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Aortic Reconstruction With Femoral-Popliteal Vein: Graft Stenosis Incidence, Risk And Re-Intervention

Adam W. Beck, Erin H. Murphy, Jennie Hocking, Guanghua Xiao, Frank R Arko, Carlos H. Timaran, J. Gregory Modrall, R. James Valentine, G. Patrick Clagett.
UT-Southwestern Medical Center, Dallas, TX.

OBJECTIVES: Management of aortic graft infections using femoral-popliteal vein (FPV) is now an accepted therapy and is performed frequently at our institution. A high re-intervention rate for FPV graft stenosis has recently been reported. The purpose of this study was to determine the incidence of FPV graft stenosis after neo-aortoiliac system (NAIS) reconstruction, and to identify risk factors for complication.

METHODS: A retrospective review was performed of 182 patients who underwent NAIS reconstruction at our institution between February 1992 and December 2006. All patients were entered into a prospective database and were evaluated for the incidence of vein graft stenosis requiring re-intervention, risk factors for stenosis, and the rate and type of re-intervention required to assist patency. Risk factors assessed included gender, operative features, FPV size (diameter), smoking history, and medical co-morbidities.

RESULTS: Of the 182 NAIS procedures performed, 11 (6.0%) patients required 12 graft revisions (one patient required a second intervention) using open and endovascular techniques. This provided an assisted primary patency rate at 2 and 5 years of 95% and 92%. Mean time to revision was 23.5 months (range 5.5-83.5 months). Vein graft stenosis was more common in women (n=7/78, 9.0%) than men (n=4/104, 3.8%) (p=0.2). Median FPV graft size in the non-revised patients was 7.8mm (range 4.0-11.4mm), and 6.4mm (range 4.7-8.7mm) in the revised group (p=0.003). Univariate survival analysis revealed small vein graft size (<7.15mm), coronary artery disease, and extensive smoking history as independent predictors of stenosis (p=0.003, 0.01, 0.02, respectively). Patients with coronary artery disease (CAD) combined with small graft size were found to be at especially high risk for stenosis, with 8/35 (35%) requiring revision vs. 3/135 (2%) of patients without both factors (p<0.0001).

CONCLUSIONS: FPV graft stenosis requiring revision after NAIS reconstruction is uncommon. Risk factors for stenosis include small graft size, history of CAD, and smoking. Patients exhibiting these risk factors merit close postoperative surveillance and aggressive counseling for smoking cessation.