Safety and Effectiveness of Endovenous Thermal Ablation for Incompetent Saphenous Veins with an Aneurysm Close to the Junction

OBJECTIVE

The aim was to evaluate the safety and effectiveness of endovenous thermal ablation (EVTA) with or without adding high ligation (HL) for the treatment of incompetent saphenous veins with an aneurysm (>20 mm for the great saphenous vein, >15 mm for the small saphenous vein) close to the junction.

METHODS

This was a prospective observational cohort study in a single centre. All patients presenting with saphenous aneurysms close to the junction were included. Those with a venous aneurysm more distally, at >2 cm from the junction, or with associated deep venous aneurysms were excluded. Patients were treated with EVTA alone or combined with HL in cases of an aneurysm with a diameter >30 mm. Phlebectomies were performed during the same treatment session. Patients were followed up one and six weeks, and one year after treatment. Duplex ultrasound (DUS) was performed to evaluate occlusion of the vein and aneurysm as well as possible complications such as endovenous heat induced thrombosis (EHIT) or deep vein thrombosis (DVT). Venous clinical severity scores (VCSS) were registered before and one year after treatment.

RESULTS

Thirteen patients (15 limbs) were included between February 2012 and January 2015. Eleven limbs were treated with EVTA alone, the remaining four limbs with EVTA and HL. No severe adverse events occurred (no EHIT, no DVT). After one year none of the aneurysms was still visible on DUS and the truncal obliteration rate was 80% (two partial, one segmental recanalisation). Both treatment strategies showed significant improvement of the VCSS at the one year follow up, from a median score of 6 (interquartile range [IQR] 5-7) to 2 (IQR 1-3) (p = .001).

CONCLUSION

EVTA with or without HL appeared to be a safe and effective treatment for patients presenting with incompetent saphenous veins with an aneurysm close to the junction.

Outcome of ClosureFAST radiofrequency ablation for large-diameter incompetent great saphenous vein

Purpose

There is limited data on the outcomes of radiofrequency ablation (RFA) for large diameter saphenous veins. This study aimed to determine whether the large-diameter great saphenous vein (GSV) affected closure rate, complications, and clinical and quality of life (QoL) improvement.

Methods

From January 2012 to September 2016, a total of 722 limbs were treated with ClosureFAST RFA in a single center. Patients were divided into 2 groups according to the vein diameter measured 3 cm below the saphenofemoral junction (group A ≤ 12 mm, group B > 12 mm). Vein closure was evaluated with duplex scan at 3–5 days, 1, 3, 6, and 12 months postoperatively. The incidence of complications, improvements in symptoms (measured by the Venous Clinical Severity Score [VCSS]) and QoL (measured by the Aberdeen Varicose Vein Symptom Severity Score [AVSS]) were evaluated.

Results

Groups consisted of 663 GSVs in group A (mean diameter, 6.00 ± 1.74 mm) and 59 in group B (mean diameter, 13.17 ± 1.28 mm). Vein closure rates at 12 months were 98.9% in group A and 100% in group B (P = 0.428). There was no significant difference in the incidence of complications. Both groups showed marked improvements in the VCSS and the AVSS with no significant differences.

Conclusion

For large-diameter veins, RFA showed comparable outcomes in terms of closure rate, complications, clinical and QoL improvements.

Ultrasound-based topographic analysis of tributary vein connection with the saphenous vein during ambulatory conservative hemodynamic correction of chronic venous insufficiency

OBJECTIVE

Preoperative mapping of great saphenous vein (GSV) escape points to tributary veins (TVs) and targeted intervention of escape points may reduce recurrence rates of varicose veins (VVs) after endovascular treatment of saphenous veins and prevent saphenous nerve complications. The aim of this study was to perform an analysis of cartography after Doppler ultrasound mapping of escape points in patients with VVs and to suggest one point that may prevent recurrence and nerve complications.

METHODS

Ultrasound assessment of VVs was performed from March 4, 2016, to July 15, 2016, specifically focusing on the locations of escape points from the saphenous vein to TVs. The collected data were reviewed retrospectively. The topographic distribution of escape points was as follows: from inguinal ligament to midthigh; from midthigh to knee; from knee to midcalf; and from midcalf to heel.

RESULTS

Thirty patients (41 legs) with VVs underwent ultrasound examination. All VVs were characterized by reflux at the GSV. Topographic analysis revealed a total of 79 escape points in all patients. The most common location for escape points was the third part of the leg (from knee to midcalf), where 65.8% of escape points were located; 82.3% of all escape points were located below the knee. The mean diameter of the GSV at 3 cm and 15 cm from the saphenofemoral junction was 6.8 ± 1.6 cm and 5.5 ± 1.5 cm, respectively. Mean diameter of TVs was 5.1 ± 1.9 cm. The diameter was not significantly different between saphenous veins and TVs. The mean number of escape points in each leg was 1.9 ± 1.0.

