Revision of Vein Bypass Grafts: Factors Affecting Durability of Interventions

Once the failing vein graft is identified and characterized, the clinician must choose the appropriate intervention to maintain graft patency. Limited by the single-institution, retrospective studies that are pervasive in this area, definitive data to guide these decisions are limited. In general, open surgical revisions appear to offer a modest benefit in primary patency, but likely at the cost of increased periprocedural morbidity. Although endovascular revisions are more prone to failure, these recurrent lesions are often amenable to reintervention so that the secondary patency rates for both endovascular and open interventions may be similar. Given this, endovascular intervention as an initial treatment modality seems a reasonable approach for favorable lesions. Factors associated with poor outcome for endovascular revision include longer lesions (stenosis >2 cm in length), multiple stenoses, lesions occurring within 3 months of graft placement, or interventions for graft thrombosis, where endovascular failures are high and open surgery as an initial approach is warranted. The optimum method for percutaneous intervention remains a shifting landscape. No techniques as of yet appear clearly superior to standard balloon angioplasty, but initial investigations would suggest that cutting balloons offer a modest improvement and are worthy of consideration.