Open surgical revision provides a more durable repair than endovascular treatment for unfavorable vein graft lesions.
OBJECTIVE
Lower extremity bypass grafts that develop stenoses are commonly treated with either open surgical or endovascular revision. Vein graft stenoses with unfavorable lesions (multiple lesions, lesions >2 cm in length, lesions in grafts <3 months old, lesions in grafts <3 mm in diameter) fare worse than those with favorable lesions when treated with endovascular therapy. However, it is not known if unfavorable lesions fare better with surgical revision than with endovascular treatment or than favorable lesions treated with surgery.


METHODS
We performed a retrospective review of 175 vein graft revisions performed at a single institution from 2000 to 2010. Characteristics of lesions treated with surgical and endovascular revision were identified. Cox proportional hazard models were used to identify predictors of revision failure (restenosis >75%, revision, or amputation).


RESULTS
Ninety-one failing vein grafts (52%) were treated with surgical revision and 84 with endovascular treatment (48%), with a median follow-up of 30 months. Favorable lesions fared better than unfavorable lesions after endovascular treatment, with 12-month freedom from failure of 59% vs 34% (P < .01), but not after surgical revision (66% vs 62%; P = .90). Unfavorable lesions had better freedom from failure after surgery than endovascular treatment (62% vs 34%; P < .01), and results in favorable lesions were similar (66% vs 59%; P = .57).


CONCLUSIONS
For the treatment of failing vein grafts, endovascular therapy appears adequate for favorable lesions and surgical revision is more durable for unfavorable lesions.
Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
John C
JC
McCallum
Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
Rodney P
RP
Bensley
Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
Jeremy D
JD
Darling
Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
Allen D
AD
Hamdan
Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
Mark C
MC
Wyers
Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
Chantel
C
Hile
Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
Raul J
RJ
Guzman
Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass. Electronic address: mscherme@bidmc.harvard.edu.
Marc L
ML
Schermerhorn
D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D001900:Boston; D016009:Chi-Square Distribution; D057510:Endovascular Procedures / Q000009:adverse effects; D005260:Female; D006083:Graft Occlusion, Vascular / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D006801:Humans; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D016016:Proportional Hazards Models; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D017211:Treatment Failure; D058017:Vascular Grafting / Q000009:adverse effects*; D014654:Vascular Patency; D014680:Veins / Q000503:physiopathology / Q000637:transplantation*