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Milutinović A, Klajević J, Živković I, Milošević N, Gradinac S, Stanković S, Antonić Ž, Tomić S, Šljivo A, Perič M, Bojić M, Radoičić D. Early Experiences of Serbian Surgeons Using No-Touch Technique for Vein Conduits in CABG Patients: A Follow-Up Study with Multi-Slice CT Angiography. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1427. [PMID: 39336468 PMCID: PMC11434431 DOI: 10.3390/medicina60091427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Revised: 08/25/2024] [Accepted: 08/30/2024] [Indexed: 09/30/2024]
Abstract
Background and Objectives: The saphenous vein graft (SVG) remains the most frequently used conduit worldwide, despite its common disadvantage of early graft failure. To solve the problem and reduce the SVG damage, Souza implemented a new technique where a vein is harvested with surrounding fascia and fat tissue (the so-called no-touch technique). Materials and Methods. A prospective study conducted from February 2019 to June 2024 included 23 patients who underwent myocardial revascularization using a no-touch vein, with follow-up control examinations using computed tomographic angiography to detect graft stenosis or occlusion. Results. Of the entire patient group, 17 (73.9%) were male, with a mean age of 67.39 ± 7.71 years. The mean follow-up period was 25 months. There were no major adverse cardiovascular or cerebrovascular events (MACCEs) during hospitalization, although one patient died in the hospital. Another patient died due to malignancy, but no MACCEs occurred during the follow-up period. According to multi-slice CT coronary angiography, the results were impeccable, with an astonishing 100% patency observed in all 20 IMA grafts and 58 no-touch SVGs examined. Conclusions. The excellent patency rate during the early follow-up period confirmed that the no-touch technique is a good option for surgical revascularization.
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Affiliation(s)
- Aleksandar Milutinović
- Cardiovascular Institute “Dedinje”, 11000 Belgrade, Serbia; (A.M.); (J.K.)
- Faculty of Medicine, University of Belgrade, 11001 Belgrade, Serbia
| | - Jelena Klajević
- Cardiovascular Institute “Dedinje”, 11000 Belgrade, Serbia; (A.M.); (J.K.)
| | - Igor Živković
- Cardiovascular Institute “Dedinje”, 11000 Belgrade, Serbia; (A.M.); (J.K.)
| | - Nemanja Milošević
- Cardiovascular Institute “Dedinje”, 11000 Belgrade, Serbia; (A.M.); (J.K.)
| | - Siniša Gradinac
- Cardiovascular Institute “Dedinje”, 11000 Belgrade, Serbia; (A.M.); (J.K.)
| | - Stefan Stanković
- Cardiovascular Institute “Dedinje”, 11000 Belgrade, Serbia; (A.M.); (J.K.)
| | - Želimir Antonić
- Cardiovascular Institute “Dedinje”, 11000 Belgrade, Serbia; (A.M.); (J.K.)
| | - Slobodan Tomić
- Cardiovascular Institute “Dedinje”, 11000 Belgrade, Serbia; (A.M.); (J.K.)
| | - Armin Šljivo
- Clinical Center of University of Sarajevo, 71000 Sarajevo, Bosnia and Herzegovina
| | - Miodrag Perič
- Cardiovascular Institute “Dedinje”, 11000 Belgrade, Serbia; (A.M.); (J.K.)
| | - Milovan Bojić
- Cardiovascular Institute “Dedinje”, 11000 Belgrade, Serbia; (A.M.); (J.K.)
| | - Dragana Radoičić
- Cardiovascular Institute “Dedinje”, 11000 Belgrade, Serbia; (A.M.); (J.K.)
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Mikami T, Dashwood MR, Kawaharada N, Furuhashi M. An Obligatory Role of Perivascular Adipose Tissue in Improved Saphenous Vein Graft Patency in Coronary Artery Bypass Grafting. Circ J 2024; 88:845-852. [PMID: 37914280 DOI: 10.1253/circj.cj-23-0581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
The gold standard graft for coronary artery bypass grafting (CABG) is the internal thoracic artery (ITA), and the second recommendation is the radial artery. However, complete revascularization with arterial grafts alone is often difficult, and the saphenous vein (SV) is the most commonly used autologous graft for CABG, because it is easier to use without restriction for the length of the graft. On the other hand, the patency of SV grafts (SVGs) is poor compared with that of arterial grafts. The SVG is conventionally harvested as a distended conduit with surrounding tissue removed, a procedure that may cause vascular damage. A no-touch technique of SVG harvesting has been reported to result in improved long-term patency in CABG comparable to that when using the ITA for grafting. Possible reasons for the excellent long-term patency of no-touch SVGs are the physical support provided by preserved surrounding perivascular adipose tissue, preservation of the vascular wall structure including the vasa vasorum, and production of adipocyte-derived factors. In this review, we discuss recent strategies aimed at improving the performance of SVGs, including no-touch harvesting, minimally invasive harvesting and mechanical support using external stents.
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Affiliation(s)
- Takuma Mikami
- Department of Cardiovascular Surgery, Sapporo Medical University
| | - Michael R Dashwood
- Surgical and Interventional Sciences, Royal Free Hospital Campus, University College London Medical School
| | | | - Masato Furuhashi
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University
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3
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Behr JM, Wong YS, Venkatraman S. Small-Diameter Blood Vessel Substitutes: Biomimetic Approaches to Improve Patency. Biomimetics (Basel) 2024; 9:97. [PMID: 38392143 PMCID: PMC10886630 DOI: 10.3390/biomimetics9020097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 12/22/2023] [Accepted: 01/04/2024] [Indexed: 02/24/2024] Open
Abstract
Small-dimeter blood vessels (<6 mm) are required in coronary bypass and peripheral bypass surgery to circumvent blocked arteries. However, they have poor patency rates due to thrombus formation, intimal hyperplasia at the distal anastomosis, and compliance mismatch between the native artery and the graft. This review covers the state-of-the-art technologies for improving graft patency with a focus on reducing compliance mismatch between the prosthesis and the native artery. The focus of this article is on biomimetic design strategies to match the compliance over a wide pressure range.
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Affiliation(s)
- Jean-Marc Behr
- SMD Swiss Medical Devices AG, 8222 Beringen, Switzerland
| | - Yee Shan Wong
- Biomedical Engineering, School of Engineering, Temasek Polytechnic, Singapore 529757, Singapore
| | - Subbu Venkatraman
- Materials Science and Engineering, National University of Singapore, Singapore 117575, Singapore
- iHealthTech, National University of Singapore, Singapore 117599, Singapore
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Chen H, Wang Z, Si K, Wu X, Ni H, Tang Y, Liu W, Wang Z. External stenting for saphenous vein grafts in coronary artery bypass grafting: A meta-analysis. Eur J Clin Invest 2023; 53:e14046. [PMID: 37395498 DOI: 10.1111/eci.14046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/03/2023] [Accepted: 06/17/2023] [Indexed: 07/04/2023]
Abstract
OBJECTIVES Autologous saphenous vein grafts (SVGs) are the most commonly used bypass conduits in coronary artery bypass grafting (CABG) with multivessel coronary artery disease. Although external support devices for SVGs have shown promising outcomes, the overall efficacy and safety remains controversial. We aimed to evaluate external stenting for SVGs in CABG versus non-stented SVGs. METHODS MEDLINE, EMBASE, Cochrane Library and clinicaltrails.gov were searched for randomized controlled trials (RCTs) to evaluate external-stented SVGs versus non-stented SVGs in CABG up to 31 August 2022. The risk ratio and mean difference with 95% confidence interval were analysed. The primary efficacy outcomes included intimal hyperplasia area and thickness. The secondary efficacy outcomes were graft failure (≥50% stenosis) and lumen diameter uniformity. RESULTS We pooled 438 patients from three RCTs. The external stented SVGs group showed significant reductions in intimal hyperplasia area (MD: -0.78, p < 0.001, I2 = 0%) and thickness (MD: -0.06, p < 0.001, I2 = 0%) compared to the non-stented SVGs group. Meanwhile, external support devices improved lumen uniformity with Fitzgibbon I classification (risk ratio (RR):1.1595, p = 0.05, I2 = 0%). SVG failure rates were not increased in the external stented SVGs group during the short follow-up period (RR: 1.14, p = 0.38, I2 = 0%). Furthermore, the incidences of mortality and major cardiac and cerebrovascular events were consistent with previous reports. CONCLUSIONS External support devices for SVGs significantly reduced the intimal hyperplasia area and thickness, and improved the lumen uniformity, assessed with the Fitzgibbon I classification. Meanwhile, they did not increase the overall SVG failure rate.
