Primary revision of mid-vein stenoses in venous bypass conduits: Venous patch versus interposition vein
Article Outline
Purpose
Patients after infrainguinal vein bypasses are a group at risk of graft stenosis and occlusion. Revision of failing grafts has been shown to significantly improve bypass patency and limb salvage. Options for surgical revision of mid bypass stenosis includes either patch angioplasty (PA) or interposition grafting (IG). We reviewed our experience with surgical revision of vein bypass stenosis.
Methods
From April 1968 to March 2006, 7557 autogenous vein bypasses were performed at Albany Medical Center and its affiliated institutions, of these 316 required single or multiple revision of vein grafts with patch angioplasty or interposition vein grafting. Excluded were proximal and distal anastomotic revisions. Only 235 bypasses had single revisions as either patch angioplasty (n = 108) or interposition grafting (n = 127) and are the focus of this review. The initial bypass revisions in these two groups are analyzed for indications, clinical parameters, operative strategies, and long-term patencies and clinical outcomes.
Results
There were no significant differences in mean age, gender, or frequency of comorbid conditions (coronary artery disease, pulmonary disease, hypertension, and diabetes) between the two patient groups. Secondary patency of patch angioplasty revision at 5 years was 79%. Patencies for interposition grafting revision at 5 years were equivalent to patch angioplasty group at 75%. When bypasses were evaluated on the basis of initial reconstructions (ie, in situ vs excised vein bypass), the results showed that in situ bypasses that required initial revision had similar 5-year patencies when interposition grafting was used as the first revision strategy vs patch angioplasty (80% vs 73%). Excised vein bypasses had similar patency when patch was their first revision strategy vs interposition grafting (4 year secondary patency 92% vs 75% respectively).
Conclusion
Autogenous vein bypasses are at risk for developing significant stenosis and occlusion with time. Bypass stenosis that develops in the main body of the graft can be effectively repaired using either patch angioplasty or interposition grafting. Depending on the host of other factors, such as availability of autogenous venous conduit, location of stenosis, accessibility for operative repair, and the patient’s anatomic characteristics, either operative strategy is effective in prolonging the patency of the bypass.
Infrainguinal vein bypass is a well-established therapeutic option in patients with critical limb ischemia and claudication. The use of autogenous vein as a bypass conduit has been associated with improved patency results compared with prosthetic conduits.1, 2, 3 A significant number, however, will require operative revision to maintain graft patency. Approximately 20% to 30% of lower extremity vein grafts require revision to maintain patency in long-term follow-up.4, 5, 6 An aggressive strategy of bypass surveillance with duplex ultrasound imaging is recommended as a means of identifying grafts at risk for developing stenoses.7, 8 Once the failing vein graft is identified by these hemodynamic criteria, one must decide the best procedural strategy to maintain bypass patency.
Numerous centers have reported their experiences with long-term outcomes of revised lower extremity bypass grafts.9, 10, 11, 12 The options for revision of bypass graft stenosis depends on the etiology and location of the lesion threatening bypass patency. Options include surgical and endovascular interventions. Surgical revisions have traditionally enjoyed longer patency then their endovascular counterparts.13, 14 Surgical revision options include patch angioplasty, interposition grafting, sequential or jump grafting, excision, and primary repair.
The techniques most commonly used for the main body of the vein bypass include patch angioplasty or interposition grafting using other available autogenous veins. A paucity of data exists on the efficacy of vein patch vs interposition vein grafting in managing the failing vein bypass.14 This study reviewed our experience with 235 vein bypasses that were revised for the first time using vein patch or interposition vein grafting.
Methods
From April 1968 to March of 2006, 7557 autogenous vein bypasses were performed at our institution. Of these, 4689 were in situ reconstructions, 2003 were excised vein bypasses (reversed or orthograde), and 865 were splice vein bypasses. Postoperatively, vein bypasses undergo routine surveillance using clinical examination, pulse volume recordings (PVRs), and duplex ultrasound imaging every 3 months for the first year then every 6 six months thereafter. Bypasses with smaller veins (<3 mm), spliced veins, or partial in situ veins were considered high risk and were monitored every 2 months during the first year after surgery. In general, our duplex criteria for revision are peak systolic velocity > 300 cm/s and a PVR >3.5.
