Strategic Management Of Cadaveric Lower Extremity Bypass With Aggressive Duplex Ultrasound Surveillance In Conjunction With Open And Percutaneous Intervention
Aaron Hayson, MD1, Panagiotis Koutakis, PhD2, Derek Hillison, PhD3, Catalina Breton, MD1, Ahmed Ismaeel, MS2, Dan Kaelin, MD1, Denise Smith, M.D.1, Robert Brumberg, MD1.
1FSU/TMH General Surgery Residency, Tallahassee, FL, USA, 2Florida State University, Tallahassee, FL, USA, 3Tallahassee Memorial Hospital, Tallahassee, FL, USA.
OBJECTIVES: Cryopreserved conduits are increasingly used for lower extremity limb salvage with suboptimal results. It has been shown that duplex ultrasound surveillance can predict bypass graft compromise and trigger early intervention to prevent graft thrombosis amongst autologous and prosthetic conduits utilized for limb salvage. We analyzed our experience with the use of duplex ultrasound to define its utility in optimizing patency of cadaveric bypass.
METHODS: A retrospective review of cadaveric lower extremity bypass procedures were reviewed from a single tertiary referral center between the years of 2011 - 2018. After bypass creation, grafts were scanned with duplex ultrasound at a standard time protocol of 1, 3, 6 and 12 months initially and then biannually. Grafts with peak systolic velocity greater than 300 and velocity ratio greater than 3.5 were treated either by endovascular or open therapy. Primary outcomes of the bypassed conduits were patency rate and limb salvage. RESULTS: A total of 65 patients underwent lower extremity bypass with cadaveric conduits (14 femoral arteries and 51 saphenous veins). 63 of the 65 patients, underwent infrageniculate bypasses with > 90% for rest pain and tissue loss. The median age of our cohort was 67.2 years of age. The median time for first ultrasound graft scan for all bypasses was 94 days. 85% (12/14) of the arterial and 58% (30/51) of the venous conduits required interventions to maintain patency based upon duplex findings. Peak systolic velocities (PSV) greater than 250cm/sec or lower than 50 cm/sec lead to greater than 70% graft failure regardless of time of surveillance. Graft patency was not dependent upon use of anticoagulation nor antiplatelet therapy. Forty-two grafts failed at primary patency, 12 grafts (20%) were occluded at 30 days. Only 7 (16%) complied with the initial duplex at 30 days which showed a patent graft.
CONCLUSIONS: From our cohort, early graft failure of cryopreserved bypasses is common. Lack of early duplex scanning was associated with primary graft failure regardless of type of conduit. Aggressive endovascular or open intervention at PSV > 250cm/sec or < 50cm/sec may improve overall patency rates. Overall, cadaveric artery has a higher rate of intervention than cadaveric vein. Vascular surgeons must be aware that early duplex surveillance is a key factor affecting the viability of cadaveric lower extremity bypass.
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