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Affiliation(s)
- Huiru Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Jiangsu Province, China
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zilan Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Jiangsu Province, China
| | - Ke Si
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaoxiao Wu
- Suzhou Medical College of Soochow University, Suzhou, China
| | - Hanyu Ni
- Suzhou Medical College of Soochow University, Suzhou, China
| | - Yanbing Tang
- Suzhou Medical College of Soochow University, Suzhou, China
| | - Wei Liu
- Department of Medicine, The Tianjin North China Hospital, Tianjin, China
| | - Zhong Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Jiangsu Province, China
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Dashwood MR, Samano N, Souza DS. Saphenous vein harvesting for CABG: wear a VEST or keep the fat? EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2022; 62:6608695. [PMID: 35703951 DOI: 10.1093/ejcts/ezac349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 06/13/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Michael R Dashwood
- Surgical and Interventional Sciences, Royal Free Hospital Campus, University College Medical School, London, UK
| | - Ninos Samano
- Department of Cardiothoracic and Vascular Surgery and University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Domingos S Souza
- Department of Cardiothoracic and Vascular Surgery and University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Maselli D, Garoffolo G, Cassanmagnago GA, Vono R, Ruiter MS, Thomas AC, Madeddu P, Pesce M, Spinetti G. Mechanical Strain Induces Transcriptomic Reprogramming of Saphenous Vein Progenitors. Front Cardiovasc Med 2022; 9:884031. [PMID: 35711359 PMCID: PMC9197233 DOI: 10.3389/fcvm.2022.884031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/28/2022] [Indexed: 11/23/2022] Open
Abstract
Intimal hyperplasia is the leading cause of graft failure in aortocoronary bypass grafts performed using human saphenous vein (SV). The long-term consequences of the altered pulsatile stress on the cells that populate the vein wall remains elusive, particularly the effects on saphenous vein progenitors (SVPs), cells resident in the vein adventitia with a relatively wide differentiation capacity. In the present study, we performed global transcriptomic profiling of SVPs undergoing uniaxial cyclic strain in vitro. This type of mechanical stimulation is indeed involved in the pathology of the SV. Results showed a consistent stretch-dependent gene regulation in cyclically strained SVPs vs. controls, especially at 72 h. We also observed a robust mechanically related overexpression of Adhesion Molecule with Ig Like Domain 2 (AMIGO2), a cell surface type I transmembrane protein involved in cell adhesion. The overexpression of AMIGO2 in stretched SVPs was associated with the activation of the transforming growth factor β pathway and modulation of intercellular signaling, cell-cell, and cell-matrix interactions. Moreover, the increased number of cells expressing AMIGO2 detected in porcine SV adventitia using an in vivo arterialization model confirms the upregulation of AMIGO2 protein by the arterial-like environment. These results show that mechanical stress promotes SVPs' molecular phenotypic switching and increases their responsiveness to extracellular environment alterations, thus prompting the targeting of new molecular effectors to improve the outcome of bypass graft procedure.
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Affiliation(s)
- Davide Maselli
- IRCCS MultiMedica, Milan, Italy
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Gloria Garoffolo
- Unità di Ingegneria Tissutale Cardiovascolare, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Giada Andrea Cassanmagnago
- IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | | | - Matthijs S. Ruiter
- Unità di Ingegneria Tissutale Cardiovascolare, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Anita C. Thomas
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Paolo Madeddu
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Maurizio Pesce
- Unità di Ingegneria Tissutale Cardiovascolare, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Gaia Spinetti
- IRCCS MultiMedica, Milan, Italy
- *Correspondence: Gaia Spinetti
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Dashwood MR, Pinheiro BB, Souza DSR. Thirty Years of No-Touch Saphenous Vein Harvesting: A Timely Jubilee Gift. Circulation 2022; 145:319-320. [PMID: 35100022 DOI: 10.1161/circulationaha.121.057959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Michael R Dashwood
- Surgical and Interventional Sciences, Royal Free Hospital Campus, University College London Medical School, United Kingdom (M.R.D.)
| | - Bruno Botelho Pinheiro
- Department of Cardiovascular Surgery, Hospital do Coração Anis Rassi, Goiânia, Goiás, Brazil (B.B.P.)
| | - Domingos S R Souza
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Sweden (D.S.R.S.)
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Xiaohe W, Yuanyuan Z, Zhen L, Guocun H. A modified no-touch technique for anastomosis to create a radiocephalic arteriovenous fistula. J Vasc Surg Cases Innov Tech 2021; 7:686-690. [PMID: 34746531 PMCID: PMC8556484 DOI: 10.1016/j.jvscit.2021.08.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/31/2021] [Indexed: 11/19/2022] Open
Abstract
The application of a no-touch technique to create an autologous radiocephalic arteriovenous fistula might improve the patency rate. In the present report, we have expanded the concept of the no-touch technique by introducing a modified no-touch technique in which we preserve the perivenous vascular tissue, followed by a functional end-to-side anastomosis to create a radiocephalic arteriovenous fistula with early maturation for hemodialysis.
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9
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Pinheiro BB, Dashwood M, Souza DSR. The "No-touch" Harvesting Technique Revives the Position of the Saphenous Vein as an Important Conduit in CABG Surgery: 30-year Anniversary. Braz J Cardiovasc Surg 2021; 36:I-III. [PMID: 34673522 PMCID: PMC8597598 DOI: 10.21470/1678-9741-2021-0959] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Bruno Botelho Pinheiro
- Department of Cardiovascular Surgery, Hospital do Coração Anis Rassi, Goiânia, Goiás, Brazil
| | - Michael Dashwood
- Surgical and Interventional Sciences, Royal Free Hospital Campus, University College London Medical School, London, United Kingdom
| | - Domingos S R Souza
- Department of Cardiovascular Surgery, Hospital do Coração Anis Rassi, Goiânia, Goiás, Brazil.,Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Kim MS, Kim KB. Reopening of the occluded saphenous vein composite grafts after coronary artery bypass grafting. J Card Surg 2021; 36:4061-4067. [PMID: 34436786 DOI: 10.1111/jocs.15936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 08/12/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND We have observed reopening of the occluded "no-touch" saphenous vein (NT SV) composite grafts on follow-up angiograms in patients who underwent coronary artery bypass graftings (CABGs). METHODS Between 2008 and 2018, 1283 patients received NT SV conduits without or with surrounding pedicle tissue as composite grafts based on the in situ left internal thoracic artery (ITA) for CABG and underwent early postoperative angiographies. Among the 1283 patients, 53 patients showed 55 occluded SV conduit anastomoses, and 46 patients who had 48 occluded SV anastomoses were re-evaluated by 1-year postoperative angiographies. RESULTS Early postoperative angiographies in 1283 patients demonstrated overall occlusion rates of 1.2% (56/4518); occlusion rates of the ITA and SV were 0.08% (1/1259) and 1.7% (55/3260), respectively. One-year angiograms demonstrated that 14 occluded SV anastomoses (29.2% [14/48 occluded SV]) of 14 patients became patent. Reopening of occluded SV conduits occurred more frequently in NT SV with pedicle tissue than in NT SV without pedicle tissue (45.0% [9/20] vs. 17.9% [5/28]; p = .057). When we examined the preoperative and 1-year postoperative angiograms, reopening of the occluded SV conduits was not related with progression (p = .258) or preoperative reversibility score (p = .115) of native target coronary artery disease. CONCLUSIONS More than a quarter of the occluded SV composite grafts on early postoperative angiograms were patent in the 1-year angiograms. The reopening rates were higher in patients who had received NT SV conduits with pedicle tissue than those who had received NT SV conduits without pedicle tissue.
