|6. Lower Extremity Vein Bypass Graft Surveillance|
|ABI and Duplex ultrasound of lower extremity vein bypass site|
|Numerator||Patients who had an ABI and Duplex ultrasound of their infrainguinal vein bypass graft revascularization site at least once during the 1-y measurement period.|
|Denominator||All patients age ≥40 y who have undergone arterial bypass with autologous vein graft surgery for infrainguinal revascularization.|
■ Patients with synthetic bypass grafts
■ Patients with medical reason(s) documented by a physician, advanced practice nurse, or physician assistant for not performing ABI and Duplex ultrasound (e.g., patients who have undergone major lower limb amputation remote from their revascularization procedure)
■ Documented patient reason(s) that ABI and Duplex ultrasound could not be performed (e.g., patient refusal)
|Period of Assessment||1-y measurement period|
|Sources of Data||Prospective flow sheet, retrospective medical record review, electronic medical record, vascular laboratory data reports|
|Infrainguinal venous bypass grafts are at risk for developing stenoses, which, if unrecognized, may result in graft thrombosis. Once thrombosed, the secondary patency rates of these grafts are poor. Performing physical examination and ABI testing are insufficient methods of determining whether a stenosis is present. Routine Duplex scan surveillance has been demonstrated to identify vein grafts at risk for failure. Although there is some conflict in the literature, identification and revision of these grafts has been shown to improve long-term results. Synthetic grafts may also develop stenoses; however, graft thrombosis is relatively easily managed with surgical thrombectomy, and secondary patency rates are similar to those of primary assisted patency.|
Similar data do not exist in infrainguinal endovascular intervention; however, if the revascularization was complex, and the challenges of restoring patency after failure of the intervention are great, it is intuitive that surveillance in a manner similar to that of infrainguinal venous bypass grafts be employed.
The durability of suprainguinal bypass grafts and endovascular interventions are superior to those of infrainguinal interventions, and given the challenges of Duplex ultrasound surveillance in iliac arteries, routine surveillance is not recommended.
|ACC/AHA 2005 Guidelines for the Management of Patients With Peripheral Arterial Disease (12)|
Long-term patency of infrainguinal bypass grafts should be evaluated in a surveillance program, which should include an interval vascular history, resting ABIs, physical examination, and a Duplex ultrasound at regular intervals if a venous conduit has been used. (Level of Evidence: B)
Duplex ultrasound is recommended for routine surveillance after femoral-popliteal and femoral-tibial-pedal bypass with a venous conduit. Minimum surveillance intervals are approximately 3, 6, and 12 months, and then yearly after graft placement. (Level of Evidence: A)
|This measure should be reported by vascular specialists or vascular specialist practices only. The level of “aggregation” (clinician versus practice) will depend upon the availability of adequate sample sizes to provide stable estimates of performance.|
|Method of Reporting|
Whether ABI and Duplex ultrasound of the revascularization site was performed at least once during the measurement period.
Per patient population:
Percentage of patients for whom ABI and Duplex ultrasound of the revascularization site was performed at least once during the measurement period.
|Challenges to Implementation|
|■ This requires a vascular laboratory skilled in performance of lower extremity arterial Duplex ultrasonography, as well as having a method to schedule surveillance testing of patients with infrainguinal lower extremity revascularization. |
■ Sample size may preclude reporting of reliable performance estimates, particularly at the clinician level.
ABI indicates ankle-brachial index.