Editor's Choice - Nationwide Analysis of Patients Undergoing Iliac Artery Aneurysm Repair in the Netherlands

OBJECTIVE

The new 2019 guideline of the European Society for Vascular Surgery (ESVS) recommends consideration for elective iliac artery aneurysm (eIAA) repair when the iliac diameter exceeds 3.5 cm, as opposed to 3.0 cm previously. The current study assessed diameters at time of eIAA repair and ruptured IAA (rIAA) repair and compared clinical outcomes after open surgical repair (OSR) and endovascular aneurysm repair (EVAR).

METHODS

This retrospective observational study used the nationwide Dutch Surgical Aneurysm Audit (DSAA) registry that includes all patients who undergo aorto-iliac aneurysm repair in the Netherlands. All patients who underwent primary IAA repair between 1 January 2014 and 1 January 2018 were included. Diameters at time of eIAA and rIAA repair were compared in a descriptive fashion. The anatomical location of the IAA was not registered in the registry. Patient characteristics and outcomes of OSR and EVAR were compared with appropriate statistical tests.

RESULTS

The DSAA registry comprised 974 patients who underwent IAA repair. A total of 851 patients were included after exclusion of patients undergoing revision surgery and patients with missing essential variables. eIAA repair was carried out in 713 patients, rIAA repair in 102, and symptomatic IAA repair in 36. OSR was performed in 205, EVAR in 618, and hybrid repairs and conversions in 28. The median maximum IAA diameter at the time of eIAA and rIAA repair was 43 (IQR 38-50) mm and 68 (IQR 58-85) mm, respectively. Mortality was 1.3% (95% CI 0.7-2.4) after eIAA repair and 25.5% (95% CI 18.0-34.7) after rIAA repair. Mortality was not significantly different between the OSR and EVAR subgroups. Elective OSR was associated with significantly more complications than EVAR (intra-operative: 9.8% vs. 3.6%, post-operative: 34.0% vs. 13.8%, respectively).

CONCLUSION

In the Netherlands, most eIAA repairs are performed at diameters larger than recommended by the ESVS guideline. These findings appear to support the recent increase in the threshold diameter for eIAA repair.

Intravascular ultrasound evidence for stabilization of compensatory enlargement of the femoropopliteal segment after endograft placement

PURPOSE

To document whether the vasodilatory response seen at the anastomotic segment 6 months after placement of a balloon-expandable endograft in the femoropopliteal segment progresses between 6 and 24 months.

METHODS

Twelve patients (9 men; median age 65 years, range 47-75) treated with an investigational polytetrafluoroethylene (PTFE) endograft for obstructive disease of the femoropopliteal segment were studied with intravascular ultrasound (IVUS) immediately after placement and at 6 months (first follow-up period) and 24 months (second follow-up period). Matched IVUS cross sections derived from the endograft and the anastomotic segment were analyzed for changes in lumen (LA), vessel (VA), and plaque areas (PLA).

RESULTS

Five patients had complete IVUS surveillance at both the first (mean 8 months, range 7-9) and second (mean 25 months, range 23-26) follow-up periods; 1 patient was lost to follow-up during the second interval, and another 6 were excluded owing to graft occlusion (n = 4) or no IVUS surveillance available (n = 2) during the second follow-up period. Matched IVUS cross sections derived from the endograft showed no significant change in LA during both follow-up periods (-8% and +1%, respectively). There was no evidence for intimal hyperplasia or endograft recoil. During both follow-up periods, IVUS cross sections derived from the anastomotic segment revealed significant increases in LA (+37% and +8%, respectively) and VA (+26% and +6%, respectively) (both p < 0.05). The change in PLA during both follow-up periods was not significant (+13% and +3%, respectively).

CONCLUSIONS

The PTFE endograft seems to inhibit both intimal hyperplasia and constrictive remodeling. The short-term (6-month) vascular dilatory response seen at the anastomotic segment tends to stabilize at 2 years. Therefore, this endovascular anastomosis acts as an "ideal" end-to-end anastomosis.