CONCLUSIONS

Most escape points (65.8%) are located from knee to midcalf (third part of the leg), and 82.3% of all escape points are located below the knee. The diameter of TVs near the escape point is about 90% of that of the GSV. Thermal ablations of below-knee saphenous vein have potential nerve damage. Ablation of saphenous veins above the knee alone may result in residual shunting and formation of persistent reservoirs in TVs. These persistent reservoirs may be removed effectively with sclerotherapy or miniphlebectomy, especially trying to remove TVs near the escape point. Direct ligation of a TV near the escape point from the saphenous vein, just like saphenofemoral junction ligation, could be performed. These approaches may be able to prevent residual shunting and may reduce recurrence rates and nerve injury.

[Plaque features in saphenous vein graft evaluated by virtual histology intravascular ultrasound]

Objective: To investigate the features of plaques of saphenous venous graft (SVG) with virtual histology intravascular ultrasound (VH-IVUS) in patients underwent coronary artery bypass graft surgery. Methods: From March 2016 to March 2018, a total of 45 patients ((64.4±7.9) years old, 88.9% male (40 cases)) with ischemic symptoms after coronary artery bypass graft surgery and with coronary artery angiography evidenced SVG stenosis greater than or equal to 50%, who received percutaneous coronary intervention in Tianjin chest hospital were continuously included in this study, and the clinical data were retrospectively analyzed. VH-IVUS was performed before PCI to analyze plaque composition. The patients were divided into no smoking group (21 cases) and smoking group (24 cases), no diabetes group (30 cases) and diabetes group (15 cases), normal very low density lipoprotein cholesterin (VLDL-C) group (24 cases) and elevated VLDL-C group (21 cases), stable angina pectoris group (5 cases) and acute coronary syndrome group (40 cases), plaque burden (PB) < 70% group (11 cases) and PB ≥ 70% group (34 cases), without thin-cap fibroatheroma group (35 cases) and thin-cap fibroatheroma group (10 cases), and plaque features were compared between different groups. Results: The graft age was (8.9±3.7) years.The stenosis degree of SVG lesions was 90 (90, 98) %. The minimum lumen diameter was 1.6 (1.5, 1.8) mm. The vessel cross-sectional area was (12.1±4.0) mm(2). The plaque area was 8.6 (5.7,12.0) mm(2). The minimum lumen area was 2.5 (2.1,3.3) mm(2). The plaque burden was (75.3±8.3)%. The fibrotic tissue (FI) ratio was (65.1±10.1)%, fibrofatty plaque (FF) ratio was 13.8 (5.4,25.3) %, necrotic core tissue (NC) ratio was 12.0 (5.4,24.0)%, and dense calcium tissue (DC) ratio was1.0 (0.2,3.8)% in SVG lesions. There were no significant differences in SVG plaque area, FI area,FF area,NC area,and DC area between no smoking group and smoking group, no diabetes group and diabetes group, and normal VLDL-C group and elevated VLDL-C group. SVG plaque volume was significantly higher in acute coronary syndrome group than in stable angina pectoris group (262.2 (148.5,401.2) mm(3) vs. 93.1 (50.6,155.9) mm(3),P=0.006), and plaque area (10.1 (6.6,13.3) mm(2) vs. 5.0 (3.6,6.9) mm(2), P<0.001), FI area(4.8 (3.2,6.8) mm(2) vs. 2.8 (1.9,3.0) mm(2), P<0.001),and FF area (1.15 (0.60, 2.07) mm(2) vs. 0.30 (0.10,0.90) mm(2), P=0.009) were significantly larger in PB ≥ 70% group than in PB < 70% group.The NC area (1.75(0.40,2.78) mm(2) vs. 0.60 (0.20,1.30) mm(2), P=0.030) and DC area (0.35 (0.10,0.50) mm(2) vs. 0.00 (0.00,0.10) mm(2), P=0.006) were significantly larger in thin-cap fibroatheroma group than that in without thin-cap fibroatheroma group. Spearman correlation analysis showed that the plaque area of SVG lesion was positively correlated with FF area (r=0.64, P<0.001) and NC area (r=0.43, P=0.003). PB was positively correlated with FF area (r=0.50, P<0.001) and NC area (r=0.33, P=0.028). Graft age was positively correlated with FF area (r=0.30, P=0.047). Conclusions: The main components of SVG plaque are fibrotic tissue, conversely, calcified tissue is rare in patients with SVG stenosis after coronary artery bypass graft surgery. Fibrofatty tissue is increased in the plaque in patients with PB ≥ 70%. The necrotic component is also increased in patients with thin-cap fibroatheroma. The fibrofatty component increases and the plaque tends to be unstable in proportion with increaing age of the graft in this patient cohort.

