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Chlupac J, Frank J, Sedmera D, Fabian O, Simunkova Z, Mrazova I, Novak T, Vanourková Z, Benada O, Pulda Z, Adla T, Kveton M, Lodererova A, Voska L, Pirk J, Fronek J. External Support of Autologous Internal Jugular Vein Grafts with FRAME Mesh in a Porcine Carotid Artery Model. Biomedicines 2024; 12:1335. [PMID: 38927542 PMCID: PMC11201386 DOI: 10.3390/biomedicines12061335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 05/28/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Autologous vein grafts are widely used for bypass procedures in cardiovascular surgery. However, these grafts are susceptible to failure due to vein graft disease. Our study aimed to evaluate the impact of the latest-generation FRAME external support on vein graft remodeling in a preclinical model. METHODS We performed autologous internal jugular vein interposition grafting in porcine carotid arteries for one month. Four grafts were supported with a FRAME mesh, while seven unsupported grafts served as controls. The conduits were examined through flowmetry, angiography, macroscopy, and microscopy. RESULTS The one-month patency rate of FRAME-supported grafts was 100% (4/4), whereas that of unsupported controls was 43% (3/7, Log-rank p = 0.071). On explant angiography, FRAME grafts exhibited significantly more areas with no or mild stenosis (9/12) compared to control grafts (3/21, p = 0.0009). Blood flow at explantation was higher in the FRAME grafts (145 ± 51 mL/min) than in the controls (46 ± 85 mL/min, p = 0.066). Area and thickness of neo-intimal hyperplasia (NIH) at proximal anastomoses were similar for the FRAME and the control groups: 5.79 ± 1.38 versus 6.94 ± 1.10 mm2, respectively (p = 0.558) and 480 ± 95 vs. 587 ± 52 μm2/μm, respectively (p = 0.401). However, in the midgraft portions, the NIH area and thickness were significantly lower in the FRAME group than in the control group: 3.73 ± 0.64 vs. 6.27 ± 0.64 mm2, respectively (p = 0.022) and 258 ± 49 vs. 518 ± 36 μm2/μm, respectively (p = 0.0002). CONCLUSIONS In our porcine model, the external mesh FRAME improved the patency of vein-to-carotid artery grafts and protected them from stenosis, particularly in the mid regions. The midgraft neo-intimal hyperplasia was two-fold thinner in the meshed grafts than in the controls.
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Affiliation(s)
- Jaroslav Chlupac
- Transplantation Surgery Department, Institute for Clinical and Experimental Medicine (IKEM), Videnska 1958/9, 140 21 Prague, Czech Republic; (J.F.); (T.N.); (J.F.)
- Department of Anatomy, Second Faculty of Medicine, Charles University, V Uvalu 84, 150 06 Prague, Czech Republic
| | - Jan Frank
- Transplantation Surgery Department, Institute for Clinical and Experimental Medicine (IKEM), Videnska 1958/9, 140 21 Prague, Czech Republic; (J.F.); (T.N.); (J.F.)
| | - David Sedmera
- Institute of Anatomy, First Faculty of Medicine, Charles University, U Nemocnice 3, Praha 2, 128 00 Prague, Czech Republic;
| | - Ondrej Fabian
- Clinical and Transplant Pathology Centre, Institute for Clinical and Experimental Medicine (IKEM), Videnska 1958/9, 140 21 Prague, Czech Republic; (O.F.); (M.K.); (A.L.); (L.V.)
- Department of Pathology and Molecular Medicine, Third Faculty of Medicine, Charles University, and Thomayer University Hospital, Ruska 87, 100 00 Prague, Czech Republic
| | - Zuzana Simunkova
- Experimental Medicine Centre, Institute for Clinical and Experimental Medicine (IKEM), Videnska 1958/9, 140 21 Prague, Czech Republic; (Z.S.); (I.M.); (Z.V.)
| | - Iveta Mrazova
- Experimental Medicine Centre, Institute for Clinical and Experimental Medicine (IKEM), Videnska 1958/9, 140 21 Prague, Czech Republic; (Z.S.); (I.M.); (Z.V.)
| | - Tomas Novak
- Transplantation Surgery Department, Institute for Clinical and Experimental Medicine (IKEM), Videnska 1958/9, 140 21 Prague, Czech Republic; (J.F.); (T.N.); (J.F.)
| | - Zdenka Vanourková
- Experimental Medicine Centre, Institute for Clinical and Experimental Medicine (IKEM), Videnska 1958/9, 140 21 Prague, Czech Republic; (Z.S.); (I.M.); (Z.V.)
| | - Oldrich Benada
- Laboratory of Molecular Structure Characterization, Institute of Microbiology of the Czech Academy of Sciences, Vídeňská 1083, 142 00 Prague, Czech Republic;
| | - Zdenek Pulda
- Department of Imaging Methods, Institute for Clinical and Experimental Medicine (IKEM), Videnska 1958/9, 140 21 Prague, Czech Republic; (Z.P.); (T.A.)
| | - Theodor Adla
- Department of Imaging Methods, Institute for Clinical and Experimental Medicine (IKEM), Videnska 1958/9, 140 21 Prague, Czech Republic; (Z.P.); (T.A.)
| | - Martin Kveton
- Clinical and Transplant Pathology Centre, Institute for Clinical and Experimental Medicine (IKEM), Videnska 1958/9, 140 21 Prague, Czech Republic; (O.F.); (M.K.); (A.L.); (L.V.)
- Third Faculty of Medicine, Charles University, Ruska 87, 100 00 Prague, Czech Republic
| | - Alena Lodererova
- Clinical and Transplant Pathology Centre, Institute for Clinical and Experimental Medicine (IKEM), Videnska 1958/9, 140 21 Prague, Czech Republic; (O.F.); (M.K.); (A.L.); (L.V.)
| | - Ludek Voska
- Clinical and Transplant Pathology Centre, Institute for Clinical and Experimental Medicine (IKEM), Videnska 1958/9, 140 21 Prague, Czech Republic; (O.F.); (M.K.); (A.L.); (L.V.)
| | - Jan Pirk
- Cardiovascular Surgery Department, Institute for Clinical and Experimental Medicine (IKEM), Videnska 1958/9, 140 21 Prague, Czech Republic;
| | - Jiri Fronek
- Transplantation Surgery Department, Institute for Clinical and Experimental Medicine (IKEM), Videnska 1958/9, 140 21 Prague, Czech Republic; (J.F.); (T.N.); (J.F.)
- Department of Anatomy, Second Faculty of Medicine, Charles University, V Uvalu 84, 150 06 Prague, Czech Republic
- First Surgical Clinic, First Faculty of Medicine, Charles University, U Nemocnice 499/2, 128 08 Prague, Czech Republic
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Gemelli M, Addonizio M, Geatti V, Gallo M, Dixon LK, Slaughter MS, Gerosa G. Techniques and Technologies to Improve Vein Graft Patency in Coronary Surgery. Med Sci (Basel) 2024; 12:6. [PMID: 38249082 PMCID: PMC10801616 DOI: 10.3390/medsci12010006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/22/2023] [Accepted: 01/05/2024] [Indexed: 01/23/2024] Open
Abstract
Vein grafts are the most used conduits in coronary artery bypass grafting (CABG), even though many studies have suggested their lower patency compared to arterial alternatives. We have reviewed the techniques and technologies that have been investigated over the years with the aim of improving the quality of these conduits. We found that preoperative and postoperative optimal medical therapy and no-touch harvesting techniques have the strongest evidence for optimizing vein graft patency. On the other hand, the use of venous external support, endoscopic harvesting, vein preservation solution and anastomosis, and graft configuration need further investigation. We have also analyzed strategies to treat vein graft failure: when feasible, re-doing the CABG and native vessel primary coronary intervention (PCI) are the best options, followed by percutaneous procedures targeting the failed grafts.
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Affiliation(s)
- Marco Gemelli
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35128 Padova, Italy; (M.A.); (V.G.); (G.G.)
| | - Mariangela Addonizio
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35128 Padova, Italy; (M.A.); (V.G.); (G.G.)
| | - Veronica Geatti
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35128 Padova, Italy; (M.A.); (V.G.); (G.G.)
| | - Michele Gallo
- Department of Cardiothoracic Surgery, University of Louisville, Louisville, KY 40292, USA; (M.G.); (M.S.S.)
| | - Lauren K. Dixon
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London WC2A 3PE, UK;
| | - Mark S. Slaughter
- Department of Cardiothoracic Surgery, University of Louisville, Louisville, KY 40292, USA; (M.G.); (M.S.S.)
| | - Gino Gerosa
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35128 Padova, Italy; (M.A.); (V.G.); (G.G.)