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Affiliation(s)
- Min-Seok Kim
- Department of Thoracic and Cardiovascular Surgery, Hanseo Hospital, Busan, Korea
| | - Ki-Bong Kim
- Cardiovascular Center, Myongji Hospital, Goyang-si, Gyeonggi-do, Korea
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11
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Dashwood MR, Loesch A, Souza DS. HArVeSTing vein grafts under different preparative techniques: Raising more questions than answers. J Card Surg 2021; 36:3019-3020. [PMID: 33938585 DOI: 10.1111/jocs.15594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 03/29/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Michael R Dashwood
- Surgical and Interventional Sciences, Royal Free Hospital Campus, University College Medical School, London, UK
| | - Andrzej Loesch
- Centre for Rheumatology, Royal Free Hospital Campus, University College Medical School, London, UK
| | - Domingos S Souza
- Department of Cardiothoracic and Vascular Surgery, Örebro University, Örebro, Sweden
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12
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What is the impact of preserving the endothelium on saphenous vein graft performance? Comments on the 'NO' touch harvesting technique. J Cardiothorac Surg 2021; 16:21. [PMID: 33726786 PMCID: PMC7968164 DOI: 10.1186/s13019-021-01397-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/04/2021] [Indexed: 11/15/2022] Open
Abstract
Saphenous veins used for coronary artery bypass surgery are subjected to considerable vascular trauma when harvested by conventional methods. This vascular damage is responsible, at least in part, for the inferior patency of the saphenous vein when compared with the internal thoracic artery. The performance of saphenous vein grafts is improved when this conduit is harvested atraumatically using the no-touch technique. There is growing evidence that the success of the no-touch technique is due to the preservation of a number of vascular structures including the endothelium, vasa vasorum and perivascular fat. There is conflicting evidence regarding the degree of endothelial damage to the endothelium of conventional versus no-touch saphenous vein grafts. In general, it has been shown that this single layer of cells lining the lumen exhibits considerable damage associated with a combination of vascular trauma and high pressure intraluminal distension. Increased platelet aggregation and thrombus formation at the exposed subendothelial membrane is due to a local reduction of endothelium-derived factors including nitric oxide. In addition, damage to the vasa vasorum of conventionally-harvested veins will reduce transmural blood flow, a condition shown to promote neointimal hyperplasia and atheroma formation. By stripping off the perivascular fat during conventional harvesting, mechanical support of the graft is reduced and the source of adipocyte-derived factors potentially beneficial for graft patency removed. While most agree that endothelial damage to the saphenous vein affects graft patency, the contribution of other tissue-derived factors affected by vascular damage at harvesting need to be considered.
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Lima ML, Silva HSM, Lougon LN, Barros FS, Gomes WJ. Remodeling of ipsilateral ulnar artery after radial artery harvesting for coronary artery bypass graft. Can J Physiol Pharmacol 2021; 99:231-236. [PMID: 33590782 DOI: 10.1139/cjpp-2020-0432] [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] [Indexed: 11/22/2022]
Abstract
There are controversies in the literature on the blood supply to the forearm after surgical removal of the radial artery in coronary artery bypass grafting (CABG). The objective was to investigate the arterial remodeling of the ulnar artery after the removal of the radial artery in myocardial revascularization by means of ultrasound examination with color Doppler in the pre- and post-operative periods. This paper describes an observational prospective study of the remodeling of the left brachial and ulnar arteries (donor arm) in 103 right-handed non-consecutive adult patients undergoing CABG with removal of the ipsilateral radial artery using the color Doppler ultrasound examination. In the ulnar artery, a significant increase (P < 0.05) was seen in the following measurements: lumen diameter by 13%, lumen area by 26%, peak systolic flow by 40%, and average flow by 46%. Intima-media thickness measured in the ulnar artery did not show a statistically significant difference (P = 0.22), except in diabetic patients (P = 0.007). We conclude that the ulnar artery undergoes positive physiological remodeling, adapting to the new requirements of chronic increase in flow after the ipsilateral removal of the radial artery to serve as a graft in CABG. There was no evidence of increased intima-media thickness, except in diabetic patients.
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Affiliation(s)
- Melchior L Lima
- Cardiovascular Surgery Center, Meridional Hospital, R. Meridional, 200 - Alto Lage, Cariacica, Espírito Santo, 29151-920, Brazil
| | - Héber S M Silva
- Cardiovascular Surgery Center, Meridional Hospital, R. Meridional, 200 - Alto Lage, Cariacica, Espírito Santo, 29151-920, Brazil
| | - Lourival N Lougon
- Cardiovascular Surgery Center, Meridional Hospital, R. Meridional, 200 - Alto Lage, Cariacica, Espírito Santo, 29151-920, Brazil
| | - Fanilda S Barros
- Cardiovascular Surgery Center, Meridional Hospital, R. Meridional, 200 - Alto Lage, Cariacica, Espírito Santo, 29151-920, Brazil
| | - Walter J Gomes
- Discipline of Cardiovascular Surgery, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, SP, Brazil
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Samano N, Souza D, Dashwood MR. Saphenous veins in coronary artery bypass grafting need external support. Asian Cardiovasc Thorac Ann 2020; 29:457-467. [PMID: 33307718 PMCID: PMC8167919 DOI: 10.1177/0218492320980936] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The saphenous vein is the most commonly used conduit for coronary artery bypass grafting. Arterial grafts are harvested with the outer pedicle intact whereas saphenous veins are harvested with the pedicle removed in the conventional graft harvesting technique. This conventional procedure causes considerable vascular damage. One strategy to improve vein graft patency has been to provide external support. Ongoing studies show that fitting a metal external support improves conventionally harvested saphenous vein graft patency. On the other hand, the no-touch technique of harvesting the saphenous vein provides an improved graft with long-term patency comparable to that of the internal mammary artery. This improvement is suggested to be due to preservation of vessel structures. Interestingly, many of the mechanisms proposed to be associated with the beneficial actions of an artificial external support on saphenous vein graft patency are similar to those underlying the beneficial effect of no-touch saphenous vein grafts where the intact outer layer acts as a natural support. Additional actions of external supports have been advocated, including promotion of angiogenesis, increased production of vascular-protective factors, and protection of endothelial cells. Using no-touch harvesting, normal vascular architecture is maintained, tissue and cell damage is minimized, and factors beneficial for graft patency are preserved. In this review, the significance of external support of saphenous vein grafts in coronary artery bypass grafting is discussed.
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Affiliation(s)
- Ninos Samano
- Department of Cardiothoracic and Vascular Surgery and University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Domingos Souza
- Department of Cardiothoracic and Vascular Surgery and University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Michael R Dashwood
- Surgical and Interventional Sciences, Royal Free Hospital Campus, University College Medical School, London, UK
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15
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Topal G, Loesch A, Dashwood MR. COVID-19 - Endothelial Axis and Coronary Artery Bypass Graft Patency: a Target for Therapeutic Intervention? Braz J Cardiovasc Surg 2020; 35:757-763. [PMID: 33118741 PMCID: PMC7598985 DOI: 10.21470/1678-9741-2020-0303] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
It has been reported that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection induces endothelial inflammation, therefore facilitating the progression of endothelial and vascular dysfunction in coronavirus disease 2019 (COVID-19) patients. Coronary artery bypass grafting (CABG) involves mainly the use of the saphenous vein (SV) and internal mammary artery as graft material in the stenosed coronary arteries. Unfortunately, graft patency of the SV is low due to endothelial dysfunction and inflammation. We propose that SARS-CoV-2 might cause vascular inflammation, endothelial dysfunction, and thrombosis in coronary artery bypass graft vessels by binding angiotensin-converting enzyme 2 receptor. Therefore, in this Special Article, we consider the potential influence of COVID-19 on the patency rates of coronary artery bypass graft vessels, mainly with reference to the SV. Moreover, we discuss the technique of SV graft harvesting and the therapeutic potential of focusing on endothelial dysfunction, vascular inflammation, and thrombosis for protecting coronary artery bypass grafts in COVID-19 infected CABG patients.