A total of 316 bypasses required single or multiple revisions using patch angioplasty or interposition grafting. Of these, only 235 bypasses were identified that represented a single, first time revision as either patch angioplasty (n = 108) or interposition grafting (n = 127). All bypasses were patent at the time of revision (ie, none underwent lysis or surgical thrombectomy) and are the subject of this study. Excluded from the analysis were the other 81 bypasses that required simultaneous revision at two different locations, multiple revisions at the same location or different location of the bypass, inflow or outflow revisions, or primary repair (Table I).
Table I. Total vein bypass revisions performed during the study period (1968-2006)
| In situ n (%) | Reversed n (%) | Orthograde excised, n (%) | Spliced n (%) | |
|---|---|---|---|---|
| Total | 4689 | 1793 | 210 | 865 |
| Multiple revisions | ||||
 5 | 0(0) | 3(0.2) | 0(0.0) | 2(0.2) |
| 4 | 7(0.1) | 0(0.0) | 0(0.0) | 4(0.5) |
| 3 | 35(0.7) | 4(0.2) | 1(0.5) | 8(0.9) |
| 2 | 138(2.9) | 36(2.0) | 2(1.0) | 47(5.4) |
| 1 | 467(10.0) | 127(7.1) | 11(5.2) | 113(13.1) |
| 0 | 4042(86.2) | 1623(90.5) | 196(93.3) | 691(79.9) |
| Inflow revisions | ||||
| Total | 83(1.8) | 40(2.2) | 2(1.0) | 4(0.5) |
| Direct repairs | 9(0.2) | 5(0.3) | 0(0.0) | 0(0.0) |
| Interposition | 63(1.3) | 26(1.5) | 2(1.0) | 4(0.5) |
| Patch | 11(0.2) | 9(0.5) | 0(0.0) | 0(0.0) |
| Outflow revisions | ||||
| Total | 137(2.9) | 28(1.6) | 3(1.4) | 6(0.7) |
| Direct repairs | 4(0.1) | 2(0.1) | 1(0.5) | 0(0.0) |
| Interposition | 131(2.8) | 25(1.4) | 2(1.0) | 5(0.6) |
| Patch | 2(0.0) | 1(0.1) | 0(0.0) | 1(0.1) |
| Proximal vein revisions | ||||
| Total | 91(1.9) | 43(2.4) | 2(1.0) | 12(1.4) |
| Direct repairs | 7(0.1) | 4(0.2) | 1(0.5) | 3(0.3) |
| Interposition | 51(1.1) | 23(1.3) | 1(0.5) | 4(0.5) |
| Patch | 33(0.7) | 16(0.9) | 0(0.0) | 5(0.6) |
| Mid-vein revisions | ||||
| Total | 105(2.2) | 51(2.8) | 3(1.4) | 22(2.5) |
| Direct repairs | 5(0.1) | 6(0.3) | 0(0.0) | 2(0.2) |
| Interposition | 59(1.3) | 27(1.5) | 3(1.4) | 16(1.8) |
| Patch | 41(0.9) | 18(1.0) | 0(0.0) | 4(0.5) |
| Distal vein revisions | ||||
| Total | 110(2.3) | 29(1.6) | 3(1.4) | 14(1.6) |
| Direct repair | 3(0.1) | 2(0.1) | 0(0.0) | 1(0.1) |
| Interposition | 62(1.3) | 20(1.1) | 2(1.0) | 8(0.9) |
| Patch | 45(1.0) | 7(0.4) | 1(0.5) | 5(0.6) |
| Valve lysis | 84(1.8) | 6(0.3) | 1(0.5) | 5(0.6) |
| Angioplasty | 3(0.1) | 1(0.1) | 0(0.0) | 2(0.2) |
| Lytic therapy | 7(0.1) | 4(0.2) | 1(0.5) | 5(0.6) |
The subjects for this study were the patients who had a first revision patch or interposition in the proximal, mid, or distal vein position. The decision to perform vein patch or vein interposition was at the surgeon’s discretion. Short, focal lesions were treated primarily with patch, whereas more diffuse lesions were treated with interposition bypass. Preoperative angiograms were routine except when contraindicated because of renal or allergic issues or not deemed necessary by the operating surgeon.