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Gemelli M, Gallo M, Addonizio M, Pahwa S, Van den Eynde J, Trivedi J, Slaughter MS, Gerosa G. Venous External Support in Coronary Artery Bypass Surgery: A Systematic Review and Meta-Analysis. Curr Probl Cardiol 2023; 48:101687. [PMID: 36931334 DOI: 10.1016/j.cpcardiol.2023.101687] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 03/02/2023] [Indexed: 03/17/2023]
Abstract
OBJECTIVES Neointimal hyperplasia and lumen irregularities are major contributors to vein graft failure and the use of VEST(R) should prevent this. In this review, we aim to evaluate the angiographic outcomes of externally supported vein grafts. METHODS Medline, Embase and Cochrane Library were systematically reviewed for randomized clinical trials published by August 2022. The primary outcome was graft failure. Secondary outcomes included graft ectasia, intimal hyperplasia area and thickness, and graft non-uniformity. Odds ratios (OR) for dichotomous variables and mean difference (MD) for continuous variables with 95% confidence intervals (CI) were pooled using a fixed-effects model. RESULTS Three randomized controlled trials with a total of 437 patients were included with follow-up ranging from 1 to 2 years. The odds of graft failure were similar in the two groups (OR 1.22; 95%CI 0.88 to 1.71; I²=0%). Intimal hyperplasia area [MD -0.77 mm2; 95%CI -1.10 to -0.45; I2=0%] and thickness [MD -0.06 mm; 95%CI -0.08 to -0.04; I2=0%] were significantly lower in the VEST group. Fitzgibbon Patency Scale of II or III (representing angiographic conduit non-uniformity; OR 0.67; 95%CI 0.48 to 0.94; I2=0%) and graft ectasia (OR 0.53; 95%CI 0.32 to 0.88; I2=33%) were also significantly lower in the VEST group. CONCLUSIONS At short-term follow-up, VEST does not seem to reduce the incidence of graft failure, although it is associated with attenuation of intimal hyperplasia and non-uniformity. Longer angiographic follow-up is warranted to determine whether these positive effects might translate into a positive effect in graft failure and in long-term clinical outcomes.
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Affiliation(s)
- Marco Gemelli
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy
| | - Michele Gallo
- Department of Cardiothoracic Surgery, University of Louisville, Louisville, Kentucky, USA.
| | - Mariangela Addonizio
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy
| | - Siddharth Pahwa
- Department of Cardiothoracic Surgery, University of Louisville, Louisville, Kentucky, USA
| | | | - Jaimin Trivedi
- Department of Cardiothoracic Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Mark S Slaughter
- Department of Cardiothoracic Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Gino Gerosa
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy
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Ono M, Kageyama S, O’Leary N, El-Kurdi MS, Reinöhl J, Solien E, Bianco RW, Doss M, Meuris B, Virmani R, Cox M, Onuma Y, Serruys PW. 1-Year Patency of Biorestorative Polymeric Coronary Artery Bypass Grafts in an Ovine Model. JACC. BASIC TO TRANSLATIONAL SCIENCE 2022; 8:19-34. [PMID: 36777172 PMCID: PMC9911320 DOI: 10.1016/j.jacbts.2022.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 06/29/2022] [Accepted: 06/29/2022] [Indexed: 11/10/2022]
Abstract
Many attempts have been made to inhibit or counteract saphenous vein graft (SVG) failure modes; however, only external support for SVGs has gained momentum in clinical utility. This study revealed the feasibility of implantation, and showed good patency out to 12 months of the novel biorestorative graft, in a challenging ovine coronary artery bypass graft model. This finding could trigger the first-in-man trial of using the novel material instead of SVG. We believe that, eventually, this novel biorestorative bypass graft can be one of the options for coronary artery bypass graft patients who have difficulty harvesting SVG.
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Key Words
- CABG, coronary artery bypass grafting
- CPB, cardiopulmonary bypass
- IH, intimal hyperplasia
- LAD, left anterior descending artery
- OCT, optical coherence tomography
- QCA, quantitative coronary angiography
- QFR, quantitative flow ratio
- RVG, restorative vascular graft
- SVG, saphenous vein graft
- coronary artery bypass graft
- coronary artery disease
- coronary revascularization
- ePTFE, expanded polytetrafluoroethylene
- polymeric bypass graft
- preclinical model
- quantitative flow ratio
- restorative vascular graft
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Affiliation(s)
- Masafumi Ono
- Amsterdam Universitair Medische Centra, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
| | - Shigetaka Kageyama
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
| | - Neil O’Leary
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
| | | | | | - Eric Solien
- American Preclinical Services, LLC, Minneapolis, Minnesota, USA
| | - Richard W. Bianco
- Experimental Surgical Services, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mirko Doss
- Department of Cardiac Surgery, Helios Clinic, Siegburg, Germany
| | - Bart Meuris
- Department of Cardiac Surgery, University Hospital Leuven, Leuven, Belgium
| | - Renu Virmani
- CVPath Institute, Inc, Gaithersburg, Maryland, USA
| | | | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
| | - Patrick W. Serruys
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
- NHLI, Imperial College London, London, United Kingdom
- Address for correspondence: Dr Patrick W. Serruys, National University of Ireland, Galway (NUIG), University Road, Galway H91 TK33, Ireland.
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Goldstein DJ. Device Profile of the VEST for External Support of SVG Coronary Artery Bypass Grafting: Historical Development, Current Status and Future Directions. Expert Rev Med Devices 2021; 18:921-931. [PMID: 34311644 DOI: 10.1080/17434440.2021.1960504] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
A search for strategies to address saphenous vein graft (SVG) failure - the main factor limiting the long-term success of coronary bypass grafting - has led to trialing of external stenting technologies. AREAS COVERED The manuscript covers historical development and current status of external scaffolding for the treatment of SVG intimal hyperplasia. Comprehensive literature review and personal communication with VGS leadership, the developer of the VEST device, served as the sources. EXPERT OPINION If the external scaffolding concept proves to be successful in mitigating the intimal hyperplasia inherent to arterialized saphenous vein conduits, it could have a dramatic impact on the recurrence of anginal symptoms, the need for repeat revascularization, and the incidence of myocardial infarction following CABG surgery. These laudable sequelae could ultimately convey significant public health repercussions by reducing healthcare resource use and improving the long-term survival and quality of life of CABG recipients.
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Affiliation(s)
- Daniel J Goldstein
- Montefiore Medical Center - Cardiothoracic Surgery, Bainbridge Ave MAP Building, 5th Fl Bronx, New York, USA
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Zilla P, Deutsch M, Bezuidenhout D, Davies NH, Pennel T. Progressive Reinvention or Destination Lost? Half a Century of Cardiovascular Tissue Engineering. Front Cardiovasc Med 2020; 7:159. [PMID: 33033720 PMCID: PMC7509093 DOI: 10.3389/fcvm.2020.00159] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 07/28/2020] [Indexed: 12/19/2022] Open
Abstract
The concept of tissue engineering evolved long before the phrase was forged, driven by the thromboembolic complications associated with the early total artificial heart programs of the 1960s. Yet more than half a century of dedicated research has not fulfilled the promise of successful broad clinical implementation. A historical account outlines reasons for this scientific impasse. For one, there was a disconnect between distinct eras each characterized by different clinical needs and different advocates. Initiated by the pioneers of cardiac surgery attempting to create neointimas on total artificial hearts, tissue engineering became fashionable when vascular surgeons pursued the endothelialisation of vascular grafts in the late 1970s. A decade later, it were cardiac surgeons again who strived to improve the longevity of tissue heart valves, and lastly, cardiologists entered the fray pursuing myocardial regeneration. Each of these disciplines and eras started with immense enthusiasm but were only remotely aware of the preceding efforts. Over the decades, the growing complexity of cellular and molecular biology as well as polymer sciences have led to surgeons gradually being replaced by scientists as the champions of tissue engineering. Together with a widening chasm between clinical purpose, human pathobiology and laboratory-based solutions, clinical implementation increasingly faded away as the singular endpoint of all strategies. Moreover, a loss of insight into the healing of cardiovascular prostheses in humans resulted in the acceptance of misleading animal models compromising the translation from laboratory to clinical reality. This was most evident in vascular graft healing, where the two main impediments to the in-situ generation of functional tissue in humans remained unheeded–the trans-anastomotic outgrowth stoppage of endothelium and the build-up of an impenetrable surface thrombus. To overcome this dead-lock, research focus needs to shift from a biologically possible tissue regeneration response to one that is feasible at the intended site and in the intended host environment of patients. Equipped with an impressive toolbox of modern biomaterials and deep insight into cues for facilitated healing, reconnecting to the “user needs” of patients would bring one of the most exciting concepts of cardiovascular medicine closer to clinical reality.
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Affiliation(s)
- Peter Zilla
- Christiaan Barnard Division for Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa.,Cardiovascular Research Unit, University of Cape Town, Cape Town, South Africa
| | - Manfred Deutsch
- Karl Landsteiner Institute for Cardiovascular Surgical Research, Vienna, Austria
| | - Deon Bezuidenhout
- Cardiovascular Research Unit, University of Cape Town, Cape Town, South Africa
| | - Neil H Davies
- Cardiovascular Research Unit, University of Cape Town, Cape Town, South Africa
| | - Tim Pennel
- Christiaan Barnard Division for Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa
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Yang Q, Lei D, Huang S, Yang Y, Jiang C, Shi H, Chen W, Zhao Q, You Z, Ye X. A novel biodegradable external stent regulates vein graft remodeling via the Hippo-YAP and mTOR signaling pathways. Biomaterials 2020; 258:120254. [PMID: 32805499 DOI: 10.1016/j.biomaterials.2020.120254] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 07/15/2020] [Accepted: 07/20/2020] [Indexed: 01/10/2023]
Abstract
Coronary artery bypass graft (CABG) has been confirmed to effectively improve the prognosis of coronary artery disease, which is a major public health concern worldwide. As the most frequently used conduits in CABG, saphenous vein grafts have the disadvantage of being susceptible to restenosis due to intimal hyperplasia. To meet the urgent clinical demand, adopting external stents (eStents) and illuminating the potential mechanisms underlying their function are important for preventing vein graft failure. Here, using 4-axis printing technology, we fabricated a novel biodegradable and flexible braided eStent, which exerts excellent inhibitory effect on intimal hyperplasia. The stented grafts downregulate Yes-associated protein (YAP), indicating that the eStent regulates vein graft remodeling via the Hippo-YAP signaling pathway. Further, as a drug-delivery vehicle, a rapamycin (RM)-coated eStent was designed to amplify the inhibitory effect of eStent on intimal hyperplasia through the synergistic effects of the Hippo and mammalian target of rapamycin (mTOR) signaling pathways. Overall, this study uncovers the underlying mechanisms of eStent function and identifies a new therapeutic target for the prevention of vein graft restenosis.
