Authored by Miroslav Bulvas
Mini Review
The goal of surgical and/or endovascular therapy in patients with lower limb ischemia is the elimination of return or progression of serious and threatening ischemic symptoms (rest pain, ischemic ulcers or gangrene) [1-3]. Thus, bypass occlusion can be associated with renewed acute or critical ischemia and endangered lower extremity. Early (> 30 days) graft failure rate 6.3% was reported in the study that collected 9217 bypass procedures [4] with higher frequency in preceding emergency and re-operative procedures (8.2%). Typically, it can be ascribed to technical factors (kinking or twisting of the graft, technical anastomotic problems. inadequate runoff, clamp injury, retained valves,) and prothrombotic state [5]. Intermediate graft failure (from 30 days to 18 months) is commonly associated with my intimal hyperplasia formation at the sites of anastomoses or valves (venous bypass grafts). Late graft failure is largely caused by the progression of atherosclerosis in the outflow or inflow vessels Figures 1 & 6. Excellent and long-lasting results (5-year primary patency rate 85-88%) can be expected with aortoiliac reconstruction at low risk patients. Acute thrombosis of an aortofemoral graft limb occurs in about 2% of patients during early perioperative period [6]. Primary patency rates 87-100% (1 month), 69-86% (1 year) and 51-72% (5 years) were reported [7] in femoropopliteal bypasses with better results for suprageniculate and autovenous saphenous grafts.
Patients who have undergone placement of lower limb bypass grafts are followed up with periodic evaluations that record return or progression of ischemic symptoms. Therefore, hemodynamic deterioration caused by progression of proximal or distal atherosclerosis and/or intimal hyperplasia can be detected before thrombosis and occlusion develop. In those cases, preventive balloon angioplasty, stenting or percutaneous atherectomy are used to assist the primary patency.
Surgical treatment of acutely thrombosed vein graft is usually associated with thrombectomy, thrombolysis and subsequent repair of the defects responsible for graft failure. Unfortunately, only 23% of vein grafts remained patent 3 years after successful thrombolysis and revision [5,8]. For intermediate to late vein graft failure, a new surgical reconstruction is recommended in patients with threatened extremity. Nevertheless, advanced comorbidities and anatomy can preclude major reoperation. Furthermore, it can be difficult to find sufficient vein for reoperation in patients with occluded prosthetic grafts. For secondary bypass grafts, 25% primary patency (prosthetic) and 43% (autogenous vein) were reported [5] five years after reoperation.
Surgical or thrombolytic limitation is the driving force for usage of the modalities with purely endovascular, mechanical approach in the management of occluded bypasses. For the Rotarex catheter, 98 -100 % technical success was reported in the series with acute and subacute occlusions of femorpopliteal bypasses [9,10]. Lichtenberg et al. managed 22 patients with venous (12) and prosthetic (10) occluded by passes without major complication, death or reintervention during 6-month follow-up. Wissgott et al. reported 98 % technical success in 42 patients with 81% of venous bypasses, 4.8% of complications (no amputation, no death) and 66% of 12-month primary patency [11]. Reported lower primary success (78%) in 9 patients with occluded femoropopliteal bypasses compared to 91 cases of infraaortic occlusions. Mixed series of 316 patients [12] with acute and subacute lower limb ischemia (72 femoropopliteal bypass occlusions) reached 100% technical success at the level of target vessels with only a minor complication (8%) associated with debulking therapy. The overall therapeutic success was negatively influenced by infrapopliteal artery status and the low potential for effective endovascular and surgical treatment in this runoff area [12].
Conclusion
Mechanical debulking with the Rotarex catheter can be used as an initial treatment in patients with occluded lower limb bypasses especially in those, at high surgical risk or predisposed to bleeding.
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