Three-dimensional intravascular ultrasound assessment of abdominal aortic aneurysm necks

PURPOSE

To document the accuracy of an automated analysis system for measuring lumen diameter and neck lengths of abdominal aortic aneurysms (AAAs) from intravascular ultrasound (IVUS) images and to describe additional features associated with 3-dimensional (3D) IVUS imaging.

METHODS

Twenty-two aortic aneurysms were studied with IVUS. Lumen diameters obtained using the automated analysis system were compared with manual measurements from axial IVUS scans, as were neck lengths obtained using automated analysis versus those measured with the aid of a displacement sensing device. Automated analyses were repeated by a second observer. Agreement was expressed as the coefficient of variation (CV).

RESULTS

Twenty proximal aortic, 6 distal aortic, and 3 iliac necks were available for analysis. Comparison between automated analysis and manual measurements for lumen diameter revealed a difference of 0.45 +/- 0.42 mm (mean +/- SD, Pearson's r = 0.99, p < 0.001, CV = 2.1%) and a difference of 0.05 +/- 0.12 cm (r = 0.99, p = 0.04, CV = 4.1%) for neck length. Interobserver difference for lumen diameter was 0.13 +/- 0.66 mm (r = 0.99, p < 0.001, CV = 3.4%) and 0.05 +/- 0.11 cm for length measurements (r = 0.99, p = 0.02, CV = 3.5%). The 3D IVUS imaging facilitated the identification of neck configuration.

CONCLUSIONS

Automated analysis of IVUS images allows accurate measurement of the lumen diameter of proximal and distal AAA necks and gives length measurements comparable to those of manual analysis. Longitudinal display of IVUS images aids in the elucidation of neck anatomy.

Effect of simvastatin on restenosis after percutaneous transluminal angioplasty of femoropopliteal arterial obstruction

This retrospective observational intravascular ultrasound study evaluated whether simvastatin therapy limits lumen area reduction 1-year after percutaneous transluminal angioplasty (PTA) by reducing reactive plaque growth, reducing reactive vasoconstriction, or both. This study showed that plaque growth is a general response 1 year after PTA regardless of the use of simvastatin; simvastatin has the potential to induce positive vascular remodeling, thereby reducing the occurrence of restenosis.

Endovascular repair of an extracranial internal carotid artery aneurysm complicated by heparin-induced thrombocytopenia and thrombosis

PURPOSE

To report the endovascular treatment of a symptomatic extracranial internal carotid artery (ICA) aneurysm that was complicated by heparin-induced thrombocytopenia and thrombosis.

METHODS AND RESULTS

After undergoing a coronary artery bypass graft procedure, a patient was diagnosed with a symptomatic, 3.5-cm ICA aneurysm by computed tomography and angiography. Via a semiclosed access, an Enduring vascular graft was inserted under controlled back bleeding from the ICA. The patient was recovering uneventfully when routine duplex scanning on the fifth postoperative day suggested multiple thrombi within the graft, which was confirmed by arteriography. Thrombectomy and local fibrinolysis were performed; however, the graft occluded the next day without causing neurological symptoms. Heparin-induced thrombocytopenia was diagnosed by enzyme-linked immunosorbent assay.

CONCLUSIONS

Endovascular repair of high cervical extracranial ICA aneurysms is feasible, and protection against intracerebral embolization can be achieved using a semiclosed technique with controlled back bleeding from the ICA during endograft deployment. However, multiple thrombi or thrombotic occlusion during the postoperative period, particularly in a patient already sensitized to heparin, should direct attention toward possible heparin-induced thrombocytopenia.

Vascular response in the femoropopliteal segment after implantation of an ePTFE balloon-expandable endovascular graft: an intravascular ultrasound study

PURPOSE

To use intravascular ultrasound (IVUS) to document changes in vascular dimensions after placement of a balloon-expandable endograft.