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Affiliation(s)
- Qi Yang
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China
| | - Dong Lei
- State Key Laboratory for Modification of Chemical Fibers and Polymer Materials, Shanghai Belt and Road Joint Laboratory of Advanced Fiber and Low-dimension Materials (Donghua University), College of Materials Science and Engineering, Donghua University, Shanghai, 201620, China
| | - Shixing Huang
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China
| | - Yang Yang
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China
| | - Chenyu Jiang
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China
| | - Hongpeng Shi
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China
| | - Wenyi Chen
- State Key Laboratory for Modification of Chemical Fibers and Polymer Materials, Shanghai Belt and Road Joint Laboratory of Advanced Fiber and Low-dimension Materials (Donghua University), College of Materials Science and Engineering, Donghua University, Shanghai, 201620, China
| | - Qiang Zhao
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China.
| | - Zhengwei You
- State Key Laboratory for Modification of Chemical Fibers and Polymer Materials, Shanghai Belt and Road Joint Laboratory of Advanced Fiber and Low-dimension Materials (Donghua University), College of Materials Science and Engineering, Donghua University, Shanghai, 201620, China.
| | - Xiaofeng Ye
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China.
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Yang Q, Lei D, Huang S, Yang Y, Yang Y, Ye X, You Z, Zhao Q. Effects of the different-sized external stents on vein graft intimal hyperplasia and inflammation. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:102. [PMID: 32175395 DOI: 10.21037/atm.2020.01.16] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background The poor long-term patency ratio of vein grafts prevents patients from benefiting from coronary artery bypass graft (CABG). It is reported that external venous stents have notably improved the patency ratio of stented vein grafts in animal models. The most crucial influence on stented grafts' fate is the size of the stents. This study aims to investigate the effects on intimal hyperplasia and inflammation of vein graft by using different sizes of stents and explore the potential mechanism. Methods Two different sizes of external stents were fabricated through 3D printing technology. Male SD rats were divided into three groups. In the control group rat's autologous left jugular vein was grafted on the ipsilateral artery directly. In the stent groups, grafts were surrounded by two different-sized stents before anastomosing with arteries. The patency ratio and diameter of the grafts were examined by ultrasound. Masson staining was used to characterize intimal hyperplasia. The expression of inflammatory factors was detected by immunohistochemical staining. Moreover, TUNEL staining was used to label apoptotic cells. Results The two sizes of external stents were fabricated by 3D printing technology. In the control group, the intima area and wall thickness dramatically increased 8 weeks after implantation. While in the stent groups, these data only slightly increased, especially in the 1.5 mm-stent group. The expressions of inflammatory factors in TNF signaling were more remarkable than in the control group. On the contrary, the expressions were rarely detected in the stent groups. Similarly, the number of TUNEL positive cells dramatically decreased by using the appropriate-sized stent. Conclusions In this study, we concluded that the appropriate sizes of external stents could effectively inhibit vein graft neointima formation, attenuate inflammatory reaction and reduce cell apoptosis, which might improve the long-term patency ratio of vein grafts.
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Affiliation(s)
- Qi Yang
- Department of Cardiac Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Dong Lei
- State Key Laboratory for Modification of Chemical Fibers and Polymer Materials, Shanghai Belt and Road Joint Laboratory of Advanced Fiber and Low-dimension Materials (Donghua University), College of Materials Science and Engineering, Donghua University, Shanghai 201620, China
| | - Shixing Huang
- Department of Cardiac Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Yi Yang
- Department of Cardiac Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Yang Yang
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Xiaofeng Ye
- Department of Cardiac Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Zhengwei You
- State Key Laboratory for Modification of Chemical Fibers and Polymer Materials, Shanghai Belt and Road Joint Laboratory of Advanced Fiber and Low-dimension Materials (Donghua University), College of Materials Science and Engineering, Donghua University, Shanghai 201620, China
| | - Qiang Zhao
- Department of Cardiac Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
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El-Kurdi M, Soletti L, McGrath J, Linhares S, Rousselle S, Greisler H, Edelman E, Schoen FJ. Functional remodeling of an electrospun polydimethylsiloxane-based polyether urethane external vein graft support device in an ovine model. J Biomed Mater Res A 2019; 107:2135-2149. [PMID: 31094084 PMCID: PMC6689261 DOI: 10.1002/jbm.a.36724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/13/2019] [Accepted: 05/07/2019] [Indexed: 11/07/2022]
Abstract
Saphenous vein graft (SVG) failure rates are unacceptably high, and external mechanical support may improve patency. We studied the histologic remodeling of a conformal, electrospun, polydimethylsiloxane-based polyether urethane external support device for SVGs and evaluated graft structural evolution in adult sheep to 2 years. All sheep (N = 19) survived to their intended timepoints, and angiography showed device-treated SVG geometric stability over time (30, 90, 180, 365, or 730 days), with an aggregated graft patency rate of 92%. There was minimal inflammation associated with the device material at all timepoints. By 180 days, treated SVG remodeling was characterized by minimal/nonprogressive intimal hyperplasia; polymer fragmentation and integration; as well as the development of a neointima, and a confluent endothelium. By 1-year, the graft developed a media-like layer by remodeling the neointima, and elastic fibers formed well-defined structures that subtended the neo-medial layer of the remodeled SVG. Immunohistochemistry showed that this neo-media was populated with smooth muscle cells, and the intima was lined with endothelial cells. These data suggest that treated SVGs were structurally remodeled by 180 days, and developed arterial-like features by 1 year, which continued to mature to 2 years. Device-treated SVGs remodeled into arterial-like conduits with stable long-term performance as arterial grafts in adult sheep.
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Affiliation(s)
| | | | | | | | | | - Howard Greisler
- Loyola University, Maywood, IL and Hines VA Hospital, Hines, IL
| | - Elazer Edelman
- Massachusetts Institute of Technology, Cambridge, MA, Harvard Medical School, Boston, MA, Brigham and Women’s Hospital, Boston, MA
| | - Frederick J. Schoen
- Brigham and Women’s Hospital, Boston, MA, and Harvard Medical School, Boston, MA
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10
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Taggart DP, Webb CM, Desouza A, Yadav R, Channon KM, De Robertis F, Di Mario C. Long-term performance of an external stent for saphenous vein grafts: the VEST IV trial. J Cardiothorac Surg 2018; 13:117. [PMID: 30453984 PMCID: PMC6245530 DOI: 10.1186/s13019-018-0803-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 11/05/2018] [Indexed: 01/04/2023] Open
Abstract
Background Externally stenting saphenous vein grafts reduces intimal hyperplasia, improves lumen uniformity and reduces oscillatory shear stress 1 year following surgery. The present study is the first to present the longer-term (4.5 years) performance and biomechanical effects of externally stented saphenous vein grafts. Methods Thirty patients previously implanted with the VEST external stent in the randomized, within-patient-controlled VEST I study were followed up for adverse events; 21 of these were available to undergo coronary angiography and intravascular ultrasound. Results Twenty-one stented and 29 nonstented saphenous vein grafts were evaluated by angiography and ultrasound at 4.5 ± 0.3 years. Vein graft failure rates were comparable between stented and nonstented grafts (30 and 23% respectively; p = 0.42). All failures were apparent at 1 year except for one additional nonstented failure at 4.5 years. In patent vein grafts, Fitzgibbon perfect patency remained significantly higher in the stented versus nonstented vein grafts (81 and 48% respectively, p = 0.002), while intimal hyperplasia area (4.27 mm2 ± 1.27 mm2 and 5.23 mm2 ± 1.83 mm2 respectively, p < 0.001) and thickness (0.36 mm ± 0.09 mm and 0.42 mm ± 0.11 mm respectively, p < 0.001) were significantly reduced. Intimal hyperplasia proliferation correlated with lumen uniformity and with the distance between the stent and the lumen (p = 0.04 and p < 0.001 respectively). Conclusions External stenting mitigates saphenous vein graft remodeling and significantly reduces diffuse intimal hyperplasia and the development of lumen irregularities 4.5 years after coronary artery bypass surgery. Close conformity of the stent to the vessel wall appears to be an important factor. Trial registration NCT01415245. Registered 11 August 2011.
