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Duplex Surveillance of Infrainguinal Bypass Grafts

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Noninvasive Vascular Diagnosis

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Abstract

Infrainguinal bypass using greater saphenous vein is a well-established treatment for lower-extremity critical limb ischemia. Alternative conduits for revascularization (arm vein, spliced vein, or prosthetic graft) may be used in the absence of a greater saphenous vein. Myointimal hyperplasia resulting in stenosis of the conduit remains the most common etiology of graft failure outside of the perioperative period. Clinical assessment for sign and symptoms of limb ischemia lacks the diagnostic sensitivity to detect many stenoses. Consequently duplex surveillance is recommended after infrainguinal bypass grafting to identify abnormalities in graft flow characteristics while the graft is still patent. Since the goal of infrainguinal bypass surveillance is to prolong patency and avoid thrombotic events, the measure of its success is the “assisted primary patency rate.” Optimum results are obtained when duplex surveillance is initiated in the operating room or prior to discharge. The likelihood of graft revision varies with the vein bypass type and is increased when a graft defect is identified on a “predischarge” or early (<6-week) duplex scan. Duplex findings can also be used to select endovascular or surgical treatment options. Additionally, the efficacy of duplex surveillance may be enhanced by modifying testing protocols, e.g., rigorous surveillance for “higher-risk” bypasses based on initial duplex scan results and other characteristics.

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Author information

Authors and Affiliations

  1. Department of Surgery, Division of Vascular/Endovascular Surgery, West Virginia University/Charleston Division, Charleston, WV, 25304, USA

    Patrick A. Stone MD & Jenna L. C. Kazil MD, RPVI

  2. Vascular Surgery, University of California School of Medicine, 3110 MacCorkle Ave., SE, La Jolla, CA, USA

    Dennis F. Bandyk MD

Authors
  1. Patrick A. Stone MD
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  2. Jenna L. C. Kazil MD, RPVI
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  3. Dennis F. Bandyk MD
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Corresponding author

Correspondence to Patrick A. Stone MD .

Editor information

Editors and Affiliations

  1. Charleston, West Virginia, USA

    Ali F. AbuRahma

Review Questions

Review Questions

  1. 1.

    Most infrainguinal bypasses develop graft stenosis due to

    1. a.

      Technical error

    2. b.

      Intrinsic graft lesions

    3. c.

      Failure to adequately anticoagulate postoperatively

    4. d.

      Myointimal hyperplasia

  2. 2.

    Graft thrombosis is most likely to occur

    1. a.

      In the immediate postoperative period

    2. b.

      In the first 3 months

    3. c.

      In the first year after surgery

    4. d.

      Five years after surgery

  3. 3.

    A low PSV in a graft

    1. a.

      Always predicts graft failure

    2. b.

      Can be found normally in a graft with a diameter of >6 mm

    3. c.

      Is normal in inframalleolar bypasses

    4. d.

      Is classified as anything <20 cm/s

  4. 4.

    The appropriate duplex surveillance interval after a below-knee fem-pop bypass using the saphenous vein is

    1. a.

      Once within the first 3 months then every 6 months after that

    2. b.

      Immediately after surgery then every 3 months for 2 years

    3. c.

      Once within the first month then 3 months later then every 6 months

    4. d.

      Every 6 months as long as there is a palpable pulse

  5. 5.

    The factor that most likely will predict the need for intervention using duplex ultrasound is

    1. a.

      Abnormal velocity (>180–300 cm/s)

    2. b.

      Use of anticoagulation

    3. c.

      More than one segment of the vein used for conduit

    4. d.

      Multiple previous failed bypasses

Answer Key

1. d

2. a

3. b

4. c

5. a

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Stone, P.A., Kazil, J.L.C., Bandyk, D.F. (2017). Duplex Surveillance of Infrainguinal Bypass Grafts. In: AbuRahma, A. (eds) Noninvasive Vascular Diagnosis. Springer, Cham. https://doi.org/10.1007/978-3-319-54760-2_25

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  • DOI: https://doi.org/10.1007/978-3-319-54760-2_25

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-54758-9

  • Online ISBN: 978-3-319-54760-2

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