Saphenous vein: advances

Although the saphenous vein (SV) is a widely used conduit for coronary artery bypass graft surgery (CABG), lower long-term graft patency rates and worse clinical outcomes have been reported after CABG performed with SV grafts compared with CABG performed with internal thoracic artery (ITA) grafts. Of various efforts to overcome the limitations of SV that are resulting from structural and functional differences from arterial conduit, recent improvement in harvesting techniques including no-touch technique, surgical strategy of using the SV as part of a composite graft over an aortocoronary bypass graft, and external stenting of the SV will be discussed in this topic.

The Effect of Saphenous Vein Ablation on Combined Segmental Popliteal Vein Reflux

Background

This study examined the role of superficial vein surgery in patients with combined superficial venous reflux and segmental popliteal vein reflux.

Methods

We retrospectively reviewed 42 limbs in 38 patients with combined superficial venous reflux and segmental popliteal vein reflux who underwent saphenous vein ablation between January 2014 and February 2017. Patients underwent outpatient follow-up duplex ultrasonography at 3, 6, and 12 months postoperatively. Resolution of deep vein reflux was defined as reversed blood flow in a popliteal segment for less than 1.0 second and a decrease in the reflux time of more than 20% of the preoperative reflux time.

Results

The mean follow-up period was 9 months (range, 3–23 months). Saphenous vein ablations were performed by stripping in 24 limbs and radiofrequency ablation in 18 limbs. Preoperative segmental popliteal vein reflux resolved in 21 of the 42 limbs (50%).

Conclusion

This study demonstrated that superficial venous surgery corrected segmental popliteal vein reflux in 50% of limbs with combined superficial venous reflux and segmental popliteal vein reflux. Other prospective studies are necessary to elucidate the etiology of the non-reversible cases.

Foam sclerotherapy for lower-limb varicose veins: impact on saphenous vein diameter

Objective

To assess changes in the great saphenous vein (GSV) after foam sclerotherapy for varicose veins.

Materials and Methods

This was a prospective study of 33 patients who were treated with polidocanol foam sclerotherapy after having had varicose veins with a clinical severity-etiology-anatomy-pathophysiology classification of C4-C6 for three months. The patients were evaluated by ultrasound before, during, and after the procedure (on post-procedure days 7, 15, 30, 60, and 90). The GSV diameter, the rate of venous occlusion, and the rate of reflux elimination were determined. Two patients were excluded for having a history of deep vein thrombosis history, and one was excluded for having bronchial asthma.

Results

Thirty patients (26 females and 4 males, with mean age of 62 years) completed the protocol. The mean pre-procedure GSV diameter was 6.0 ± 0.32 mm (range, 3.6-11.2 mm). During the sclerotherapy, the mean GSV diameter was reduced to 1.9 ± 0.15 mm (range, 0.6-3.8 mm). On post-procedure day 7, the mean GSV diameter increased to 6.3 ± 0.28 mm (range, 3.9-9.7 mm). On post-procedure day 90, the mean GSV diameter was 4.0 ± 0.22 mm (range, 1.9-8.2 mm). The rate of GSV reflux was significantly lower in the assessment performed on post-procedure day 90 than in the pre-procedure assessment (p < 0.0028).

Conclusion

On the basis of our ultrasound analysis, we can conclude that foam sclerotherapy for varicose veins results in a significant reduction in GSV diameter, as well as in the elimination of GSV reflux.

Anti-phosphorylcholine IgM, an Anti-inflammatory Mediator, Predicts Peripheral Vein Graft Failure: A Prospective Observational Study

OBJECTIVES

One third of infrainguinal vein bypasses may fail within the first 1.5 years. Pro- and anti-inflammatory mechanisms are thought to be involved in these graft stenoses and occlusions. In previous studies, low levels of anti-phosphorylcholine IgM (anti-PC IgM, an innate anti-inflammatory IgM) have been associated with increased cardiovascular events. In this study, the peri-operative dynamics of anti-PC IgM levels were established during leg bypass surgery, and associations assessed between anti-PC IgM levels and primary graft patency.

DESIGN AND METHODS

This was a prospective, observational cohort study of infrainguinal autogenous vein bypass for peripheral arterial occlusive disease involving four university affiliated hospitals. Plasma cytokine and anti-PC IgM levels were measured pre- and post-operatively. The outcome of interest was loss of primary graft patency because of occlusion or intervention for graft stenosis.

