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1 Early graft failure after femorodistal bypass N. Dayes SUNY Downstate 07/30/09
2 DL M comes to ED complaining of pain in the Left lower extremity 2 days after angiogram and angioplasty. Pre-procedure angiogram. Past Medical Hx - HIV, HTN. Vascular exam Cool left lower extremity. Absent DP and PT pulses in left leg. 2+ femoral pulse. Normal sensation and motor function.
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10 DL Labs WBC 4.8 H/H 14/42 Plt- 236 Coags PT -11.1, 1 aptt- 31, INR Chem - Na 139, K -4.8, Cl 109, co2 24, Glc 88, Bun 6, Cr
11 DL Angiogram showed proximal progression of popliteal occlusion. Pt. initially refused bypass operation and was started t on a heparin and a tpa infusion. i Pt. s left leg showed no improvement after tpa.
12 DL HOD #3 Pt. consents to bypass operation. He undergoes femoral to peroneal tibial trunk bypass with reversed cryogenic saphenous vein. 1 1 hour post-op op the patient was noted to have non-palpable or dopplerable pulses in recovery room.
13 DL Pt was immediately taken back to OR for revision of bypass. Graft was retunneled thru an anatomical plane. Distal anastomosis was redone. Completion angiogram.
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18 DL HOD #4 Pt. was again noted to lose DP and PT pulses in post-op op period. The patient was placed on heparin. Hypercoagubility bl work-up was started. Pt. was found to be serologically positive for lupus anticoagulant. Long term anticoagulation was started.
19 Discussion I. Common causes of early graft failure. II. Patency of different graft types. III. Long term graft outcome for patients with hypercoagulable states.
20 Technical Defects as a Cause of Early Graft Failure after Femorodistal Bypass Stept L, Yao J, et.al. Arch Surg 1987; 122: Retrospective review of 849 femorodistal bypass operations from 10/78 to 1/86. Early graft failure rate of 7.3% (n=62). Study included PTFE, reversed or in situ saphenous vein grafts. All patients with documented graft failure were re-explored. explored.
21 Stept L, Yao J, et.al. Arch Surg 1987; 122: Technical Defects as a Cause of Early Graft Failure after Femorodistal Bypass.
22 Stept L, Yao J, et.al. Arch Surg 1987; 122: Technical Defects as a Cause of Early Graft Failure after Femorodistal Bypass.
23 Technical Defects as a Cause of Early Graft Failure after Femorodistal Bypass Stept L, Yao J, et. al. Arch Surg 1987; 122: Conclusions In addition to technical problems, this analysis shows that embolization, distal outflow, and disorders of coagulation are of equal significance in early graft failure.
24 Technical factors affecting autogenous vein graft failure: Observations from a large multicenter trail Schanzer A, Conte MS J Vasc Surg Dec;46(6): Authors used the PREVENT III database. Randomized cohort of 1404 patients that underwent lower extremity revascularization procedures for critical ischemia. Technical variables analyzed included vein diameter, conduit type, graft length, vein orientation, location of proximal and distal anastomoses, and performance of completion imaging
25 Schanzer A, Conte MS Technical factors affecting autogenous vein graft failure: Observations from a large multicenter trail. J Vasc Surg Dec;46(6):
26 Schanzer A, Conte MS Technical factors affecting autogenous vein graft failure: Observations from a large multicenter trail. J Vasc Surg Dec;46(6):
27 Technical factors affecting autogenous vein graft failure: Observations from a large multicenter trail Schanzer A, Conte MS Conclusion J Vasc Surg Dec;46(6): Graft diameter and length emerged as a technical determinants of 30-day and 1-year graft failure. Completion imaging may not be essential.
28 Graft Patency Rates Dalman RL, Taylor LM: Basic Data related to infrainguinal revascularization procedures, Ann Vasc Surg 4:309,1990.
29 Walker PJ, Mehigan JT. Early experience with cryopreserved saphenous vein allografts as a conduit for complex limb salvage procedures. J Vasc Surg Oct; 18(4):561 8
30 Long-term outcome of infrainguinal bypass grafting in patients with serologically proven hypercoagulability Curi MA, Schwartz L. J Vasc Surg 2003;37:301-6 Retrospective review of 528 infrainguinal bypass grafts in 456 patients from 1/94 to 1/01. Included all hypercoagable states. Total of 74 grafts were done in 57 patients with hypercoagable states. Lupus anticoagulant patients were on long- term anticoagulation with warfarin.
31 Curi MA, Schwartz L. Long-term outcome of infrainguinal bypass grafting in patients with serologically proven hypercoagulability. J Vasc Surg 2003;37:301-6
32 Curi MA, Schwartz L. Long-term outcome of infrainguinal bypass grafting in patients with serologically proven hypercoagulability. J Vasc Surg 2003;37:301-6
33 Curi MA, Schwartz L. Long-term outcome of infrainguinal bypass grafting in patients with serologically proven hypercoagulability. J Vasc Surg 2003;37:301-6
34 Conclusion Long-term outcome of infrainguinal bypass grafting in patients with serologically proven hypercoagulability Curi MA, Schwartz L. J Vasc Surg 2003;37:301-6 Patients with serologically proven hypercoagulability have inferior long-term patency and survival rates. Authors advocate pre-op serologic screening for younger patients.
35 Conclusion In addition to technical problems, disorders of coagulation should be considered when dealing with early graft failure. Conduit diameter and length contribute to early graft failure. Patients with serologically proven hypercoagulability have inferior i long-term patency rates.
36 References Stept L, Yao J, et.al. Arch Surg 1987; 122: Technical Defects as a Cause of Early Graft Failure after Femorodistal Bypass. Schanzer A, Conte MS Technical factors affecting autogenous vein graft failure: Observations from a large multicenter trail. J Vasc Surg Dec;46(6): Dalman RL, Taylor LM: Basic Data related to infrainguinal revascularization procedures, Ann Vasc Surg 4:309,1990. Curi MA, Schwartz L. Long-term outcome of infrainguinal bypass grafting in patients with serologically proven hypercoagulability. J Vasc Surg 2003;37:301-6.
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