The characteristics and anatomic distribution of lesions that cause reversed vein graft failure: A five-year prospective study

Purpose: The cause of vein graft failure in the intermediate postoperative period (3 to 18 months) has not been well defined. To delineate the incidence, characteristics, and anatomic distribution of lesions that cause graft failure in this critical interval, 227 consecutive infrainguinal reversed vein grafts (IRVGs) constructed at a single institution from July 1986 to December 1991 were prospectively entered into a duplex scan surveillance protocol. Methods: Duplex surveillance with arteriographic confirmation identified 29 patent, hemodynamically failing IRVGs during a mean follow-up of 22 months (range 1 to 64 months). An additional 18 grafts thrombosed before detection of any underlying abnormality; thrombolytic therapy and repeat operation uncovered the cause of occlusion in 12 of these grafts. The cause of graft failure (failing as well as failed) was therefore clear in 41 (87.2%) of 47 instances. Results: The causes of failure were intrinsic graft stenosis (n = 28; 59.6%), inflow failure (n = 6; 12.8%), outflow failure (n = 4; 8.5%), muscle entrapment (n = 2; 4.3%), and hypercoagulable state (n = 2; 4.3%). The most common intrinsic graft lesion was focal intimal hyperplasia (18 lesions in 16 grafts) in the juxtaanastomotic position, occurring solely in the vein graft itself. It occurred with equal frequency immediately distal to the proximal anastomosis or proximal to the distal anastomosis. Only rarely (n = 5) did this involve the juxtaanastomotic artery. Focal midgraft valvular stenoses (n = 6) and diffuse myointimal hyperplasia (n = 4) were also detected. The peak incidence of graft failure was 4 to 12 months after operation (70% within 12 months, 80% within 18 months). Conclusions: We conclude that duplex surveillance of IRVGs is warranted by the 21% incidence of potentially remediable graft failure. A significant portion of these failures occur during the intermediate postoperative period (3 to 18 months), usually as a result of focal intrinsic vein graft lesions. With reversed vein conduits, these lesions arise predominantly in the vein graft itself, in the juxtaanastomotic position.