2007 Abstracts: Target Lesion Characteristics in Failing Vein Grafts Predict the Success of Endovascular and Open Revision

Background: The purpose of this study was to examine 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.
Methods: Consecutive open and endovascular revisions for graft threatening lesions were reviewed. We evaluated both graft durability and individual target lesion (TL) response to open and endovascular treatment to determine characteristics which may influence outcomes. Treatment failure was defined as TL restenosis or graft occlusion.
Results: Eighty-four (endovascular = 58; open = 26) infrainguinal vein graft revisions were performed in 67 failing, non-thrombosed infrainguinal vein grafts. Vein graft results: Overall assisted graft patency at 4 years was 42.2% [95% confidence interval (CI): 27-56; follow-up: 29.7±19.3 months]. Grafts with multiple vs. single lesions were associated with inferior 4 year patency [12.2% (95% CI: 8-40) vs. 52.5% (95% CI: 34-71); p = 0.031]. Grafts treated for early lesions (< 6 months) failed more frequently than late occurring lesions [23.5% (95% CI: 7-49) vs. 57.9% (95% CI: 35-75) at 48 months; p = 0.0005]. Target lesion results: Overall TL revascularization patency was 44% (95% CI: 34-56.5) at 4 years. Average time to TL revascularization failure was 6.1±5.5 months with no significant difference noted between endovascular and open treatment groups. Overall TL revascularization patency was not significantly different between open and endovascular groups [53% (95% CI: 29-72) vs. 40% (95% CI: 24-55.5) at 3 years; p = 0.16]. When divided by early occurring and late TL lesions, no difference in patency was seen between open and endovascular treatment groups. However, when divided by TL location (anastomotic vs. mid-graft), treatment for both proximal and distal anastomotic target lesions was associated with inferior patency compared to mid-graft revision [34.8% (95% CI: 20.5-49.3) vs. 71.6% (95% CI: 47-86) at 3 years; p = 0.038). Results of anastomotic target lesions treated with endovascular vs. open revision were equivalent; neither modality demonstrated superiority in treatment durability. In contrast, mid-graft target lesions treated with open revisions were uniformly successful compared to a 40% failure rate with endovascular treatment. Short target lesions (< 2 cm) responded better to endovascular treatment than long lesions (p = 0.0065), and short lesions fared equally well with endovascular treatment and open treatment. Adjusting for age, multivariate logistic regression noted female gender, anastomotic stenoses, long lesions and endovascular treatment were associated with significantly increased odds of failure.
Conclusion: Early lesions and multiplicity of lesions within failing grafts suggest compromised initial conduit and fare poorly regardless of treatment modality. Lesions involving anastomoses of failing grafts are treated with endovascular or open treatment with equal success. However, long lesions and mid graft stenoses should be preferentially treated with open repair.