplex surveillance program and therefore. category 2. Asterisk shows extreme outlying data point.

01.243-5. 6. log-rank test) (Figure 5). symptomatic cases still demonstrated a lower PSV.ARCHSURG.2 Symptomatic Asymptomatic + Censored 0.578.0-0. midgraft lesion. Peak systolic velocities were lower in patients with symptomatic recurrence. use of an alternate conduit (odds ratio.633. and outflow) had significantly lower mean PSVs (347 [108] cm/s.307. P = . 1 = change in ABI 0. The results of the univariate analysis in this study sugWWW. Figure 4.01) and change in ABI (odds ratio. However. were significantly greater asymptomatic stenoses in the lower ABI categories (P =.1% in patients presenting with symptoms and 96. graft conduit. 43% of category 2 patients. cerebrovascular disease. most frequently within the first year.03. 2 = change in ABI 0. and 45% of category 3 patients (P =. No other factors were significant in the multivariate model.2.005. analysis of variance with Bonferroni correction).6 0. and 5 years.258. graft outflow. ␹2 test) (Figure 4).4. respectively. Lesions were asymptomatic in 70% of category 0 patients. 84.50 A B 60 Symptomatic stenoses 50 Asymptomatic stenoses 40 40 Frequency.957-5.06). 3 = change in ABI Ն 0. There was a nonsignificant trend toward the presence of a 1. 95% confidence interval. 0. the reason for the symptomatic nature of stenoses has not been defined. Number of cases in each change in ankle brachial index (ABI) category (0 = change in ABI Յ 0.4). The data were filtered to remove these cases. Proximal (inflow. SEP 2007 851 ©2007 American Medical Association. P =. Symptomatic (A) vs asymptomatic (B) stenoses categorized in order by change in ankle brachial index (ABI) category (0=change in ABI Յ 0. 3. 95% confidence interval.0-0.561.8% in patients presenting with asymptomatic stenoses (P =. P =. The backward stepwise model begins with all factors entered in the model and then removes nonsignificant factors in a stepwise fashion. midgraft lesion predicting asymptomatic lesions (odds ratio. In the final model.02) were significant predictors of recurrent symptoms at the time of revision. PSV was stratified by location of lesion. 1 = change in ABI 0.2. 1. of Cases 30 30 20 20 10 10 0 0 1 2 3 0 1 2 3 0 0 1 2 3 Change in ABI Category Change in ABI Category Figure 3. % No. and change in ABI) as independent variables. 95% confidence interval. All rights reserved. such that only statistically significant factors are retained in the final model. 2.2-0. while distal lesions (distal graft. and 82. 2.2-0. analysis of variance with Bonferroni correction).COM (REPRINTED) ARCH SURG/ VOL 142 (NO.9%. A backward stepwise logistic regression model was created with the absence or presence of symptoms as the dependent variable.jamanetwork.com/ by oceana mega on 05/10/2013 . and 87.0%.5%.4.418-32. and the previously noted variables (hypercholesterolemia. Downloaded From: http://archsurg. graft inflow. Mann-Whitney test). 3=change in ABI Ն 0. P =.803. Because absolute PSV was confounded by lesion site. 93. proximal anastomosis. COMMENT This study differentiates and defines patients with lower extremity vein graft stenoses who present with recurrent symptoms vs those who present with asymptomatic stenoses. and proximal graft) and midgraft lesions had similar mean PSVs (415 [105] cm/s vs 406 [132] cm/s. distal anastomosis. However.1%.30. There were 29 revisions performed for uniformly low PSVs throughout the graft. 2=change in ABI 0.8 ++++ ++ + ++ + +++++++ + + +++ +++++ +++ + + + ++ + +++ + +++ + + + +++ + ++ ++++ + + ++ + + +++++ + Assisted Primary Patency 0. only lesion site was entered into the multivariate model.0 0 10 20 30 40 50 60 Months Figure 5. P =.4). 63% of category 1 patients. 20% to 30% of patients undergoing lower extremity vein grafts develop graft stenoses. Historically. which resulted in a reduction in the difference between PSV in symptomatic and asymptomatic cases. operative indication. Assisted primary patency of grafts with symptomatic vs asymptomatic lower extremity vein graft stenoses. coronary artery disease. distal lesion.0 0. 9). Owing to a greater number of symptomatic cases that had distal lesions.4 0. was 94. Assisted primary patency of revised grafts at 1. 1.70.