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Affiliation(s)
- David P Taggart
- Nuffield Department of Surgery, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Carolyn M Webb
- National Heart & Lung Institute, Imperial College London, London, UK. .,Department of Cardiology, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK.
| | - Anthony Desouza
- Department of Cardiothoracic Surgery, Royal Brompton Hospital, Sydney Street, London, UK
| | - Rashmi Yadav
- Department of Cardiothoracic Surgery, Royal Brompton Hospital, Sydney Street, London, UK
| | - Keith M Channon
- Department of Cardiovascular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Fabio De Robertis
- Department of Cardiothoracic Surgery, Harefield Hospital, Middlesex, London, UK
| | - Carlo Di Mario
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
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11
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Mylonaki I, Trosi O, Allémann E, Durand M, Jordan O, Delie F. Design and characterization of a perivascular PLGA coated PET mesh sustaining the release of atorvastatin for the prevention of intimal hyperplasia. Int J Pharm 2018; 537:40-47. [DOI: 10.1016/j.ijpharm.2017.12.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 11/28/2017] [Accepted: 12/10/2017] [Indexed: 12/29/2022]
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12
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Mawhinney JA, Mounsey CA, Taggart DP. The potential role of external venous supports in coronary artery bypass graft surgery†. Eur J Cardiothorac Surg 2017; 53:1127-1134. [DOI: 10.1093/ejcts/ezx432] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 11/07/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | - David P Taggart
- Department of Cardiothoracic Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
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13
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McKavanagh P, Yanagawa B, Zawadowski G, Cheema A. Management and Prevention of Saphenous Vein Graft Failure: A Review. Cardiol Ther 2017; 6:203-223. [PMID: 28748523 PMCID: PMC5688971 DOI: 10.1007/s40119-017-0094-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Indexed: 12/16/2022] Open
Abstract
Coronary artery bypass grafting (CABG) remains a vital treatment for patients with multivessel coronary artery disease (CAD), especially diabetics. The long-term benefit of the internal thoracic artery graft is well established and remains the gold standard for revascularization of severe CAD. It is not always possible to achieve complete revascularization through arterial grafts, necessitating the use of saphenous vein grafts (SVG). Unfortunately, SVGs do not have the same longevity, and their failure is associated with significant adverse cardiac outcomes and mortality. This paper reviews the pathogenesis of SVG failure, highlighting the difference between early, intermediate, and late failure. It also addresses the different surgical techniques that affect the incidence of SVG failure, as well as the medical and percutaneous prevention and treatment options in contemporary practice.
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Affiliation(s)
- Peter McKavanagh
- Terrence Donnelly Heart Center, Divisions of Cardiology and Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Canada.
| | - Bobby Yanagawa
- Terrence Donnelly Heart Center, Divisions of Cardiology and Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - George Zawadowski
- Terrence Donnelly Heart Center, Divisions of Cardiology and Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - Asim Cheema
- Terrence Donnelly Heart Center, Divisions of Cardiology and Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Canada
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14
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Mylonaki I, Allémann É, Saucy F, Haefliger JA, Delie F, Jordan O. Perivascular medical devices and drug delivery systems: Making the right choices. Biomaterials 2017; 128:56-68. [PMID: 28288349 DOI: 10.1016/j.biomaterials.2017.02.028] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 02/13/2017] [Accepted: 02/26/2017] [Indexed: 12/31/2022]
Abstract
Perivascular medical devices and perivascular drug delivery systems are conceived for local application around a blood vessel during open vascular surgery. These systems provide mechanical support and/or pharmacological activity for the prevention of intimal hyperplasia following vessel injury. Despite abundant reports in the literature and numerous clinical trials, no efficient perivascular treatment is available. In this review, the existing perivascular medical devices and perivascular drug delivery systems, such as polymeric gels, meshes, sheaths, wraps, matrices, and metal meshes, are jointly evaluated. The key criteria for the design of an ideal perivascular system are identified. Perivascular treatments should have mechanical specifications that ensure system localization, prolonged retention and adequate vascular constriction. From the data gathered, it appears that a drug is necessary to increase the efficacy of these systems. As such, the release kinetics of pharmacological agents should match the development of the pathology. A successful perivascular system must combine these optimized pharmacological and mechanical properties to be efficient.
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Affiliation(s)
- Ioanna Mylonaki
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, rue Michel Servet 1, CH-1211 Geneva 4, Switzerland
| | - Éric Allémann
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, rue Michel Servet 1, CH-1211 Geneva 4, Switzerland
| | - François Saucy
- Department of Vascular Surgery, Lausanne University Hospital, rue du Bugnon 46, CH-1011 Lausanne, Switzerland
| | - Jacques-Antoine Haefliger
- Department of Vascular Surgery, Lausanne University Hospital, rue du Bugnon 46, CH-1011 Lausanne, Switzerland
| | - Florence Delie
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, rue Michel Servet 1, CH-1211 Geneva 4, Switzerland
| | - Olivier Jordan
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, rue Michel Servet 1, CH-1211 Geneva 4, Switzerland.
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15
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Boire TC, Balikov DA, Lee Y, Guth CM, Cheung-Flynn J, Sung HJ. Biomaterial-Based Approaches to Address Vein Graft and Hemodialysis Access Failures. Macromol Rapid Commun 2016; 37:1860-1880. [PMID: 27673474 PMCID: PMC5156561 DOI: 10.1002/marc.201600412] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 08/15/2016] [Indexed: 12/19/2022]
Abstract
Veins used as grafts in heart bypass or as access points in hemodialysis exhibit high failure rates, thereby causing significant morbidity and mortality for patients. Interventional or revisional surgeries required to correct these failures have been met with limited success and exorbitant costs, particularly for the US Centers for Medicare & Medicaid Services. Vein stenosis or occlusion leading to failure is primarily the result of neointimal hyperplasia. Systemic therapies have achieved little long-term success, indicating the need for more localized, sustained, biomaterial-based solutions. Numerous studies have demonstrated the ability of external stents to reduce neointimal hyperplasia. However, successful results from animal models have failed to translate to the clinic thus far, and no external stent is currently approved for use in the US to prevent vein graft or hemodialysis access failures. This review discusses current progress in the field, design considerations, and future perspectives for biomaterial-based external stents. More comparative studies iteratively modulating biomaterial and biomaterial-drug approaches are critical in addressing mechanistic knowledge gaps associated with external stent application to the arteriovenous environment. Addressing these gaps will ultimately lead to more viable solutions that prevent vein graft and hemodialysis access failures.
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Affiliation(s)
- Timothy C Boire
- Department of Biomedical Engineering, Vanderbilt University, 37235, Nashville, TN, USA
| | - Daniel A Balikov
- Department of Biomedical Engineering, Vanderbilt University, 37235, Nashville, TN, USA
| | - Yunki Lee
- Department of Biomedical Engineering, Vanderbilt University, 37235, Nashville, TN, USA
| | - Christy M Guth
- Division of Vascular Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, 37235, USA
| | - Joyce Cheung-Flynn
- Division of Vascular Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, 37235, USA
| | - Hak-Joon Sung
- Department of Biomedical Engineering, Vanderbilt University, 37235, Nashville, TN, USA
- Severance Biomedical Science Institute, College of Medicine, Yonsei University, Seoul, 120-752, Republic of Korea
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Abstract
In coronary artery bypass graft surgery, saphenous vein graft (SVG) patency is much lower than that of the internal mammary artery (IMA). To address this problem, an external support device, the eSVS Mesh was developed. A prospective randomized First-in-Man feasibility trial was conducted in 90 patients after institutional ethics committee approval at seven international centers. The left IMA was used to bypass the anterior descending artery. A mesh-supported (treated) saphenous vein was randomized to either the right or the circumflex coronary system, and an unsupported (control) vein was grafted to the opposing territory. Device diameters available for use were 3.0, 3.5, 4.0, and 4.5 mm. Primary end-points were 30 day adverse cardiac and cerebral events and angiographic patency at 9-12 months. Eighty-five of 90 patients returned for 30 day clinical follow-up (94%). Five patients refused to return, but by telephone contacts were asymptomatic. There was one late noncardiac death and 73 patients returned for angiography (82%), thus 12 additional patients were lost to follow-up at 1 year. Overall patency rate was 49% for the treated versus 81% for controls (p < 0.001). Subset analysis revealed significantly lower patency at one center and with use of the 3.0 mm device (p < 0.05). Removing these data, patency was 72% vs. 81% (p = NS). Sternal wound infection was higher than expected at 5.0%, but this was center specific. The eSVS Mesh is safe, but at up to 1 year, patency is equivalent to untreated vein grafts after removal of outlying data. This study provides insight into operative events and parameters that may optimize outcomes and point to potential improvements in the external SVG support device. Furthermore, longer term studies are pending.
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17
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External Saphenous Vein Support Mesh Does Not Interfere With Transit-Time Flow Measurement on Venous Coronary Bypass Conduit: Clinical Confirmation. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016; 11:70-2. [PMID: 26901750 DOI: 10.1097/imi.0000000000000238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A 65-year-old patient underwent double coronary artery bypass grafting using the left internal thoracic artery on the left anterior descending coronary artery and nitinol alloy mesh [external Saphenous Vein Support (eSVS)]-covered saphenous vein graft to the right posterior descending coronary artery. Transit-time flow measurements (TTFMs) were obtained on meshed and bare parts of the vein graft. There was no difference in TTFM parameters (flow, pulsatility index, and diastolic fraction values) obtained from the eSVS mesh-covered and the uncovered parts of the venous graft. This observation confirms that eSVS mesh does not interfere with TTFM on venous coronary bypass conduits.