Available autogenous conduits used for revision were mapped preoperatively with duplex ultrasound. All patients received systemic anticoagulation intraoperatively if not contraindicated. The stenoses were marked by duplex ultrasound imaging preoperatively and then confirmed intraoperatively with hand-held Doppler. Angiography was performed selectively. If the lesions appeared focal (<2 cm), angiography was not performed and the ultrasound findings were used to treat the lesions. Longer lesions and veins of smaller caliber (<2.5 cm) were further evaluated with contrast angiography.
After proximal and distal control, longitudinal venotomy was performed over the area of concern. The proximal and distal bypass was filled with dextran solution mixed with heparin and papaverine to dilate the vein and minimize clot formation. Revision was then performed with patch or interposition.
Selection of procedure was dependent on the length of stenosis, availability of conduit, preference of the vascular surgeon, and exposure of the bypass area involved. In general, short focal stenoses (ie, retained valve or venovenostomy) were repaired using patch angioplasty, and long diffuse areas of stenosis (intrinsic vein abnormalities) were repaired using interposition grafting. The decision of which technique to use was based upon the length of the lesion. If the surgeon judged that the total suture line length would be greater for a patch than for end-to-end anastomosis, the interposition would be selected.
The technique used for interposition vein revision is similar to what we have done when performing splice vein bypass.15 Venovenostomy was performed end to end with 8.0 polypropylene sutures. The ends of the bypass and the vein being interposed are spatulated to avoid purse stringing the anastomosis. All wounds were closed with nonabsorbable sutures and staples.
All patients were admitted after surgery, and PVRs and duplex imaging were performed before discharge. After revision, patients were followed up for surgical complications and underwent periodic surveillance every 3 months or more frequently with duplex ultrasound imaging and PVRs.
Data on patients undergoing peripheral bypasses were maintained in a vascular registry for retrospective review. Information on patient demographics, comorbidities, indication and type of original bypass, and postoperative complications were recorded on all patients.
Statistical analysis
Differences between groups were compared using the χ2 test for categoric data. The life-table method was used to determine patency after the first graft revision. Data are presented in accordance with published reporting standards.16 The log-rank test was used to analyze differences. P < .05 was considered significant.
Results
From April 1968 to March of 2006, 235 bypasses underwent a first revision for bypass stenosis with either patch angioplasty (n = 108) or interposition grafting (n = 127). Of the 108 patch angioplasty procedures, 64 (64%) were done on in situ bypasses, 19 (20%) on excised, and 25 (26%) spliced vein bypasses. Of the 127 interposition graft procedures, 62 (50%) were performed on in situ bypasses, 33 (25%) on spliced, and 32 (25%) on excised vein bypasses. There was no significant difference in mean age (69 years vs 68 years, P = NS) or gender, or in the frequency of coronary disease, hypertension, pulmonary disease, diabetes, renal insufficiency, or smoking (Table II). Operative indication is given in Table III.