excellent patency can be achieved with these grafts. The majority of vein graft stenoses occur within the first year though. Downloaded From: http://archsurg. Likewise. and WWW. and alternate vein grafts. In a previous study. graft patency and limb salvage were significantly greater in the duplex surveillance group at both 1 and 3 years. and surveillance data—that predicted the recurrence of symptoms with the development of vein graft stenoses. Acquisition of data: Landry. there were no differences in patency.gested multiple features—including patients’ demographic factors. Nonetheless. All of these may be considered markers for patients with more severe disease at the outset or patients who had already undergone previous revascularization procedures in the same leg. Alternate conduit bypass grafts are clearly disadvantaged from the outset.COM (REPRINTED) ARCH SURG/ VOL 142 (NO.17 and an increased cost of treating graft occlusions within the first year vs prophylactic repair of graft-threatening lesions. OR 97239-3098 (landryg@ohsu. with an increased incidence of significant graft stenoses in patients with early duplex abnormalities.6 Among original graft characteristics. There were no demographic factors that were significantly predictive of symptomatic recurrence in either univariate or multivariate analysis. costs incurred were significantly greater in the group observed with duplex surveillance. This was recently addressed in a multicenter randomized trial from the United Kingdom. though half of all brachial vein grafts required revision and one-third required more than 1 revision. tibial outflow. Oregon Health & Science University.06). and a known hypercoagulable state were independent risk factors for graft occlusion. coronary artery disease. routine surveillance of the graft outflow may be unnecessary.com/ by oceana mega on 05/10/2013 . Duplex surveillance therefore seems most appropriate for the midbody of the graft. in a similar study by Fasih et al. Lesions of the graft inflow or proximal portions of the graft did not predict symptomatic recurrence. P =. with only one-third of bypasses performed in vessels distal to the popliteal artery. and the symptomatic nature of these lesions was not reported. though patients with diabetes or renal failure or who currently smoked were not more likely to present with recurrent symptoms.07-13. Approximately one-third of patients in this study had claudication. There was a strong trend toward significant symptomatic recurrence in patients with other systemic manifestations of atherosclerotic disease (cerebrovascular disease. P Ͻ . clinical follow-up remains important. graft and operative characteristics.51. it is not clear how these data apply to a group of patients with more compromised graft anatomy.8 In contrast. Portland. Others have also demonstrated beneficial effects of early duplex surveillance.06.19 The finding in this study that the majority of revisions after the first year were related with symptoms supports the argument that less vigilant duplex surveillance beyond the first year is justified. 3. there was no significant patency difference between grafts that presented with asymptomatic ste- noses and those that presented with symptomatic stenoses.14 In this study.ARCHSURG.12. Division of Vascular Surgery. Landry. suggesting the importance of ongoing duplex surveillance. Lesion site was a strong predictor of symptomatic recurrence. and more than 90% of grafts performed in the saphenous vein. Thus. Author Contributions: Study concept and design: Landry and Moneta. Accepted for Publication: May 6. MD. Mail Code OP11.jamanetwork. However. P =. which suggests that these factors are more likely to be associated with graft occlusion without associated symptoms. Giswold et al6 demonstrated that failure to undergo duplex scanning within the first 3 months following bypass resulted in a hazard ratio of 2. the use of alternate conduit was a significant predictor of symptomatic recurrence. primarily clinical follow-up with ABI assessment thereafter may be an appropriate surveillance strategy.7 Others have shown the increased need for revision in tibial bypasses. accumulating data suggest that a reappraisal of the role of duplex surveillance following lower extremity vein grafts is warranted. In this study. Correspondence: Gregory J. where high-grade lesions can occur without recurrent symptoms and with minimal ABI changes. In this study. Isolated lesions within the body of the graft were more frequently asymptomatic. In contrast.edu). 9). This leads to the question of whether duplex surveillance is necessary at all following the placement of lower extremity vein grafts or if it is sufficient to follow patients clinically and wait until symptoms recur before assessing the graft. Aggressive duplex surveillance in the first year after bypass followed by less frequent.16 an increased threat to graft patency in unrevised lesions. 