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18
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Mootoosamy P, Jolou J, Myers PO, Walpoth BH, Kalangos A, Cikirikcioglu M. External Saphenous Vein Support Mesh Does Not Interfere with Transit-Time Flow Measurement on Venous Coronary Bypass Conduit: Clinical Confirmation. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016. [DOI: 10.1177/155698451601100113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Parmeseeven Mootoosamy
- Division of Cardiovascular Surgery, University Hospitals and Medical Faculty of Geneva, Geneva, Switzerland
| | - Jalal Jolou
- Division of Cardiovascular Surgery, University Hospitals and Medical Faculty of Geneva, Geneva, Switzerland
| | - Patrick O. Myers
- Division of Cardiovascular Surgery, University Hospitals and Medical Faculty of Geneva, Geneva, Switzerland
| | - Beat H. Walpoth
- Division of Cardiovascular Surgery, University Hospitals and Medical Faculty of Geneva, Geneva, Switzerland
| | - Afksendiyos Kalangos
- Division of Cardiovascular Surgery, University Hospitals and Medical Faculty of Geneva, Geneva, Switzerland
| | - Mustafa Cikirikcioglu
- Division of Cardiovascular Surgery, University Hospitals and Medical Faculty of Geneva, Geneva, Switzerland
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19
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A novel biodegradable external mesh stent improved long-term patency of vein grafts by inhibiting intimal–medial hyperplasia in an experimental canine model. Gen Thorac Cardiovasc Surg 2015; 64:1-9. [DOI: 10.1007/s11748-015-0591-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 09/17/2015] [Indexed: 10/23/2022]
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20
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Inderbitzin DT, Bremerich J, Matt P, Grapow MTR, Eckstein FS, Reuthebuch O. One-year patency control and risk analysis of eSVS®-mesh-supported coronary saphenous vein grafts. J Cardiothorac Surg 2015; 10:108. [PMID: 26253565 PMCID: PMC4529720 DOI: 10.1186/s13019-015-0293-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 06/19/2015] [Indexed: 11/10/2022] Open
Abstract
Background The eSVS® external venous nitinol mesh (Kips Bay Medical, Minneapolis, USA) was designed to improve long-term patency of coronary saphenous vein grafts (SVG) by preventing pressure-induced wall stress and reactive neo-intimal hyperplasia. We present one-year-patency rates of meshed SVGs assessed by coronary computed tomographic angiography (cCTA). Patients and Methods Data from consecutive patients receiving an eSVS® meshed coronary bypass SVG from 06/2010 to 06/2011 were prospectively collected and analysed post-hoc. Patient characteristics, coronary artery disease, SVG quality, surgery (including number of anastomoses and transit time flow-measurement: TTFM), postoperative course and graft patency by cCTA were recorded. Potential risk factors for meshed graft occlusion were evaluated. Results 22 patients received an eSVS® mesh (18 isolated CABG, 4 combined with aortic valve replacement). Three patients died prior to the one-year follow-up and were excluded. All 19 surviving patients (mean age 70.4 ± 9.5 years, 3 female) completed a cCTA of all grafts at 12 ± 0.1 months after surgery including 21 meshed SVGs (33 distal anastomoses), 7 unmeshed SVGs (13 distal anastomoses) and 22 arterial grafts (30 distal anastomoses). Mesh application was safe with patent grafts (by intraoperative TTFM) and perioperative course uneventful in all patients. The average graft/anastomosis number per patient was 2.6 ± 0.5/3.7 ± 0.8. Patency was unrestricted in all arterial and unmeshed SVGs (cCTA). Meshed SVG patency was 85 % (n = 28/33) for distal anastomoses and 76 % (n = 16/21) among meshed SVGs. Four SVGs with single distal anastomosis to the right coronary were completely occluded. One sequential graft to the left coronary was occluded between proximal and first distal anastomosis (see Fig. 1). Patency was independent of target site, coronary run-off, SVG quality and sequential distal grafting. All patients were asymptomatic. Conclusions The overall one-year patency rate of eSVS® meshed SVGs/anastomoses was 76 %/85 %. Surgical implantation is safe independently of target site, run-off, vein quality and sequential distal anastomoses. However, graft patency of meshed veins (76 %) was inferior to non-meshed (100 %) or arterial grafts (100 %). Thus our mid-term data do not sustain the concept of improving vein graft patency by external reinforcing with the eSVS® mesh. Further long-term follow-up is warranted.
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Affiliation(s)
- Devdas T Inderbitzin
- Department of Cardiac Surgery, University Hospital of Basel, Spitalstrasse 21, CH-4031, Basel, Switzerland.
| | - Jens Bremerich
- Division of Radiology, University Hospital Basel, Petersgraben 4, CH-4031, Basel, Switzerland
| | - Peter Matt
- Department of Cardiac Surgery, University Hospital of Basel, Spitalstrasse 21, CH-4031, Basel, Switzerland
| | - Martin T R Grapow
- Department of Cardiac Surgery, University Hospital of Basel, Spitalstrasse 21, CH-4031, Basel, Switzerland
| | - Friedrich S Eckstein
- Department of Cardiac Surgery, University Hospital of Basel, Spitalstrasse 21, CH-4031, Basel, Switzerland
| | - Oliver Reuthebuch
- Department of Cardiac Surgery, University Hospital of Basel, Spitalstrasse 21, CH-4031, Basel, Switzerland
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21
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Ferrari E, von Segesser L, Berdajs D. Improving coronary artery bypass graft durability: use of the external saphenous vein graft support. Multimed Man Cardiothorac Surg 2015; 2015:mmv005. [PMID: 25976117 DOI: 10.1093/mmcts/mmv005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 04/07/2015] [Indexed: 11/14/2022]
Abstract
Coronary bypass grafting remains the best option for patients suffering from multivessel coronary artery disease, and the saphenous vein is used as an additional conduit for multiple complete revascularizations. However, the long-term vein graft durability is poor, with almost 75% of occluded grafts after 10 years. To improve the durability, the concept of an external supportive structure was successfully developed during the last years: the eSVS Mesh device (Kips Bay Medical) is an external support for vein graft made of weft-knitted nitinol wire into a tubular form with an approximate length of 24 cm and available in three diameters (3.5, 4.0 and 4.5 mm). The device is placed over the outer wall of the vein and carefully deployed to cover the full length of the graft. The mesh is flexible for full adaptability to the heart anatomy and is intended to prevent kinking and dilatation of the vein in addition to suppressing the intima hyperplasia induced by the systemic blood pressure. The device is designed to reduce the vein diameter of about 15-20% at most to prevent the vein radial expansion induced by the arterial blood pressure, and the intima hyperplasia leading to the graft failure. We describe the surgical technique for preparing the vein graft with the external saphenous vein graft support (eSVS Mesh) and we share our preliminary clinical results.
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Affiliation(s)
- Enrico Ferrari
- Cardiac Surgery Unit, University Hospital of Lausanne, Lausanne, Switzerland Cardiovascular Research Unit, University Hospital of Lausanne, Lausanne, Switzerland
| | - Ludwig von Segesser
- Cardiovascular Research Unit, University Hospital of Lausanne, Lausanne, Switzerland
| | - Denis Berdajs
- Cardiovascular Research Unit, University Hospital of Lausanne, Lausanne, Switzerland
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22
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Singh C, Wang X. A new design concept for knitted external vein-graft support mesh. J Mech Behav Biomed Mater 2015; 48:125-133. [PMID: 25916819 DOI: 10.1016/j.jmbbm.2015.04.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 03/31/2015] [Accepted: 04/01/2015] [Indexed: 11/24/2022]
Abstract
Autologous vein-graft failure significantly limits the long-term efficacy of coronary artery bypass procedures. The major cause behind this complication is biomechanical mismatch between the vein and coronary artery. The implanted vein experiences a sudden increase (10-12 fold) in luminal pressures. The resulting vein over-distension or 'ballooning' initiates wall thickening phenomenon and ultimate occlusion. Therefore, a primary goal in improving the longevity of a coronary bypass procedure is to inhibit vein over-distension using mechanical constriction. The idea of using an external vein-graft support mesh has demonstrated sustained benefits and wide acceptance in experimental studies. Nitinol based knitted structures have offered more promising mechanical features than other mesh designs owing to their unique loosely looped construction. However, the conventional plain knit construction still exhibits limitations (radial compliance, deployment ease, flexibility, and bending stresses) which limit this design from proving its real clinical advantage. The new knitted mesh design presented in this study is based on the concept of composite knitting utilising high modulus (nitinol and polyester) and low modulus (polyurethane) material components. The experimental comparison of the new design with a plain knit design demonstrated significant improvement in biomechanical (compliance, flexibility, extensibility, viscoelasticity) and procedural (deployment limit) parameters. The results are indicative of the promising role of new mesh in restoring the lost compliance and pulsatility of vein-graft at high arterial pressures. This way it can assist in controlled vein-graft remodelling and stepwise restoration of vein mechanical homoeostasis. Also, improvement in deployment limit parameter offers more flexibility for a surgeon to use a wide range of vein diameters, which may otherwise be rendered unusable for a plain knit mesh.
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Affiliation(s)
- Charanpreet Singh
- Australian Future Fibres Research and Innovation Centre, Institute for Frontier Materials, Deakin University, Geelong, Victoria 3216, Australia
| | - Xungai Wang
- Australian Future Fibres Research and Innovation Centre, Institute for Frontier Materials, Deakin University, Geelong, Victoria 3216, Australia; School of Textile Science and Engineering, Wuhan Textile University, Wuhan 430073, China.
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23
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Implantation of the eSVS Mesh: modification of recommended technique. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2015; 10:146-9. [PMID: 25807171 DOI: 10.1097/imi.0000000000000130] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The eSVS Mesh is a knitted wire lattice manufactured in cylindrical sheaths of various diameters, designed to be placed around the outer surface of a saphenous vein graft before use in coronary surgery. The goal is to improve long-term vein graft patency by preventing expansive endothelial injury obviating neointimal hyperplasia and subsequent graft atherosclerosis. Since the First-In-Man feasibility trial of the eSVS Mesh, postmarket studies in Europe and a feasibility trial in the United States are ongoing. Consensus from the principal investigators indicated the trials had confounding variables that may impact results other than evaluation of the eSVS Mesh alone. With input from these investigators, the recommended operative technique has been modified for future trials by removing the mesh from proximal and distal anastomoses and eliminating the use of fibrin sealant. These changes allow for use of an implant technique closer to standard vein bypass grafting and a more focused evaluation of the eSVS Mesh.
