title: Revision of failed infrainguinal bypass graft: principles of management.
abstract: Our experience with 112 patients whose infrainguinal bypass grafts (IIBPGs) failed more than 30 days after insertion was reviewed. Cumulative patency rates (CPRs) after graft revision (GR) were 71% at 6 months, 62% at 12 months, 57% at 24 months, 54% at 36 months, and 46% at 48 months. CPRs of IIBPGs that failed more than 12 months after insertion were higher than those of grafts that failed earlier (60% vs. 36% at 36 months (p less than 0.05). Failure of the initial GR did not preclude a successful secondary revision. The 3-year CPR of the initial GR was 31% compared with 49% for secondary GR (p = no significance). The results of GR are significantly better when graft failure is diagnosed before graft thrombosis. Revision of the 37 hemodynamically failed but patent grafts resulted in a CPR of 89% at 12 months and 77% at 36 months compared with a CPR of 33% at 12 months and 26% at 36 months after revision of the 75 thrombosed grafts (p less than 0.01). Hemodynamically failed but patent grafts occurred in 36 of 68 patients (53%) with failed autogenous veins but only 1 of 44 patients (2%) with a failed prosthetic graft had GR before thrombosis of the graft. There is a significant improvement in early CPR when a new bypass graft is inserted as compared with original graft thrombectomy and angioplasty. The CPR for new bypass grafts at 6 and 12 months was 61% and 41%, respectively, compared with a CPR of 26% and 20% for the same time intervals with graft thrombectomy and angioplasty (p less than 0.05). The presence of thrombus in the outflow artery at the site of GR is a contraindication to anastomosis at that site even if arterial thrombectomy reestablishes backflow. When distal arterial thrombus was not present, the CPR after GR was 62% at 6 months, 42% at 12 months, and 33% at 36 months. When distal arterial thrombectomy was necessary, the CPR after GR was only 14% at 6 months and zero at 12 months (p less than 0.05).
mesh_terms: D001807:Blood Vessel Prosthesis / Q000009:adverse effects*; D005260:Female; D005263:Femoral Artery / Q000601:surgery; D006083:Graft Occlusion, Vascular / Q000601:surgery; D006801:Humans; D007866:Leg / Q000098:blood supply* / Q000601:surgery; D008297:Male; D011150:Popliteal Artery / Q000601:surgery; D012086:Reoperation; D012189:Retrospective Studies; D012501:Saphenous Vein / Q000637:transplantation; D012907:Smoking; D013927:Thrombosis / Q000601:surgery