Infra-inguinal vein graft surveillance

1. ASSESSMENT OF RISK OF FAILURE
FOLLOWING INFRAINGUINAL VEIN GRAFT
BYPASS
Reza Mofidi MB MCh MSc MBA FRCS
Consultant Vascular Surgeon
James Cook University Hospital
Middlesbrough
United Kingdom

2. Infra-inguinal vein grafts
■ Gold Standard lower limb revascularization1
■ At risk of failure
■ Threatens 20-25% of grafts
■ Often asymptomatic
1Adam DJ et al. BASIL Trial participants. Bypass versus angioplasty for severe ischaemia of the
leg (BASIL): multicentre, randomized controlled trial. Lancet. 2005;366(9501): 1925-34.

3. Vein graft failure
■ Multifactorial in aetiology
■ Classified chronologically
Early (<6 weeks)
Hypercoaguable state
Technical issues
Intermediate
neointimal hyperplasia
Late (>2 years)
Progression of
disease

4. de Varies MG, et al. Nature Reviews in Cardiology 2016;13: 470-471
doi:10.1038/nrcardio.2016.76
Endothelial Injury Exposed Media Platelet aggregation

5. Kidney International 2004 66, 2061-2069DOI: (10.1111/j.1523-1755.2004.00985.x)
Copyright © 2004 International Society of Nephrology Terms and Conditions
smooth muscle cells
Contractile
phenotype
Secretory phenotype
Collagen
deposition
Neointimal Hyperplasia

6. Cardiovasc Res. 1997;36(3):408-428. doi:10.1016/S0008-6363(97)00184-3
Cardiovasc Res | Copyright © 1997, European Society of Cardiology

7. Matrix /Fibrous tissue deposition Remodelling
Proliferation of Myo-fibroblasts
Collagen secretion
TGF-β production Matrix metalloproteinases (MMPs)
MMP-2, MMP-9
Phenotypic switch Re-shape anastomotic area
Haemodynamics
ACE Inhibitor: Nitric Oxide accumulation
Tacrolimus eluting stents: Controls proliferative processes

8. Turbulence
PSV
EDV
Spectral
Broadening

9. Reduced PSV

10. PSV at the site of
stenosis
Post stenotic
PSV
Drop in
ABPI
Absolute
value (cm/s)
PSV ratio
Low risk grafts <200 <2 >0.5 <0.15
Moderate stenosis 200-300 2-3 0.5-0.4 < 0.15
Critical stenosis >300 >3 <0.4 >0.15
Duplex US Classification of Grafts
PSV – Peak systolic Velocity
ABPI – Ankle Brachial Pressure Index

11. Site of vein graft stenosis
Eur JVascEndovascSurg 34, 327e332 (2007)
doi:10.1016/j.ejvs.2007.04.008

12. Ann Vasc Surg 2009; 23: 17-23
DOI: 10.1016/j.avsg.2008.04.013

13. Quality of venous conduit
Ann Vasc Surg 2009; 23: 17-23 DOI:
10.1016/j.avsg.2008.04.013

14. Quality of venous conduit
Ann Vasc Surg 2009; 23: 17-23 DOI:
10.1016/j.avsg.2008.04.013

15. Schanzer A et al., https://doi.org/10.1016/j.jvs.2007.08.033

16. caveats
■ Vein graft diameter is not uniform
■ Effected by the procedure
■ Effected by branch points, tributaries
■ Effected by splicing
■ Effected by source of vein
■ In-situ and reversed LSV vein grafts have similar outcomes

17. Vein graft surveillance
■ US Graft surveillance is controversial
■ Vein Graft Surveillance Trials excluded
patients with early graft failure (<6 weeks)
■ Intensive surveillance:
– Increase in workload
– Financial implications

18. https://doi.org/10.1016/S1078-5884(98)80087-7

19. A.H. Davies et al. Circulation. 2005;112:1985-1991
Copyright © American Heart Association, Inc. All rights reserved.

20. Intraoperative assessment
Completion angiogram or Papaverine
Augmented duplex scan
Test interpretation and managment
Severe stenosis
Repair /reexamine
Moderate Stenosis
Re-examine after augmented flow
conditions
No stenosis/low
flow state
Check BP and cardiac output
Repeat papaverine injection
Consider improving graft flow
by fashioning an AV fistula
Anticoagulate post op
Normal Investigation
No action
https://doi.org/10.1016/j.rvm.2017.04.00

21. Early postoperative assessment
Eur JVascEndovascSurg 34, 327e332 (2007)
doi:10.1016/j.ejvs.2007.04.008

22. Ann Vasc Surg 2016; 36: 182–189
http://dx.doi.org/10.1016/j.avsg.2016.02.031

23. Infra inguinal
vein graft
Revision
Bypass
Primary
Bypass
Tibial
bypass
Below Knee
Popliteal
Above knee
Popliteal
Early scan
Diabetic
Non diabetic
Early scan
No
stenosis
Severe
stenosis
Moderate
stenosis
No
Stenosis
Moderate
stenosis
Severe
stenosis
Smoker Non smoker
Treat + US based surveillance
US based surveillance
Decision Tree
Clinical surveillance
Ann Vasc Surg 2017; 40: 216–222
http://dx.doi.org/10.1016/j.avsg.2016.07.082
Ann Vasc Surg 2016; 36: 182–189
http://dx.doi.org/10.1016/j.avsg.2016.02.031

24. Risk of graft failure
Ann Vasc Surg 2017; 40: 216–222
http://dx.doi.org/10.1016/j.avsg.2016.07.082

25. Risk of amputation
Ann Vasc Surg 2017; 40: 216–222
http://dx.doi.org/10.1016/j.avsg.2016.07.082

26. Endovascular treatment of vein graft stenosis
Mofidi R et al. doi:10.1016/j.ejvs.2008.10.018
Patel SD et al. J Vasc Surg 2016;63(1):126-32.
van Oostenbrugge TJ et al. Vasc Surg 2014; 60(3):696-701.
Mathur K et al. Vascular 2015:1708538115602835.Prevost AG, et al. Vasa 2013;42(6):435-41.

27. Simosa H, Pomposelli F, Dahlberg S, et al. J Vasc Surg 2009; 49: 117-

28. Simosa H, Pomposelli F, Dahlberg S, et al. J Vasc Surg 2009; 49: 117- 121

29. https://doi.org/10.1016/j.rvm.2017.04.002

30. https://doi.org/10.1016/j.rvm.2017.04.002

31. Endovascular treatment of a failing
graft
doi:10.1016/j.ejvs.2008.10.018

32. Endovascular treatment of a failing graft
doi:10.1016/j.ejvs.2008.10.018

34. • Patch repair
• Jump graft
Surgical Repair

35. Graft surveillance Continuum
Vein graft bypass
Surveillance
Identify
threatened
grafts
Repair threatened
grafts
Quality
Assurance