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24
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Emery RW, Solien E, Puskas JD. Implantation of the eSVS Mesh: Modification of Recommended Technique. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2015. [DOI: 10.1177/155698451501000213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - John D. Puskas
- Icahn School of Medicine at Mount Sinai, New York, NY USA
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25
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Xie P, Shi E, Gu T, Zhang Y, Mao N. Inhibition of intimal hyperplasia of the vein graft with degradable poly lactic-co-glycolic acid vascular external sheaths carrying slow-release bosentan. Eur J Cardiothorac Surg 2015; 48:842-9; discussion 849. [DOI: 10.1093/ejcts/ezv025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Accepted: 12/11/2014] [Indexed: 11/14/2022] Open
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26
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Cohn WE, Frazier OH, Mallidi HR, Cooley DA. Surgical Treatment of Coronary Artery Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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27
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Longchamp A, Allagnat F, Berard X, Alonso F, Haefliger JA, Deglise S, Corpataux JM. Procedure for human saphenous veins ex vivo perfusion and external reinforcement. J Vis Exp 2014:e52079. [PMID: 25350681 DOI: 10.3791/52079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
The mainstay of contemporary therapies for extensive occlusive arterial disease is venous bypass graft. However, its durability is threatened by intimal hyperplasia (IH) that eventually leads to vessel occlusion and graft failure. Mechanical forces, particularly low shear stress and high wall tension, are thought to initiate and to sustain these cellular and molecular changes, but their exact contribution remains to be unraveled. To selectively evaluate the role of pressure and shear stress on the biology of IH, an ex vivo perfusion system (EVPS) was created to perfuse segments of human saphenous veins under arterial regimen (high shear stress and high pressure). Further technical innovations allowed the simultaneous perfusion of two segments from the same vein, one reinforced with an external mesh. Veins were harvested using a no-touch technique and immediately transferred to the laboratory for assembly in the EVPS. One segment of the freshly isolated vein was not perfused (control, day 0). The two others segments were perfused for up to 7 days, one being completely sheltered with a 4 mm (diameter) external mesh. The pressure, flow velocity, and pulse rate were continuously monitored and adjusted to mimic the hemodynamic conditions prevailing in the femoral artery. Upon completion of the perfusion, veins were dismounted and used for histological and molecular analysis. Under ex vivo conditions, high pressure perfusion (arterial, mean = 100 mm Hg) is sufficient to generate IH and remodeling of human veins. These alterations are reduced in the presence of an external polyester mesh.
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Affiliation(s)
- Alban Longchamp
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School;
| | - Florent Allagnat
- Laboratory of Experimental Medicine, Department of Medicine, CHUV University Hospital
| | - Xavier Berard
- Department of Vascular Surgery, Pellegrin Hospital, University of Bordeaux
| | - Florian Alonso
- Laboratory of Experimental Medicine, Department of Medicine, CHUV University Hospital
| | | | - Sébastien Deglise
- Department of Thoracic and Vascular Surgery, CHUV University Hospital
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Computerized tomographic angiography in patients having eSVS Mesh(R) supported coronary saphenous vein grafts: intermediate term results. J Cardiothorac Surg 2014; 9:138. [PMID: 25123948 PMCID: PMC4413552 DOI: 10.1186/1749-8090-9-126] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 08/13/2014] [Indexed: 11/16/2022] Open
Abstract
Background The Saphenous Vein (SVG) is used in over 80% of coronary artery bypass procedures (CABG) and SVG patency is the Achilles heel of CABG. To address this issue, the eSVS Mesh®, an external Nitinol knitted mesh, fitted like a sleeve over the vein graft preventing over expansion in the high pressure arterial system, has been introduced to improve disease management. Patency data is limited. The objective of this retrospective study is to report patency rates (>3 months) in patients having external mesh support as part of CABG. Methods From October 25, 2010 through February 13, 2012, 21 patients had external mesh support of SVG grafts in addition to internal thoracic artery grafting to the Anterior Descending artery. Patients were invited to return for patency evaluation using Computerized Tomographic angiography (CTA) an average of 7.2 months post-operative (R = 3-14 months). Results 21 male patients (age 57 +/- 9 years) underwent on-pump surgery. The eSVS Mesh was successfully placed on all SVGs. All grafts were determined patent intra-operative by transit time Doppler measurement and there were no operative revisions. There was no operative mortality. 12 of the 21 contacted patients returned for CTA, 8 non-returning patients contacted were alive and asymptomatic but refused to return due to travel restrictions or cost. One patient was lost to follow up. 11 returning patients underwent CTA. One patient was excluded (asymptomatic) due to elevated creatinine. Of the 23 anastomoses in 11 patients (Average: 2.09 grafts/patient) using SVG available for examination, 21 were patent (92%). Conclusions In this retrospective non-randomized experience, the external mesh supported grafts displayed excellent intermediate patency. Electronic supplementary material The online version of this article (doi:10.1186/1749-8090-9-126) contains supplementary material, which is available to authorized users.
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Use of the eSVS Mesh: external vein support does not negatively impact early graft patency. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2014; 8:211-4. [PMID: 23989815 DOI: 10.1097/imi.0b013e3182a326ed] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The aim of this study was to assess early graft patency in eSVS Mesh-covered saphenous vein grafts (SVGs) in patients undergoing coronary artery bypass grafting. METHODS In 20 patients meeting criteria for double arterial grafting to the left-sided coronary system and eSVS Mesh-covered SVG to the right-sided coronary system, patency was evaluated intraoperatively by transit time flow measurement and at 5 days postoperatively by computed tomographic angiography. RESULTS Twenty patients underwent 49 arterial and 22 venous grafts (mean, 3.55/patient) using off-pump techniques. All grafts were determined to be patent intraoperatively. On computed tomographic angiography, arterial graft patency was 100%. In one venous anastomosis, the distal limb of a sequential graft was occluded, for an overall patency rate of 95%. CONCLUSIONS The eSVS Mesh does not compromise early SVG patency.
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The use of external mesh reinforcement to reduce intimal hyperplasia and preserve the structure of human saphenous veins. Biomaterials 2014; 35:2588-99. [DOI: 10.1016/j.biomaterials.2013.12.041] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 12/18/2013] [Indexed: 01/14/2023]
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Intraoperative transit-time flow measurement is not altered in venous bypass grafts covered by the eSVS mesh. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2013; 8:37-41. [PMID: 23571792 DOI: 10.1097/imi.0b013e31828e5d1e] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to determine whether the eSVS Mesh interferes with transit-time flow measurement (TTFM) assessing intraoperative coronary vein graft patency. METHODS In four swine undergoing off-pump bypass grafting to the anterior descending coronary artery, five TTFMs were sequentially obtained on meshed and bare grafts at baseline and under Dobutamine stress at five separate locations on the graft in each animal. The Medistim VeriQ was used for TTFM. The grafts were examined for patency after the swine were killed. RESULTS There was no difference in hemodynamics or TTFM either at baseline or under Dobutamine stress between the eSVS Mesh covered and uncovered grafts. Dobutamine, however, significantly increased hemodynamics and graft flow parameters measured from baseline. CONCLUSIONS The eSVS Mesh does not interfere with Doppler flow measurement in covered coronary vein grafts.
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Byrom MJ, Ng MKC, Bannon PG. Biomechanics and biocompatibility of the perfect conduit-can we build one? Ann Cardiothorac Surg 2013; 2:435-43. [PMID: 23977620 DOI: 10.3978/j.issn.2225-319x.2013.05.04] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Accepted: 05/17/2013] [Indexed: 01/24/2023]
Abstract
No currently available conduit meets the criteria for an ideal coronary artery bypass graft. The perfect conduit would combine the availability and complication-free harvest of a synthetic vessel with the long-term patency performance of the internal mammary artery. However, current polymer conduits suffer from inelastic mechanical properties and especially poor surface biocompatibility, resulting in early loss of patency as a coronary graft. Approaches to manufacture an improved conduit using new polymers or polymer surfaces, acellular matrices, or cellular constructs have to date failed to achieve a commercially successful alternative. Elastin, by mimicking the native extracellular environment as well as providing elasticity, provides the 'missing link' in vascular conduit design and brings new hope for realization of the perfect conduit.
