Question

A 55-year-old male underwent a common femoral artery to below knee popliteal artery bypass using reversed great saphenous vein graft one month ago.
After 6 months, PSV were found to be increased on distal anastomotic site on colour doppler. What is the likely etiology at this juncture? How will you proceed further?

Hint:

Increased PSV at the anastomotic site suggests graft stenosis. Timely intervention with imaging and potential revision is critical to prevent graft failure.

Answer 1

Step 1: Understanding the findings.
An increase in PSV (Peak Systolic Velocity) at the distal anastomotic site on color Doppler suggests that there may be a narrowing or stenosis at this site. This could indicate the development of graft stenosis, which is a common complication following bypass surgeries.

Step 2: Likely etiology.
The likely etiology of increased PSV at the distal anastomosis is graft stenosis or intimal hyperplasia at the anastomotic site. These issues can occur due to turbulent flow, endothelial injury, or a mismatch in the diameter between the graft and the vessel. The stenosis could be caused by the formation of a neointimal layer that narrows the lumen of the graft.

Step 3: Further management.
1. Repeat imaging: Confirm the diagnosis with angiography or a more detailed CT angiogram to assess the extent of stenosis and the possibility of graft occlusion.
2. Graft revision: If significant stenosis is detected (usually if the PSV is greater than 200 cm/s), surgical revision or angioplasty of the graft may be needed to restore patency.

Step 4: Conclusion.
Increased PSV at the distal anastomotic site likely indicates graft stenosis or intimal hyperplasia. Further imaging and potential revision or angioplasty are needed to restore normal blood flow.