3181 SW Sam Jackson Park Rd. clinical follow-up alone is probably sufficient. limb salvage. These revisions were based on duplex surveillance data.10 Armstrong et al11 recently demonstrated a 3-year assisted primary patency of 91% in brachial vein bypasses. In the multivariate model. as many as one-third of graft revisions occur after the first year.001) for graft occlusion.43 (95% confidence interval. Since these lesions are more likely to present with clinical symptoms and changes in ABI. SEP 2007 852 ©2007 American Medical Association. patients with saphenous vein grafts arising from the common femoral artery and going to the popliteal artery had a trend for asymptomatic recurrence. However. or healthrelated quality of life between the groups that were observed with clinical and duplex surveillance. nonetheless. This was also demonstrated in our previous study in which patients with profunda femoral inflow were more likely to have multiple lesions that were not completely delineated on duplex surveillance. the authors demonstrated that smoking. while lesions involving the distal graft or arterial outflow were more likely to be symptomatic. in this and previous studies.9. A weakness of the data in our study is that it includes only patients who underwent revision and does not include patients whose grafts occluded without revision. It has been shown that the failure to undergo early duplex surveillance following bypass is an independent risk factor for lower extremity reversed vein graft occlusion.15 97 patients with claudication and critical limb ischemia who were undergoing revascularization were randomized to clinical vs duplex surveillance. 2007. there were trends toward greater symptomatic recurrence among patients with profunda femoral inflow. In a previous study. Edwards. The clinical significance of proximal inflow lesions as a threat to graft patency has been questioned.18 Duplex surveillance beyond the first year is more controversial. renal failure.13 One could certainly argue that asymptomatic proximal graft lesions can be managed conservatively and that the routine surveillance of this region of the graft may be unnecessary. All rights reserved.

Is duplex surveillance of value after leg vein grafting? Circulation. Those with critical stenoses do not do well.22(4):466-474. Porter JM. The discussions that follow this article are based on the originally submitted manuscript and not the revised manuscript. Even the best lower extremity vein graft is at risk due to progression of disease many years after successful implantation. 1 to 2 patients a month were revised. Alternative conduits (arm veins) were significant predictors of recurrent symptoms. Edwards JM. Hughes JD. I have 4 questions for Dr Moneta: (1) You included patients with moderate or intermediate stenosis with focal peak systolic velocities of 200 cm/s. Sydes MR. 1995. Ihnat DM. Idu MM. Optimizing infrainguinal arm vein bypass patency with duplex ultrasound surveillance and endovascular therapy. Mills JL. James DC. Taylor LM. Infrainguinal vein bypass graft surveillance: how to do it. and 82%. What percentage of vein graft stenosis in these patients were critical stenosis with peak systolic velocities greater than 300 and a ratio of greater than 3. Subodh A. Pomposelli FB. Early-appearing lesions noted at the first duplex ultrasound postop or lesions that are already there when we implant the graft are more aggressive than lesions detected later. but even in symptomatic patients it was 94%. Administrative. Analysis and interpretation of data: Landry. Vein graft lesions: time of onset and rate of progression. Moneta GL. Bhattacharya V. Devine J. 35(1):56-63. In symptomatic patients. Study supervision: Landry. With recent advances in medical and cardiac care. The focus of this paper was to determine the differences in patients with lower extremity vein bypass grafts who presented with symptoms compared to those who were asymptomatic. 20(4):558-565.” As John Porter used to say “what is remarkable here” is that this paper concludes with the statement “a reappraisal of the role of duplex surveillance following lower extremity vein graft is warranted. Infrainguinal vein bypass revision: factors affecting long-term outcome. 2002. 15. SEP 2007 853 WWW. Downloaded From: http://archsurg. Towne JB. Moneta GL. Rudol G. Wixon CL.” since the majority of the revisions after the first year were symptomatic and identifiable with clinical follow-up alone and a change in the ankle brachial index. and is published after peer review and revision. Surveillance versus nonsurveillance for femoro-popliteal bypass grafts. 2005. J Vasc Surg. Menard MT. Landry GJ. 2007. The natural history of intermediate and critical vein graft stenoses: recommendations for continued surveillance or repair. randomized. 