Lower-Extremity Arterial Bypass Graft

Interventions 64
Scott L. Stevens, Chandler A. Long, and Sagar S. Gandhi

Contents
Introduction ................................................................................... 797
Treatment of Failing Lower-Extremity Grafts ........................... 797
Discussion.......................................................................................
Contour Balloons (Cutting and Sculpting) .....................................
Stents ...............................................................................................
Graft Surveillance Protocols and Thresholds for Intervention .......
Treating Failed Grafts .....................................................................
References ...................................................................................... 802
Introduction
Considering the increasing incidences of peripheral arterial
disease (PAD), the need for vascular intervention will expand
800 and the number of repeat interventions will grow. As endo-
800
vascular techniques and tools advance, this less-invasive
800
800 approach will continue to be increasingly used to repair
800 bypass grafts. The average cost for a lower-extremity (LE)
bypass is $19,331 $5,300. The average cost for elective
treatment of a duplex-identified stenosis is $13,003 $5,935
for surgical graft revision and $3,623 $445 for endovascu-
lar repair. After graft thrombosis, the salvage cost is $18,519
$8,267 with thrombectomy and $22,532 $4,750 with
endovascular thrombolysis. The most expensive is major
amputation which costs $36,273 $9,336 [1, 2].

Treatment of Failing Lower-Extremity Grafts

Case 1
This patient is a 49-year-old diabetic and heavy smoker.
He had a femoropopliteal bypass using the autogenous
saphenous vein for severe claudication 18 months
prior. At the follow-up office visit, he reported a return
of claudication and was noted to have decreased distal
pulses. Surveillance duplex evaluation demonstrated
low graft flow (less than 40 cm/s) and an arteriogram
was performed. Demonstrated were focal, high-grade
S.L. Stevens, MD (*)
Division of Vascular/Transplant Surgery, Department of Surgery,
stenoses immediately distal to the outflow anastomo-
University of Tennessee Medical Center, sis. Treatment of all three tibial origins was successful
1924 Alcoa Highway Box U-11, Knoxville, using an endovascular approach (Figs. 64.1 and 64.2).
TN 37920, USA 1. Obtaining access: When addressing failing grafts,
C.A. Long, MD S.S. Gandhi, MD our first choice is retrograde femoral cannulation.
Department of Surgery, University of Tennessee Medical This provides a forehand approach for easier cath-
CenterKnoxville,
1924 Alcoa Highway Box U-11, Knoxville,
eter and wire manipulation.
TN 37920, USA

