The aims of peripheral arterial revascularisation are to heal wounds, salvage the limb and to ameliorate claudication. Postoperatively the aim is to keep the bypass patent. Significant structural defects will occur in almost one third of infra-inguinal bypasses (most within 6-9 months) and most of these defects will be due to intimal hyperplasia. A variety of methods have been advocated to identify graft defects so that they can be repaired preemptively so as to prevent graft failure. These methods include intraoperative assessment with angiography, duplex, angioscopy, or flow measurement; clinical evaluation with or without ABI assessment and claudication exercise testing; impedance analysis; duplex ultrasound graft surveillance and angiography, CTA or MRA for selected cases. The conventional wisdom has been that the patency of bypass grafts can be significantly prolonged if developing graft lesions are identified and corrected before graft thrombosis and thus limb salvage can be improved. It has been accepted that duplex surveillance is mandatory and the expense is justified. Two randomised studies in the 1990s comparing duplex surveillance with "clinical follow-up" provided conflicting results. Most recently the Vein Graft Surveillance Trial (2005) concluded that intensive surveillance with duplex does not improve limb salvage, bypass graft patency, or QOL scores, but comes with a significant additional cost. This has resulted in a rethink by clinicians with renewed focus on identifying clinical and early duplex features that might allow the identification of "high risk grafts" that require more rigorous clinical and duplex surveillance compared to "low risk grafts" that could be followed with clinical follow-up and ABI measurement alone.

This presentation will discuss the rationale for peripheral arterial bypass graft surveillance and the evidence base that supports its current role.