METHODS

Thirteen patients (9 men; mean age 62 years, range 47-75) treated with an investigational polytetrafluoroethylene endograft for obstructive disease of the femoropopliteal segment were studied with IVUS immediately after endograft implantation and at follow-up. Corresponding IVUS cross sections were analyzed for changes in lumen, vessel, and plaque areas seen inside the endograft, in the anastomotic segment, and in the remote arterial segment.

RESULTS

A mean 6-month (range 1.5-9) follow-up was completed in 12 patients. Matched IVUS cross sections derived from within the endograft (n = 12) and at the endograft edges (n = 23) showed no change in lumen area (LA) in 17, reduction in 11, and dilatation in 7. Median changes within the endograft (+3%) were not significant (p = 0.28) and no neointima was found. Cross sections obtained at the anastomotic segment revealed a significant increase in LA (85%, p < 0.001), which was associated with a significant increase in both vessel area (VA) (42%, p < 0.001) and plaque area (PLA) (15%, p = 0.003) area. In the remote arterial segment, the change in LA was minimal (6%, p = 0.07), as were changes in the VA (9%, p = 0.04) and PLA (10%, p = 0.07).

CONCLUSIONS

Following endograft placement, luminal changes within the endograft, at the endograft edges, and at the remote arterial segments were minimal. Intimal hyperplasia was not observed in the endograft. The distinct LA increase at the anastomotic segments was determined by the extent of VA and PLA change.

Endovascular stent-grafts for aneurysms of the femoral and popliteal arteries

Our objective was to investigate the preliminary use of endovascular stent-grafts for the treatment of femoropopliteal artery aneurysm. Ten patients with an aneurysm of the femoropopliteal artery referred for endovascular treatment were investigated. The series consisted of patients with a true aneurysm of the superficial femoral artery (n = 2); a true aneurysm of the popliteal artery (n = 4); an aneurysmal dilatation of a Biograft bypass (n = 2); a false aneurysm of the superficial femoral aneurysm (n = 1); and a false aneurysm of a composite bypass (n = 1). In 8 of the 10 patients the stent-graft was composed of one or more Palmaz stents sutured to an ePTFE tube graft; in the other 2 patients a venous covering was used in combination with Palmaz stents. The procedure was guided by angiography and intravascular ultrasound. The results of our investigation showed that endovascular stent-grafting of aneurysms of the femoropopliteal artery is a feasible but experimental technique that should be restricted to a selected group of patients.

Accurate assessment of abdominal aortic aneurysm with intravascular ultrasound scanning: validation with computed tomographic angiography

PURPOSE

The purpose of this study was to assess the accuracy of intravascular ultrasound (IVUS) parameters of abdominal aortic aneurysm, used for endovascular grafting, in comparison with computed tomographic angiography (CTA).

METHODS

This study was designed as a descriptive study. Between March 1997 and March 1998, 16 patients with abdominal aortic aneurysms were studied with angiography, IVUS (12.5 MHz), and CTA. The length of the aneurysm and the length and lumen diameter of the proximal and distal neck obtained with IVUS were compared with the data obtained with CTA. The measurements with IVUS were repeated by a second observer to assess the reproducibility. Tomographic IVUS images were reconstructed into a longitudinal format.

RESULTS

IVUS results identified 31 of 32 renal arteries and four of five accessory renal arteries. A comparison of the length measurements of the aneurysm and the proximal and distal neck obtained with IVUS and CTA revealed a correlation of 0.99 (P <.001), with a coefficient of variation of 9%. IVUS results tended to underestimate the length as compared with the CTA results (0.48 +/- 0.52 cm; P <.001). A comparison of the lumen diameter measurements of the proximal and distal neck derived from IVUS and CTA showed a correlation of 0.93 (P <.001), with a coefficient of variation of 9%. IVUS results tended to underestimate aneurysm neck diameter as compared with CTA results (0.68 +/- 1.76 mm; P =.006). Interobserver agreement of IVUS length and diameter measurements showed a good correlation (r = 1.0; P <.001), with coefficients of variation of 3% and 2%, respectively, and no significant differences (0.0 +/- 0.16 cm and 0.06 +/- 0.36 mm, respectively). The longitudinal IVUS images displayed the important vascular structures and improved the spatial insight in aneurysmal anatomy.