Table II. Demographic data on patients undergoing either vein patch angioplasty or interposition vein bypass revision*
| Interposition, n(%) | Patch, n(%) | |
|---|---|---|
| Age, mean years | 69 | 68 |
| Males | 78(61) | 72(67) |
| Smokers | 49(39) | 39(36) |
| Diabetes mellitus | 75(59) | 48(44) |
| Coronary artery disease | 24(60) | 24(80) |
| Hypertension | 26(65) | 23(74) |
| COPD | 6(15) | 4(13) |
| Renal | 7(17) | 6(20) |
| Cholesterol | 16(40) | 20(30) |
Table III. Original bypass indication in patients undergoing vein patch angioplasty or interposition vein bypass revision⁎
| Interposition, n(%) | Patch, n(%) | |
|---|---|---|
| Claudication | 10(9) | 8(7) |
| Gangrene | 25(20) | 20(19) |
| NHU | 51(40) | 48(44) |
| Rest pain | 35(27) | 31(29) |
| Others | 6(4) | 1(1) |
| Total | 127(100) | 108(100) |
⁎All data analyzed by χ2. P was significant at < .05; all data not significant. |
No operative mortality was encountered in either group. The major morbidity from these revisions was wound infections and swelling, which were equally prevalent in both groups (20% vs 15%, P = NS). The rate for limb loss at 5 years was 6.4% for vein patch and 3.1% for interposition repair. The overall patient survival at 5 years was 70% for the vein patch group vs 76%, and at 10 years was 46% for patch angioplasty and 35% for the interposition group (P = NS).
Secondary patency rates for patch angioplasty and interposition after revision were similar (79% vs 75%, P = NS; Table IV). These patency data represent the patency of the entire conduit after this initial revision. Restenosis within the patch or interposition after initial revision was 8% for patch and 9% for interposition.
Table IV. Overall patency after first revision for all bypasses using vein patch or venous interposition
| Interposition(all bypasses) | |||||
|---|---|---|---|---|---|
| Year | Total | Occluded, n | Censored, n | Patency, % | SE, % |
| 0-1 | 127 | 14 | 33 | 87 | 4 |
| 1-2 | 80 | 3 | 19 | 84 | 5 |
| 2-3 | 58 | 1 | 15 | 82 | 6 |
| 3-4 | 42 | 3 | 12 | 75 | 8 |
| 4-5 | 27 | 0 | 5 | 75 | 9 |
| 5-6 | 22 | 0 | 9 | 75 | 11 |
| Patch (all bypasses) | |||||
|---|---|---|---|---|---|
| Year | Total | Occluded, n | Censored, n | Patency, % | SE, % |
| 0-1 | 108 | 13 | 22 | 87 | 4 |
| 1-2 | 73 | 4 | 14 | 81 | 5 |
| 2-3 | 55 | 0 | 13 | 81 | 6 |
| 3-4 | 42 | 0 | 9 | 81 | 6 |
| 4-5 | 33 | 1 | 7 | 79 | 8 |
| 5-6 | 25 | 0 | 3 | 79 | 8 |
When stratified according to the initial bypass procedures, in situ bypasses repaired with interposition grafting had equivalent 5-year patency (80%) vs patch angioplasty repair (73%, P = NS; Table V). The excised vein bypasses demonstrated better patency with patch than interposition grafting (92% vs 75%) but did not reach statistical significance (Table VI). Revised spliced vein bypasses repaired with patch had a patency of 81% at 2 years compared with 78% for those revised with interposition bypass (Table VII).