RESULTS

One hundred and forty-two consecutive patients were enrolled: mean age 66 (46-91); 91% white race and male; 72.5% critical limb ischaemia (Fontaine III or IV). Median pre-operative anti-PC IgM levels were 49 units/mL (IQR 32.3-107.7, mean 89.8 + 101 sd). During follow up of an average of 1.8 years (1 month-7.4 years), 50 (35.2%) grafts lost primary patency. Pre-operative levels of interleukin 6 or C-reactive protein did not predict graft failure. Patients with pre-operative anti-PC IgM values in the lowest quartile had a twofold increased risk of graft failure (multivariable Cox proportional hazard, p = .03, HR 2.11, 95% CI 1.09-4.07), even after accounting for the other significant factors of conduit diameter, distal anastomosis, smoking, and the severity of leg ischaemia.

CONCLUSIONS

Low levels of anti-PC IgM are associated with vein bypass graft failure. This biological mediator may be a useful marker to identify patients at higher risk, and offers the potential for novel, directed therapies for vascular inflammation and its consequences.

Vasa vasorum inside out/outside in communication: a potential role in the patency of saphenous vein coronary artery bypass grafts

The saphenous vein (SV) is the most commonly used conduit for revascularization in patients undergoing coronary artery bypass surgery (CABG). The patency rate of this vessel is inferior to the internal thoracic artery (ITA). In the majority of CABG procedures the ITA is removed with its outer pedicle intact whereas the (human) SV (hSV) is harvested with pedicle removed. The vasa vasorum, a microvessel network providing the adventitia and media with oxygen and nutrients, is more pronounced and penetrates deeper towards the lumen in veins than in arteries. When prepared in conventional CABG the vascular trauma caused when removing the hSV pedicle damages the vasa vasorum, a situation affecting transmural flow potentially impacting on graft performance. In patients, where the hSV is harvested with pedicle intact, the vasa vasorum is preserved and transmural blood flow restored at graft insertion and completion of CABG. By maintaining blood supply to the hSV wall, apart from oxygen and nutrients, the vasa vasorum may also transport factors potentially beneficial to graft performance. Studies, using either corrosion casts or India ink, have shown the course of vasa vasorum in animal SV as well as in hSV. In addition, there is some evidence that vasa vasorum of hSV terminate in the vessel lumen based on ex vivo perfusion, histological and ultrastructural studies. This review describes the preparation of the hSV as a bypass conduit in CABG and its performance compared with the ITA as well as how and why its patency might be improved by harvesting with minimal trauma in a way that preserves an intact vasa vasorum.

Clinical factors that influence the cellular responses of saphenous veins used for arterial bypass

OBJECTIVE

When an autogenous vein is harvested and used for arterial bypass, it suffers physical and biologic injuries that may set in motion the cellular processes that lead to wall thickening, fibrosis, stenosis, and ultimately graft failure. Whereas the injurious effects of surgical preparation of the vein conduit have been extensively studied, little is known about the influence of the clinical environment of the donor leg from which the vein is obtained.

METHODS

We studied the cellular responses of fresh saphenous vein samples obtained before implantation in 46 patients undergoing elective lower extremity bypass surgery. Using an ex vivo model of response to injury, we quantified the outgrowth of cells from explants of the adventitial and medial layers of the vein. We correlated this cellular outgrowth with the clinical characteristics of the patients, including the Wound, Ischemia, and foot Infection classification of the donor leg for ischemia, wounds, and infection as well as smoking and diabetes.

RESULTS

Cellular outgrowth was significantly faster and more robust from the adventitial layer than from the medial layer. The factors of leg ischemia (P < .001), smoking (P = .042), and leg infection (P = .045) were associated with impaired overall outgrowth from the adventitial tissue on multivariable analysis. Only ischemia (P = .046) was associated with impaired outgrowth of smooth muscle cells (SMCs) from the medial tissue. Co-culture of adventitial cells and SMCs propagated from vein explants revealed that adventitial cells significantly inhibited the growth of SMCs, whereas SMCs promoted the growth of adventitial cells. The AA genotype of the -838C>A p27 polymorphism (previously associated with superior graft patency) enhanced these effects, whereas the factor of smoking attenuated adventitial cell inhibition of SMC growth. Comparing gene expression, the cells cultured from the media overexpress Kyoto Encyclopedia of Genes and Genomes pathways associated with inflammation and infection, whereas those from the adventitia overexpress gene families associated with development and stem/progenitor cell maintenance.

CONCLUSIONS

The adverse clinical environment of the leg may influence the biologic behavior of the cells in the vein wall, especially the adventitial cells. Chronic ischemia was the most significant factor that retards adventitial cell outgrowth. The cells arising from the vein adventitia may be key players in determining a healthy adaptive or a pathologic response to the injuries associated with vein grafting.

Vasa vasorum of the failed aorto-coronary venous grafts

PURPOSE

This study was designed to investigate the distribution of vasa vasorum in walls of failed aorto-coronary venous grafts.

METHODS

Fifty-one diseased venous grafts harvested from 39 patients underwent qualitative histological evaluation. The morphology of the grade of the pathological changes and the extent of the vascularisation were examined, and related to the length of the interval between the primary surgery and the explantation. The obtained results were placed into five groups, substantially differing one from the other in morphology and vascularisation.