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Affiliation(s)
- Gokce Topal
- Istanbul University Faculty of Pharmacy Department of Pharmacology Istanbul Turkey Department of Pharmacology, Faculty of Pharmacy, Istanbul University, Istanbul, Turkey
| | - Andrzej Loesch
- University College Medical School Royal Free Hospital Campus Centre for Rheumatology London United Kingdom Centre for Rheumatology, Royal Free Hospital Campus, University College Medical School, London, United Kingdom
| | - Michael R Dashwood
- University College Medical School Royal Free Hospital Campus Department of Surgical and Interventional Sciences London United Kingdom Department of Surgical and Interventional Sciences, Royal Free Hospital Campus, University College Medical School, London, United Kingdom
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16
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Abstract
Revascularization surgeries such as coronary artery bypass grafting (CABG) are sometimes necessary to manage coronary heart disease (CHD). However, more than half of these surgeries fail within 10 years due to the development of intimal hyperplasia (IH) among others. The cytokine transforming growth factor-beta (TGFß) and its signaling components have been found to be upregulated in diseased or injured vessels, and to promote IH after grafting. Interventions that globally inhibit TGFß in CABG have yielded contrasting outcomes in in vitro and in vivo studies including clinical trials. With advances in molecular biology, it becomes clear that TGFß exhibits both protective and damaging roles, and only specific components such as some Smad-dependent TGFß signaling mediate vascular IH. The activin receptor-like kinase (ALK)-mediated Smad-dependent TGFß signaling pathways have been found to be activated in human vascular smooth muscle cells (VSMCs) following injury and in hyperplastic preimplantation vein grafts. It appears that focused targeting of TGFß pathway constitutes a promising therapeutic target to improve the outcome of CABG. This study dissects the role of TGFß pathway in CABG failure, with particular emphasis on the therapeutic potentials of specific targeting of Smad-dependent and ALK-mediated signaling.
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Affiliation(s)
- Marzuq A Ungogo
- Department of Veterinary Pharmacology and Toxicology, 58989Ahmadu Bello University, Zaria, Nigeria.,Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
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17
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Samano N, Souza D, Pinheiro BB, Kopjar T, Dashwood M. Twenty-Five Years of No-Touch Saphenous Vein Harvesting for Coronary Artery Bypass Grafting: Structural Observations and Impact on Graft Performance. Braz J Cardiovasc Surg 2020; 35:91-99. [PMID: 32270965 PMCID: PMC7089755 DOI: 10.21470/1678-9741-2019-0238] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The saphenous vein is the most common conduit used in coronary artery bypass grafting (CABG) yet its failure rate is higher compared to arterial grafts. An improvement in saphenous vein graft performance is therefore a major priority in CABG. No-touch harvesting of the saphenous vein is one of the few interventions that has shown improved patency rates, comparable to that of the left internal thoracic artery. After more than two decades of no-touch research, this technique is now recognized as a Class IIa recommendation in the 2018 European Society of Cardiology and the European Association for Cardio-Thoracic Surgery guidelines on myocardial revascularization. In this review, we describe the structural alterations that occur in conventional versus no-touch saphenous vein grafts and how these changes affect graft patency. In addition, we discuss various strategies aimed at repairing saphenous vein grafts prepared at conventional CABG.
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Affiliation(s)
- Ninos Samano
- Örebro University Faculty of Medicine and Health Örebro Sweden Department of Cardiothoracic and Vascular Surgery and University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Domingos Souza
- Örebro University Faculty of Medicine and Health Department of Cardiothoracic and Vascular Surgery Örebro Sweden Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Bruno Botelho Pinheiro
- Hospital do Coração Anis Rassi Department Cardiovascular Surgery Goiânia GO Brazil Department Cardiovascular Surgery, Hospital do Coração Anis Rassi, Goiânia, GO, Brazil
| | - Tomislav Kopjar
- University Hospital Centre Zagreb University of Zagreb School of Medicine Department of Cardiac Surgery Zagreb Croatia Department of Cardiac Surgery, University of Zagreb School of Medicine and University Hospital Centre Zagreb, Zagreb, Croatia
| | - Michael Dashwood
- University College London Medical School Royal Free Hospital Campus Surgical and Interventional Sciences London UK Surgical and Interventional Sciences, Royal Free Hospital Campus, University College London Medical School, London, UK
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18
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Behr J, Irvine SA, Thwin C, Shah AH, Bae MK, Zussman E, Venkatraman S. Matching Static and Dynamic Compliance of Small‐Diameter Arteries, with Poly(lactide‐
co
‐caprolactone) Copolymers: In Vitro and In Vivo Studies. Macromol Biosci 2020; 20:e1900234. [DOI: 10.1002/mabi.201900234] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 11/06/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Jean‐Marc Behr
- School of Materials Science and EngineeringNanyang Technological University 50 Nanyang Avenue Singapore 639798 Singapore
| | - Scott Alexander Irvine
- School of Materials Science and EngineeringNanyang Technological University 50 Nanyang Avenue Singapore 639798 Singapore
| | - Chaw‐Su Thwin
- School of Materials Science and EngineeringNanyang Technological University 50 Nanyang Avenue Singapore 639798 Singapore
| | - Ankur Harish Shah
- School of Materials Science and EngineeringNanyang Technological University 50 Nanyang Avenue Singapore 639798 Singapore
| | - Min‐Chul Kraun Bae
- School of Materials Science and EngineeringNanyang Technological University 50 Nanyang Avenue Singapore 639798 Singapore
| | - Eyal Zussman
- Nano Engineering groupFaculty of Mechanical EngineeringTechnion–Israel Institute of Technology Haifa 32000 Israel
| | - Subbu Venkatraman
- School of Materials Science and EngineeringNanyang Technological University 50 Nanyang Avenue Singapore 639798 Singapore
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19
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Špaček M, Měřička P, Janoušek L, Dalecká M, Benda A, Krs O, Slížová D, Špunda R, Hrubý J, Matia I, Honegrová B, Lindner J. Comparison of Different Thawing Protocols in Human Cryopreserved Venous Grafts. Ann Vasc Surg 2019; 64:347-354. [PMID: 31743787 DOI: 10.1016/j.avsg.2019.11.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/12/2019] [Accepted: 11/12/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND The aim of our study was to assess the impact of different thawing protocols on morphological changes arising in cryopreserved human saphenous vein grafts. METHODS The study was performed in 12 saphenous vein grafts harvested in brain death donors. Storage in the vapor phase of liquid nitrogen for 3 or 5 years followed. Two thawing protocols were tested: slow thawing in a refrigerator at temperature +4°C for 2 hr and rapid thawing-in a water bath at +37°C. Grafts were processed for scanning electron microscopy. Comparisons of continuous parameters under study between experimental groups were performed using the t-test (age, cold ischemia time, exposure to cryoprotectant, time of storage, total thawing time, mean thawing rate, morphology scoring of thawed HSVG) and the median test (HSVG length). Categorical parameters (sex and blood group) were formally tested using the chi-square test. RESULTS All samples were evaluated according to morphological changes and scored in terms of morphologically intact endothelium, confluent endothelium with structural inhomogeneity, disruption of the intercellular contacts, separation of the endothelial cells, complete loss of the endothelium, and damage of the subendothelial layers. There is no statistically significant difference between the sample sets at the significance level of 0.05. There was no association with donors' age, sex, and time of storage. CONCLUSIONS Human cryopreserved saphenous vein grafts in our experimental work showed no difference in terms of structural deterioration of the endothelial surface and basal membrane depending on different thawing protocols used.