R.S. Dieter et al. (eds.), Endovascular Interventions, 797

DOI 10.1007/978-1-4614-7312-1_64, Springer Science+Business Media New York 2014
798
If surgery is required, a contralateral femoral cannu-
lation preserves the ipsilateral surgical side from hema-
toma- and access-related complications. Retrograde
access facilitates accurate puncture directly over the
femoral head, especially in obese patients.
Key points: In patients who require anticoagulation or
lytic therapy, successful graft intervention is predicated
on accurate femoral cannulation. The femoral head is
routinely marked with fluoroscopy and a hemostat. Next
the artery is punctured at the 12 oclock position using a
micro system and ultrasound guidance. Care is taken to
avoid back wall arterial puncture and to minimize the
risk of hematoma. Pre-cannulation fluoroscopy often
gives important clues that impact access strategy, such as
vascular calcifications, prior stents, or hardware.
For patients who have had previous aortic grafts,
stents at the aortic bifurcation, anatomically difficult
Fig. 64.1 Failing saphenous vein graft with critical stenoses in
region of distal anastomosis
Fig. 64.2 Failing saphenous vein graft after correction of outflow
stenoses using directional atherectomy
S.L. Stevens et al.
iliac vessels, or distal lesions, an antegrade approach is
used. Once an antegrade common femoral access is
achieved, a long sheath can be fixed to the lower
abdominal wall with a sticky drape to simulate a retro-
grade femoral access (Figs. 64.3 and 64.4).
Brachial access is rarely used due to the risk of ves-
sel and nerve injury. Also, the long working distance
from the brachial artery to the lesion makes graft inter-
ventions from this approach difficult to accomplish.
2. Wires, sheaths, and catheters for lower-extremity graft
interventions: After access is gained, an atraumatic
0.35 wire is advanced under fluoroscopic guidance
to the mid-descending thoracic aorta. Next a 4 F
sheath is placed and a Soss multi-side-hole catheter is
positioned at the L1L2 junction. After a diagnostic
run demonstrates aortic and iliac inflow anatomy, the
aortic bifurcation is crossed with the same Soss flush
Fig. 64.3 Adhesive drape used to fix long sheath to lower abdomi-
nal wall
Fig. 64.4 Long sheath fixed to the abdominal wall to simulate a
retrograde femoral access
64 Lower-Extremity Arterial Bypass Graft Interventions
catheter, and contralateral femoral position is achieved
using a telescoping maneuver.
Key points: Prior to intervention, the sheath must be
upsized to a 6 or 7 F sheath over a 0.35 wire. We typi-
cally use a 45 cm sheath over the aortic bifurcation and
into the proximal femoral artery. Parking the tip of the
sheath in the common femoral artery prevents it from
obturating and obstructing flow in the superficial femoral
artery. If the lesion is at the distal portion of the graft, we
occasionally use a 55 cm sheath to decrease friction points
and to allow better torque control of catheters and wires.
3. Injecting contrast: Site-specific contrast rates and vol-
umes are listed below (Table 64.1).
Key points: Since our patient had renal insufficiency,
nephrotoxicity of the contrast was a concern. To mini-
mize renal insult, we used half-strength contrast. If an
ipsilateral femoral pulse is crisply palpable, we con-
clude that there is no hemodynamically significant
proximal disease, and we minimize contrast dose by
avoiding abdomen and pelvic runs. We then cross the
bifurcation and land the catheter in the target femoral
artery by brail (i.e., radiographic landmarks and
pulse). In addition, we place the catheter as close to the
lesion as possible and always use digital subtraction
angiography (DSA) for contrast imaging.
4. Pharmacotherapy: Once the lesion has been identified
and an intervention is planned, unfractionated heparin
is injected on a weight-based protocol (100 units/kg)
and the sheath is upsized.
Key points: In our shop, the administration of heparin is
linked to upsizing the access sheath. This helps prevent
intervening without anticoagulation. If heparin-induced
thrombocytopenia is suspected, we use bivalirudin (The
Medicines Company). By having the anesthetist repeat
back the medication and dose and also notify us when
2 min have elapsed, a dialogue is created that helps avoid
interventions without anticoagulation. To prevent proce-
dural medication errors, syringes on the back table are stan-
dardized for content by size and morphology of plunger.
For lower-extremity interventions, nitroglycerin is
used liberally to minimize vasospasm (300600 mcg
doses titrated to blood pressure). Papaverine is seldom
used because it causes discomfort and precipitates
patient movement. When cases become prolonged or
Table 64.1 Site-specific settings for contrast injector
Flow (cc per second) Total volume
Bifurcation 8 12
Iliac 4 8
Femoral 5 10
Popliteal/trifurcation 8 12
LE runoff 33 0 imaging at any given point up and down the axis of the
799
complicated, we turn to a re-dosing cocktail of rtPA,
nitroglycerin, and heparin to avoid procedure-related
thrombus and vasospasm. Antiplatelet agents are rou-
tinely used for lower-extremity graft interventions.
5. Crossing the lesion: The lesion is typically addressed
and crossed with a 0.014 wire.
Key points: A 0.014 wire is used to decrease the risk of
causing an intimal flap or dissection with a 0.035 wire.
Crossing the lesion without vessel injury is of paramount
importance. When crossing the lesion, back-and-forth
torque is placed on the wire which causes the tip to rotate
as it is advanced across the lesion. This allows the tip of
the wire to seek the true lumen. If the wire tip engages the
vessel wall and starts to bend in a J configuration, it is
withdrawn slightly to prevent dissection. Torque devices
are used when multiple friction points make wire control
difficult. When an expanded reach for the wire tip is
needed, angled catheters are telescoped over the wire. It is
important to use magnified DSA images and orthogonal
views to characterize lesion anatomy.
6. Treating the lesion: This patient had para-anastomotic
lesions secondary to neointimal hyperplasia, and an
atherectomy was performed over a 0.014 wire. A
3 mm Spider (ev3) distal protection filter was deployed