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Affiliation(s)
- Michael J Byrom
- The Baird Institute for Applied Heart and Lung Surgical Research, Sydney, Australia; ; Royal Prince Alfred Hospital, Sydney, Australia; ; University of Sydney, Sydney, Australia
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Expandable external support device to improve Saphenous Vein Graft Patency after CABG. J Cardiothorac Surg 2013; 8:122. [PMID: 23641948 PMCID: PMC3661403 DOI: 10.1186/1749-8090-8-122] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Accepted: 04/29/2013] [Indexed: 11/20/2022] Open
Abstract
Objectives Low patency rates of saphenous vein grafts remain a major predicament in surgical revascularization. We examined a novel expandable external support device designed to mitigate causative factors for early and late graft failure. Methods For this study, fourteen adult sheep underwent cardiac revascularization using two vein grafts for each; one to the LAD and the other to the obtuse marginal artery. One graft was supported with the device while the other served as a control. Target vessel was alternated between consecutive cases. The animals underwent immediate and late angiography and were then sacrificed for histopathologic evaluation. Results Of the fourteen animals studied, three died peri-operatively (unrelated to device implanted), and ten survived the follow-up period. Among surviving animals, three grafts were thrombosed and one was occluded, all in the control group (p = 0.043). Quantitative angiographic evaluation revealed no difference between groups in immediate level of graft uniformity, with a coefficient-of-variance (CV%) of 7.39 in control versus 5.07 in the supported grafts, p = 0.082. At 12 weeks, there was a significant non-uniformity in the control grafts versus the supported grafts (CV = 22.12 versus 3.01, p < 0.002). In histopathologic evaluation, mean intimal area of the supported grafts was significantly lower than in the control grafts (11.2 mm^2 versus 23.1 mm^2 p < 0.02). Conclusions The expandable SVG external support system was found to be efficacious in reducing SVG’s non-uniform dilatation and neointimal formation in an animal model early after CABG. This novel technology may have the potential to improve SVG patency rates after surgical myocardial revascularization.
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Genoni M, Odavic D, Loblein H, Dzemali O. Use of the eSVS Mesh: External Vein Support Does Not Negatively Impact Early Graft Patency. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2013. [DOI: 10.1177/155698451300800307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Michele Genoni
- Stadtspital Triemli, Klinik für Herzchirurgie, Zurich, Switzerland
| | - Dragan Odavic
- Stadtspital Triemli, Klinik für Herzchirurgie, Zurich, Switzerland
| | - Helen Loblein
- Stadtspital Triemli, Klinik für Herzchirurgie, Zurich, Switzerland
| | - Omer Dzemali
- Stadtspital Triemli, Klinik für Herzchirurgie, Zurich, Switzerland
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Abstract
Saphenous vein remains a widely used conduit in coronary surgery. However, the long-term success of surgical myocardial revascularization is largely limited by the development of neointimal hyperplasia and superimposed atherosclerosis in vein grafts. Although strategies for preventing vein graft failure have been constantly explored, few therapeutic interventions to date have shown sustained benefits in the clinical setting. The application of external support has emerged as a promising strategy for modulating the overall biomechanical responses in venous wall. Nonetheless, clinical translation of this intervention has been formerly challenged, primarily due to several technique limitations. The purpose of the current review is to summarize the possible mechanisms involved in the external support strategy for preventing vein graft failure. Furthermore, several previously tested biomaterials and delivery techniques are also highlighted.
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Affiliation(s)
- Jia Hu
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, People's Republic of China
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Moodley L, Franz T, Human P, Wolf MF, Bezuidenhout D, Scherman J, Zilla P. Protective constriction of coronary vein grafts with knitted nitinol. Eur J Cardiothorac Surg 2013; 44:64-71. [PMID: 23295444 DOI: 10.1093/ejcts/ezs670] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Different flow patterns and shear forces were shown to cause significantly more luminal narrowing and neointimal tissue proliferation in coronary than in infrainguinal vein grafts. As constrictive external mesh support of vein grafts led to the complete suppression of intimal hyperplasia (IH) in infrainguinal grafts, we investigated whether mesh constriction is equally effective in the coronary position. METHODS Eighteen senescent Chacma baboons (28.8 ± 3.6 kg) received aorto-coronary bypass grafts to the left anterior descending artery (LAD). Three groups of saphenous vein grafts were compared: untreated controls (CO); fibrin sealant-sprayed controls (CO + FS) and nitinol mesh-constricted grafts (ME + FS). Meshes consisted of pulse-compliant, knitted nitinol (eight needles; 50 μm wire thickness; 3.4 mm resting inner diameter, ID) spray attached to the vein grafts with FS. After 180 days of implantation, luminal dimensions and IH were analysed using post-explant angiography and macroscopic and histological image analysis. RESULTS At implantation, the calibre mismatch between control grafts and the LAD expressed as cross-sectional quotient (Qc) was pronounced [Qc = 0.21 ± 0.07 (CO) and 0.18 ± 0.05 (CO + FS)]. Mesh constriction resulted in a 29 ± 7% reduction of the outer diameter of the vein grafts from 5.23 ± 0.51 to 3.68 ± 0 mm, significantly reducing the calibre discrepancy to a Qc of 0.41 ± 0.17 (P < 0.02). After 6 months of implantation, explant angiography showed distinct luminal irregularities in control grafts (ID difference between widest and narrowest segment 74 ± 45%), while diameter variations were mild in mesh-constricted grafts. In all control grafts, thick neointimal tissue was present [600 ± 63 μm (CO); 627 ± 204 μm (CO + FS)] as opposed to thin, eccentric layers of 249 ± 83 μm in mesh-constricted grafts (ME + FS; P < 0.002). The total wall thickness had increased by 363 ± 39% (P < 0.00001) in CO and 312 ± 61% (P < 0.00001) in CO + FS vs 82 ± 61% in ME + FS (P < 0.007). CONCLUSIONS In a senescent non-human primate model for coronary artery bypass grafts, constrictive, external mesh support of saphenous veins with knitted nitinol prevented focal, irregular graft narrowing and suppressed neointimal tissue proliferation by a factor of 2.5. The lower degree of suppression of IH compared with previous infrainguinal grafts coincided with a lesser reduction of calibre mismatch in the coronary grafts.
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Affiliation(s)
- Loven Moodley
- Chris Barnard Department of Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa
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37
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Emery RW, Solien E. Intraoperative Transit-Time Flow Measurement is Not Altered in Venous Bypass Grafts Covered by the eSVS Mesh. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2013. [DOI: 10.1177/155698451300800107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Robert W. Emery
- Cardiovascular Surgery, St. Joseph's Hospital, St Paul, MN USA
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Zilla P, Moodley L, Scherman J, Krynauw H, Kortsmit J, Human P, Wolf MF, Franz T. Remodeling leads to distinctly more intimal hyperplasia in coronary than in infrainguinal vein grafts. J Vasc Surg 2012; 55:1734-41. [DOI: 10.1016/j.jvs.2011.11.057] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Revised: 11/02/2011] [Accepted: 11/09/2011] [Indexed: 11/25/2022]
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Collins MJ, Li X, Lv W, Yang C, Protack CD, Muto A, Jadlowiec CC, Shu C, Dardik A. Therapeutic strategies to combat neointimal hyperplasia in vascular grafts. Expert Rev Cardiovasc Ther 2012; 10:635-47. [PMID: 22651839 PMCID: PMC3401520 DOI: 10.1586/erc.12.33] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Neointimal hyperplasia (NIH) in bypass conduits such as veins and prosthetic grafts is an important clinical entity that limits the long-term success of vascular interventions. Although the development of NIH in the conduits shares many of the same features of NIH that develops in native arteries after injury, vascular grafts are exposed to unique circumstances that predispose them to NIH, including surgical trauma related to vein handling, hemodynamic changes creating areas of low flow, and differences in biocompatibility between the conduit and the host environment. Multiple different approaches, including novel surgical techniques and targeted gene therapies, have been developed to target and prevent the causes of NIH. Recently, the PREVENT trials, the first molecular biology trials in vascular surgery aimed at preventing NIH, have failed to produce improved clinical outcomes, highlighting the incomplete knowledge of the pathways leading to NIH in vascular grafts. In this review, we aim to summarize the pathophysiologic pathways that underlie the formation of NIH in both vein and synthetic grafts and discuss current and potential mechanical and molecular approaches under investigation that may limit NIH in vascular grafts.
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Affiliation(s)
- Michael J Collins
- Department of Surgery and the Interdepartmental Program in Vascular Biology and Therapeutics, Yale University School of Medicine, New Haven, CT, USA
| | - Xin Li
- Department of Surgery and the Interdepartmental Program in Vascular Biology and Therapeutics, Yale University School of Medicine, New Haven, CT, USA
- Department of Vascular Surgery, Xiangya Second Hospital of Central South University, Changsha, Hunan, China
| | - Wei Lv
- Department of Surgery and the Interdepartmental Program in Vascular Biology and Therapeutics, Yale University School of Medicine, New Haven, CT, USA
- Department of Vascular Surgery, Shandong Provincial Hospital, Shandong University School of Medicine, Jinan, Shandong, China
| | - Chenzi Yang
- Department of Surgery and the Interdepartmental Program in Vascular Biology and Therapeutics, Yale University School of Medicine, New Haven, CT, USA
- Department of Vascular Surgery, Xiangya Second Hospital of Central South University, Changsha, Hunan, China
| | - Clinton D Protack
- Department of Surgery and the Interdepartmental Program in Vascular Biology and Therapeutics, Yale University School of Medicine, New Haven, CT, USA
| | - Akihito Muto
- Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Caroline C Jadlowiec
- Department of Surgery and the Interdepartmental Program in Vascular Biology and Therapeutics, Yale University School of Medicine, New Haven, CT, USA
| | - Chang Shu
- Department of Vascular Surgery, Xiangya Second Hospital of Central South University, Changsha, Hunan, China
| | - Alan Dardik
- Department of Surgery and the Interdepartmental Program in Vascular Biology and Therapeutics, Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
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Wiedemann D, Kocher A, Bonaros N, Semsroth S, Laufer G, Grimm M, Schachner T. Perivascular administration of drugs and genes as a means of reducing vein graft failure. Curr Opin Pharmacol 2012; 12:203-16. [DOI: 10.1016/j.coph.2012.02.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Revised: 02/20/2012] [Accepted: 02/23/2012] [Indexed: 01/21/2023]
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Thomas AC. Animal models for studying vein graft failure and therapeutic interventions. Curr Opin Pharmacol 2012; 12:121-6. [PMID: 22281067 DOI: 10.1016/j.coph.2012.01.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Accepted: 01/05/2012] [Indexed: 11/25/2022]
Abstract
Vein grafts have been extensively used to bypass blockages in arteries, but are themselves subject to early closure by thrombosis or later obstruction by vein graft disease (neointimal hyperplasia and remodelling). Animal models are a crucial means of testing potential therapeutic and surgical interventions to prevent graft stenosis and occlusion. This review outlines many of the animal models of vein grafting. Recent studies include targeted gene therapy to prevent acute vein graft thrombosis and the use of folic acid to limit graft failure in diabetic pigs.
