Prediction of early graft occlusion in femoropopliteal and femorodistal reconstruction by measurement of volume flow with a transit time flowmeter and calculation of peripheral resistance

doi:10.1016/S0950-821X(05)80720-0

European Journal of Vascular Surgery

Volume 7, Issue 6, November 1993, Pages 704-708

https://doi.org/10.1016/S0950-821X(05)80720-0 Get rights and content

A transit time flowmeter (Transonic TC101D™, Transonic Inc., U.S.A.) was used for flow measurements and calculation of peripheral resistance in 48 primary femoropopliteal and femorodistal reconstructions. The results were correlated with primary graft occlusions during the first 90 postoperative days. There were 25 men and 23 women with a median age of 75 years (67–83). Eight were diabetic. Indications for surgery were rest pain (n = 23), ischaemic ulcer (n = 16), gangrene (n = 8) and popliteal aneurysm (n = 1). Measurements were made before reconstruction on the artery at the site of the distal anastomosis. After reconstruction flow measurements were made on the graft near the proximal and distal anastomoses together with a proximal graft pressure measurement. The peripheral resistance was calculated. Eleven grafts occluded and six patients died, four with patent grafts. Patients with graft occlusions had a significantly lower flow before (4 vs. 20 ml/min) and after (60 vs. 110 ml/min) reconstruction and a higher peripheral resistance, (1238 vs. 625 mPRU) than patients with patent grafts. The most significant differences were found in the femorodistal bypass grafts. The transit time flowmeter was easy to use. The flow before and after reconstruction as well as the peripheral resistance could be used for the prediction of graft function within 90 days of surgery.

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Cited by (30)

