Outcome analysis and surveillance of infra inguinal arterial bypass graft

Ashok Kumar, D (2012) Outcome analysis and surveillance of infra inguinal arterial bypass graft. Masters thesis, Stanley Medical College, Chennai.


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BACK GROUND : In Crtical Limb Ischemia, Infrainguinal bypass surgery is the mainstay of therapeutic interventions aimed at limb salvage. The outcome of surgery is the chief determinant of limb salvage and is affected by multiple factors. The graft patency rates have been related to clinical severity of ischemia, distal run-off,patients risk factors, and Diabetes. This study is planned to review the factors that will influence the outcome of infrainguinal bypass and to identify those factors that are modifiable, and will help in improving the outcome of the procedures ,improve the patency of the graft and limb salvage rate. AIM : To assess early postoperative outcomes in patients undergoing Infrainguinal bypass surgery ,to study the factors affecting the outcomes and to identify failing graft. METHODS AND MATERIALS : It is Prospective study in 56 patients from January 2010 to January 2012.Case records and angiograms of patients who underwent femoropopliteal bypass procedures. CLI and incapicitating claudication is the main indication for surgery. Data pertaining to patient risk factors and co-morbidities were evaluated. CT angio performed in all patients to assess the occlusive pattern, status of popliteal artery and run off status and the lesions were classified as per TASC 2007 classification. Infrainguinal bypass surgery were considered for all patients. Standard operative procedures were followed. Postoperatively all patients were given Plain Heparin or LMWH for 5 days & Tab. Aspirin 150mg OD & Tab. Clopidogrel 75mg and other drugs as per their co-morbidities. Graft surveillance was done by symptomatic analysis of rest pain status, palpable popliteal pulse and distal pulses, examination with handheld Doppler for signals and with Pre and post operative ABI. All patients were followed from the day of surgery to the end of 12th month. Statistical analysis of the graft patency rates were calculated with respect to the CT Angio run off status,risk factors, etiolgical factors,and limb salvage rate. RESULTS : In this study, most of the patients had presented at the age around 40 to 60 yrs. Smoking obviously forms a significant risk factor in the development of PAD as the incidence of smoking in this case series was 83.3%. Toe gangrene is commonest clinical presentation is58.9%. ASO is commonest etiology of 67.8%. Incidence of CAD, CKD and diabetes mellitus was very high in patients with outflow via collaterals. The incidence of CLI patients with single vessel runoff group are 53.5%, double vessel runoff group are 41.07% and three vessels run off group is 5.3%. Among total of 56 patients, femoro popliteal bypass forms the common form of bypass with 43 patients compared to femoro distal bypass in other patients. Among various post operative complications minor amputations being 33.9% is the commonest complication. Patients with wound infection in our series was 12.5%. During the post operative follow up period one patient expired in the early postoperative period due to myocardial infarction. In our study group infra inguinal arterial bypass surgery, out of total 56 grafts, for 43patients RGSV and 13 (1 = Composite graft) PTFE grafts used. Graft occlusion rate is 16.07% and Graft failing rate is 10.7%.Primary patency rate of graft at the end of one year is 80 % (n=44) .Graft thrombosis rate in this study is 16.36% (n=9). Six grafts were identified during their failing stage in the study, out of which 3 patients underwent Redo bypass surgery (PAP 82.1%). Among redo group for 2, grafts patency restored and their limbs salvaged and 1 graft occluded subsequently and resulted in limb amputation. The p values for primary patency, cumulative patency rates with respect to the run off status at 12th month were 0.324, 0.509 respectively and were statistically insignificant.Primary assisted patency rate in this study is 82.1%. Limb salvage rate was 94.54%. Failing graft in this study is 10.9% ( n=6 ). Major Amputation rate in this study is (5.3 %). The graft patency was compared in relation to etiological factors in 56 patients. In atherosclerosis group of 38 grafts used, out them n=29 had patent grafts, n=4 occluded and n=6 were failing. In thromboangitis obliterans n=11 were patent and n=4 were occuled. In Arteritis group n=1 patent and n=1 occuled. TAO and arteritis had increased risk of graft occlusion during the follow up. The occurrence of graft stenosis or occlusion is more common in patients who underwent infragenicular bypasses than above knee bypass. In this study one case of Atrial myxoma presented with CLI , had undergone femoro-proximal popliteal bypass surgery and graft was patent compared with literature (18) Vascular. 2005 Jul-Aug;13(4):222-9. The rate of limb salvage in patients with failed grafts was 83.3% fo 1 year, when compared to literature (only 50% at 2 yrs after failure. - Midwestern vascular surgical society Chicago September 2003). CONCLUSION : • Infrainguinal revasularisation surgery has acceptable graft patency and survival rates. • Graft patency rates were not adversely affected by poor runoff vessels, and when there was a reformation of the popliteal artery even when the out flow vessels were not adequately visualized angiographically. • High limb salvage rates when compared to the relatively low graft patency rates explains the collateral formation after bypass procedures. • Femoro popliteal bypass grafting is still treatment of choice where endovascular facilities available for patients with disabling claudicants and in CLI especially with TASC C and D lesions. • Patients with poor conduit quality, active tobacco use and LV dysfunction have poorer clinical outcome • Graft surveillance is essential throughout the life to identify the failing graft and to intervene at appropriate time,to prolong the graft patency. KEY WORDS Infrainguinal revasularisation, Graft surveillance, Graft patency,Conduit, CT angio, Primary Assited Patency.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Outcome analysis ; surveillance ; infra inguinal arterial bypass graft.
Subjects: MEDICAL > Vascular Surgery
Depositing User: Kambaraman B
Date Deposited: 10 Nov 2017 18:47
Last Modified: 10 Nov 2017 18:47
URI: http://repository-tnmgrmu.ac.in/id/eprint/3893

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