RESULTS

The intervals between grafts implantation and explantation ranged from 1 day to 35 years. The onset of arterialization of the graft media was observed on average at 1 month after bypass implantation. During this same time period massive intimal hyperplasia and atherosclerosis occurred. Vasa vasorum proliferation from the adventitia to the outer layers of the media was first apparent between 7 and 24 months after implantation. Proliferation of the vasa vasorum throughout the entire atherosclerotic media and hyperplastic intima continued for a much longer time interval.

CONCLUSION

No correlation between neoangiogenesis and age, sex or type of bypassed coronary branch was proven. Regarding the given findings, the authors believe that changes in hemodynamic conditions and endothelial trauma are primarily responsible for the development of graft disease and that vasa vasorum proliferation is only a secondary reaction to the structural changes of the graft wall. To what extent the frequently present pre-existing intimal hyperplasia of venous bypass grafts play in the development of graft disease remains questionable.

Thrombus removal prior to recanalization in vein graft occlusion intervention

A saphenous vein graft chronic total occlusion intervention is uncommonly performed, partly due to the high risk of distal embolization. We described a strategy in which after successful wiring of a saphenous vein graft chronic total occlusion, balloon dilatation was performed to create a blind sac within the lesion, followed by aspiration thrombectomy to remove all the dislodged debris. Thereafter, balloon dilatation and stenting were safely performed in the distal occluded segment, to achieve complete recanalization.

Ten-year real-life effectiveness of coronary artery bypass using radial artery or great saphenous vein grafts in a single centre Chinese hospital

OBJECTIVES

Long-term effectiveness of coronary artery bypass grafting using radial artery (RA) or great saphenous vein (SVG) grafts as a second conduit was compared.

METHODS

Patients received simple elective off-pump coronary artery bypass involving both the left internal thoracic artery (LITA) and the left anterior descending artery between January 1999 and December 2005 at Ruijin Hospital, Shanghai Jiaotong University School of Medicine, China. RA graft patients (n = 147 LITA + RA and n = 61 LITA + RA + SVG) were matched with SVG graft patients (n = 208 LITA + SVG). Mean follow-up was 86.5 months.

RESULTS

Baseline characteristics were comparable before and after surgery. Intraoperative hospital mortality was not significantly different. In all, 378 (90.9%) patients completed postoperative follow-up (197 in the RA and 181 in SVG). Overall survival was significantly better in the RA group (Log-rank, P = 0.017) with 88% 10-year survival in the RA group and 81% in the SVG group. All-cause mortality was significantly lower in the RA group (hazard ratio 0.42, 95% confidence interval 0.20-0.88, P = 0.020). Major adverse cardiovascular event-free survival was significantly better in the RA group than in the SVG group (Log-rank, P = 0.019). No significant difference in the length of postoperative angina relief was found.

CONCLUSIONS

Using the RA as the secondary graft for coronary artery bypass grafting improved long-term postoperative survival and reduced the incidence of postoperative major adverse cardiovascular events.

Comparing the Effects of Krebs Plus Verapamil Solution on Endothelial Function of Harvested Human Greater Saphenous Vein with Heparinized Blood, an Invitro Study

INTRODUCTION

Integrity of the great saphenous vein (GSV) endothelium is the most important key element for long-term patency rate of grafts in coronary artery bypass graft (CABG). Storage solutions play an important role in maintaining viability of vein endothelium. Diminished nitric oxide (NO) because of endothelial dysfunction may facilitate vascular inflammation and formation of atherosclerotic plaque.

AIM

So, we decided to find a reasonable alternative preservative solution instead of heparinized blood (HB) by measuring NO concentration with Griess assay.

MATERIAL AND METHOD

SVG samples were obtained from 54 patients undergoing elective CABG. 3 mm rings were stored in solutions: heparinized blood (HB), Krebs (K), Krebs + Propranolol (K+P) 6.66 g/l, Krebs + Adrenaline (K+A) 200 µl/l, and Krebs + Verapamil (K+V) 200 µl/l for 30, 45, 60 and 90 min. Nitrite concentration was measured by Griess assay at 540 nm. H&E staining was performed for histologic test. Statistical analysis was performed using SPSS (V16). Results were expressed as (Means ± SE) followed by One-Way ANOVA for finding best preservative solution. Repeated measurement test was used to investigate best time. In all analysis, (P<0.05) was considered significant.