19. Gentile AT. This lesion most commonly results from preexisting conduit defects or intimal hyperplasia that develops after arterialization.29(2):270-280. J Vasc Surg. Yeager RA. Incidentally detected stenoses proximal to grafts originating below the common femoral artery. Abnormal duplex findings at the proximal anastomosis of infrainguinal bypass grafts: does revision enhance patency? Ann Vasc Surg. 5. when to intervene.33(2):273-280. Taylor LM. Ubbink D. Angiology.40(4):724-731. Kohala Coast. Erickson CA. Freischlag JA. Is early postoperative duplex surveillance of leg bypass grafts clinically important? J Vasc Surg. Drafting of the manuscript: Landry. Raviola C. 6. At this time. Lombardi J.23(2):272-280. since clinical follow-up and simple ABI is all that is needed.5? (2) What percentage had arteriography preoperatively before vein graft revision. Nguyen LL. 1994. Hughes JD. My own bias and the authors Landry and Moneta are published proponents of duplex ultrasound surveillance for the life of the graft. Liem. J Vasc Surg. Taylor LM. Rohan DL. and known hypercoagulable states have been identified previously by these authors as significant risk factors for graft oc- (REPRINTED) ARCH SURG/ VOL 142 (NO.jamanetwork.112(13):1985-1991. Portland.31(1. Pulling MC. 219 patients over 12 years. Bergelin RO.ARCHSURG. 2004. J Vasc Surg. expensive to maintain both the machine and the trained vascular technologist. Results of bypass to the popliteal and tibial arteries with alternative sources of autogenous vein. Yeager RA. Duplex ultrasound surveillance is now widely accepted. some series have reported 50% survival at 10 years. J Vasc Surg. et al. Duplex scanning alone is not sufficient imaging before secondary procedures after lower extremity reversed vein bypass grafts. and Moneta. Hawdon AJ. 2002. Liem. Edwards. Edwards JM. Lawrence PF. Westerbrand A. Symptomatic proximal graft lesions can be managed conservatively and routine surveillance is thus superfluous.32 (6):1180-1189. 93%. only an increase in cost.37(1):47-53. 2000. Vasc Endovascular Surg. Mills JL. Landry and Moneta in the Journal of Vascular Surgery in 2002 documented excellent patency of revised grafts through 10 years and recommended “an aggressive regimen of duplex surveillance for the life of the graft.COM ©2007 American Medical Association. The use of arm vein in lower extremity revascularization: results of 520 procedures performed in eight years. and 5 years in asymptomatic patients was 97%. with no significant patency difference. Mitchell. February 20. Arteriography is expensive and occasionally morbid. J Vasc Surg. J Vasc Surg. A major consideration within the current health care climate is cost-effectiveness. 9). 2003. 1999. Ongoing vascular laboratory surveillance is essential to maximize long-term in situ saphenous vein bypass patency. 88%. Oregon: The Achilles heel of autogenous vein bypass grafting for infrainguinal arterial reconstruc- tion is vein graft stenosis. Taylor LM. It showed no improvement in limb salvage or quality of life with duplex ultrasound surveillance. Dougherty MJ. 9. Longterm outcome of revised lower extremity bypass grafts. controlled trial from the UK. An economic appraisal of lower extremity bypass graft maintenance. Smakowski P. Ashrafi A. 7. et al. technical. Bandyk DF.40(5):916-923. Critical revision of the manuscript for important intellectual content: Landry. DISCUSSION James Peck. Previous Presentation: This paper was presented at the 78th Annual Meeting of the Pacific Coast Surgical Association. Knox R. Calligaro K. Caps MT. REFERENCES 1. Mitchell. 2005. Seabrook GR. 2004. and pre. renal failure. Landry GJ. 2001. Bandyk DF. The authors cited a 2005 article in Circulation of 594 patients in a multicenter. Faries PL. 11. 3. 2000. Likewise. J Vasc Surg. 17. 2004. Porter JM. Lee RW. 4. Surgical treatment of threatened reversed infrainguinal vein grafts. Moneta GL. Shames ML. Chang M. arteriosclerosis is incurable.Moneta. Obtained funding: Landry. J Vasc Surg. and is it cost effective? J Am Coll Surg. 2003. Wilson JS. 2. Cantwell-Gab K. Westerbrand A. 13. Edwards JM.39(4):317-324. Giswold ME.com/ by oceana mega on 05/10/2013 . Fasih T. Hughes JD.15(1):98-103. Thompson SG. J Vasc Surg. 2000.55(3):251-256. Porter JM. 14.and intrastenotic systolic velocities ratios of 3. Statistical analysis: Landry. In this study. Durrani T. Johnson BL.194(1)(suppl):S40-S52. Treiman GS. and expensive to fund additional interventions.37 (3):495-500. Nehler MR. MD. Wixon CL. Szilagi 34 years ago identified these lesions in a third of 377 patient vein bypasses using arteriograms. Financial Disclosure: None reported. All patients in this series had arteriography. the simple change in ABI was the most relevant clinical marker. Ryan SV. routine surveillance of graft outflow is superfluous. High-grade stenoses are frequent precursors to thrombosis. 