CONCLUSION

Intravascular ultrasound scanning results provided accurate and reproducible measurements of abdominal aortic aneurysm. The longitudinal reconstruction of IVUS images provided additional knowledge on the anatomy of the aneurysm and its proximal and distal neck.

Plaque area increase and vascular remodeling contribute to lumen area change after percutaneous transluminal angioplasty of the femoropopliteal artery: an intravascular ultrasound study

OBJECTIVE

The aim of the study was to assess the change in lumen area (LA), plaque area (PLA), and vessel area (VA) after percutaneous transluminal angioplasty (PTA) of the femoropopliteal artery.

METHODS

This was a prospective study. Twenty patients were studied with intravascular ultrasound (IVUS) immediately after PTA and at follow-up examination. Multiple corresponding IVUS cross-sections were analyzed at the segments that were dilated by PTA (ie, treated sites; n = 168), including the most stenotic site (n = 20) and the nondilated segments (ie, reference sites; n = 77).

RESULTS

At follow-up examination, both the PLA increase (13%) and the VA decrease (9%) resulted in a significant LA decrease (43%) at the most stenotic sites (P =.001). At the treated sites, the LA decrease (15%) was smaller and was caused by the PLA increase (15%). At the reference sites, the PLA increase (15%) and the VA increase (6%) resulted in a slight LA decrease (3%). An analysis of the IVUS cross-sections that were grouped according to LA change (difference >/=10%) revealed a similar PLA increase in all the groups: the type of vascular remodeling (VA decrease, no change, or increase) determined the LA change. At the treated sites, the LA change and the VA change correlated closely (r = 0.77, P <.001). At the treated sites, significantly more PLA increase was seen in the IVUS cross-sections that showed hard lesion or media rupture (P <.05). No relationship was found between the presence of dissection and the quantitative changes.

CONCLUSION

At the most stenotic sites, lumen narrowing was caused by plaque increase and vessel shrinkage. Both the treated sites and the reference sites showed a significant PLA increase: the type of vascular remodeling determined the LA change at follow-up examination. The extent of the PLA increase was significantly larger in the IVUS cross-sections that showed hard lesion or media rupture.

Three-dimensional ultrasound study of carotid arteries before and after endarterectomy; analysis of stenotic lesions and surgical impact on the vessel

BACKGROUND AND PURPOSE

It has been proved that symptomatic patients with severe carotid stenosis benefit from endarterectomy. Currently used methods for quantitation of the severity of carotid stenosis have limitations, and the impact of endarterectomy on the operated region of carotid artery remains unknown. The purpose of this study was to examine the accuracy of a 3-D ultrasound system for quantitation of stenotic lesions and to evaluate changes in regional vessel volume and cross-sectional area after carotid endarterectomy.

METHODS

We studied 14 patients with both carotid angiography and 3-D ultrasound. Of 13 patients who underwent surgery, 12 were reexamined with 3-D ultrasound after surgery. The length and volume of 20 randomly selected plaques were measured from 3-D data sets. The severity of stenosis was quantified by 3-D ultrasound using both a diameter method and an area method on cross-sectional views at the most stenotic site; the results were then compared with those from carotid angiography. The segmental vessel volume and average cross-sectional area of the operated artery both before and after endarterectomy were measured from 3-D ultrasound data.

