Original Articles from the New England Society for Vascular Surgery
Angioscopically directed interventions improve arm vein bypass grafts*,**

Presented at the Nineteenth Annual Meeting of the New England Society for Vascular Surgery, Dixville Notch, N.H., Sept. 23-25, 1992.
https://doi.org/10.1016/0741-5214(93)90669-DGet rights and content

Abstract

Purpose: Our purpose was to determine the incidence and segmental distribution of intraluminal disease in the arm veins of patients in whom saphenous vein was unavailable or inadequate for bypass, determine whether angioscopic evaluation and directed interventions can upgrade the quality of arm vein conduit and improve early graft patency, and describe the angioscopic technique of in situ retrograde arm vein inspection. Methods: Retrospective review of 109 infrainguinal arm vein bypass grafts in 104 patients performed with intraoperative angioscopic vein preparation and monitoring between August 1989 and March 1992 was undertaken. Four additional arm veins harvested were discarded because of diffuse disease. Results: Intraluminal disease was noted in 71 (62.8%) of 113 arm veins, “webs” in 61 (54%), vein sclerosis in 25 (22.1%), localized stenosis in 11 (9.7%), and thrombus in 7 (6.2%). Intraluminal disease was most common in the cephalic (forearm 49.2%; arm 35.1%) and median cubital (33.3%) veins and least common in the basilic vein (11.7%). Eighty-three angioscopically directed interventions in 68 of 71 abnormal arm veins resulted in upgraded vein conduit quality in 47 (66.1%) of 71. Primary patency (<30 days) was 99 (90.8%) of the 109 grafts, 85 (95.5%) of 89 grafts with normal or upgraded quality conduits, and 14 (70%) of 20 inferior-quality grafts (p = 0.0024). These differences persisted through 1 year by life-table analysis, (p < 0.001). Conclusions: Not only is the routine use of the angioscope in arm vein bypass grafting a sensitive technique to detect the intraluminal diseases so prevalent in arm veins but it can also direct endoluminal and surgical interventions that upgrade the quality of the vein conduit and improve early graft patency. (J VASC SURG 1993;17:994-1004.)

Section snippets

Patients and methods

Between August 1989 and March 1992, 109 infrainguinal arm vein bypass grafts in 104 patients were performed with intraoperative angioscopic vein preparation and monitoring. An additional four patients underwent operative exploration and angioscopic evaluation of arm vein segments that were ultimately discarded as unsuitable bypass conduits and either no bypass graft was performed or expanded polytetrafluoroethylene (ePTFE) graft conduit was used.

All data concerning the initial (assessed during

Results

The clinical details of the 104 patients constituting the study group are summarized in Table I.All but three patients underwent surgical intervention for limb-threatening ischemia, most commonly manifested as ischemic ulceration or rest pain. The use of arm vein as conduit was necessitated by prior use of greater saphenous vein for infrainguinal or coronary revascularization in 80% of the cases. The finding of inadequate saphenous vein on the basis of insufficient length, poor quality, or

Discussion

Our study shows that routine use of the angioscope in arm vein bypass grafting not only is a sensitive technique to detect the intraluminal diseases so prevalent in arm veins but also can direct endoluminal and surgical interventions that upgrade the quality of the vein conduit and improve early graft patency rates. This improved early patency rate is comparable to that achieved with angioscopically normal arm vein and appears to be maintained, at least for the first postoperative year. Our

Acknowledgements

We thank the Olympus Corp., Lake Success, N.Y., for supplying the equipment used in this study.

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*

Supported in part by a grant from the Olympus Corporation, Lake Success, N.Y.

**

Reprint requests: Arnold Miller, MD, 110 Francis St., Suite 3B, Boston, MA 02215.

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Copyright © 1993 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter. Published by Elsevier Inc. All rights reserved.