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Affiliation(s)
- Anita C Thomas
- Bristol Heart Institute, University of Bristol, Bristol, BS2 8HW, United Kingdom.
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42
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Zilla P, Moodley L, Wolf MF, Bezuidenhout D, Sirry MS, Rafiee N, Lichtenberg W, Black M, Franz T. Knitted nitinol represents a new generation of constrictive external vein graft meshes. J Vasc Surg 2011; 54:1439-50. [DOI: 10.1016/j.jvs.2011.05.023] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Revised: 05/12/2011] [Accepted: 05/12/2011] [Indexed: 11/16/2022]
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Inderbitzin DT, Matt P, Eckstein FS, Reuthebuch O. eComment: external nitinol meshing of venous coronary artery bypass grafts: is safety of application really in doubt? Interact Cardiovasc Thorac Surg 2011; 13:400. [PMID: 21934129 DOI: 10.1510/icvts.2010.265116a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Schoettler J, Jussli-Melchers J, Grothusen C, Stracke L, Schoeneich F, Stohn S, Hoffmann G, Cremer J. Highly flexible nitinol mesh to encase aortocoronary saphenous vein grafts: first clinical experiences and angiographic results nine months postoperatively. Interact Cardiovasc Thorac Surg 2011; 13:396-400. [PMID: 21724659 DOI: 10.1510/icvts.2010.265116] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Saphenous vein graft patency is frequently limited by degeneration. Experimental studies have indicated that rigid external support of venous grafts by a flexible, tubular nitinol mesh may improve graft patency. The study presented was part of a prospective, randomized, multicenter first-in-man trial investigating the safety and effectiveness of nitinol-supported venous grafts in coronary artery bypass graft (CABG) surgery. From our clinic, 25 subjects with multivessel coronary artery disease requiring saphenous vein graft CABG of the right coronary artery (RCA) and the circumflex artery were entered into the trial. Subjects were randomized to receive a mesh-supported graft on one of these arteries; the other vessel received an untreated vein graft. Graft patency was assessed by coronary angiography nine months after surgery. The implantation of mesh grafts was simple and safe. In 10 cases, a nitinol mesh-supported venous graft was anastomosed to the circumflex artery and in 15 cases to the RCA. All patients survived the observation period. A total of 72% of the patients underwent control coronary angiography. The patency rate of mesh-supported grafts was 27.8% nine months postoperatively. Conventional vein grafts showed an 85.7% patency, and arterial grafts had a 100% patency. No complications directly related to the implantation of mesh-supported grafts were observed. The promising experimental results of mesh-supported venous grafts could not be reproduced in the study presented. A critical item seems to be correct selection of nitinol mesh diameter, the anastomotic method and fixation of the mesh tube to the venous graft.
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Affiliation(s)
- Jan Schoettler
- Department of Cardiovascular Surgery, Christian-Albrechts-University of Kiel, Kiel, Germany.
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45
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Franz T, Human P, Dobner S, Reddy BD, Black M, Ilsley H, Wolf MF, Bezuidenhout D, Moodley L, Zilla P. Tailored sizes of constrictive external vein meshes for coronary artery bypass surgery. Biomaterials 2010; 31:9301-9. [DOI: 10.1016/j.biomaterials.2010.08.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Accepted: 08/24/2010] [Indexed: 10/19/2022]
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Liu K, Cao G, Zhang X, Liu R, Zou W, Wu S. Pretreatment with intraluminal rapamycin nanoparticle perfusion inhibits neointimal hyperplasia in a rabbit vein graft model. Int J Nanomedicine 2010; 5:853-60. [PMID: 21042547 PMCID: PMC2963931 DOI: 10.2147/ijn.s13112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Poly lactic-co-glycolic acid nanoparticles (PLGA-NP) are widely used as a biodegradable biomaterial in medicine. Rapamycin-eluting stents have been used for prevention of restenosis during surgery. This study investigated the effect of pretreatment with intraluminal perfusion of carbopol-encapsulated rapamycin-loaded PLGA nanoparticles (RAP-PLGA-NP) on neointimal hyperplasia in a rabbit vein graft model. METHODS A segment of common carotid artery was replaced with a segment of external jugular vein in 60 rabbits which were then separated into four treatment groups, ie, Group 1, in which vein grafts were pretreated with intraluminal RAP-PLGA-NP perfusion, Group 2 in which vein grafts underwent equivalent empty vehicle (PLGA-NP) perfusion, Group 3, in which vein grafts received no treatment, and Group 4, which served as a sham operation group receiving normal vein contrast. On postoperative day 28, the grafts and normal veins were harvested for histologic examination, flow cytometry analysis, and high-performance liquid chromatography measurement. RESULTS Compared with Group 1, the intima of the grafts were thickened, the ratio of intimal area to vessel area increased, and the collagen volume index of the vein grafts increased significantly in Groups 2 and 3. The cell proliferation index in Group 1 (21.11 ± 3.15%) was much lower than that in Group 2 (30.35 ± 2.69%) and in Group 3 (33.86 ± 8.72%). By high-performance liquid chromatography measurement, retention of rapamycin was detected in Group 1 (11.2 ± 0.37 μg/10 mg) 28 days after single drug perfusion. CONCLUSION Pretreatment with intraluminal RAP-PLGA-NP perfusion may inhibit neointimal hyperplasia in vein grafts by penetrating into local tissue and limiting cell proliferation.
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Affiliation(s)
- Kai Liu
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Jinan, People’s Republic of China
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47
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A Computational Study of Structural Designs for a Small-Diameter Composite Vascular Graft Promoting Tissue Regeneration. Cardiovasc Eng Technol 2010. [DOI: 10.1007/s13239-010-0023-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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48
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Rationale and practical techniques for mouse models of early vein graft adaptations. J Vasc Surg 2010; 52:444-52. [PMID: 20573477 DOI: 10.1016/j.jvs.2010.03.048] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2010] [Revised: 03/19/2010] [Accepted: 03/20/2010] [Indexed: 11/21/2022]
Abstract
Mouse models serve as relatively new yet powerful research tools to study intimal hyperplasia and wall remodeling of vein bypass graft failure. Several model variations have been reported in the past decade. However, the approach demands thoughtful preparation, selected sophisticated equipment, microsurgical technical expertise, advanced tissue processing, and data acquisition. This review compares several described models and aims (building on our personal experiences) to practically aid the investigators who want to utilize mouse models of vein graft failure.
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49
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Desai M, Mirzay-Razzaz J, von Delft D, Sarkar S, Hamilton G, Seifalian AM. Inhibition of neointimal formation and hyperplasia in vein grafts by external stent/sheath. Vasc Med 2010; 15:287-97. [DOI: 10.1177/1358863x10366479] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Synthetic and to a lesser extent vein graft failure is still a major problem in the treatment of peripheral arterial disease, with neointimal hyperplasia being the main cause for graft occlusion in the medium and long term. This review aims to establish the current status of external stents or sheaths in the prevention of intimal hyperplasia in small diameter (< 6 mm) vein grafts.
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Affiliation(s)
- Mital Desai
- Centre for Nanotechnology and Regenerative Medicine, Division of Surgery & Interventional Science, University College London, London, UK, Cardiovascular Haemodynamic Group, University College London, London, UK
| | - Jalaledin Mirzay-Razzaz
- Centre for Nanotechnology and Regenerative Medicine, Division of Surgery & Interventional Science, University College London, London, UK, Cardiovascular Haemodynamic Group, University College London, London, UK
| | - Dirk von Delft
- Christiaan Barnard Division of Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa
| | - Sandip Sarkar
- Centre for Nanotechnology and Regenerative Medicine, Division of Surgery & Interventional Science, University College London, London, UK
| | - George Hamilton
- Vascular Unit, Royal Free Hampstead NHS Trust Hospital, London, UK
| | - Alexander M Seifalian
- Centre for Nanotechnology and Regenerative Medicine, Division of Surgery & Interventional Science, University College London, London, UK, Cardiovascular Haemodynamic Group, University College London, London, UK,
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50
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Abstract
Despite increasing competition from percutaneous interventions and other novel methods of non-surgical coronary revascularization, coronary artery bypass grafting (CABG) remains one of the most definitive and durable treatments for coronary artery disease, especially for those patients with extensive and diffuse disease. In recent years the CABG procedure itself has undergone innovation and evolution. This review article provides a brief historical perspective on the procedure, and examines the current state of modern variations including off-pump, limited-access, and robotic-assisted CABG.
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Affiliation(s)
- Frank W Sellke
- Department of Cardiothoracic Surgery, Alpert Medical School of Brown University, Providence, RI, USA.
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