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RIO GRANDE, P.R. -- Characteristics of lesions that threaten infrainguinal vein grafts--such as lesion count, timing, length, and location--can help predict outcomes with endovascular and surgical revision, Dr. Ryan Hagino said at the annual meeting of the Southern Association for Vascular Surgery.

Multiple lesions and early lesions, for example, suggest a compromised initial conduit and predict a poor outcome.

"Such grafts fare poorly regardless of treatment method," said Dr. Hagino, an associate professor at the University of Texas at San Antonio.

The findings are from a study of 84 infrainguinal vein graft revisions in 67 failing, nonthrombosed grafts in 64 patients treated over a 68-month period. Both graft durability and lesion response to either open or endovascular treatment were evaluated to determine characteristics that might influence outcome.

Cumulative assisted graft patency, or freedom from graft occlusion at 5 years, was 63%. Primary assisted patency, or freedom from all-cause failure inclusive of graft occlusion and lesion recurrence, was 29%. Graft survival did not differ based on age, risk factors, operative indications, inflow source, conduit type, or outflow level, he said. Occlusion did not occur more often in grafts that developed lesions earlier, compared with those that developed lesions later, and neither the type of initial intervention (open vs. endovascular) nor the need for repeated intervention for lesion recurrence influenced long-term patency.

Multiple versus single lesions, however, were associated with significantly inferior patency at 5 years (42% vs. 75%).

This finding suggests that it is the quality of the initial conduit rather than the type of treatment of a graft-threatening lesion that is the primary determinant of graft survival, he said. For primary assisted patency, however, early lesion onset (within 6 months of revision), compared with later lesion onset, was associated with earlier graft failure (35% vs. 39% patency). Initial treatment type did not influence primary assisted patency.

In regard to the target lesions, including only those treated for initial stenosis, 32% involved the main body of the graft, and 68% occurred at an anastomosis. Overall target lesion revascularization patency was 45% at 4 years; most failures occurred within the first year after revision. Treatment method selected did not appear to be based on lesion characteristics, and again, outcomes did not differ based on treatment method.

About a third of lesions required additional intervention. Most (73%) required only one additional intervention, 20% required two, and 7% required more than two. The number of additional interventions did not differ significantly based on treatment type.

Shorter lesion length (2 cm or less), however, was associated with significantly better patency than longer lesion length (53% vs. 14% patency at 3 years). Overall failure rates and times did not differ based on treatment method; longer lesions had uniformly poor patency regardless of treatment method, but the average time to failure for lesions greater than 2 cm was significantly longer in the open treatment group (10 vs. 3 months).

Treatment durability also did not differ based on time of lesion occurrence, but early lesions treated endovascularly had inferior outcomes (24% vs. 73% patency at 3 years). Lesion location also played a role in outcomes; anastomotic lesions fared better overall than midgraft lesions after revision, regardless of treatment type (72% vs. 36% patency at 3 years). However, with anastomotic lesions, initial failure rates with both open and endovascular treatments were modest at about 46% 3-year patency for each, with neither modality demonstrating superiority, whereas for midgraft lesions, open revision was uniformly better than endovascular revision (100% vs. 61% patency at 3 years).

On multivariate analysis, anastomotic target lesion location, longer lesions, and endovascular treatment were associated with significantly increased odds of failure of primary target lesion revision; endovascular treatment demonstrated a fourfold higher risk of failure than open treatment. It appears that this finding, which was not seen on univariate analysis or on graft-specific multivariate analysis, is largely a result of the use of endovascular techniques for midgraft lesions, which had a nearly 40% failure rate in this study, compared with the 100% success seen with open surgical management, Dr. Hagino said.

Based on results of this study, it appears that long lesions and early-onset lesions are best treated with open revision, and although midgraft lesions also fare better with open revisions, the success in these lesions should be weighed against the risk of wound complications with open surgery. Anastomotic lesions can be treated with either open or endovascular approaches, but only modest durability should be expected with either approach, Dr. Hagino added.