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Affiliation(s)
- Miroslav Špaček
- 2nd Department of Surgery-Department of Cardiovascular Surgery, 1st Medical Faculty, Charles University and General University Hospital, Prague, Czech Republic.
| | - Pavel Měřička
- Tissue Bank University Hospital Hradec, Hradec Králové, Czech Republic
| | - Libor Janoušek
- Department of Transplantation Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Markéta Dalecká
- Imaging Methods Core Facility at BIOCEV, Faculty of Science, Charles University in Prague, Kralove, Czech Republic
| | - Aleš Benda
- Imaging Methods Core Facility at BIOCEV, Faculty of Science, Charles University in Prague, Kralove, Czech Republic
| | - Otakar Krs
- Department of Anatomy, Faculty of Medicine in Hradec Králové, Charles University in Prague, Hradec Králové, Czech Republic
| | - Dáša Slížová
- Department of Anatomy, Faculty of Medicine in Hradec Králové, Charles University in Prague, Hradec Králové, Czech Republic
| | - Rudolf Špunda
- 2nd Department of Surgery-Department of Cardiovascular Surgery, 1st Medical Faculty, Charles University and General University Hospital, Prague, Czech Republic
| | - Jan Hrubý
- 2nd Department of Surgery-Department of Cardiovascular Surgery, 1st Medical Faculty, Charles University and General University Hospital, Prague, Czech Republic
| | - Ivan Matia
- Department of Cardio-Vascular Surgery, Nord Hospital and Karl Landsteiner Institute for Cardio-Vascular Research, Vienna, Austria
| | - Barbora Honegrová
- Tissue Bank University Hospital Hradec, Hradec Králové, Czech Republic
| | - Jaroslav Lindner
- 2nd Department of Surgery-Department of Cardiovascular Surgery, 1st Medical Faculty, Charles University and General University Hospital, Prague, Czech Republic
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20
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Loesch A, Pinheiro BB, Dashwood MR. Why Use the Radial Artery? The Saphenous Vein is the Second Graft of Choice for CABG in Brazil. Braz J Cardiovasc Surg 2019; 34:480-483. [PMID: 31454203 PMCID: PMC6713382 DOI: 10.21470/1678-9741-2019-0212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The saphenous vein (SV) is the most commonly used conduit for coronary artery bypass surgery (CABG) and the second conduit of choice in Brazil and many other countries. The radial artery (RA) is suggested, by some, to be superior to SV grafts, although its use in the USA declined over a 10 year period. The patency of SV grafts (SVG) is improved when the vein is harvested with minimal trauma using the no-touch (NT) technique. This improved performance is due to the preservation of the outer pedicle surrounding the SV and reduction in vascular damage that occurs when using conventional techniques (CT) of harvesting. While the patency of NT SVGs has been shown superior to the RA at 36 months in one study, data from the RADIAL trial suggests the RA to be the superior conduit. When additional data using NT SVG is included in this trial the difference in risk of graft occlusion between the RA and SV grafts dissipates with there no longer being a significant difference in patency between conduits. The importance of preserving SV structure and the impact of NT harvesting on conduit choice for CABG patients are discussed in this short review.
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Affiliation(s)
- Andrzej Loesch
- University College London Medical School Centre for Rheumatology London United Kingdom Centre for Rheumatology, University College London Medical School, London, United Kingdom
| | - Bruno Botelho Pinheiro
- Hospital do Coração Anis Rassi Department of Cardiovascular Surgery Goiânia GO Brazil Department of Cardiovascular Surgery, Hospital do Coração Anis Rassi, Goiânia, GO, Brazil
| | - Michael Richard Dashwood
- University College London Medical School Surgical and Interventional Sciences London United Kingdom Surgical and Interventional Sciences, University College London Medical School, London, United Kingdom
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21
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Inaba Y, Yamazaki M, Ohono M, Yamashita K, Izumida H, Hayashi K, Takahashi T, Kimura N, Ito T, Shimizu H. No-touch saphenous vein graft harvesting technique for coronary artery bypass grafting. Gen Thorac Cardiovasc Surg 2019; 68:248-253. [PMID: 31376117 DOI: 10.1007/s11748-019-01186-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 07/28/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Although the patency of internal artery grafts in coronary artery bypass grafting (CABG) is superior to that of saphenous vein grafts (SVGs), good long-term patency rates have been reported with SVGs harvested using the no-touch technique. Here, we report the early results of CABG with no-touch SVGs (NT-SVGs) along with the precautions required while handling these grafts. METHODS This retrospective study included 41 patients who underwent CABG with NT-SVGs between May 2016 and March 2018. NT-SVGs were harvested with minimal electric scalpel use, and post-harvesting vascular overdilation with a syringe was not performed. Blood with heparinized saline was used to prevent vascular endothelial damage. A drain was inserted into the SVG harvest site, which was closed with a single interrupted suture, and elasticated bandage and compression stockings were used to prevent fluid retention and avoid delayed wound healing. RESULTS There was no case of postoperative thoracotomy due to bleeding or myocardial infarction, and postoperative graft assessment confirmed graft patency in all patients, with a little mismatch between the diameters of SVG and the anastomotic vessel. Delayed wound healing at the graft harvest site seemed to improve after introducing the above procedures. CONCLUSIONS Early results of CABG with NT-SVGs were good. Some precautions must be taken during harvesting and anastomosis. Taking precautions described in this study may help reduce the risk of perioperative complications and make the no-touch technique the standard procedure for harvesting SVGs for CABG.
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Affiliation(s)
- Yu Inaba
- Department of Cardiovascular Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Masataka Yamazaki
- Department of Cardiovascular Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.
| | - Masatoshi Ohono
- Department of Cardiovascular Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Kentaro Yamashita
- Department of Cardiovascular Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Hiroaki Izumida
- Department of Cardiovascular Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Kanako Hayashi
- Department of Cardiovascular Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Tatsuo Takahashi
- Department of Cardiovascular Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Naritaka Kimura
- Department of Cardiovascular Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Tsutomu Ito
- Department of Cardiovascular Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Hideyuki Shimizu
- Department of Cardiovascular Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
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23
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Dashwood MR. Why 'EXTENT' for coronary artery bypass surgery when the saphenous vein should need no support? Eur J Cardiothorac Surg 2019; 55:1021. [PMID: 30534985 DOI: 10.1093/ejcts/ezy412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 11/06/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Michael R Dashwood
- Division of Surgery and Interventional Science, University College London Medical School, London, UK
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24
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Dashwood MR, Loesch A. Arterial versus venous conduits in coronary artery bypass surgery: Comparing apples with oranges. J Thorac Cardiovasc Surg 2019; 157:e253-e254. [PMID: 30745049 DOI: 10.1016/j.jtcvs.2018.11.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 11/13/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Michael R Dashwood
- Surgical and Interventional Sciences, Royal Free Hospital Campus, University College Medical School, London, United Kingdom
| | - Andrzej Loesch
- Centre for Rheumatology, Royal Free Hospital Campus, University College Medical School, London, United Kingdom
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25
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Hastaoğlu İO, Toköz H, Özgen A, Bilgen F. Comparison of the one-year patency rates of radiocephalic arteriovenous fistulas created using no-touch versus conventional technique. TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2019; 27:43-48. [PMID: 32082826 PMCID: PMC7021369 DOI: 10.5606/tgkdc.dergisi.2019.16136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 09/21/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND This study aims to compare the patency rates of radiocephalic arteriovenous fistulas prepared preserving the perivenous vascular tissues versus those prepared using the conventional technique. METHODS A total of 169 patients (107 males, 62 females; mean age 59.5 years; range, 39 to 87 years) who underwent a radiocephalic arteriovenous fistula construction were included in this study. In 95 patients, the tissues surrounding the cephalic vein were stripped off as per the conventional method, while the no-touch technique preserving the perivenous vascular tissues was utilized for vein harvesting in 74 patients. Patients were followed-up to compare primary and secondary patency rates of the arteriovenous fistulas at one year. RESULTS Fistula failure developed in 22 patients within the first year resulting in primary patency rates of 90.5% versus 84.2% for the no-touch and the conventional groups, respectively (p=0.225). Likewise, secondary patency rates were 94.6% versus 93.7% for the no-touch and the conventional groups, respectively (p=0.803). The two groups did not differ with regards to primary or secondary patency rates. CONCLUSION Findings of this study were not in favor of the no-touch technique compared to the conventional methods in terms of arteriovenous fistula patency at one year.
