Duplex Ultrasound Surveillance is a Worthwhile Method to Identify Failing Aortobifemoral Grafts
Krystal Maloni, MD, Keith Calligaro, MD, Nicholas Madden, DO, Douglas Troutman, DO, Kunal Vani, DO, Matthew Dougherty, MD.
Pennsylvania Hospital, Philadelhpia, PA, USA.
Objective: The Society for Vascular Surgery practice guidelines on follow-up after vascular surgery arterial procedures mentioned there are no studies describing long-term surveillance for aortobifemoral (AoBF) bypasses. The guidelines suggested that clinical examination and ankle-brachial index, with or without duplex ultrasound (DU), be performed on a regular basis. Our goal was to identify the value of DU studies as a surveillance tool for AoBF bypasses.
Methods: We retrospectively identified patients in our prospectively maintained database who underwent ABF grafts between 1995 – 2018. “Abnormal” DU findings suggesting a failing graft included focal peak systolic velocities (PSVs) > 350 cm/sec or an adjacent PSV ratio > 3.5 at any site from the proximal aortic to distal femoral anastomosis. Surveillance was performed post-operatively, every six months for one year, and then annually if there were no abnormalities.
Results: Of 153 ABF grafts, 60 patients with 120 graft limbs fulfilled our post-operative surveillance protocol.During an average follow-up of 4 years (0.5-24 years), “normal” DU studies were documented in 96% (115/120) of cases. Of these, 1.7% (2/115) of limbs developed acute occlusion.
The other 4% (5) of ABF limbs developed “abnormal” DU findings during follow-up (all at the distal femoral anastomosis). However, 2 of the 5 patients complained of ischemic symptoms which prompted earlier DU studies. Therefore, DU alone without clinically suspicious findings identified only 2.5% (3/120) of ABF limbs as failing. Graft revision (3 endovascular, 1 open) was ultimately performed in 4 of the 5 cases, while 1 asymptomatic patient with persistent “abnormal” DU studies suggesting a failing limb did not undergo intervention due to surgeon discretion and the stenosis remained stable during three years follow-up.
Conclusion: In this series, the incidence of acute occlusion of an ABF limb in the setting of normal DU studies during follow-up (1.7%) approximated the incidence of prophylactic
intervention for an ABF limb based solely on “abnormal” DU studies (2.5%). Due to the low likelihood of graft stenosis during long-term follow-up of ABF grafts, our results suggest DU is not a useful surveillance tool for ABF grafts using the above criteria.
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