RESULTS

Average concentration of NO in (K+V) compare with HB (1st control), K (2nd control), (K+A) and (K+P) showed higher rate in all times from 30 to 90 min (16.55±1.85:) and in (K+A, K+P) compare with (HB) and (K) there was no statistically significant difference in the same times. Comparing the average concentration of (NO) between (HB) and (K) showed no significant difference (K+V>HB=K=K+A=K+P). Also, our investigations showed that NO concentration in (K+V) has the highest rate in time 90 min (10.07±0.56, p=0.002):. More than 50 percent of endothelial cells stay normal in (K+V) compare with other solutions.

CONCLUSION

It seems that (K+V) is the best solution for the maintenance of normal physiology of SVGs endothelial cells. The most appropriate SVGs endothelial function is within 90 minutes after harvesting.

Preoperative factors predicting saphenous vein graft occlusion in coronary artery bypass grafting: a multivariate analysis

Saphenous vein segments are frequently used as aortocoronary bypass grafts, particularly in patients over 65 years of age. In the majority of patients, venous grafts maintain their patency for 5–6 years; however, some become occluded within 12 months after surgery. There are some defined predictive biological factors used to assess saphenous vein graft long-term patency rates, but little is known about molecular parameters for estimating the risk of early vein occlusion. The pathogenesis of this process involves the proliferation of stem cells, as well as progenitor cells, in the graft wall. Histologically, this is reflected by CD34 and CD133 expression in endothelial and smooth muscle cells. Thus, the aim of present work was to perform a multivariate analysis of stem cell and progenitor cell markers in saphenous vein graft walls before transplantation to arterial circulation and correlate these results with early graft occlusion. A total of 718 patients, who underwent coronary artery bypass grafting using a saphenous vein graft, were enrolled in this prospective study. CD34, CD133 and von Willebrand factor expression was evaluated via immunohistochemistry. A multivariate analysis revealed that strong CD133 expression in smooth muscle cells can be considered a risk factor for early graft failure. Our findings suggest that CD133 expression in smooth muscle cells of the tunica media in saphenous vein grafts obtained from coronary artery bypass graft patients before graft transplantation to coronary circulation might predict the possibility of early graft occlusion.

Bedside Vein Mapping for Conduit Size in Coronary Artery Bypass Surgery

Background and Objectives:

The greater saphenous vein has been used in coronary artery bypass grafting (CABG) for more than 50 years. Endoscopic vein harvesting has greatly reduced the morbidity associated with obtaining the vein, but the quality of the vein could not be assessed before its was exposed surgically or after the endoscopic procedure had been performed. This study was conducted to evaluate the accuracy of preoperative mapping of the greater saphenous vein at the bedside in assessing suitable conduit size for use in CABG.

Methods:

Seventy-two consecutive patients undergoing saphenous vein harvesting for use as a conduit during CABG underwent preoperative ultrasonographic vein mapping on the operating table after the leg was positioned for vein harvesting. Vein diameters at 3 distinct locations were measured by ultrasonography after vein harvesting and preparation. Similar linear regression was used to determine the correlation between measurements by ultrasonography and the true vein size after harvesting. Standard methods of computing 95% lower and upper confidence limits for single predicted values were also used.

Results:

Two hundred twenty measurements were obtained from 72 patients. Mean vein diameters were 3.4 ± 0.9 and 4.6 ± 0.9 mm as measured by ultrasonography and after vein harvest, respectively. True vein size was an average of 1.2 ± 0.4 mm larger than that measured by ultrasonography. Ultrasonographic determination of vein diameters closely correlated with the true vein diameter (correlation coefficient, 0.91; P < .001), and the measurement obtained predicted the true measurement within 1.6 mm with 95% confidence.

Conclusion:

Bedside ultrasonographic vein mapping provides an accurate noninvasive method for preoperative assessment to determine the suitability of the greater saphenous vein for use as a bypass conduit. It is therefore an important component of preoperative planning before CABG.

Rare Vascular Anomalies in the Femoral Triangle During Varicose Vein Surgery

Background

We observed several cases of rare vascular anomalies within the femoral triangle during varicose vein operations.

Methods

From among 2,093 patients who underwent stripping operations of the great saphenous vein between January 2002 and June 2016, 14 cases of rare vascular anomalies were enrolled in this study.

Results

Twelve cases of femoral artery and vein transposition (0.57%), 1 case of separate entrance of the great saphenous vein trunk and its tributaries (0.05%), and 1 case of separate entrance with femoral artery and vein transposition (0.05%) were observed. The preoperative diagnosis rate was 71% (10 of 14) using duplex ultrasound. In all cases of femoral artery and vein transposition, the saphenofemoral junction was located at the lateral or posterolateral side of the superficial femoral artery, corresponding to complete or incomplete transposition, respectively. Among the 12 cases of femoral artery and vein transposition, 5 cases were complete transposition and 7 cases were incomplete transposition. In 2 cases of separate entrance of the great saphenous vein trunk and its tributaries, the separated tributaries formed a common trunk before connecting to the femoral vein.

