Lysis/balloon angioplasty versus thrombectomy/ open patch angioplasty of failed femoropopliteal polytetrafluoroethylene bypass grafts.

PURPOSE Several studies have reported on the outcome of lysis/percutaneous transluminal balloon angioplasty (PTA) of failed or failing femoropopliteal bypass grafts (FPGs) with mixed results. None of these studies have compared the results of lysis/PTA versus thrombectomy/open patch repair for failed above-knee polytetrafluoroethylene (PTFE) FPGs. METHODS Patients with failed (thrombosed) above-knee FPGs (PTFE, Goretex) during a 10-year period were given the option to choose between thrombectomy/open patch repair for localized anastomotic short stenosis (less-than-or-equal2 cm; group A, 31 patients) and lysis/PTA or thrombectomy/balloon angioplasty when lysis failed or was contraindicated (group B, 26 patients). The cumulative patency rates were compared by using a Kaplan-Meier life table analysis. All patients underwent routine color duplex ultrasound scanning/ankle brachial index measurements at 30 days, 6 months, and every 6 months thereafter. RESULTS Demographic and clinical characteristics and indications for intervention were comparable in both groups. The mean follow-up period was 54.1 and 46.2 months in group A and group B, respectively. There were four perioperative complications in group A (13%) and seven perioperative complications in group B (27%). Initial technical success and 30-day secondary graft patency rates were 100% in both groups. Overall, 17 of 31 patients (55%) had open grafts, with no further revisions in group A and six of 26 patients (23%) in group B requiring further revisions (P =.012). Nine of 31 grafts (29%) failed in group A versus 15 of 26 grafts (58%) in group B (P =.027). The rate of limb loss was comparable in both groups (6% vs 12%). The overall cumulative secondary patency rates at 6 months and 1, 2, 3, 4, and 5 years were 100%, 93%, 85%, 72%, 67%, and 62% for group A and 100%, 96%, 88%, 76%, 63%, and 45% for group B (P =.035). Thirty-five further interventions were needed to maintain graft patency in group B (mean, 1.35; range, 0-3) versus five further interventions in group A (mean, 0.16; range, 0-1; P <.05). CONCLUSION Thrombectomy/open surgical repair is superior to lysis/PTA (or thrombectomy/balloon angioplasty) for the treatment of failed above-knee PTFE FPGs with anastomotic stenoses. Therefore, balloon angioplasty should be reserved for patients who are at high risk for surgery.