Prognostic Significance of Intraoperative Graft Flow in Distal Bypass on Long-Term Outcomes in Patients with Chronic Limb-Threatening Ischemia
2022, Annals of Vascular Surgery
The aim of the study was to determine the prognostic significance of measurement of graft flow on the patency of distal bypass.
A retrospective analysis was performed for 208 distal bypasses (208 limbs, 170 patients) with a single segment great saphenous vein conducted in a nonreversed manner from January 2009 to December 2019 in Japan. Patient backgrounds, operative details (including intraoperative mean graft flow), hospital outcomes, and long-term outcomes were evaluated. The primary endpoints were the primary, assisted primary, and secondary patency of the distal bypass graft and the secondary endpoints were limb salvage and wound healing.
The median intraoperative graft flow was 18 [10–30] mL/min. The follow-up rate was 98% in a mean follow-up period of 31 ± 26 months. Primary, assisted primary, and secondary patency in the cohort were 51%, 72%, and 73% at 1 year, and 39%, 59%, and 61% at 3 years, respectively. In multivariate analysis, the independent risk factors for primary patency were low graft flow (P = 0.0022) and female sex (P = 0.0016), and those for secondary patency were also low graft flow (P = 0.0025) and female sex (P < .001). The cut-offs for graft flow predicting primary and secondary patency were both 16 mL/min. The limb salvage rate was 94% at 1 year and 89% at 3 years; and the wound healing rates were 55%, 71% and 84% at 3, 6, and 12 months, respectively. Limb salvage and wound healing were not significantly associated with intraoperative graft flow.
Intraoperative graft flow was an independent predictor for graft patency in distal bypass, but had no influence on limb salvage and wound healing. The cut-off value for the mean graft flow predicting primary and secondary patency was 16 mL/min.
Graft flow predictive equation in distal bypass grafting for critical limb ischemia
2019, Journal of Vascular Surgery
Citation Excerpt :
These impaired endothelial functions with low nitric oxide, severe calcification, and diseased runoff may influence GF immediately after surgery. The efficacy of GF measurement to predict graft patency is controversial,2,16,26,27 although in Japan the cost of GF measurement is covered by health insurance owing to the supposed efficacy. Especially in pedal bypasses, it was impossible to set an absolute cutoff value.16
Graft flow (GF) seems to be an important prognostic predictor in distal bypass for critical limb ischemia, but previous studies have failed to clarify the association between GF and the graft prognosis. GF differs significantly among grafts, and each graft seems to have an optimal GF depending on various factors. We hypothesized that comparison between the measured GF (mGF) and optimal estimated GF (eGF) would be important in predicting graft prognosis. Herein, we aimed to develop a GF predictive equation by assessing GF determinants and to validate the equation against a clinical dataset.
A total of 198 distal bypasses with vein grafts for critical limb ischemia from 2011 to 2016 were enrolled. Of these grafts, 135 normal grafts without any abnormalities on early postoperative ultrasound examination were used to develop and validate the equation. Various anatomic and patient-related factors were analyzed to detect GF determinants with stepwise selection, and the GF predictive equation was developed with multiple linear regression analysis. After developing the equation, all 198 grafts were categorized into two groups according to the equation developed based on data from the 135 normal grafts as follows: optimal flow grafts (OFGs), in which mGF > eGF – 14.6, and suboptimal flow grafts (SFGs), in which mGF < eGF – 14.6. The cutoff value of 14.6 was determined using receiver operating characteristic curves to detect graft abnormalities. By comparing OFGs and SFGs, the efficacy of the equation in predicting bypass abnormalities and graft prognosis was assessed.
The GF determinants were runoff, hemodialysis (HD), diabetes mellitus (DM), and graft quality (GQ). The predictive equation was estimated as follows: $GF (ml / \min) = (32.9 \times run - off) + (9.9 \times G Q) - (13.0 \times D M) - (35.1 \times H D) + 12.1$ (R² = 0.71, coefficient: runoff and GQ, 3 [good], 2 [fair], 1 [poor]; DM and HD, 1 [yes], 0 [no]). In the efficacy assessment of the equation, SFGs showed a significantly higher rate of bypass abnormalities (64.0% vs 12.2%; P < .0001), graft intermediate stenosis (10.7% vs 1.6%; P = .0071), graft critical stenosis (28.0% vs 3.2%; P < .0001), and early graft occlusion (17.3% vs 4.3%; P = .0037) than OFGs and were associated with a higher rate of revision surgery within 2 years after surgery (50.7% vs 34.2%; P = .026). SFGs also showed significantly lower primary patency rates (P < .0001) and secondary patency rates (P = .0005).
GF was well-estimated with runoff, GQ, and the presence of DM and HD. A comparison between mGF and eGF, calculated with the equation, will help to detect bypass abnormalities and determine the necessity of additional intraoperative procedures and, thus, achieve optimal outcomes.
The effect of congestive heart failure on perioperative outcomes in patients undergoing lower extremity revascularization
2016, Journal of Vascular Surgery
Citation Excerpt :
CHF has a known association with endothelial dysfunction that likely has an effect on perioperative morbidity and potential mortality.17-19 In addition, CHF is associated with abnormalities of arterial flow (low cardiac output, dilated cardiac chambers), abnormalities of blood constituents (platelets), and chronic inflammation leading to increased a propensity for thrombosis.19-25 One might therefore expect an increase in early graft failure among CHF patients.
As the management of peripheral arterial disease evolves, determining the factors affecting the outcome of lower extremity interventions is important. The presence of peripheral arterial disease is associated with a twofold increase in the prevalence of congestive heart failure (CHF), with reports of increased perioperative complications. This study evaluated CHF as a predictor of acute postoperative complications in patients undergoing lower extremity bypass.
The study group consisted of all patients entered in a prospective, multicenter database (American College of Surgeons National Surgical Quality Improvement Program) undergoing infrainguinal bypass (IIB) from 2005 to 2010. Patients with a new diagnosis of CHF ≤30 days before surgery were compared with those without such a diagnosis. Patency rates at 30 days, morbidity, and mortality were compared between groups using a multivariate logistic regression analysis controlling for covariates.
There were 18,645 IIB patients, of which 488 (2.6%) had history of CHF. CHF patients were older and had higher rates of comorbidities than those without CHF. In univariate analysis, IIB graft failure was not significantly different for patients with CHF (6.8%) vs those without (5.2%; P = .13). There was no difference in patency for femoral popliteal grafts (no CHF, 96.5%; CHF, 96.3%; P = .89) or for femoral-tibial grafts (no CHF, 91.9%; CHF, 89.3%; P = .20). However, CHF was significantly associated with postsurgery cardiac events (P = .007), pneumonia, prolonged intubation, reintubation, sepsis, return to the operating room, 30-day mortality, and length of stay >9 days (all P < .0001). After adjusting for covariates associated with CHF, compared with patients without CHF, those with CHF had an 82% higher odds of postoperative pneumonia (95% confidence interval [CI], 13%-94%; P = .014), an 87% increase in the odds of prolonged intubation (95% CI, 16%-201%; P = .011), a 73% increase in the odds of reintubation (95% CI, 12%-167%; P = .014), a 55% increase in the odds of sepsis or septic shock (95% CI, 11%-118%; P = .011), a 29% increase in the odds of returning to the operating room (95% CI, 4%-61%; P = .022), a 121% increase in the odds of 30-day mortality (95% CI, 56%-214%; P < .0001), and a 102% increase in the odds of postsurgery length of stay >9 days (95% CI, 64%-148%; P < .0001).