RESULTS

Good correlation was obtained between 3-D ultrasound and carotid angiography in quantitative analysis of carotid stenosis (SEE=12.4%, r=0.76, and mean difference=7.0+/-12.3% with the diameter method; SEE=10.5%, r=0.82, and mean difference=1.8+/-10.5% with the area method by 3-D ultrasound). 3-D ultrasound had excellent reproducibility and small intraobserver and interobserver variability in plaque length and volume measurements. No significant changes in segmental vessel volume and average cross-sectional area of the operated artery were observed after surgery in patients with suture closure. However, a significant increase in segmental vessel volume was obtained in patients with polyfluorethylene patches applied to the surgical opening of the artery.

CONCLUSIONS

3-D ultrasound can be used for both qualitative and quantitative analysis of plaques in the carotid artery and to detect and quantify significant carotid stenosis. Its volumetric potential has important clinical implications in serial follow-up studies for observing the progression or regression of stenotic lesions and for evaluating the outcome of interventional procedures such as endarterectomy or stent placement.

Comparison of angiography and intravascular ultrasound before and after balloon angioplasty of the femoropopliteal artery

PURPOSE

To compare angiographic and intravascular ultrasound (IVUS) data before and after balloon angioplasty (PTA) of the femoropopliteal artery.

METHODS

Qualitative and quantitative analyses were performed on corresponding angiographic and IVUS levels obtained from 135 patients.

RESULTS

IVUS detected more lesions, calcified lesions, and vascular damage than angiography. Sensitivity of angiography was good for the presence of a lesion (84%), moderate for eccentric lesions (53%) and for vascular damage (52%), and poor for calcified lesions (30%). The increase in angiographic diameter stenosis was associated with a decrease in lumen area and increase in percentage area stenosis on IVUS.

CONCLUSIONS

Angiography is less sensitive than IVUS for detecting lesion eccentricity, calcified lesions, and vascular damage. Presence of a lesion and amount of plaque were underestimated angiographically. Only before PTA was good agreement found between angiographic diameter stenosis and lumen size on IVUS.

Intravascular ultrasound in endovascular stent-grafts for peripheral aneurysm: a clinical study

PURPOSE

To evaluate the potential diagnostic information of intraprocedural intravascular ultrasound (IVUS) in patients undergoing endovascular stent-grafting for peripheral aneurysm.

METHODS

IVUS was used in 17 patients preprocedurally to measure the diameter of the proximal and distal neck and the length of the aneurysm. Balloon and stent-graft sizes were selected based on these measurements. Following stent-graft deployment, angiography and IVUS were used to document stent apposition and the configuration and diameter of the stent-graft.

RESULTS

Stent-graft insertion was considered successful in 8 patients based on angiography and IVUS images. In 9 others, both imaging modalities showed inadequate results, necessitating 12 additional procedures: balloon angioplasty for stent-graft stenosis (2) and inadequate stent-graft apposition (1); an additional stent-graft (4); an extra stent (1); thrombectomy (2); and conversion (2) for inadequate stent-graft position and a graft rupture. In these patients, intraprocedural IVUS was superiorto angiography in contributing vital information to aid in the selection of the additional interventions.

CONCLUSIONS

During management of peripheral aneurysms with endovascular stent-grafts, IVUS monitoring was a useful adjunct when the initial procedure was unsatisfactory and/ or when intraprocedural angiographic studies were inconclusive.

Validation of automated contour analysis of intravascular ultrasound images after vascular intervention

PURPOSE

The purpose of this study was to determine the feasibility of automated contour analysis of intravascular ultrasound images obtained after vascular intervention.

STUDY DESIGN

This was a descriptive study.

METHODS

Intravascular ultrasound images obtained from patients after balloon angioplasty (n = 10), stent (n = 10), or stent graft placement (n = 10) were analyzed. A comparison was made between lumen area measured with an automated and a manual system. The location showing the smallest lumen area derived from the automated system was compared with the smallest lumen area selected by visual estimation.