Table V. Patency rate after first revision with either vein patch or vein interposition in in situ vein bypasses
| Interposition (in situ bypasses) | |||||
|---|---|---|---|---|---|
| Year | Total | Occluded, n | Censored, n | Patency, % | SE, % |
| 0-1 | 62 | 7 | 18 | 87 | 0 |
| 1-2 | 37 | 1 | 9 | 84 | 5 |
| 2-3 | 27 | 0 | 5 | 84 | 7 |
| 3-4 | 22 | 1 | 7 | 80 | 7 |
| 4-5 | 14 | 0 | 2 | 80 | 8 |
| 5-6 | 12 | 0 | 5 | 80 | 9 |
| Patch(in situ bypasses) | |||||
|---|---|---|---|---|---|
| Year | Total | Occluded, n | Censored, n | Patency, % | SE, % |
| 0-1 | 64 | 10 | 11 | 83 | 0 |
| 1-2 | 43 | 3 | 8 | 76 | 6 |
| 2-3 | 32 | 0 | 5 | 76 | 7 |
| 3-4 | 27 | 0 | 3 | 76 | 8 |
| 4-5 | 24 | 1 | 3 | 73 | 10 |
| 5-6 | 20 | 0 | 1 | 73 | 12 |
Table VI. Patency rate after first revision with either vein patch or vein interposition in excised vein bypasses
| Interposition(excised vein bypasses) | |||||
|---|---|---|---|---|---|
| Year | Total | Occluded, n | Censored, n | Patency, % | SE, % |
| 0-1 | 52 | 6 | 11 | 87 | 6 |
| 1-2 | 35 | 2 | 10 | 81 | 8 |
| 2-3 | 23 | 0 | 8 | 81 | 10 |
| 3-4 | 15 | 1 | 4 | 75 | 13 |
| 4-5 | 10 | 0 | 3 | 75 | 15 |
| 5-6 | 7 | 0 | 2 | 75 | 18 |
| Patch(excised vein bypasses) | |||||
|---|---|---|---|---|---|
| Year | Total | Occluded, n | Censored, n | Patency, % | SE, % |
| 0-1 | 33 | 1 | 10 | 96 | 4 |
| 1-2 | 22 | 1 | 4 | 92 | 6 |
| 2-3 | 17 | 0 | 5 | 92 | 8 |
| 3-4 | 12 | 0 | 5 | 92 | 10 |
| 4-5 | 7 | 0 | 3 | 92 | 13 |
| 5-6 | 4 | 0 | 2 | 92 | 19 |
Table VII. Patency after first revision with either vein patch or interposition vein in spliced vein bypasses
| Interposition(splice vein bypasses) | |||||
|---|---|---|---|---|---|
| Year | Total | Occluded, n | Censored, n | Patency, % | SE, % |
| 0-1 | 13 | 1 | 4 | 91 | 10 |
| 1-2 | 8 | 1 | 2 | 78 | 17 |
| 2-3 | 5 | 1 | 1 | 61 | 27 |
| 3-4 | 3 | 0 | 2 | 61 | 54 |
| Patch(splice vein bypasses) | |||||
|---|---|---|---|---|---|
| Year | Total | Occluded, n | Censored, n | Patency, % | SE, % |
| 0-1 | 11 | 2 | 1 | 81 | 12 |
| 1-2 | 8 | 0 | 2 | 81 | 14 |
| 2-3 | 6 | 0 | 3 | 81 | 20 |
| 3-4 | 3 | 0 | 1 | 81 | 25 |
Discussion
A significant number of lower extremity vein bypasses may require revision during their life span. Repair of these failing bypasses is paramount, as rescuing thrombosed vein grafts does not generally result in a durable solution.17, 18 In addition, replacement of the failed bypass with new bypasses, beyond being a challenge to the surgeon, are generally inferior when compared with the initial index bypass.19, 20, 21 Routine surveillance of vein bypasses with physical examination, PVRs, and duplex ultrasound imaging has therefore become the routine to maintain the durability of the venous conduit. The duplex examination is highly specific for identifying lesions that may cause hemodynamic alterations detrimental to long-term patency.
The report of this previous experience was to compare long-term patency of vein bypasses that had been revised with those that never required revision. This was different than our present series because it comprised all revisions, including valve lysis, fistula ligation, and anastomotic revisions. The focus of our present series is on primary mid-vein lesions in conduits undergoing their first revision.
When these lesions are identified, the surgeon must decide what procedure to perform to revise the lesion. Surgical options include primary repair, vein patch, interposition vein bypass, or jump bypass for inflow and outflow lesions. Lesions in the mid graft are amenable to primary repair, balloon angioplasty, vein patch, prosthetic patch, or interposition vein. Of the surgical options, primary repair is not possible when the lesion is longer and the vein not redundant enough. We have not used prosthetic patch (Dacron, polytetrafluoroethylene, or bovine pericardium) for these mid-vein lesions. Our experience with prosthetic patch is limited to repair of proximal anastomotic stenosis. In our experience to date, we have been able to find adequate vein for revision of these mid-vein stenoses in either patch or interposition configuration.
