Target lesion characteristics in failing vein grafts predict the success of endovascular and open revision

Abstract

This study examined the association of anatomic and temporal characteristics of graft-threatening lesions with the efficacy of percutaneous and open graft revision for failing infrainguinal vein grafts. Consecutive open and endovascular revisions for graft threatening lesions were reviewed. We evaluated graft durability and individual target lesion response to open and endovascular treatment to determine characteristics that may influence outcomes. Treatment failure was defined as target lesion restenosis or graft occlusion. Eighty-four (58 endovascular, 26 open) infrainguinal vein graft revisions were performed in 67 failing, nonthrombosed infrainguinal vein grafts. Primary assisted graft patency at 5 years was 63% (95% confidence interval [CI], 46% to 77%). Follow-up was 29.5 +/- 19.2 months. Grafts treated for early lesions (<6 months) failed (occlusion or need for additional interventions) more frequently than those with late occurring lesions (P = .03). Overall target lesion revascularization patency was 45% (95% CI, 32% to 58%) at 3 years. Average time to target lesion revascularization failure was 7.5 months, with no significant difference noted between endovascular and open treatment groups. Overall target lesion revascularization patency at 3 years was also not significantly different between open and endovascular groups at 54% (95% CI, 30% to 73%) vs 41% (95% CI, 25% to 56%; P = .15). When divided by early and late-occurring target lesions, endovascular treatment of early lesions was associated with inferior patency compared with open procedures; no difference in patency was seen between treatment groups for late lesions. When divided by target lesion location (anastomotic vs mid-graft), treatment for both proximal and distal anastomotic target lesion was associated with inferior patency compared with mid-graft revision at 32% (95% CI, 17% to 47%) vs 62% (95% CI, 37% to 87%) at 3 years (P = .03). In addition, although results of anastomotic target lesion treatment significantly favored open repair, even open repair of anastomotic target lesions was associated with a <50% patency rate at 3 years. In contrast, mid-graft target lesions treated with open revisions were uniformly successful compared with a 54% patency at 3 years with endovascular treatment (P = .24). Short lesions (<2 cm) fared equally well with either endovascular or open treatment. Univariate analysis noted only anastomotic treatment was associated with significantly increased odds of failure. Grafts that develop early lesions fare poorly regardless of treatment modality. Lesions involving anastomoses of failing grafts are better treated with open revision, but patency after treatment of such lesions is still worse than treatment of mid-graft lesions. In contrast, the method of treatment does not influence outcome after treatment of mid-graft target lesions. Thus, endovascular therapy should be reserved for focal, late-appearing lesions involving the mid-graft.