Comparison of angioscopy and angiography for monitoring infrainguinal bypass vein grafts: Results of a prospective randomized trial

doi:10.1016/0741-5214(93)90423-J

Journal of Vascular Surgery

Volume 17, Issue 2, February 1993, Pages 382-398

Presented at the Fortieth Scientific Meeting of the International Society for Cardiovascular Surgery, North American Chapter, Chicago, Ill., June 9-10, 1992.

https://doi.org/10.1016/0741-5214(93)90423-J Get rights and content

Abstract

Purpose: This study was designed to determine whether, in primary infrainguinal bypass grafts in which only saphenous vein is used as the graft conduit, routine monitoring with intraoperative angioscopy can improve early graft patency as compared with standard monitoring with intraoperative completion angiography; and to delineate the advantages and disadvantages of these two modalities and their respective roles for the routine monitoring of the infrainguinal bypass graft. Methods: A total of 293 patients undergoing primary saphenous vein infrainguinal bypass grafting were prospectively randomized and monitored with either completion angioscopy or completion angiography. Clinical parameters, indications for operation, graft anatomy, and configuration were evenly matched in both groups. Forty-three bypasses were excluded from the study after randomization, including 12 veins randomized to angiogram, deemed inferior, and prepared with angioscopy. Results: In the 250 bypass grafts (angioscopy 128, angiography 122) there were 39 interventions (conduit, 29; anastomosis, 8; distal artery, 2), 32 with angioscopy and 7 with angiography (p < 0.0001). Twelve (4.8%) of the 250 grafts failed in less than 30 days, four (3.1%) of 128 in the angioscopy group and eight (6.6%) of 122 in the angiography group (p = 0.11 by one-sided hypothesis test). Conclusion: Although no statistical improvement in the proportions of failures in primary saphenous vein bypass grafts routinely monitored with completion angioscopy rather than the standard completion angiogram was demonstrated, the study delineates a trend that favors completion angioscopy for routine vein graft monitoring and demonstrates the advantages of angioscopy in preparing the optimal vein conduit. (J VASC SURG 1993;17:382-98.)

Section snippets

Patients and methods

Between February 1, 1990, and October 30, 1991, 293 patients undergoing primary infrainguinal bypass grafting with the greater saphenous vein from either limb were prospectively randomized into two groups, in which either intraoperative angiography or angioscopy was used to monitor the bypass procedure at its completion. Randomization was performed with the use of a table of random numbers provided by the Rand Corporation (Freepress Publishers, Glencoe, Ill.).

All patients undergoing repeat

Results

Of 293 patients prospectively randomized to monitoring of the completed infrainguinal bypass graft with either completion angioscopy or completion angiography, 250 were included in this study (Table I).No patient enrolled in the study underwent more than one primary infrainguinal bypass grafting procedure. Forty-three (14.7%) of 293 patients randomized preoperatively and enrolled were subsequently excluded from the study. Table II summarizes details of the 43 bypasses excluded from study 1,

Discussion

The results of our prospectively randomized study of 250 primary saphenous vein infrainguinal bypass grafts do not demonstrate any statistically significant improvement in the early (< 30 days) patency of infrainguinal bypass grafts routinely monitored with completion angioscopy rather than the standard completion angiogram. Detailed analysis of the study delineated a trend that favors completion angioscopy for the routine monitoring of these primary autogenous vein bypass grafts and reveals a

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Cited by (50)

