Duplex Ultrasound Criteria for Femorofemoral Bypass Revision.

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Patrick A. Stone, MD¹, Paul A. Armstong, DO¹, Dennis F. Bandyk, MD¹, Robert S. brumberg, do¹, Sarah K. Flaherty, BS², Brent Keeling, MD¹, Murray Shames, MD¹, Brad Johnson, MD¹, Martin Back, MD¹.
¹University of south florida, Tampa, FL, USA, ²West Virginia Universtiy, Charleston, WV, USA.

BACKGROUND:
To evaluate the results of duplex surveillance after femorofemoral bypass performed for symptomatic peripheral arterial occlusive disease (PAD).
METHODS:
During a 10-year period, 108 (78 men, 30 women, mean age 62±10 years) patients underwent femorofemoral prosthetic (n=99) or vein (n=9) bypass grafting for symptomatic (claudication, 38%; critical limb ischemia, 42%; infection, 10%) PAD. Prior or concomitant iliac stenting was performed in 40 (37%) of patients and in 19(18%) patients a “redo” bypass was performed. Duplex surveillance was performed to assess graft (mid-graft flow velocity) hemodynamics and identify inflow or outflow occlusive lesions. Repair was recommended for lesions with peak systolic velocity >300 cm/s. Life-table analysis was used to estimate primary, assisted-primary, and secondary patency.
RESULTS:
During a mean 40 month (range: 3 to 219 mo.) follow-up, 27 (25%) bypasses were revised; 16 for a duplex-detected stenosis involving the inflow iliac artery (n=13) and/or anastomotic stenosis (n=4), and 11 for thrombosis. Abnormal iliac inflow (PSV>300 cm/s) or mid-graft flow velocity (PSV<60/s) was measured in 8 of 11 grafts prior to thrombosis. The accuracy of duplex surveillance for predicting stenosis requiring repair or graft thrombosis was 84%. Time to revision was 31±27 mo. The 1-, 3-, and 5-yr primary patencies were 88%, 81%, and 68%. Correction of duplex-detected stenosis increased (p<0.0001, log-rank) assisted-primary patency to 89% at 3-yr and 86% at 5-yr. Secondary patencies were 99% at 1-yr, and 94% at 3- and 5-yrs. Graft revision for stenosis/thrombosis was increased (p<0.05) in patients with prior iliac stenting (16 of 40, 40%).
CONCLUSIONS:
A surveillance strategy following femorofemoral bypass that includes duplex imaging of the inflow iliac artery and graft, coupled with repair of identified stenosis (PSV>300 cm/s) was associated with an excellent 5-year patency. Changes in inflow artery or graft hemodynamics correlated with failure.

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