Duplex ultrasound criteria for femorofemoral bypass revision

Abstract

Purpose: This study was conducted to evaluate the impact of duplex ultrasound surveillance on the patency of femorofemoral bypasses performed for symptomatic peripheral arterial occlusive disease (PAOD).

Methods: A retrospective review was conducted of 108 patients (78 men, 30 women) with a mean age of 62 +/- 10 years who underwent femorofemoral prosthetic (n = 100) or vein (n = 8) bypass grafting for symptomatic PAOD (claudication, 38%; rest pain, 41%; tissue loss, 11%; infection, 10%) during a 10-year period. Prior or concomitant inflow iliac artery stenting was performed in 26 patients (24%), and a redo femorofemoral bypass was performed in 19 patients (18%). Duplex ultrasound surveillance of the reconstruction was performed at 6-month intervals to assess patency, graft (midgraft peak systolic flow velocity) hemodynamics, and identify inflow or outflow stenotic lesions. Repair was recommended for a stenosis with a peak systolic velocity (PSV) >300 cm/s and a PSV ratio >3.5. Life-table analysis was used to estimate primary, assisted-primary, and secondary graft patency.

Results: During a mean 40-month follow-up (range, 2 to 120 months), 31 bypasses (29%) were revised: 19 duplex-detected stenosis involving the inflow iliac artery (n = 15) or anastomotic stenosis (n = 4), or both, 11 for graft thrombosis, and 1 for graft infection. Abnormal inflow iliac (PSV >300 cm/s) hemodynamics or a mid-graft PSV <60 cm/s was measured in eight of 11 grafts before thrombosis. Mean time to revision was 30 +/- 17 months. The primary graft patency at 1, 3, and 5 years was 86%, 78%, and 62%, respectively. Correction of duplex-detected stenosis resulted in assisted-primary patency of 95% at 1 year and 88% at 3 and 5 years (P < .0001, log-rank). Secondary graft patency was 98% at 1 year and 93% at 3 and 5 years.

Conclusions: Vascular laboratory surveillance after femorofemoral bypass that included duplex ultrasound imaging of the inflow iliac artery and graft accurately identified failing grafts. A duplex-detected identified stenosis with a PSV >300 cm/s correlated with failure, and repair of identified lesions was associated with excellent 5-year patency.