3. J Vasc Surg. 10. prospective. and how many had intraoperative arteriogram at the time of revision? How many patients had arteriography with no revision in this 12-year study? (3) No demographic factor was predictive of symptomatic recurrence in this study. 2001. Davies AH. Mills JL. The fate of unrevised stenoses in infrainguinal autologous vein grafts as detected by intraoperative duplex scanning. Modifiable patient factors are associated with reverse vein graft occlusion in the era of duplex scan surveillance. pt 1):50-63. and 88%. Moneta GL.32 (1):1-12. 1996. Armstrong PA.23(1):18-26. Current (active) smokers. Sexton GJ. Landry GJ. A duplex surveillance program is expensive to establish. 16. 12. Conte MS. Ferris BL. Hawaii. Assisted primary patency of the revised vein grafts at 1. Legemate DA. Cambria RA. 18. Ashour H. Patients who were asymptomatic were more likely to have midgraft lesions. and Moneta. 8. et al. 57% were asymptomatic. All rights reserved. J Vasc Surg. and material support: Landry. Vein grafts with no stenosis do well. Back MR. J Vasc Surg. 1996. while symptomatic patients were more likely to have a stenosis in the distal part of the graft or the native arterial outflow. Strandness DE. Mudawi A.

Steve Etheredge. MD.clusion. 9). and then between duplex evaluations they present with an occluded graft. I don’t think it means we should stop surveillance because of this occasional unexpected graft occlusion. do you routinely. This obviously is perplexing and it’s the very problem you are trying to prevent by prophylactic duplex scanning.COM ©2007 American Medical Association. what is your current recommendation for the practicing vascular surgeon in the community? Is less vigilant duplex ultrasound surveillance after the first year reasonable? Dr Moneta: Thank you very much. I think we should continue surveillance beyond the first year for most patients in the fashion that we have been doing. however. We do worry about vein grafts where the peak systolic velocity exceeds 200 cm/s or where the velocity ratio exceeds 3. or is it just extremity pain? If it is extremity pain. We are grateful for the opportunity to present these data. Los Angeles. Financial Disclosure: None reported. Dr Moneta: We have had the same experience you are describing. such as a nearby collateral vessel. many are done with endovascular techniques. or stenoses in smaller caliber grafts I think should be revised surgically. willing to consider that a good-quality saphenous vein to the popliteal artery that hasn’t had any trouble for the first year may be one that we can follow less intensely. It is a source of frustration. especially if they have a high-risk conduit. The second question is once you find a stenosis. when you categorize into symptomatic and asymptomatic. Some of my other colleagues now will routinely or almost routinely do an angiographic completion study at the end of the procedure. since you have been a leader in this area. I was wondering if you could stratify somewhat your lesions. but what was the cause of the stenotic process? Dr Moneta: I think the stenotic process in most cases is an intimal hyperplastic lesion within the vein graft. MD. I would like to flip this around a little bit and ask a question about a problem that plagues us at Stanford.5:4 and peak systolic velocities greater than 300 cm/s. California: Greg. those grafts aren’t routinely revised. In that study. Some may occlude for reasons unrelated to graft stenosis. not just the stenotic process. he asked about intermediate velocity levels. Fortunately it doesn’t happen all that often. Symptoms were a new ulcer. Now. essentially all of the patients underwent angiography preoperatively. my personal tendency has been to just use continuous wave Doppler. all revisions were done open. we tried to be a little careful about that. I wonder if you have any thoughts about how to avoid this particular problem and prevent graft failure. are you routinely repairing these by open methods or have you moved toward endovascular treatment with the cutting balloon technology? And finally. I therefore tend to try to get the angiogram preoperatively to avoid a potentially unnecessary trip to the operating room. We’re a little picky on which ones to do endovascularly. When there is nonconcordance between the angiogram and the duplex study. California: Dr Moneta. Cornelius Olcott. based on this study. Dr Peck wanted to know if there was any reason to continue surveillance after the first year postoperatively. but every year we have 3 or 4 patients that occlude their graft between surveillance appointments. We have addressed this issue in a previous paper. I thought I would take the