Introduction of an Adequate Saphenous Vein Lack of usable GSV is - - PowerPoint PPT Presentation

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Introduction of an Adequate Saphenous Vein Lack of usable GSV is - - PowerPoint PPT Presentation

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Bypass Surgery Options in the Absence Introduction of an Adequate Saphenous Vein Lack of usable GSV is common: 20-40% Matthew T. Menard, M.D . Re-operative lower extremity bypass Brigham and Womens Hospital Prior CABG, vein

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Bypass Surgery Options in the Absence

  • f an Adequate Saphenous Vein

Matthew T. Menard, M.D.

Brigham and Women’s Hospital Harvard Medical School

Introduction

  • Lack of usable GSV is common: 20-40%
  • Re-operative lower extremity bypass
  • Prior CABG, vein stripping

PREVENT III

Vein Graft Size Schanzer, JVS 2007

PREVENT III

Conduit Type Schanzer, JVS 2007

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PREVENT III

High vs Low Risk Conduit Schanzer, JVS 2007

General Strategies

  • Perform the best, most durable procedure

possible.

  • Use the best available autogenous vein.

Re-operative Survey: Challenges

  • Vascular bad actors: Intimal hyperplasia,

sclerotic veins, hypercoagulable states, etc

  • Scarring
  • More advanced disease.

Options

  • Contralateral Greater Saphenous Vein
  • Arm Vein
  • Lesser Saphenous Vein
  • Cryopreserved vein
  • Prosthetic grafts
  • Endovascular/hybrid
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Contralateral GSV

JVS 2002

CLV Harvest and Fate of the Contralateral Limb

  • Only 16% needed intervention in contra leg
  • 12% bypass
  • 4% amputation
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Arm Vein

Disadvantages:

  • Can be tenuous quality

»Antecubital scarring »Focal phlebitis, sclerosis »Short vein segments.

  • Tedious harvest of basilic/brachial vein
  • Prone to twisting

Infrainguinal Bypass in the Absence of GSV: Lesser Saphenous Vein

Advantages:

  • Same operative field.
  • Can be qualitatively similar to GSV.

Disadvantages:

  • Tedious exposure.
  • Unreliable quality.
  • Short vein segments.

Composite Vein Grafts: Demographics (Chew 1998)

  • 154 patients
  • Limb salvage in 90%
  • Redo: 48%
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Number of Segments

2 Seg 75% 3 Seg 23% 4 Seg 2%

Time (months)

10 20 30 40 50 60 70

% Cumulative Patency

10 20 30 40 50 60 70 80 90 100 110

Patency of Composite Grafts

LS 79% + 5% SP 65% + 5% PP 44% + 5%

Composite Vein Grafts

Chew, JVS, 2001

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Patency Rates

10 20 30 40 50 60 70 80 90 1 4 7 10 13 16 19 22 Months Cumulative Patency (%) Primary Patency Rate Primary Assisted Patency Rate Secondary Patency Rate

P=ns, Log-rank test

Prosthetic Grafts

Summary of meta-analysis data since 1981

Distaflo Grafts

carbon lined engineered cuffs

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Distaflo Grafts

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Propaten:

Thromboresistant lumenal graft surface

Heparin Bonded PTFE

  • Italian, 7 center, retrospective review
  • 425 bypass for CLI (101 AK, 324 BK)
  • 36 month results: PP 61%, SP 70%
  • No diff AK vs BK

Pulli et al, JVS, 2010;51:1167

Linton patch

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Miller cuff

  • St. Mary’s boot

Tyrell MR, Wolfe JHN; Br J Surg 1991 Tyrell MR, Wolfe JHN; Br J Surg 1991

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Tyrell MR, Wolfe JHN; Br J Surg 1991 Tyrell MR, Wolfe JHN; Br J Surg 1991 Tyrell MR, Wolfe JHN; Br J Surg 1991 Tyrell MR, Wolfe JHN; Br J Surg 1991

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Taylor patch

Dardik H, et al J Vasc Surg 1996

Secondary Patency

10 20 30 40 50 60 70 80 90 100 12 24 36 48 60

Months

% Patency

Alternative Vein Prosthetic

33 25 21 AV 17 12 10 Number at risk 52 34 25 Pros 14 9 8

P=0.488

68.8% 68.4%

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Summary

  • Do the best operation/procedure you can
  • Use the best vein available.
  • Prosthetic is reasonable option, and is better

than bad vein

  • Need for appropriate creativity in hybrid era