An alternative method of salvaging occluded suprainguinal bypass grafts with operative angioscopy and endovascular intervention.

PURPOSE

A study of technical feasibility was undertaken to determine whether angioscopy and parallel endovascular instrumentation could effectively evaluate and restore inflow into occluded suprainguinal grafts.

METHODS

Several endobronchial instruments were selected for adaptation for use in clearing occluded grafts under angioscopic guidance. These instruments were used in the treatment of 12 thrombosed grafts limbs in 10 patients who were admitted 1 to 40 days after occlusion. The occluded suprainguinal graft limbs were exposed just proximal to the femoral anastomosis. Blind retrograde balloon thrombectomy and clot extraction were performed. Graft limbs underwent angioscopy, and the presence of luminal defects were recorded. Endoluminal instruments were then inserted parallel to the angioscope, and luminal defects were corrected. After inflow was reestablished, the distal portion of the graft was thrombectomized, and any necessary distal revisions were performed.

RESULTS

Blind retrograde thrombectomy was successful in restoring inflow deemed normal in (67%) eight of 12 graft limbs and present but diminished in two (17%) graft limbs. Balloon thrombectomy was ineffective in restoring graft flow in two (17%) graft limbs. Angioscopy revealed luminal defects in 10 (83%) graft limbs after blind retrograde thrombectomy. Only 2 (17%) graft limbs had no luminal defects after thrombectomy. Findings included pseudointimal flap in eight of 12 (67%), adherent residual thrombus in 4 (33%), and kinked graft limbs in 2 (17%) graft limbs. Endovascular instrumentation was successful in resecting all luminal disease under angioscopic guidance. There were no deaths, no episodes of graft injury or distal embolization, and only one groin hematoma. During a mean follow-up period of 6 months (2 to 13 months), there was one late reocclusion at 7 months.

CONCLUSION

We conclude that angioscopically guided thrombectomy and endovascular graft revision is a useful approach to the treatment of the occluded suprainguinal graft. Enhanced luminal visualization permits refined diagnostic assessment and definitive therapy. This may prolong the benefit of suprainguinal reconstructions.