RESULTS

Images containing a dissection as a result of balloon angioplasty could not be analyzed by the automated system. The coefficient of variation between the lumen area measurements obtained with the automated system and the manual tracing system of images with a stent (n = 76) or stent graft (n = 79) was 2.7% and 2.1%, respectively. Correlation between the two systems was high (r = 1.00, p < 0.01) both for images containing stents or stent grafts. Minimum lumen area measured with the automated analysis system was smaller than minimum lumen area selected by visual estimation (mean difference 0.8 mm2 (4.9%) for stents and 2.4 mm2 (10.9%) for stent grafts). The location of the smallest lumen area determined with both systems was the same (<1 cm) in 16 cases and differed more than 1 cm in 4 other cases.

CONCLUSIONS

The automated analysis system shows good agreement with manual contour analysis of lumen area in images with a stent or stent graft and is a reliable tool for determination of the smallest lumen area. The system is not able to analyze an irregular-shaped lumen area caused by a dissection.

Intravascular ultrasonography allows accurate assessment of abdominal aortic aneurysm: an in vitro validation study

OBJECTIVE

The objective of this study was to acquire insight into the interpretation of intravascular ultrasound images of the abdominal aorta and to assess to what extent this technique can provide useful parameters for the endovascular treatment of patients with abdominal aortic aneurysm.

STUDY DESIGN

This was a descriptive study.

METHODS

Fifteen abdominal aortic specimens (normal, atherosclerotic, or aneurysmal) were studied. Ultrasonic images and corresponding histologic sections were compared for vessel wall characteristics, lesion morphologic characteristics, and lumen diameter. The length of the aneurysm and the length of the proximal and distal neck were measured and compared with external measurements. Tomographic images were reconstructed to a three-dimensional format.

RESULTS

Normal aortic wall was seen as a two- or three-layered structure corresponding with intima, media, and adventitia. A distinction could be made among fibrous lesion, calcified lesion, and thrombus and between normal and aneurysmal aorta. Correlation between the histologic specimens and intravascular ultrasonography for lumen diameter measurements was high (r = 0.93; p < 0.001). In a similar fashion, correlation between external measurements and intravascular ultrasound measurements on the length of the aneurysm and its proximal and distal neck was high (r = 0.99; p < 0.001). Three-dimensional analysis enhanced interpretation of the tomographic images by visualizing the spatial position of anatomic structures and contributed to understanding the shape and dimensions of the aneurysm.

CONCLUSIONS

Intravascular ultrasonography provides accurate information on the vessel wall, lesion morphologic characteristics, and quantitative parameters of the abdominal aorta. Spatial information supplied by three-dimensional analysis contributes to a more realistic interpretation of the tomographic images.

Discrepancy between stent deployment and balloon size used assessed by intravascular ultrasound

OBJECTIVES

This study was designed to assess the discrepancy in stent deployment seen on intravascular ultrasound and its relation to the balloon size selected for stent delivery.

DESIGN

Prospective study.

MATERIALS AND METHODS

The study group comprised 27 patients treated using a stent (n = 18) or stent-graft combination (n = 9). Following angiographically optimal stent deployment (< 10% residual stenosis) intravascular ultrasound was used to compare the smallest intra-stent lumen area with measurements at both stent edges and the lumen area of the proximal and distal reference sites.

RESULTS

In 14 of the 27 stents the intra-stent dimension was the same as the dimension of the stent edge (difference < or = +/- 10%). Of the remaining stents the intra-stent dimension was smaller (difference > 10%) than the proximal stent edge in seven stents (range 11-39%), smaller than the distal stent edge in three stents (range 11-20%) and smaller than both stent edges in three stents (range 12-37%). Both in patients treated with a stent or stent-graft combination, the resulting smallest intra-stent lumen area was smaller than the balloon size used (mean difference 32% and 42%, respectively) and smaller than the mean lumen area of the reference sites (mean difference 25% and 23%, respectively).