Routine use of completion imaging after infrainguinal bypass is not associated with higher bypass graft patency
2014, Journal of Vascular Surgery
Significant variability exists in completion imaging (CIM) after infrainguinal lower extremity bypass (LEB). We evaluated the use of CIM and compared graft patency in patients treated by surgeons who performed routine CIM vs those who performed selective CIM.
We reviewed the Vascular Study Group of New England database (2003-2010) and assessed the use of CIM (angiography or duplex ultrasound) among patients undergoing LEB. The surgeon-specific CIM strategy was categorized as routine (≥80% of LEBs) vs selective (<80% of LEBs). Exclusion criteria included acute limb ischemia, bilateral procedures, and surgeon volume <10 cases per study period. Primary graft patency at discharge and at 1 year was analyzed on the basis of CIM use and surgeon-specific CIM strategy. Multivariable analyses were performed using Poisson regression.
Among 2032 LEB procedures performed by 48 surgeons, CIM was used in 1368 cases (67.3%). CIM was performed in 72% of autogenous LEBs and 52% of prosthetic grafts. Dialysis (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.1-2.6; P = .01), elective LEB (OR, 2.6; 95% CI, 1.4-4.8; P = .002), great saphenous vein conduit (OR, 2.0; 95% CI, 1.6-2.5; P < .001), and tibial or pedal target artery (OR, 1.8; 95% CI, 1.4-2.3; P < .001) were associated with CIM use. In multivariate models, CIM was not associated with improved primary graft patency at discharge (OR, 1.1; 95% CI, 0.7-1.7; P = .64) or at 1 year (OR, 0.9; 95% CI, 0.7-1.2; P = .47). Sixteen surgeons (33%) were routine users and 32 (67%) were selective users of CIM. Among patients of routine vs selective CIM users, primary graft patency at discharge and at 1 year was 96% vs 94% (P = .21) and 68% vs 72% (P = .09), respectively. In multivariate analysis, routine or selective CIM strategy was not associated with improved discharge (rate ratio, 0.8; 95% CI, 0.6-1.1; P = .31) or 1-year (rate ratio, 1.1; 95% CI, 0.9-1.2; P = .56) graft patency.
In our observational cohort, CIM does not improve short-term and 1-year bypass graft patency in infrainguinal LEB. The surgeon-specific strategy of selective CIM after LEB has outcomes comparable to those of routine CIM.
Surgical Intervention for Lower Extremity Arterial Occlusive Disease: Femoropopliteal and Tibial Interventions
2009, Comprehensive Vascular and Endovascular Surgery: Second Edition
Patency of infra-inguinal vein grafts - effect of intraoperative Doppler assessment and a graft surveillance program
2009, Journal of Vascular Surgery
Citation Excerpt :
Furthermore, completion angiography has not been shown to alter short- or intermediate-term graft patency.10 Angioscopy had its proponents in the 1990s8 and proved more useful in assessing the quality of the venous conduit than angiography but has fallen out of favor, largely due to the inability to adequately assess the distal vasculature.11 Intraoperative Duplex assessment of grafts appears to be the most useful modality to assess graft function and may have the ability to predict future stenotic development and graft failure.9,18,19
To assess the value of intraoperative graft flow and resistance measurements and a graft surveillance program to predict at-risk infra-inguinal bypass grafts.
Four hundred sixty-eight infra-inguinal bypass procedures performed between 1995-2006 underwent intraoperative measurement of graft flow and resistance using a Scimed OpDop. These data were correlated with graft outcome at six weeks. Two hundred fifty-four (73%) grafts were entered into a graft surveillance program and the effect of this on primary-assisted graft patency was assessed.
Overall primary and primary-assisted graft patency was 81% and 83% at six weeks and 42% and 64% at three years. Grafts failing by six weeks had significantly lower flow (130.5 mL/min vs. 150.5 mL/min, P = .009) and higher resistance (0.67 peripheral resistance units (PRU) vs. 0.57 PRU, P = .004) than those remaining patent. However, OpDop measured flow and resistance was a poor predictor of graft failure in individual cases (area under ROC curve, 0.57). While there was no statistical difference in primary 18-month patency rates between grafts undergoing surveillance and those undergoing clinical follow up (55% vs. 76%, P = .133), primary-assisted 18-month patency rates were significantly higher in the surveillance group (83% vs. 77%, P = .042).
Intraoperative measurements of graft flow and resistance do not predict graft outcome at six weeks. However, surveillance does identify at-risk grafts and improves mid-term primary-assisted patency.
Intra-operative Doppler flow measurement do not predict 'At-risk' status of infrainguinal bypass grafts
2005, European Journal of Vascular and Endovascular Surgery
Citation Excerpt :
Infrainguinal bypass surgery using autologous vein as a conduit is the surgical method of choice for treatment of critical limb ischaemia.1 As experience with infrainguinal revascularisation has increased, and surgical techniques have improved, several reports have suggested that intra-operative assessment of bypass grafts is an important adjunct.2–11 Surgeon preference and experience usually dictates the type of intra-operative assessment used.
Patients undergoing infrainguinal arterial reconstruction using vein conduits, frequently undergo intra-operative Doppler flow measurements to determine technical adequacy. The aim of this study was to determine the proportion of vein grafts with normal intra-operative haemodynamic parameters that were subsequently discovered to be ‘at risk’ on post-operative duplex surveillance scanning.
We prospectively collected data on 82, primary infrainguinal vein bypass grafts. Post papaverine graft flow and peripheral resistance were measured using the Scimed Opdop^® intra-operative Doppler machine. All grafts were determined to be technically adequate on the basis of measured peripheral resistance units (mPRU) being ≤1. At 1 week, a post-operative duplex surveillance scan was performed. At risk status was determined and compared to the intra-operative Doppler flow measurement. Statistical analysis was performed using the Mann–Whitney U-test.
The post-operative duplex scan demonstrated that 53 (65%) of the 82 vein bypass grafts were diagnosed as being ‘not at risk’; and 29 (35%) were regarded as at risk. When the groups were compared, there was no significant difference in intra-operative haemodynamic parameters between those not at risk and those at risk (P=0.19, Mann–Whitney U-test). The 1 month primary patency rate was 79% with a secondary patency rate of 100%.
Despite normal intra-operative Doppler flow measurements, 35% of vein grafts were regarded as being at risk at the 1 week post-operative duplex surveillance scan. No single value may be universally applicable for identifying at risk grafts intraoperatively. Indeed, graft failure appears to be a multifactorial process.
The Preoperative, Intraoperative, and Postoperative Noninvasive Evaluation of Infrainguinal Vein Bypass Grafts
2005, Vascular Diagnosis
The Preoperative, Intraoperative, and Postoperative Noninvasive Evaluation of Infrainguinal Vein Bypass Grafts
2004, Vascular Diagnosis

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^*: Reprint requests: Arnold Miller, MD, 110 Francis St., Suite 3B, Boston, MA 02215.

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Original Articles from the International Society for Cardiovascular Surgery, North American ChapterComparison of angioscopy and angiography for monitoring infrainguinal bypass vein grafts: Results of a prospective randomized trial*

Abstract

Section snippets

Patients and methods

Results

Discussion

Am J Surg

J Vasc Surg

J Vasc Surg

Am J Surg

J Vasc Surg

Am J Surg

Ann Vasc Surg

J Vasc Surg

J Vasc Surg

J Vasc Surg

Am Heart J

Ann Vasc Surg

New approaches in limb salvage by extended extraanatomic bypasses and prosthetic reconstructions to foot arteries

Surgery

Reversed vein bypass to infrapoplitcal arteries

Ann Surg

Original Articles from the International Society for Cardiovascular Surgery, North American Chapter
Comparison of angioscopy and angiography for monitoring infrainguinal bypass vein grafts: Results of a prospective randomized trial*