Factors affecting symptomatic vs asymptomatic vein graft stenoses in lower extremity bypass grafts

OBJECTIVE: To determine differences in patients undergoing lower extremity vein graft revisions presenting with and without recurrence of preoperative symptoms. DESIGN: Retrospective case-control study of a prospectively maintained database. SETTING: University and veterans' administration hospitals PATIENTS: Two hundred nineteen lower extremity vein graft revisions were performed in 161 patients from January 1995 to January 2007. Patients were categorized as asymptomatic or symptomatic (recurrence of initial symptoms) at the time of revision. MAIN OUTCOME MEASURES: Univariate analysis was performed to assess differences in patient demographics, details of initial operation, site of recurrent lesion, and follow-up surveillance data between symptomatic and asymptomatic patients. Independent predictors of symptomatic recurrence were identified with multivariate logistic regression. Primary assisted patency was compared between revisions performed for symptomatic and asymptomatic lesions. RESULTS: Vein graft stenoses were asymptomatic in 125 cases (57%) and symptomatic in 94 cases (43%). Symptomatic recurrences were associated with a significantly greater drop in ankle brachial index than asymptomatic lesions (mean [SD], 0.21 [0.03] vs 0.11 [0.02]; P = .003). Distal graft or outflow lesions were significantly associated with symptom recurrence (P = .048). Multivariate analysis identified ankle brachial index decrease (odds ratio, 6.803; 95% confidence interval, 1.418-32.258; P = .02) and the use of alternate graft conduit (odds ratio, 2.633, 95% confidence interval, 1.243-5.578; P = .01) as independent predictors of recurrent symptoms. Overall 5-year patency was the same regardless of preoperative symptoms (82% symptomatic and 88% asymptomatic; P = .30). CONCLUSIONS: Symptomatic recurrences are associated with larger decreases in ankle brachial index, distal lesions, and alternate conduit grafts. Duplex surveillance is necessary to identify asymptomatic vein graft stenoses. Because graft patency is independent of preoperative symptoms, surveillance consisting of clinical follow-up with ankle brachial index evaluation warrants further consideration.