Is Duplex Surveillance of Value After Leg Vein Bypass Grafting? The Principle Results of the Vein Graft Surveillance Randomized Trial (VGST)

Abstract

Conclusion: Intensive postoperative graft surveillance with duplex scanning following lower extremity vein bypass graft operations does not result in lower amputation rates than a simple program of clinical surveillance. Summary: This was a multicenter, randomized, prospective, controlled clinical trial. There were 594 patients with a patent vein graft 30 days following surgery. These patients were randomized to either clinical follow up alone or a duplex follow up program with studies at 6 weeks and then 3, 6, 9, 12, and 18 months postoperatively. Approximately 2/3 of the grafts were placed for critical ischemia with 2/3 of the distal anastomoses to the popliteal artery either above or below the knee. Approximately 1/3 of the patients in each group had diabetes and the median age was 70 years in each group. Ipsilateral greater saphenous vein was used in 92% of the clinical follow up group and 94% of the duplex follow up group. There are no differences in the clinical and duplex surveillance groups with respect to amputation rates (7% for each group) or vascular mortality (3% v 4%) at 18 months. There were more stenoses at 18 months in the clinical group (19% v 12% P = .04). Primary patency, primary assisted patency, and secondary patency were similar in the clinical group (69%, 75%, and 80% and the duplex group 67%, 76%, and 79%). There were no apparent differences in health related quality of life but the duplex surveillance program was more costly by an average of 495 pounds more per patient. Comment: Vein graft stenoses develop more frequently in longer grafts (ie tibial distal targets), grafts placed for limb salvage, disadvantaged grafts (composite grafts, arm vein grafts) and perhaps in patients undergoing repeat procedures. In this paper most of the patients probably had primary operations as evidenced by the high level of use of ipsilateral greater saphenous vein, 2/3 of the anastomoses were to the popliteal artery, and amputation rates appeared to have been analyzed using both claudicants and limb salvage patients for the life table, a bit of a no-no. In short, if ever there were a group of patients who are unlikely to benefit from duplex surveillance, this is the group. This paper should not lead one to abandon vascular laboratory duplex surveillance for vein grafts potentially at increased risk for stenosis as noted above. However, the data does suggest that when a vein graft is placed to a popliteal artery using ipsilateral saphenous vein, duplex surveillance may not be of much benefit in reducing amputations over the short run.