Conclusion

The anatomy of the saphenofemoral junction may infrequently be altered in some individuals. Detailed preoperative sonographic examinations and meticulous groin dissection during the operation are necessary to prepare for unexpected anatomical variations.

Efficacy of Preoperative Color Doppler Sonography of Lower Extremity Veins on Postoperative Outcomes in Candidates of Saphenectomy: A Randomized Clinical Trial

BACKGROUND

Doppler sonography is a type of sonography used for imaging the blood flow in the vessels and heart. This technique uses ultrasound waves with high frequency. In some patient candidates for venous graft, the identification of the suitable vein is not possible with clinical examination.

OBJECTIVE

This study compared the effects of preoperative color Doppler sonography of lower extremity veins on the postoperative outcomes of saphenectomy.

METHODS

This randomized clinical trial was conducted on 100 candidates of an off-pump coronary artery bypass graft (CABG) hospitalized in Afshar Hospital in Yazd in 2015. Patients were divided into two groups: 50 patients in the study group and 50 patients in the control group. Patients in the study group underwent color Doppler sonography of lower extremity veins using the Medison 8000 Live device. Patients in the control group were assessed preoperatively by routine venous examination without undergoing color Doppler sonography. The prepping and draping methods and also the preoperative antibiotics were the same for both groups. The patients were assessed for wound infection, edema, hematoma, and DVT 2 days, 1 week, and 1 month after surgery. Data were analyzed by SPSS version 16 using t-test, Chi-square, and Fisher's exact test.

RESULTS

The length of incision for saphenectomy was 29.20 ± 3.71 cm in the Doppler group and 28.98 ± 3.72 cm in the non-Doppler group with no significant difference between the two groups (p=0.768). The two groups were not significantly different with respect to age, gender, diabetes, hypertension, hyperlipidemia, smoking, and history of peripheral vessels disease, postoperative infection, postoperative organ edema, postoperative hematoma, and postoperative DVT.

CONCLUSION

Preoperative color Doppler sonography of the saphenous vein before saphenectomy has no effect on reducing the postoperative complications, and saphenectomy on the basis of intraoperative examination of the vein course by the surgeon has acceptable consequences.

CLINICAL TRIAL REGISTRATION

The trial was registered at the Thai Clinical Trials Registry (TCTR) (http://www.clinicaltrials.in.th) with the TCTR ID: TCTR20160708001.

FUNDING

The authors received no financial support for the research, authorship, and/or publication of this article.

Levels of l-ascorbic acid and cadmium in the saphenous vein of patients with coronary artery disease are negatively correlated

BACKGROUND

The aim of this study was the simultaneous determination of levels of cadmium and l-ascorbic Acid (AA) in human saphenous vein (SV) used in coronary artery bypass grafting (CABG) and check whether there is a relationship between these levels.

METHODS

Human SV were collected from 40 patients (20 men and 20 women; age, 40-75 years) at the time of routine coronary artery surgical revascularization. The concentration of cadmium in the tissue was determined according to the GF AAS-atomic absorption method. The concentration of AA was assayed in supernatant by FIA method with spectrophotometric detection.

RESULTS

AA concentration (mean±SD); men: 98,7±13,18μg/g tissue, women: 96,06±11,98μg/g tissue. Cadmium concentration(mean±SD); men: 309±103,71ng/g tissue, women: 348,5±255,71ng/g tissue. Correlations among concentrations of AA and cadmium were insignificant negative in the group of men (Pearson r=-0,1504, p=0,5269) and in the group women (Pearson r=-0339, p=0144).

CONCLUSIONS

Negative correlations among concentrations of AA and cadmium in human SV obtained in our study may indicate a protective effect of this vitamin in relation to toxic cadmium.

A comprehensive review on learning curve associated problems in endoscopic vein harvesting and the requirement for a standardised training programme

Endoscopic vein harvesting is becoming one of the most favourable vein harvesting techniques in multiple bypass coronary surgery, due to its short term post-operative benefits with high patient satisfaction. However, long-term graft patency has been both supported and questioned in the literature. Graft failure can be affected by harvesting methods and operator's experience. Endoscopic vein harvesting is associated with a learning curve period, during which the incidence of vein trauma is high due to unfamiliarity with the surgical technique. There is a paucity of structured learning tools for novice practitioners, meaning that training differs significantly between hospital centres. Inconsistent training methods can lead to poor surgical technique, which can have a significant impact on vein quality and stress level of the practitioner. In turn, this can lead to increased postoperative complications and longer surgical duration. The main aim of this literature review is to understand the impact of the learning curve on the vein conduit and whether there is a requirement for a standardised training programme for the novice practitioners.

A randomised controlled trial of mini incision or conventional incision for saphenous vein harvesting in patients undergoing myocardial revascularization

OBJECTIVE

Compare the evolution regarding the complications concerning two types of incision (conventional × mini-incision), for saphenectomy in patients that go under myocardial revascularization or otherwise known as coronary artery bypass surgery.