to decrease embolic risk. Cuts were taken at cardinal
and ordinal directions with frequent contrast injections
in orthogonal views to assess effectiveness.
Key points: To minimize the risk of dissection and to
remove lesion bulk, we used a directional atherectomy
catheter. A contour (cutting or sculpting) balloon is also
appropriate for these focal, fibrous lesions. We use distal
protection filters selectivelywhen stakes are high
(e.g., a single-vessel runoff), subacute thrombus is sus-
pected (the wire drops effortlessly through a total occlu-
sion) or the lesion appears embologenic (ulcerative,
shaggy, or calcified). To simplify deployment we back
load the distal protection filter into the catheter rather
than use the traditional, double monorail technique.
Once the lesion is treated, the filter can be retrieved
through a 0.35 catheter without uncrossing the lesion.
7. Assessing efficacy: DSA and intravascular ultrasound
images are used to confirm successful intervention.
Before the patient is transferred off of the table, the
treated foot is inspected, palpated, and, if necessary,
insonated to confirm treatment efficacy.
Key points: Information about the lesion is key to
success. Pre-case planning should include a review of
all available prior vascular images (CT, MR, or prior
catheter based). Adjuncts include magnification, use of
digital subtraction imaging, orthogonal views, and
intravascular ultrasound (IVUS). IVUS allows 360
800
vessel. IVUS is useful when fluoroscopic images do
not completely define the lesion or when radiation or
contrast dose is of particular concern.
8. Closure: A Starclose (Abbott) device was deployed
under fluoroscopic guidance to close the arteriotomy.
Discussion
Contour Balloons (Cutting and Sculpting)
Contour balloons effectively treat retained valves or fibrous,
short-segment graft lesions [3, 4]. Contour balloons provide
a controlled cleavage of these graft lesions which are charac-
terized by fibroblasts, smooth muscle cells, and an exuberant
extracellular matrix. These balloons are delivered over a
0.014 or 0.018 wire. When using contour balloons, a pitfall
can be avoided by patiently applying negative pressure to the
balloon when withdrawing the treatment blades through
the sheath. This prevents cutting the sheath and shearing the
treatment blades.
Stents
Due to high rates of restenosis in this setting, stents are
reserved for focal mechanical failures (perforations or dis-
sections). Self-expanding bare metal stents are resistant to
crushing forces and are preferred for dissections in the lower
extremity. When perforations cannot be controlled with bal-
loon tamponade, covered stents are employed. Viabahn
(Gore) stents are used in larger conduits because they have
the smallest sheath/stent ratio. For severe perforations in
small conduits, the balloon expandable covered Jostent
(Abbott) can prove to be ideal. There are strict regulations
for this device (cleared only for compassionate use in the
coronary locale), and it can be used only in emergent, life- or
limb-threatening situations.
Graft Surveillance Protocols and Thresholds
for Intervention
Ideally, a graft surveillance protocol will limit graft failure to
less than 3 % yearly [59]. Recurrent symptoms, diminished
pulses during a physical exam, and a drop in the ankle/bra-
chial index greater than 0.3 all suggest a failing graft. Duplex
scans of the graft are a critical piece of any surveillance algo-
rithm. Peak systolic velocities (PSV) above 300 cm/s or a
PSV ratio greater than 3.5 indicates a hemodynamically
significant stenosis of greater than 70 % and should trigger
S.L. Stevens et al.
Key points: If the patient requires postoperative
anticoagulation or is noncompliant to bed rest, there
is a need for shortened bed rest, or there is increased
risk of bleeding, then we consider a vessel closure
device.
graft intervention. Grafts with a high focal velocity as out-
lined by the criteria above and a low mean graft velocity (less
than 40 cm/s, sampled from three nonstenotic graft seg-
ments) are at the highest risk of graft thrombosis. In these
patients, urgent intervention should be considered. Large
conduit grafts and grafts to small tibial vessels can also have
low mean velocities, and anticoagulation should be consid-
ered to stave off low-flow thrombosis. Grafts with peak sys-
tolic velocities above 180 cm/s are considered to be abnormal,
have moderate stenosis, and should be followed with height-
ened surveillance (at 6- to 8-week intervals), in order to iden-
tify the subset of those grafts that will deteriorate, develop
high-grade lesions, and require remediation. Revised grafts
are plugged into the same surveillance schedule as the origi-
nal bypass graft. Specifically, scans are performed in the
immediate post-repair period, after a 3-month interval, and
then every 6 months thereafter. Grafts that stenose in the
early post-op period and have long-segment (greater than
3 cm) lesions are best treated surgically. In contrast, grafts
with focal lesions respond well to percutaneous repair, and
they have durability similar to grafts with focal lesions
treated surgically [10, 11].
An effective graft surveillance protocol is predicated on a
low morbidity for repair, which emphasizes the advantages
of catheter-based over open surgical interventions. Abundant
clinical data suggest that vein graft surveillance improves
patency by approximately 15 %. Cost-benefit analyses con-
ducted both in Europe and in the United States confirm that
vein graft surveillance is cost-effective and graft occlusion is
a morbid event [1, 1216].
Treating Failed Grafts
This patient is a 43-year-old diabetic. He had lower-extrem-
ity bypass grafting with a prosthetic for arterial occlusive
disease and a nonhealing foot ulcer. Eight months after his
bypass graft, he presented with acute graft occlusion and an
ischemic lower extremity. He was urgently taken for an
angiogram and catheter-based revascularization. The access
was contralateral and the graft was traversed easily. Due to
acute limb ischemia, a pulse spray technique which used the
AngioJet (Possis) catheter was performed. The clot was
laced with lytic by turning the return port off. Next, the lytic
64 Lower-Extremity Arterial Bypass Graft Interventions 801

