Slash and splash technique for treatment of infrainguinal vein bypass graft stenosis

Autologous venous bypasses effectively treat extensive infrainguinal arterial occlusive disease with excellent long-term patency rates. However, one-third of patients will experience significant vein graft stenosis, particularly within the first-year post-bypass. Current endovascular interventions yield suboptimal results, with reported re-stenosis rates of 20–50 %. This study investigates the efficacy of cutting balloon (‘slash’) followed by a drug-eluting balloon (‘splash’) angioplasty in treating vein graft stenosis. This single-centre retrospective review examines consecutive patients who underwent the ‘Slash and Splash’ technique for treating significant stenosis (>70 % stenosis and/or PSV >300 cm/s) in infrainguinal autologous bypasses from June 2017 to January 2023. Follow-up duplex ultrasound was conducted at three months, six months, and yearly thereafter. Primary outcomes assessed technical success and graft patency. Secondary outcomes included major adverse limb events (MALEs), and major amputations Twenty-three patients (mean age 67.4 ± 8.1 years, 44 % male) with significant vein graft stenoses underwent the ‘Slash and Splash’ method to salvage their bypasses. Most patients (91 %) had critical limb-threatening ischemia. Nine patients received femoral-popliteal grafts and 14 received femoral-tibial grafts, with18 utilizing saphenous in-situ conduits. The average follow-up duration was 26.1 ± 16.7 months, with no losses to follow-up. The median time from initial bypass to angioplasty was 10 months. Primary technical success was 100 % and primary patency was 95 %, with only one restenosis requiring repeat angioplasty during follow-up. Primary-assisted and secondary patency rates were 100 %. Freedom from MALEs was 90 %, with two patients requiring amputations secondary to diabetic foot infections, although bypasses remained patent at the time of amputation. The ‘Slash and Splash’ technique effectively treats severe infrainguinal vein bypass graft stenosis, offering excellent mid-term patency and freedom from MALEs. Adoption of this technique should be considered in the treatment of hemodynamically significant vein graft stenoses.