A ten-year experience with one hundred fifty failing or threatened vein and polytetrafluoroethylene arterial bypass grafts

Between Jan. 1, 1980, and Dec. 31, 1989, 2187 infrainguinal revascularization procedures were performed. In 130 of these cases with patent bypasses, hemodynamic deterioration was suspected, and urgent arteriography was performed. Twenty additional patients with aortofemoral, femorofemoral, or axillofemoral bypasses demonstrated hemodynamic deterioration. In 93% of failing grafts the condition was suspected because of recurrent symptoms or changes in the pulse examination. Two hundred eighty-five high-grade stenotic or occlusive lesions were identified in inflow arteries, outflow arteries, within the graft, or at proximal or distal anastomoses associated with these 150 grafts. One hundred sixty-one (57%) of these lesions were in patients with failing vein grafts; 115 (40%) were in patients with failing polytetrafluoroethylene (PTFE) grafts; and 9 (3%) were associated with failing composite vein/PTFE grafts. Stenotic lesions < 5 cm in length were initially treated with percutaneous transluminal balloon angioplasty (PTA). Occlusive lesions, stenoses 〉 5 cm in length, and PTA failures were treated surgically. The overall 6-year cumulative secondary patency rate for failing grafts was 65%, and the limb salvage rate was 75%. The extended patency rate after the first intervention in the failing state was 56% at 5 years. The 5-year secondary patency rate for grafts initially treated with PTA (58%) was not significantly different (p = 0.25) from that for grafts treated initially with surgery (71%). Percutaneous transluminal angioplasty was effective for inflow stenoses of the iliac, femoral, and popliteal arteries and for some outflow lesions. The 24-month extended patency rate for lesions < 1.5 cm in length within vein grafts ≥ 3 mm in diameter treated by percutaneous transluminal angioplasty (93%) was significantly better than that of lesions that were multiple, ≥ 1.5 cm in length, or within grafts < 3 mm in diameter (54%) (p = 0.001). Frequent, careful surveillance can identify the failing state in both vein and PTFE arterial reconstructions. Percutaneous transluminal angioplasty is effective in treating most short (< 5 cm) inflow lesions and graft stenoses < 1.5 cm. Surgical interventions are necessary to treat recurrent, long, diffuse, or occlusive lesions. Early detection of failing grafts and timely intervention are essential for the long-term maintenance of arterial bypass grafts. (J VASC SURG 1991;14:729-38.)