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Affiliation(s)
| | - Hamdi Toköz
- Department of Cardiovascular Surgery, Private Erdem Hospital, Istanbul, Turkey
| | - Ayça Özgen
- Department of Cardiovascular Surgery, Private Erdem Hospital, Istanbul, Turkey
| | - Fuat Bilgen
- Department of Cardiovascular Surgery, Private Erdem Hospital, Istanbul, Turkey
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26
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Saphenous vein: advances. Indian J Thorac Cardiovasc Surg 2018; 34:251-257. [PMID: 33060946 DOI: 10.1007/s12055-018-0753-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 09/24/2018] [Accepted: 09/26/2018] [Indexed: 10/28/2022] Open
Abstract
Although the saphenous vein (SV) is a widely used conduit for coronary artery bypass graft surgery (CABG), lower long-term graft patency rates and worse clinical outcomes have been reported after CABG performed with SV grafts compared with CABG performed with internal thoracic artery (ITA) grafts. Of various efforts to overcome the limitations of SV that are resulting from structural and functional differences from arterial conduit, recent improvement in harvesting techniques including no-touch technique, surgical strategy of using the SV as part of a composite graft over an aortocoronary bypass graft, and external stenting of the SV will be discussed in this topic.
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Kopjar T, Dashwood MR, Dreifaldt M, de Souza DR. No-touch saphenous vein as an important conduit of choice in coronary bypass surgery. J Thorac Dis 2018; 10:S3292-S3296. [PMID: 30370141 DOI: 10.21037/jtd.2018.08.127] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Tomislav Kopjar
- Department of Cardiac Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Michael Richard Dashwood
- Surgical and Interventional Sciences, Royal Free Hospital Campus, University College Medical School, London, UK
| | - Mats Dreifaldt
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Domingos Ramos de Souza
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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28
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Samano N, Dashwood M, Souza D. No-touch vein grafts and the destiny of venous revascularization in coronary artery bypass grafting-a 25 th anniversary perspective. Ann Cardiothorac Surg 2018; 7:681-685. [PMID: 30505753 DOI: 10.21037/acs.2018.05.15] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Ischemic heart disease is currently the leading cause of death globally, with coronary artery bypass grafting among the most common operations performed worldwide. More extensive use of arterial grafts has been advocated because of their high long-term patency, long-term survival benefit, and freedom from reinterventions. Despite this, the saphenous vein is the most frequently used conduit in patients undergoing coronary artery bypass surgery since its introduction over 50 years ago. Consequently, the saphenous vein remains an indispensable conduit in coronary artery bypass grafting and maintaining its long-term patency is one of the most crucial challenges in cardiovascular surgery. This situation led to the development of the no-touch saphenous vein harvesting technique, where the vein is harvested completely with its pedicle of surrounding tissue. Several studies report a superior long-term patency rate, slower progression of atherosclerosis, and better clinical outcomes whilst employing no-touch harvesting technique. The success of the technique is multifactorial, including the decreased risk for graft spasm-and the need for manual distension-preservation of the vaso vasorum and an intact endothelium, reducing neointimal hyperplasia and subsequent atherosclerosis. Furthermore, the intact perivascular tissue, including the surrounding cushion of fat, may act as a "natural external stent", providing mechanical support preventing the graft from kinking. We are convinced that the use of arterial grafts, in combination with the no-touch saphenous vein graft, will significantly improve the results of coronary artery bypass grafting. This is important for achieving a comprehensive and evidence-based balance between the major treatment strategies of ischemic heart disease, explicitly coronary artery bypass grafting and percutaneous coronary intervention. The no-touch technique is becoming increasingly popular among surgeons, with further studies to be initiated worldwide.
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Affiliation(s)
- Ninos Samano
- Department of Cardiothoracic and Vascular Surgery, University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Michael Dashwood
- Surgical and Interventional Sciences, Royal Free Hospital Campus, University College London Medical School, London, UK
| | - Domingos Souza
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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29
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Loesch A, Dashwood MR. Vasa vasorum inside out/outside in communication: a potential role in the patency of saphenous vein coronary artery bypass grafts. J Cell Commun Signal 2018; 12:631-643. [PMID: 30078142 PMCID: PMC6235771 DOI: 10.1007/s12079-018-0483-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 07/30/2018] [Indexed: 01/08/2023] Open
Abstract
The saphenous vein (SV) is the most commonly used conduit for revascularization in patients undergoing coronary artery bypass surgery (CABG). The patency rate of this vessel is inferior to the internal thoracic artery (ITA). In the majority of CABG procedures the ITA is removed with its outer pedicle intact whereas the (human) SV (hSV) is harvested with pedicle removed. The vasa vasorum, a microvessel network providing the adventitia and media with oxygen and nutrients, is more pronounced and penetrates deeper towards the lumen in veins than in arteries. When prepared in conventional CABG the vascular trauma caused when removing the hSV pedicle damages the vasa vasorum, a situation affecting transmural flow potentially impacting on graft performance. In patients, where the hSV is harvested with pedicle intact, the vasa vasorum is preserved and transmural blood flow restored at graft insertion and completion of CABG. By maintaining blood supply to the hSV wall, apart from oxygen and nutrients, the vasa vasorum may also transport factors potentially beneficial to graft performance. Studies, using either corrosion casts or India ink, have shown the course of vasa vasorum in animal SV as well as in hSV. In addition, there is some evidence that vasa vasorum of hSV terminate in the vessel lumen based on ex vivo perfusion, histological and ultrastructural studies. This review describes the preparation of the hSV as a bypass conduit in CABG and its performance compared with the ITA as well as how and why its patency might be improved by harvesting with minimal trauma in a way that preserves an intact vasa vasorum.
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Affiliation(s)
- Andrzej Loesch
- Centre for Rheumatology and Connective Tissue Diseases, Division of Medicine, University College London Medical School, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.
| | - Michael R Dashwood
- Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London Medical School, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.
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30
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Three arteries versus the saphenous vein for coronary artery bypass graft: Why use a damaged graft to repair a damaged heart? J Thorac Cardiovasc Surg 2018; 152:1460-1462. [PMID: 27751248 DOI: 10.1016/j.jtcvs.2016.06.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 06/16/2016] [Accepted: 06/21/2016] [Indexed: 11/20/2022]
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31
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Ramachandra AB, Humphrey JD, Marsden AL. Gradual loading ameliorates maladaptation in computational simulations of vein graft growth and remodelling. J R Soc Interface 2018; 14:rsif.2016.0995. [PMID: 28566510 DOI: 10.1098/rsif.2016.0995] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 04/28/2017] [Indexed: 12/21/2022] Open
Abstract
Vein graft failure is a prevalent problem in vascular surgeries, including bypass grafting and arteriovenous fistula procedures in which veins are subjected to severe changes in pressure and flow. Animal and clinical studies provide significant insight, but understanding the complex underlying coupled mechanisms can be advanced using computational models. Towards this end, we propose a new model of venous growth and remodelling (G&R) based on a constrained mixture theory. First, we identify constitutive relations and parameters that enable venous adaptations to moderate perturbations in haemodynamics. We then fix these relations and parameters, and subject the vein to a range of combined loads (pressure and flow), from moderate to severe, and identify plausible mechanisms of adaptation versus maladaptation. We also explore the beneficial effects of gradual increases in load on adaptation. A gradual change in flow over 3 days plus an initial step change in pressure results in fewer maladaptations compared with step changes in both flow and pressure, or even a gradual change in pressure and flow over 3 days. A gradual change in flow and pressure over 8 days also enabled a successful venous adaptation for loads as severe as the arterial loads. Optimization is used to accelerate parameter estimation and the proposed framework is general enough to provide a good starting point for parameter estimations in G&R simulations.