was allowed to marinate. Then, the return port was opened

and the clot aspirated using rheolytic percutaneous mechani-
cal thrombectomy. Once the acute thrombus was lysed and
aspirated, a focal mechanical failure point was identified in
the region of the distal anastomosis. This perianastomotic
lesion was successfully treated with a cutting balloon
angioplasty.
1. Preoperative preparation: Heparin was administered from
the time of diagnosis in the emergency room to stop the
propagation of thrombus. Treatment options for the occluded
graft, including open surgical thrombectomy, catheter-
directed therapy, and hybrid approaches, were reviewed.
With the intention to salvage the autogenous conduit and
due to the short ischemic period, the decision was made to
proceed with catheter-based therapy. Our endovascular pro-
gram utilizes the lytic protocol below (Table 64.2).
2. Engaging the lesion: See previous case for access steps.
The patient was brought to the endosuite where a throm-
bosed graft was identified.
Key points: The orifice or nub of the graft is often profiled Fig. 64.5 Ipsilateral oblique profile of graft origin
best using steep ipsilateral oblique images (Fig. 64.5).
3. Crossing the lesion: This thrombus began just distal to the
proximal anastomosis. We parked the wire in the profunda
femoris and delivered a 6 F sheath to the proximal CFA.
Then a wire test was performed using a 0.035 wire that
was easily dropped through the thrombus (Fig. 64.6).
Key points: The lesion is probed using a wire test. If
the wire crosses the occlusion with ease, it indicates a
fresh thrombus and predicts a favorable response to lysis.
If the lesion cannot be crossed easily, a chronic lesion is
indicated and less success with lysis is predicted. If gentle
probing will not penetrate the clot, more aggressive wires
and maneuvers should be considered. Judgment is required
when deciding how hard to press in order to achieve suc-
cess without causing dissection or perforation. An
approach using slow, thoughtful moves is most likely to
yield success and to avoid procedure-ending complica-
tions (e.g., perforation and dissection). Occasionally,
when the lesion cannot be crossed antegrade, a distal

