Early outcome of "cutting" balloon angioplasty for infrainguinal vein graft stenosis

Background. Recurrent stenotic lesions associated with vein graft bypass grafts are often fibrous and smooth. Unlike de novo atherosclerotic lesions, they respond poorly to balloon angioplasty, and may often result in a dissection requiring stent placement to avoid early recurrent thrombosis or open repair of residual stenosis. A novel balloon designed with three or four longitudinally placed 0.127-mm atherotomes; was used at angioplasty to treat focal peripheral vein graft stenosis, in an attempt to minimize dissection by producing a controlled plaque fracture. Methods: Over 11 months, patients with focal (< 2 cm) peripheral vein graft stenosis underwent cutting balloon angioplasty (Boston Scientific, San Diego, Calif) at two separate centers. Baseline patient demographic data, type of bypass, velocity at pre-procedural and post-procedural duplex scanning, procedural results, complications, and type of long-term anticoagulation were recorded. Follow-up consisted of duplex ultrasound scanning at 1, 3, and 6 months and every 6 months for 2 years. Results: The mean age of the patients was 66.8 +/- 10 years. No intent to treat failure was noted. In most patients a 4-mm balloon was used (15 of 19) to treat 10 above-knee vein bypass grafts and 9 below-knee vein bypass grafts. No patient required placement of a stent or conversion to open surgery because of recoil, dissection, or suboptimal angioplasty. The mean velocity at pre-procedure duplex scanning at the site of vein graft stenosis was 373 +/- 56.8 cm/s, and the mean velocity post-treatment at 1-month follow-up was 144 +/- 50 cm/s. The mean length of stay was 26 +/- 32 hours. Overall, four patients continued to receive warfarin anticoagulation therapy, in addition to aspirin. During a mean follow-up of 11.4 +/- 7 months, recurrent stenosis developed in one patient. No other complications or graft recurrent thrombosis was noted. Conclusion: Cutting balloon angioplasty may help overcome hoop stress early, by producing a controlled, longitudinal neointimal lesion laceration and thereby facilitating a fracture line along predetermined microincisions. Our study results demonstrate acceptable early outcomes, with no requirement for bail-out stenting or open surgery.