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Affiliation(s)
- Abhay B Ramachandra
- Department of Mechanical and Aerospace Engineering, University of California San Diego, La Jolla, CA, USA.,Department of Pediatrics, Institute for Computational and Mathematical Engineering, Stanford, CA, USA
| | - Jay D Humphrey
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - Alison L Marsden
- Department of Pediatrics, Institute for Computational and Mathematical Engineering, Stanford, CA, USA .,Department of Bioengineering, Stanford University, Stanford, CA, USA
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32
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de Vries MR, Quax PHA. Inflammation in Vein Graft Disease. Front Cardiovasc Med 2018; 5:3. [PMID: 29417051 PMCID: PMC5787541 DOI: 10.3389/fcvm.2018.00003] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 01/08/2018] [Indexed: 12/23/2022] Open
Abstract
Bypass surgery is one of the most frequently used strategies to revascularize tissues downstream occlusive atherosclerotic lesions. For venous bypass surgery the great saphenous vein is the most commonly used vessel. Unfortunately, graft efficacy is low due to the development of vascular inflammation, intimal hyperplasia and accelerated atherosclerosis. Moreover, failure of grafts leads to significant adverse outcomes and even mortality. The last couple of decades not much has changed in the treatment of vein graft disease (VGD). However, insight is the cellular and molecular mechanisms of VGD has increased. In this review, we discuss the latest insights on VGD and the role of inflammation in this. We discuss vein graft pathophysiology including hemodynamic changes, the role of vessel wall constitutions and vascular remodeling. We show that profound systemic and local inflammatory responses, including inflammation of the perivascular fat, involve both the innate and adaptive immune system.
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Affiliation(s)
- Margreet R de Vries
- Department of Surgery, Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Paul H A Quax
- Department of Surgery, Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, Netherlands
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Kopjar T, Ivankovic S, Lima ML, Pinheiro BB, Dashwood MR. Endoscopic or No-Touch Vein Harvesting for CABG: What is Best for the Patient? Braz J Cardiovasc Surg 2017; 31:461-464. [PMID: 28076625 PMCID: PMC5407140 DOI: 10.5935/1678-9741.20160091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 10/17/2016] [Indexed: 11/20/2022] Open
Affiliation(s)
- Tomislav Kopjar
- Department of Cardiac Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Stjepan Ivankovic
- Department of Cardiovascular Surgery, Meridional Hospital, Vitoria, ES, Brazil
| | - Melchior Luiz Lima
- Department of Cardiovascular Surgery, Clinicord, Anis Rassi Hospital, Goiania, GO, Brazil
| | - Bruno Botelho Pinheiro
- Surgical and Interventional Sciences, Royal Free Hospital Campus, University College Medical School, London, United Kingdom
| | - Michael Richard Dashwood
- Surgical and Interventional Sciences, Royal Free Hospital Campus, University College Medical School, London, United Kingdom
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34
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Activation and inflammation of the venous endothelium in vein graft disease. Atherosclerosis 2017; 265:266-274. [PMID: 28865843 DOI: 10.1016/j.atherosclerosis.2017.08.023] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 07/19/2017] [Accepted: 08/23/2017] [Indexed: 01/13/2023]
Abstract
The long saphenous vein is the most commonly used conduit in coronary artery bypass graft (CABG) surgery when bypassing multiple diseased arteries; however, its use is complicated by the development of vascular inflammation, intimal hyperplasia and accelerated atherosclerosis leading to compromised graft efficacy. Despite refinement of surgical techniques to improve graft patency, late vein graft failure remains a significant problem. Moreover, there is a lack of pharmacological interventions proven to be effective in the treatment of late vein graft failure. A greater understanding of the molecular nature of the disease and the interactions between endothelial and smooth muscle cells as a result of alterations in local haemodynamics may assist with designing future beneficial pharmacological interventions. Venous endothelial cells (ECs) are physiologically adapted to chronic low shear stress; however, once the graft is implanted into the arterial circulation, they become suddenly exposed to acute high levels of shear stress. A small number of in vitro and ex vivo studies have demonstrated that acute high shear stress is associated with the activation of a pro-inflammatory profile in saphenous vein ECs, which may be mediated by mitogen-activated protein kinase (MAPK) and nuclear factor-κB (NF-κB) signalling pathways. The impact of acute changes in shear stress on venous ECs and the role of ECs in the development of intimal hyperplasia remains incomplete and is the subject of this review.
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Fernández-Alfonso MS, Gil-Ortega M, Aranguez I, Souza D, Dreifaldt M, Somoza B, Dashwood MR. Role of PVAT in coronary atherosclerosis and vein graft patency: friend or foe? Br J Pharmacol 2017; 174:3561-3572. [PMID: 28150299 DOI: 10.1111/bph.13734] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 01/02/2017] [Accepted: 01/19/2017] [Indexed: 01/18/2023] Open
Abstract
Perivascular adipose tissue (PVAT) releases numerous factors and adipokines with paracrine effects on both vascular structure and function. These effects are variable as they depend on regional differences in PVAT among blood vessels and vary with changes in adiposity. There is considerable evidence demonstrating an association between coronary PVAT and the development and progression of coronary artery disease, which is associated with inflammation, oxidative stress, angiogenesis, vascular remodelling and blood clotting. However, PVAT also has a protective role in vascular grafts, especially the no-touch saphenous vein, in patients undergoing coronary artery bypass. This beneficial influence of PVAT involves factors such as adipocyte-derived relaxing factor, nitric oxide (NO), leptin, adiponectin, prostanoids, hydrogen sulphide and neurotransmitters, as well as mechanical protection. This article aims to highlight and compare the dual role of PVAT in the development and progression of coronary atherosclerosis, as well as in increased graft patency. Different deleterious and protective mechanisms of PVAT are also discussed and the inside-outside signalling paradigm of atherosclerosis development re-evaluated. The bidirectional communication between the arterial and venous wall and their surrounding PVAT, where signals originating from the vascular wall or lumen can affect PVAT phenotype, has been shown to be very complex. Moreover, signals from PVAT also influence the structure and function of the vascular wall in a paracrine manner. LINKED ARTICLES This article is part of a themed section on Molecular Mechanisms Regulating Perivascular Adipose Tissue - Potential Pharmacological Targets? To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v174.20/issuetoc.
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Affiliation(s)
- M S Fernández-Alfonso
- Instituto Pluridisciplinar and Facultad de Farmacia, Universidad Complutense, Madrid, Spain
| | - M Gil-Ortega
- Departamento de Ciencias Farmacéuticas y de la Salud, Facultad de Farmacia, Universidad CEU-San Pablo, Madrid, Spain
| | - I Aranguez
- Instituto Pluridisciplinar and Facultad de Farmacia, Universidad Complutense, Madrid, Spain
| | - D Souza
- Department of Cardiothoracic and Vascular Surgery and University Health Care Research Center, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - M Dreifaldt
- Department of Cardiothoracic and Vascular Surgery and University Health Care Research Center, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - B Somoza
- Departamento de Ciencias Farmacéuticas y de la Salud, Facultad de Farmacia, Universidad CEU-San Pablo, Madrid, Spain
| | - M R Dashwood
- Royal Free Hospital Campus, University College Medical School, London, UK
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Wang D, Tediashvili G, Pecha S, Reichenspurner H, Deuse T, Schrepfer S. Vein Interposition Model: A Suitable Model to Study Bypass Graft Patency. J Vis Exp 2017. [PMID: 28117809 DOI: 10.3791/54839] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Bypass grafting is an established treatment method for coronary artery disease. Graft patency continues to be the Achilles heel of saphenous vein grafts. Research models for bypass graft failure are essential for a better understanding of pathobiological and pathophysiological processes during graft patency loss. Large animal models, such as pigs or sheep, resemble human anatomical structures but require special facilities and equipment. This video describes a rat vein interposition model to investigate vein graft patency loss. Rats are inexpensive and easy to handle. Compared to mouse models, the convenient size of rats permits better operability and enables a sufficient amount of material to be obtained for further diverse analysis. In brief, the inferior epigastric vein of a donor rat is harvested and used to replace a segment of the femoral artery. Anastomosis is conducted via single stitches and sealed with fibrin glue. Graft patency can be monitored non-invasively using duplex sonography. Myointimal hyperplasia, which is the main cause for graft patency loss, develops progressively over time and can be calculated from histological cross sections.