Table 64.2 Pre- and postoperative care for thrombolytic infusion

Fig. 64.6 Wire easily traversing occlusion indicating acute thrombus
Preoperative
Type and screen
Place 2nd IV and designate for lab draws
popliteal or pedal puncture and retrograde approach will
Foley catheter prior to infusion successfully cross the lesion. Once crossed, the retrograde
Postoperative wire can be snared from and exteriorized through the
Vital signs and check puncture sites frequently larger femoral sheath. We always use ultrasound guidance
Monitor accessed and affected extremities for pulses, pain, color, and a small system for retrograde arterial access. If the
and temperature lesion still cannot be crossed, the default option is to open
Keep NPO during infusion surgical repair. Although they are less precious than
Guaiac all stools and emesis autogenous grafts, synthetic grafts can be approached
No IM injections more aggressively due to their low risk for dissection and
CBC, PT, PTT, fibrinogen, baseline, and every 6 h perforation.
802
4. Tools to treat: Once the lesion is crossed, a catheter-
directed Alteplase (Genentech) is used. Four milligrams
in 100 cc saline is laced into the thrombus using the
Angiojet and pulse spray technique. Once laced, the
Alteplase is allowed to marinate in the thrombus for
20 min. Mechanical aspiration of the thrombus is then
performed with the Angiojet traveling about 1 mm/s.
Other tools available to enhance lysis include Trellis
(Bacchus Vascular), which isolates the lytic between
inflated balloons, and the EKOSonic (EKOS Corp) sys-
tem, which uses ultrasound energy to drive the lytic agent
into the thrombus.
5. Imaging: Contrast is then hand injected and areas of the
residual thrombus are treated with focused mechanical
aspiration.
Key points: The goal is to lyse the acute clot and to
expose the underlying mechanical failure point. Once the
culprit lesion is pinpointed, it is treated according to the
same criteria as a failing graft (see above). The usual cul-
prits are perianastomotic hyperplasia and retained valves.
6. Recalcitrant thrombus: Incomplete or suboptimal therapy
(residual thrombus or distal embolization) is addressed by
spanning the thrombus with a side-hole drip catheter.
Lytic success is improved by positioning the drip catheter
such that a few centimeters of proximal side holes are
above the thrombus (i.e., in the CFA for a fem-pop throm-
bus) and the distal side holes traverse most of the throm-
bus. Fibrinogen degradation products increase the patients
sensitivity to heparin, so we administer it in subtherapeu-
tic doses. Our recipe for lytic administration is detailed
below (Table 64.3).
7. Monitoring and follow-up imaging: Patients with recalci-
trant thrombus are placed in the intensive care unit for
lytic infusion and close observation. Plans are made to
return for follow-up imaging in 612 h, depending on the
patients clinical progress. Because fibrinogen degrada-
tion products increase patients sensitivity to heparin, we
administer it in subtherapeutic doses. Although we do not
have specific trigger values, we carefully attend to PTT,
CBC, and fibrinogen trends and reassess the risk to benefit
ratio for continued lytic therapy. Minor bleeding at access
points can often be controlled with manual pressure.
Table 64.3 Thrombolytic infusion orders
Heparin 300 units/h via peripheral IV
Alteplase 25 mg in 250 cc NS at 1 mg/h
Nitroprusside drip to maintain SBP <140
Morphine 2 mg every hour for severe pain
Ranitidine 50 mg IV 1 for shaking chills
IVF hydration with NS or bicarb gtt
S.L. Stevens et al.
Persistent bleeding around a sheath is usually remedied
by upsizing the sheath. Important, refractory bleeding
requires discontinuation of therapy and coagulopathy cor-
rection. A keen eye is needed to minimize systemic reper-
fusion complications and compartment syndrome. We
keep this group of patients well hydrated and anticipate
metabolic acidosis and hyperkalemia. Disproportionate
pain, pain on passive muscle motion, and pain over the
involved compartment all point toward compartment syn-
drome. A tense compartment with wood-like character
allows the diagnosis to be made with confidence. Because
sensory nerves are most sensitive to ischemia, two-point
discrimination and vibratory sensation are diminished.
The anterior compartment of the leg is most commonly
involved and presents early with the superficial peroneal
nerve manifestation of numbness between the first two
toes. In patients who do not yield a true exam, those with
an altered mental status, compartment pressures are help-
ful, and we consider pressures greater than 3035 mmHg
diagnostic. In this arena, errors of omission are devastat-
ing and a low threshold for fasciotomy is important. If
clinical signs and symptoms of compartment are present,
we proceed directly to fasciotomy and bypass compart-
ment pressures.
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