Recently diagnosed or exacerbated CHF does not affect acute IIB graft patency. However, CHF may increase the complication rates for perioperative pneumonia, prolonged intubation, reintubation, sepsis, return to the operating room, extended length of stay, and mortality. Therefore, before pursuing lower extremity interventions in patients with a history of CHF, one should incorporate an individualized approach to optimize the success of the revascularization while minimizing medical comorbidities.
A numerical hemodynamic tool for predictive vascular surgery
2009, Medical Engineering and Physics
We suggest a new approach to peripheral vascular bypass surgery planning based on solving the one-dimensional (1D) governing equations of blood flow in patient-specific models. The aim of the present paper is twofold. First, we present the coupled 1D–0D model based on a discontinuous Galerkin method in a comprehensive manner, such as it becomes accessible to a wider community than the one of mathematicians and engineers. Then we show how this model can be applied to predict hemodynamic parameters and help therefore clinicians to choose for the best surgical option bettering the hemodynamics of a bypass. After presenting some benchmark problems, we apply our model to a real-life clinical application, i.e. a femoro-popliteal bypass surgery. Our model shows good agreement with preoperative and intraoperative measurements of velocity and pressure and post-surgical reports.
Flow measurement before and after papaverine injection in above-knee prosthetic femoropopliteal bypass
2006, Journal of Vascular Surgery
Citation Excerpt :
Angiography may detect operative technical errors, however. Lundell and Bergqvist1 reported that increased peripheral resistance was more predictive for early graft occlusion then flow measurements. In the present study, peripheral resistance was not estimated; however, the increase in papaverine flow was caused by a reduced peripheral resistance.11
To investigate the value of intraoperative blood flow measurements on early and long-term patency of above-knee prosthetic femoropopliteal bypass.
Flow was measured with a transit time flowmeter before (basal flow) and after an intragraft injection of papaverine (papaverine flow) in 87 operations (86 patients) between January 1990 and December 2001. Sixty-one grafts were of polyester, and 26 were of polytetrafluoroethylene. The operations were done under epidural anesthesia. The preoperative angiographic run-off score and clinical risk factors were recorded. Patency rates were analyzed with the product limit method and compared with the log-rank test. Variables found to be near significantly related to patency rates (P < .1) were included in a multivariate analysis performed with the Cox proportional hazard model.
Basal flow measurements were not related to patency. The 2- and 5-year patency rates for grafts with a papaverine flow ≤500 mL/min were 48% and 18% compared with 66% and 52% for grafts with a papaverine flow ≥500 mL/min. These differences were statistically significant (P = .012, hazard ratio, 2.6). Two- and 5-year patency rates for smokers vs nonsmokers were 44% and 18% vs 69% and 54%. The patency rates for patients with poor vs good run-off were 42% and 27% vs 66% and 31%. Smoking (P = .008, hazard ratio, 2.75) and poor run-off score (P = .009, hazard ratio, 2.38) were found to be independent risk factors for reduced patency rates. Poor run-off score did not correlate with low values of measured basal or papaverine flow.
Papaverine flow of ≤500 mL/min is associated with reduced mid- and long-term patency rates. Additional antithrombotic medication and frequent follow-up for these grafts should be considered. The inferior patency rates of smokers and patients with poor run-off indicate that prosthetic bypass is less suitable for these groups of patients.
Interpretation of the results of doppler ultrasound flow volume measurements of infrainguinal vein bypasses
2005, European Journal of Vascular and Endovascular Surgery
To evaluate a pattern for the interpretation of the results of intraoperative Doppler ultrasound flow volume measurement of infrainguinal vein bypasses.
Retrospective analysis of prospective data.
91 consecutively performed infrainguinal non-reversed free vein bypasses.
Using preoperative angiograms, the run-off, which can be expected after the reconstruction, was evaluated by means of a point score. A first measurement of the flow volume was taken after the release of the blood flow and a second after administration of 20 mg Alprostadil into the bypass. From these two results, we calculated an average value, which was set in relation to the run-off score. From this we computed a relative flow, i.e. the flow per open crural vessel=per run-off score unit (quotient: flow/score).
The median relative flow of angiographically perfect reconstructions was 86 ml/min. In 14 reconstructions, the control angiogram showed stenoses: median relative flow 59 ml/min, range between 20 and a maximum of 75 ml/min. The practical application of the flow measurement requires a minimum relative flow guideline for stenosis-free reconstructions. A guideline of 80 ml/min would yield a sensitivity of 100% and a specificity of 68%.
Measurement of flow volume could be used as a screen, in order to filter out reconstructions, which must be further clarified with an angiogram. A further prospective evaluation of the value of volume flow is needed before any conclusive recommendations can be drawn.

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Original articlePrediction of early graft occlusion in femoropopliteal and femorodistal reconstruction by measurement of volume flow with a transit time flowmeter and calculation of peripheral resistance

J Vasc Surg

Lancet

Ultrasound Med Biol

J Surg Res

Prospectively randomised clinical trial to compare in situ and reversed saphenous vein grafts for femoropopliteal bypass

Br J Surg

Vessel internal diameter independent volume flow measurements with ultrasound

San Diego Biomed Symp

An implantable transit-time ultrasonic blood flow meter

J Phys

Ultrasonic flowmeter uses wide-beam transit-time technique

Med Electr

In vivo calibration of a transit-time ultrasound system for measuring ascending aorta volume flow

The Pharmacologist

Volume blood flow measurements with a transit time flowmeter—an in vivo and in vitro variability and validation study

Clin Phys

The relationship between blood flow and failure of femoropopliteal reconstructive arterial surgery

Br J Surg

Prognostic indicators in femoropopliteal reconstructions

Arch Surg

Original article
Prediction of early graft occlusion in femoropopliteal and femorodistal reconstruction by measurement of volume flow with a transit time flowmeter and calculation of peripheral resistance