Long-term results of revised infrainguinal arterial reconstructions

Purpose: Infrainguinal arterial reconstruction with vein as the conduit has been regarded as the gold standard within the past two decades. However, as many as 20% of patients undergoing these bypass grafting procedures may need secondary interventions for continued patency. Once these reconstructions have been altered, there is concern about the continued patency of these types of revascularizations. In this study, we evaluated the long-term patency of venous reconstructions that had been revised, compared them with those bypass grafting procedures that did not require any intervention, and analyzed long-term outcome. Methods: In the past 15 years, 3944 infrainguinal arterial reconstructions were completed with vein as the conduit. A total of 2780 were performed with the vein in situ, and 1164 were performed by using excised vein in a single piece or spliced configuration. Indication, risk factors, and patient demographics were evaluated. Grafts were stratified into revised and unrevised, in situ and excised; excised vein was then stratified into spliced and non-spliced. All grafts were followed with duplex ultrasound scans performed at 3, 6, and 12 months in the first year and every 6 months thereafter. Statistical analysis was performed by using Gehan's generalized Wilcoxon test. Results: Demographics and indications were similar between groups. Nine percent of all excised veins required some revision, compared with 10% of all in situ reconstructions. When the excised veins were further stratified, 6% of single-piece venous conduits were revised, as opposed to 14% of reconstructions with spliced venous reconstruction. The 5-year patency rates were 67% for revised reconstructions and 78% for unrevised reconstructions (P < .0001). The 5-year patency rate of unrevised in situ bypass grafts was 81%, as compared with 69% for revised in situ reconstruction (P < .0001), and the 5-year patency rate for unrevised excised veins was 68%, with revised excised vein having a 5-year patency rate of 59% (P = not significant). Conclusion: Venous conduits that require revision have a significantly lower long-term patency rate than those that were unrevised. Grafts that require revision may be best suited for aggressive surveillance protocol to maximize long-term patency.