title: Prediction of early graft failure with intraoperative completion duplex ultrasound scan.
abstract: OBJECTIVE
  The purpose of this study was to determine intraoperative hemodynamic parameters that predict early failure of infragenicular vein grafts with intraoperative completion duplex ultrasound scan.
  
  
  METHODS
  We reviewed the results of intraoperative duplex scans that were selectively performed after completion of 45 tibial/pedal vein bypass grafts at high risk for failure. Bypass was performed for rest pain (39%) or tissue loss (61%), and 60% of the cases were disadvantaged because of compromised vein quality or poor arterial outflow. A 10-MHz low-profile transducer was used to scan the entire graft at bypass completion. All grafts were determined to be technically adequate (absence of retained valves, arteriovenous fistulas, or localized velocity increases and the presence of bypass-dependent distal pulses). Peak systolic velocity (PSV) and end diastolic velocity (EDV) were also measured at each anastomosis, in the outflow artery and in the proximal and distal portions of each graft. Resistive indices (RI) were calculated at each measurement point (PSV-EDV/PSV). Statistical analysis was performed with unpaired t test, chi(2) test, and multivariate analyses.
  
  
  RESULTS
  Twenty infragenicular vein bypass grafts (44%) thrombosed within 12 months. Intraoperative hemodynamic parameters were significantly different between grafts that remained patent or thrombosed. EDV was lower (5 +/- 1 cm/s versus 13 +/- 3 cm/s; P =.02) and RI was higher (0.90 versus 0.81; P <.01) in the proximal portions of grafts that thrombosed within 12 months. Distal EDV was also lower (6 +/- 1 cm/s versus 15 +/- 2 cm/s; P <.01) and distal RI was higher (0.89 versus 0.78; P <.01) in grafts that thrombosed. With multivariate analysis, only low distal EDV was predictive of early graft failure (P <.05). Distal bypass EDV of less than 8 cm/s predicated early graft thrombosis with 76% sensitivity and 75% specificity (positive predictive value, 71%; negative predictive value, 78%). Absence of diastolic flow (EDV of 0 cm/s) predicted early graft failure with 100% specificity and 100% positive predictive value.
  
  
  CONCLUSIONS
  In this initial experience, low EDV measured with intraoperative duplex scan was associated with early thrombosis of tibial level vein grafts. When such values are observed, measures should be taken to improve graft hemodynamic parameters. Prospective study of infragenicular vein bypass grafts may better define hemodynamic parameters predictive of early graft thrombosis.
authors.affiliation: Dartmouth-Hitchcock Medical Center, Lebannon, New Hampshire 03756, USA.
authors.forename: Eva M
authors.initials: EM
authors.lastname: Rzucidlo
authors.forename: Daniel B
authors.initials: DB
authors.lastname: Walsh
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Powell
authors.forename: Robert M
authors.initials: RM
authors.lastname: Zwolak
authors.forename: Mark F
authors.initials: MF
authors.lastname: Fillinger
authors.forename: Marc L
authors.initials: ML
authors.lastname: Schermerhorn
authors.forename: Jack L
authors.initials: JL
authors.lastname: Cronenwett
mesh_terms: D000368:Aged; D001783:Blood Flow Velocity; D019917:Blood Vessel Prosthesis Implantation; D005260:Female; D006083:Graft Occlusion, Vascular / Q000000981:diagnostic imaging* / Q000453:epidemiology; D006801:Humans; D007430:Intraoperative Care; D007866:Leg / Q000098:blood supply*; D008297:Male; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D013927:Thrombosis / Q000000981:diagnostic imaging* / Q000453:epidemiology; D018616:Ultrasonography, Doppler, Duplex; D014654:Vascular Patency