METHODS

In January 2012 to August 2013, 66 patients were prospectively selected for coronary artery bypass with cardiopulmonary bypass surgery. These were divided into two groups: Conventional and Mini-Incision, with 33 patients in each group chosen in a random fashion and with knowledge of which technique to be used being presented only at the start of the surgery. In the conventional group, the patients received an incision to the lower member of 7-10 cm. The patients in the Mini-Incision group received an incision to the lower member of 3-4 cm, both performed without the use of any special material.

RESULTS

The groups were similar in terms of clinical data and in the preoperative period. Males made up a greater part of the group with 63.7% and 81.9% in groups C and M, respectively. Among the complications analysed, edema (p = 0.011), hematoma (p = 0.020), dehiscence (p = 0.012) and infection (p = 0.012), were significantly greater in group C when compared to group M. When the matter comes to the variable in relation to the risk of Surgical Site Infections (SSI), no difference was found between the groups.

CONCLUSION

Coronary artery bypass surgery with mini-incision for saphenectomy, demonstrated a lower rate for preoperative complications when compared to saphenectomy under conventional incision procedures.

Angiotensin II, as well as 5-hydroxytriptamine, is a potent vasospasm inducer of saphenous vein graft for coronary artery bypass grafting in patients with diabetes mellitus

Diabetes mellitus (DM) is an important risk factor for adverse outcomes of coronary artery bypass grafting. The bypass grafts harvested from patients with DM tend to go into spasm after their implantation into the coronary circulation. To clarify the contribution of 5-hydroxytriptamine (5-HT) and angiotensin II (AngII) in the bypass graft spasm, we examined the contractile reactivity to 5-HT or AngII of isolated human endothelium-denuded saphenous vein (SV) harvested from DM and non-DM patients. The 5-HT-induced constriction of the SV was significantly augmented in the DM group than in the non-DM group, which is similar to our previous report. AngII-induced constriction of the SV was also significantly augmented in the DM group than the non-DM group. Especially in the non-DM group, the AngII-induced maximal vasoconstriction was markedly lower than the 5-HT-induced one. Meanwhile, the increasing rates of AngII-induced vasoconstriction in the DM group to the non-DM group were significantly greater than those of 5-HT-induced vasoconstriction. These results indicate that 5-HT is a potent inducer of SV graft spasm in both DM and non-DM patients, while AngII is a potent inducer of SV graft spasm only in patients with DM. Furthermore, the protein level of AngII AT₁ receptor (AT₁R), but not the protein level of 5-HT_2A receptor, in the membrane fraction of the SV smooth muscle cells of DM patients was significantly increased as compared with that of the non-DM patients. These results suggest that the mechanism for hyperreactivity to AngII in the SV from DM patients is due to, at least in part, the increase in the amount of AT₁R on membrane of the SV smooth muscle cells.

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The vasoconstrictive reactivity to 5-HT was significantly enhanced in the DM.

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The vasoconstrictive reactivity to AngII was significantly enhanced in the DM.

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In DM patients, the hyperreactivity to AngII was significantly higher than that to 5-HT.

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The protein level AT₁ R in membrane fraction of saphenous vein smooth muscle was significantly increased in the DM.

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AngII could be a potent inducer of SV graft spasm only in DM patients.

Original approach for thrombolytic therapy in patients with Ilio-femoral deep vein thrombosis : 2 years follow-up

Objective

The aim of the study was to discuss the results of catheter-directed thrombolysis and complementary procedures to treat acute iliofemoral deep vein thrombosis (DVT) evaluating the safety and effectivness of an easy access such as the Great Saphenous Vein.

Methods and materials

A total of 22 consecutive patients with iliofemoral thrombosis and two patients with femoro-popliteal thrombosis on recent onset diagnosed with Ultrasound Doppler and contrast venography underwent intrathrombus drip infusion of urokinase while intravenous heparin was continued using saphenical access. Residual venous stenosis were treated in six patients by percutaneous balloon Angioplasty and stenting. All patients underwent routine venous duplex imaging at 30 days, 3 months, 6 months and every 6 months thereafter.

Results

Complete patency of thrombosed veins was restored in 22 patients (91 %) with prompt symptomatic relief. There were no major complications in the immediate outcomes. At follow-up, two patients reported a persistant slim iliac vein stenosis, two patients had post-thrombotic syndrome, and two patients showed Deep Vein Reflux.

Conclusion

Local thrombolysis using saphenical access was a safe and effective approach for the treatment of acute iliofemoral deep vein thrombosis. It seems to be a valid, easy and safe alternative, reducing the risks of haematoma and venous lesions, which can be observed when using femoral, popliteal, and trans-jugular access.