opportunity to see how you are managing these vein graft stenoses and changes that have occurred in your management over the years. We have looked at other people’s data and our own data and backed off from revising most asymptomatic inflow arterial lesions. but what do you mean by symptomatic? Are we talking about somebody coming back with a new ulcer. We don’t use intraoperative duplex routinely. we found our proximal anastomoses to be more of a problem than the distal anastomoses. thanks a lot. Dr Peck asked about patient risk factors for those whose grafts occluded and weren’t revised. We appreciate that. but that [was] not a primary end point of the study. we have done some more intraoperative angiograms.ARCHSURG. toe gangrene. Candidates for endovascular revision are focal lesions.jamanetwork. Those patients are ones we try to bring back for more frequent surveillance studies. beyond 1 year. another nice paper from Oregon. Those patients seem to do okay without revision. The two biggest risk factors for unheralded graft occlusion in our practice are failure to return for surveillance and being on warfarin. In our own experience with completion duplex where we imaged the entire graft. Dr Peck. new or recurrent gangrene. First. (REPRINTED) ARCH SURG/ VOL 142 (NO. I don’t know how to identify those patients. For this study. I believe the duplex study. All rights reserved. With regard to completion studies. I recall a few falsepositive duplex studies where the angiogram was normal and indicated a possible reason for a false-positive duplex examination. how in your database do you distinguish pain from osteoarthritis vs claudication vs neurogenic pain? Dr Moneta: I will try to answer your questions in order. There is an occasional patient that comes back with a graft that is occluded and the previous duplex study seemed adequate and normal and the patient had no symptoms. If there is even a minimal angiographic abnormality in the area of the elevated velocity. Were any of these atherosclerotic inflow lesions? Were these valve ring stenosis? Were these segments of veins that were just inadequate? What is the real cause of what you have going on. I emphasize that no matter what axiom you have in surgery. I guess well over 90% of the revisions were for intimal hyperplastic lesions either in the graft or at an anastomosis. SEP 2007 854 WWW.com/ by oceana mega on 05/10/2013 . and occasionally for an atherosclerotic lesion just beyond the anastomosis. and is it a completion duplex or arteriogram? I ask this because of the finding that proximal inflow lesions were a major source of vein graft stenosis. Stanford. This finding actually made us more technically attentive to the proximal anastomosis and lowered our incidence of proximal graft stenoses. There are very few revisions for those lower levels of velocities With respect to angiography. In recent years. With respect to Dr Peck’s questions. California: Greg. and/or recurrence of classic claudication symptoms. Finally. The large majority of the revisions were for lesions within the graft or it’s at the anastomoses. We follow very much the same surveillance protocol you do because of John Harris’ and Ron Dalman’s training at Oregon. do a completion study. Fred Weaver. the trend was for better limb salvage with routine surveillance. at the close of operation. Downloaded From: http://archsurg. Until I am convinced that we can get patients to recognize vascularrelated symptoms and reliably return to the physician when they have symptoms. Revision is pretty much limited to grafts with velocity ratios greater than 3. I haven’t been disappointed with that policy. in a relatively good-sized vein graft that has been in place more than 3 months. I am. These patients are asymptomatic and they have a good duplex that does not show any significant findings. The UK study that was alluded to in both Dr Landry’s talk and in Dr Peck’s discussion was a good study although I do not necessarily agree with all the conclusions. I believe warfarin indicates a group of patients with high-risk grafts. Probably. and that is the patient who is asymptomatic and has a normal duplex study but shows up a few months later with an occluded graft. I will perform a revision. Oakland. On the other hand. I think our laboratory is pretty good though probably not flawless. I assume a few of them are patients in whom we missed the lesion. I enjoyed your paper. A very early graft stenosis. this is kind of a simplistic question. it is an ineffective therapy for high-risk grafts. In the past. a long stenosis. How many grafts were occluded without revision in this 12-year time span? (4) Finally. MD. It is very difficult sometimes for the patients to distinguish what are important symptoms. you have to continue to reexamine your methods of doing things based on new data.