Mid-term and long-term results with directional atherectomy of vein graft stenoses

Purpose: The purpose of this study was to evaluate the outcomes of our 6-year experience with directional atherectomy used for treatment of stenoses in infrainguinal vein grafts. Methods: From March 1988 to April 1994, 52 directional atherectomy procedures were undertaken in 42 patients to treat 67 stenoses in 44 vein grafts. Follow-up consisted of periodic physical examinations and graft surveillance: ankle/brachial indexes, pulse volume recordings, and color-flow duplex ultrasonography. Follow-up angiography (n = 18) was performed for recurrent symptoms, reproducible drop in ankle/brachial index of greater than 0.15, a twofold to threefold focal increase in peak systolic velocity, or incidentally during evaluation of the opposite leg. Results: Forty-nine of 52 (94%) procedures were technically successful. In two the residual diameter stenosis was greater than 30%, and in one atherectomy could not be performed. Complications were minor in six (11%) and major in three (6%): two acute graft occlusions and one delayed pseudoaneurysm at the atherectomy site. There were no deaths at 30 days. With a mean follow-up of 21 +/- 18 months, 36 of 44 grafts (82%) remained patent without restenosis; 6 others were patent but considered ''failed''-5 (11%) with restenosis, 1 with a pseudoaneurysm; and 2 grafts (5%) occluded. Clinically 33 of 44 extremities (75%) were asymptomatic during follow-up. Claudication improved in five, recurred in three, and was unchanged in one. There was one below-knee amputation. Life-table analysis including all 52 procedures reveals cumulative primary atherectomy patency rates fdr the 44 grafts of 82%, 78%, and 78%, respectively, at 1, 2, and 3 years after atherectomy, and 86%, 83%, and 83% for the 67 individual stenoses treated. Conclusions: Directional atherectomy of vein graft stenoses has high technical and clinical success rates, acceptably low morbidity rates, and offers better sustained patency rates than balloon angioplasty. Its long-term patency rate seems to approach that of surgical vein patch angioplasty.