Selective use of duplex ultrasound to replace preoperative arteriography for failing arterial vein grafts

Purpose: In an effort to minimize costs and patient discomfort, we determined whether duplex ultrasound (DU) could selectively replace preoperative arteriography performed in the radiology suite to diagnose failing arterial bypass grafts (FABs) constructed of autogenous vein. Methods Between January 1, 1994, and December 31, 1996, we treated 106 FABs. Graft revision solely on the basis of DU was performed only if a focal stenosis was dearly identified in the graft (peak systolic velocity [PSV] >300 cm/sec, ratio of adjacent PSVs >3.0) or in inflow or outflow arteries (resulting in uniform graft PSVs <45 cm/sec). Intraoperative arteriograms mere frequently obtained to confirm DU findings. Preoperative arteriograms mere obtained if DU revealed multiple or ill-defined stenoses, diffuse inflow or outflow arterial disease, uniformly low PSVs without an identifiable lesion, or equivocal stenosis despite clinical evidence of an FAB. Results: Seventy-three (69%) FABs with 81 lesions were revised on the basis of DU only. Of 76 stenotic lesions, an intraoperative arteriogram or surgical findings confirmed a diameter stenosis of 75% to 99% in 69 grafts (91%) and stenosis of 50% to 74% in three grafts (4%). DU incorrectly identified the site of stenosis or underdiagnosed the extent of disease in four grafts (5%). DU correctly identified the site of missed arteriovenous fistulas in five grafts. The 73 FABs were treated with intraoperative balloon angioplasty (30 grafts), patch angioplasty (20), interposition or jump grafts (12), ligation of arteriovenous fistula (3), a new bypass graft (1), or a combination of these interventions (7). A significant change in intraoperative strategy potentially could have been avoided if a preoperative arteriogram had been obtained in three of the 73 FABs (4.1%). Conclusions: DU can reliably be used to revise FABs and avoid the morbidity, discomfort,and cost of confirmatory arteriography in two thirds of cases.