CONCLUSION

This intravascular ultrasound study shows a discrepancy between intra-stent lumen area, the area of the stent edges and the balloon size used.

Prognostic value of dobutamine-atropine stress echocardiography for peri-operative and late cardiac events in patients scheduled for vascular surgery

Cardiac events in the peri-operative phase and late after non-cardiac vascular surgery are a major cause of morbidity and mortality. Numerous tests and diagnostic strategies--usually consisting of a combination of analysis of clinical risk factors and additional non-exercise dependent stress testing, such as thallium scintigraphy, or stress echocardiography--have been developed to preoperatively identify patients with increased risk. The tests ideally should identify three subpopulations in a group with a high prevalence of coronary artery disease; (1) low-risk patients who can be referred for surgery without extra cardiac intervention. (2) patients whose peri-operative cardiac risk outweighs the potential benefits of vascular surgery, (3) patients whose risk may be reduced by peri-operative therapeutic interventions. This review will discuss the prognostic value of dobutamine stress echocardiography for risk stratification in patients scheduled for non-cardiac vascular surgery and discuss guidelines for future management.

Stent remodeling contributes to femoropopliteal artery restenosis: an intravascular ultrasound study

This case report describes the status of femoropopliteal artery stents after intervention documented with intravascular ultrasound compared with the changes seen at follow-up. To treat an extensive dissection after balloon angioplasty, a 57-year-old man underwent placement of seven adjacent Palmaz stents. At 5-month follow-up, an angiographic and intravascular ultrasound examination revealed four distinct stenotic lesions (> or = 50%) at stent junctions. Intravascular ultrasound images obtained during the initial stent placement were compared with the corresponding images obtained at follow-up. A distinction was made between changes seen at stent junctions and stent edges (n = 8), those seen within each stent (n = 7), and those in the nonstented sections proximally and distally (n = 3). Intravascular ultrasound examination established that both intimal hyperplasia and stent area reduction (stent remodeling) resulted in lumen area reduction. The extent of the changes seen at the stent junctions were greater than that of changes seen within the stents: lumen area reduction, 67% versus 23%; stent area reduction, 26% versus 11%; and intimal hyperplasia, 10.8 versus 3.3 mm2; respectively. Changes in the nonstented sections were minimal (< 2%). The stent edge seen at the adductor canal showed elliptical deformation. Thus there is a higher risk of restenosis at the stent junctions. In addition to intimal hyperplasia, stent remodeling contributes to restenosis.

Femoropopliteal venous bypass studied with intravascular ultrasound: a case report

PURPOSE

To describe the ability of intravascular ultrasound (IVUS) to document the status of the greater saphenous vein during bypass surgery, the long-term changes in the bypass, and the effects of balloon angioplasty on vein graft stenoses.

METHODS

An 80-year-old female underwent in situ femoropopliteal venous bypass grafting. Vein graft stenosis developed 6 months later, necessitating balloon angioplasty. The angioplasty failed, and a polytetrafluoroethylene (e-PTFE) interposition graft was placed. Ten months after bypass surgery, balloon angioplasty was performed for new stenoses. This procedure also failed, and the venous bypass and interposition graft were removed and replaced by an e-PTFE graft. IVUS images obtained during the first surgery were compared with those obtained 10 months later. Histologic sections were used to confirm the IVUS findings.

RESULTS

IVUS detected a distinct narrowed venous segment, pre-existent intimal thickening, and disrupted valves. Over the follow-up period, both the pre-existent intimal thickening and the narrowed segment evolved into stenoses, necessitating treatment. Luminal gain after balloon angioplasty of graft stenosis was associated with vascular damage.

CONCLUSIONS

This report shows that IVUS has the ability to document long-term venous bypass alterations and to demonstrate the effect of balloon angioplasty on venous bypass stenoses.