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Duplex scan, arteriography, and graft flow rates were used intraoperatively to assess 56 infrainguinal arterial reconstructions for technical error. Intraoperative duplex scan identified a technical defect or low graft flow velocity in 22 of 56 (39%) grafts. Eleven of the defects were judged to be clinically significant and were corrected. Four of these defects were missed by the completion arteriogram. One technical defect identified by completion arteriography was missed by duplex scan. Fifty percent (5/10) of grafts with an abnormal intraoperative duplex scan which were not corrected occluded within 30 days. Graft flow rates measured by the electromagnetic flowmeter were neither predictive of technical defect nor early graft outcome. Although the sensitivity of arteriography and duplex scan (88% sensitivity for both) were both high for predicting early graft occlusion, the combination of duplex scan and completion arteriography was significantly more accurate (p less than .0001) in predicting early graft outcome than either study alone. Duplex scan identified significant graft defects which were not detected by completion arteriography or graft flow rate measurement. The duplex scan also provided hemodynamic information which was predictive of early graft outcome. The duplex scan can be an important adjunct to completion arteriography for the intraoperative assessment of infrainguinal arterial reconstruction.

Favorable early results with mechanical angioplasty devices and laser-assisted balloon angioplasty have resulted in aggressive marketing and a rapid increase in the use of these devices for the treatment of femoropopliteal occlusive disease. Recent reports, however, have questioned the durability of these less invasive procedures. Since 1986 we have been involved in the clinical investigation of the Kensey dynamic angioplasty instrument and laser-assisted balloon angioplasty. One hundred two balloon angioplasty procedures assisted by the Nd:YAG laser (n = 56) and the Kensey dynamic angioplasty instrument (n = 46) were performed for the treatment of femoropopliteal occlusive lesions. Both Kensey dynamic angioplasty instrument and laser-assisted balloon angioplasty groups were similar with regard to age, operative indication, preoperative ankle-brachial index, lesion length, and distal runoff. Mean follow-up was 19 months in the Kensey dynamic angioplasty instrument group and 15 months in the laser-assisted balloon angioplasty group. Technically successful recanalization was achieved in 67% of Kensey dynamic angioplasty instrument-assisted balloon angioplasty procedures and 82% of laser-assisted balloon angioplasty procedures. Early hemodynamic and clinical improvement was obtained in 59% of Kensey dynamic angioplasty instrument-assisted balloon angioplasty procedures and 57% of laser-assisted balloon angioplasty procedures. Two-year clinical success by life-table analysis was 37% in the Kensey dynamic angioplasty instrument group and 19% in the laser-assisted balloon angioplasty group. The level of subsequent surgical revascularization was not altered in any patient by Kensey dynamic angioplasty instrument-assisted balloon angioplasty or laser-assisted balloon angioplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

Laser thermal-assisted balloon angioplasty (LABA) was prospectively applied in the treatment of 56 atherosclerotic femoropopliteal occlusive lesions in 51 consecutive patients. All procedures were performed in the operating room using a neodynium:yttrium-aluminum-garnet (Nd:YAG) laser source, and patients were evaluated for immediate and long-term hemodynamic and clinical improvement. Technically successful recanalization was achieved in 82% of cases, with 57% of all patients (32 of 56) obtaining early hemodynamic and clinical improvement. Long-term clinical success (by life-table analysis) was obtained by only 22.5% at 6 months, and only 13.5% at 12 months. Patients presenting with intermittent claudication did significantly better than those presenting for limb salvage (p = 0.01), and trends toward improved outcome were noted for short versus long lesions as well as for patients with "good" versus "poor" distal runoff (NS). Procedure-related morbidity occurred in 14%, and there was one peri-procedural mortality (1.8%). We conclude that the use of LABA is associated with long-term clinical success in only a small proportion of patients, and that widespread clinical application of this technique is not indicated at the present time.