Data exist on the efficacy of vein patch and vein interposition in the revision of vein bypasses. Sullivan et al14 reported their series of 34 vein grafts revised with patch and 11 repaired with vein interposition.14 They demonstrated patency of 80% for vein patch and >70% for interposition vein at 4 years. Their philosophy for vein graft revision was generally to correct short focal lesions with patch and more diffuse lesions with vein interposition, thus favoring an approach that preserves as much conduit as possible without compromising the quality of the revision. They concluded vein path compared with interposition demonstrated no significant difference in patency. Although the graft lesions treated with patch were more focal and the lesions treated with interposition were longer, either technique represented a durable solution.
Others have demonstrated that vein patch results in a higher rate of restenosis than interposition grafting. Bandyk et al9 reported a 21% restenosis rate in vein patches and concluded that interposition repair may be a more durable solution. However, it is of note that it represented only 31 vein patches in their reported series, and 15 of these were place at juxta-anastomotic sites.
Nguyen et al21 reviewed the revisions performed at their institution and observed similar patencies with either technique.21 Patencies at 5 years were 83% for vein patch and 73% for interposition. They found that bypasses repaired with vein patch tended to require only a single revision in follow-up.
These results are all consistent with the findings in our current series that demonstrates equivalent patencies for either vein patch or vein interposition. The overall restenosis rate at the original site of revision in our series was 8% for vein patch and 9% for vein interposition.
With the recent advent of endovascular therapies, many groups have published their data with primary angioplasty of the vein bypass stenosis. Tong et al22 obtained 3-year primary assisted patencies of close to 45% using angioplasty as the first line of treatment, especially for short segment focal stenoses of <2 cm. Berkowitz et al23 reported their treatment of mid-graft lesions with balloon angioplasty and found 5-year patency of 61% for lesions treated by balloon angioplasty. Avino et al24 reported a 2-year patency rate of 63% for lesions treated by balloon angioplasty and concluded that the use of duplex criteria was critical for a successful outcome. This includes the treatment of focal lesions in good caliber vein conduits beyond the early postoperative period.
Sanchez et al25 reported a 2-year graft patency of 66% after vein graft percutaneous transluminal angioplasty when arteriography identified a concentric, short (<15 mm) stenosis in an otherwise normal vein bypass and treatment resulted in normal appearance of the lesion after the procedure. Poor results were obtained in the treatment of more complex lesions, including multiple stenoses, recurrent lesions, or small diameter vein.
So far, no randomized trials have evaluated angioplasty vs surgical bypass revision as the two main modalities. More recently, other endovascular strategies such as cutting balloons and cryoplasty have been suggested as potential available endovascular options to treat these lesions. At present, our group has limited experience with balloon angioplasty of vein bypass lesions. Given that surgical revision of these lesions carries no mortality and represents a relatively minor procedure with durable results, it is hard to deem it necessary to extend endovascular techniques to repair these lesions. Endovascular treatment may be of value in situations where anatomic circumstances (anatomically tunneled bypass), no autogenous conduit for repair, or severe comorbid patient condition preclude a more invasive repair.
Although ours is one of the largest reported series, it represents a single institution experience with the two revision techniques. It is a retrospective comparison of the two options. It should be emphasized that this does not represent a prospective randomized trial of these two techniques; therefore, certain selection bias may exist. It is possible that stenoses treated with interposition were more disadvantaged conduits, with longer stenoses not easily amenable to vein patch.
Conclusions
Patch angioplasty and vein interposition carry no mortality, afford excellent patencies, long-term limb salvage, and patient survival. Both procedures are equally effective in revising in situ, excised vein, or spliced vein bypasses. The selection of procedure should depend on location and length of lesion, available conduit, and patient comorbidities.
Author contributions
We thank the following physicians in our group for their contributions to the data presented in this manuscript: Kathleen J. Ozsvath, MD, Manish Mehta, MD, MPH, Yaron Sternbach, MD, and Dhiraj M. Shah, MD.
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Competition of interest: none.CME article
PII: S0741-5214(07)00033-X
doi:10.1016/j.jvs.2007.01.018
© 2007 The Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.