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Affiliation(s)
- Dong Wang
- Transplant and Stem Cell Immunobiology Lab, University Heart Center Hamburg; Department of Surgery, Transplant and Stem Cell Immunobiology Lab, University of California San Francisco (UCSF); Cardiovascular Research Center (CVRC) and DZHK German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck; Cardiovascular Surgery, University Heart Center Hamburg
| | - Grigol Tediashvili
- Transplant and Stem Cell Immunobiology Lab, University Heart Center Hamburg; Department of Surgery, Transplant and Stem Cell Immunobiology Lab, University of California San Francisco (UCSF); Cardiovascular Research Center (CVRC) and DZHK German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck
| | - Simon Pecha
- Cardiovascular Surgery, University Heart Center Hamburg
| | | | - Tobias Deuse
- Transplant and Stem Cell Immunobiology Lab, University Heart Center Hamburg; Department of Surgery, Transplant and Stem Cell Immunobiology Lab, University of California San Francisco (UCSF); Cardiovascular Research Center (CVRC) and DZHK German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck; Cardiovascular Surgery, University Heart Center Hamburg
| | - Sonja Schrepfer
- Transplant and Stem Cell Immunobiology Lab, University Heart Center Hamburg; Department of Surgery, Transplant and Stem Cell Immunobiology Lab, University of California San Francisco (UCSF); Cardiovascular Research Center (CVRC) and DZHK German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck; Cardiovascular Surgery, University Heart Center Hamburg;
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37
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Xia N, Li H. The role of perivascular adipose tissue in obesity-induced vascular dysfunction. Br J Pharmacol 2016; 174:3425-3442. [PMID: 27761903 PMCID: PMC5610151 DOI: 10.1111/bph.13650] [Citation(s) in RCA: 132] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 09/29/2016] [Accepted: 10/06/2016] [Indexed: 12/18/2022] Open
Abstract
Under physiological conditions, perivascular adipose tissue (PVAT) attenuates agonist‐induced vasoconstriction by releasing vasoactive molecules including hydrogen peroxide, angiotensin 1–7, adiponectin, methyl palmitate, hydrogen sulfide, NO and leptin. This anticontractile effect of PVAT is lost under conditions of obesity. The central mechanism underlying this PVAT dysfunction in obesity is likely to be an ‘obesity triad’ (consisting of PVAT hypoxia, inflammation and oxidative stress) that leads to the impairment of PVAT‐derived vasoregulators. The production of hydrogen sulfide, NO and adiponectin by PVAT is reduced in obesity, whereas the vasodilator response to leptin is impaired (vascular leptin resistance). Strikingly, the vasodilator response to acetylcholine is reduced only in PVAT‐containing, but not in PVAT‐free thoracic aorta isolated from diet‐induced obese mice, indicating a unique role for PVAT in obesity‐induced vascular dysfunction. Furthermore, PVAT dysfunction has also been observed in small arteries isolated from the gluteal/visceral fat biopsy samples of obese individuals. Therefore, PVAT may represent a new therapeutic target for vascular complications in obesity. A number of approaches are currently being tested under experimental conditions. Potential therapeutic strategies improving PVAT function include body weight reduction, enhancing PVAT hydrogen sulfide release (e.g. rosiglitazone, atorvastatin and cannabinoid CB1 receptor agonists) and NO production (e.g. arginase inhibitors), inhibition of the renin–angiotensin–aldosterone system, inhibition of inflammation with melatonin or cytokine antagonists, activators of AMP‐activated kinase (e.g. metformin, resveratrol and diosgenin) and adiponectin releasers or expression enhancers. Linked Articles This article is part of a themed section on Molecular Mechanisms Regulating Perivascular Adipose Tissue – Potential Pharmacological Targets? To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v174.20/issuetoc
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Affiliation(s)
- Ning Xia
- Department of Pharmacology, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Huige Li
- Department of Pharmacology, Johannes Gutenberg University Medical Center, Mainz, Germany.,Center for Translational Vascular Biology (CTVB), Johannes Gutenberg University, Mainz, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany
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38
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de Vries MR, Simons KH, Jukema JW, Braun J, Quax PHA. Vein graft failure: from pathophysiology to clinical outcomes. Nat Rev Cardiol 2016; 13:451-70. [PMID: 27194091 DOI: 10.1038/nrcardio.2016.76] [Citation(s) in RCA: 197] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Occlusive arterial disease is a leading cause of morbidity and mortality worldwide. Aside from balloon angioplasty, bypass graft surgery is the most commonly performed revascularization technique for occlusive arterial disease. Coronary artery bypass graft surgery is performed in patients with left main coronary artery disease and three-vessel coronary disease, whereas peripheral artery bypass graft surgery is used to treat patients with late-stage peripheral artery occlusive disease. The great saphenous veins are commonly used conduits for surgical revascularization; however, they are associated with a high failure rate. Therefore, preservation of vein graft patency is essential for long-term surgical success. With the exception of 'no-touch' techniques and lipid-lowering and antiplatelet (aspirin) therapy, no intervention has hitherto unequivocally proven to be clinically effective in preventing vein graft failure. In this Review, we describe both preclinical and clinical studies evaluating the pathophysiology underlying vein graft failure, and the latest therapeutic options to improve patency for both coronary and peripheral grafts.
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Affiliation(s)
- Margreet R de Vries
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands.,Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - Karin H Simons
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands.,Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - J Wouter Jukema
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands.,Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - Jerry Braun
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - Paul H A Quax
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands.,Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
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39
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Y vein? Y not? The underdog of the composite arterial world. J Thorac Cardiovasc Surg 2015; 150:1195-7. [PMID: 26383004 DOI: 10.1016/j.jtcvs.2015.08.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 08/18/2015] [Indexed: 11/24/2022]
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40
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Endoscopic Versus “No-Touch” Saphenous Vein Harvesting for Coronary Artery Bypass Grafting. Angiology 2015; 67:121-32. [DOI: 10.1177/0003319715584126] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The advantage in terms of wound infection, wound healing, and scarring has resulted in the recent adoption of endoscopic vein harvesting (EVH) as a standard of care for coronary artery bypass grafting in some centers. However, concerns regarding the quality of these grafts have been raised after recent evidence of decreased graft patency, increased reoperation rate, and myocardial infarct, problems that are associated with vascular trauma caused when using this technique. Simultaneously, an atraumatic, “no-touch” technique for harvesting the saphenous vein was developed producing grafts with improved patency comparable to the internal thoracic artery. However, wound complications remain a problem using this technique. This review outlines the need to consider the poor graft quality that may result from EVH and raises the question what is likely to be the “best practice principle” in saphenous vein harvesting?
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41
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Prandi F, Piola M, Soncini M, Colussi C, D’Alessandra Y, Penza E, Agrifoglio M, Vinci MC, Polvani G, Gaetano C, Fiore GB, Pesce M. Adventitial vessel growth and progenitor cells activation in an ex vivo culture system mimicking human saphenous vein wall strain after coronary artery bypass grafting. PLoS One 2015; 10:e0117409. [PMID: 25689822 PMCID: PMC4331547 DOI: 10.1371/journal.pone.0117409] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 12/21/2014] [Indexed: 01/09/2023] Open
Abstract
Saphenous vein graft disease is a timely problem in coronary artery bypass grafting. Indeed, after exposure of the vein to arterial blood flow, a progressive modification in the wall begins, due to proliferation of smooth muscle cells in the intima. As a consequence, the graft progressively occludes and this leads to recurrent ischemia. In the present study we employed a novel ex vivo culture system to assess the biological effects of arterial-like pressure on the human saphenous vein structure and physiology, and to compare the results to those achieved in the presence of a constant low pressure and flow mimicking the physiologic vein perfusion. While under both conditions we found an activation of Matrix Metallo-Proteases 2/9 and of microRNAs-21/146a/221, a specific effect of the arterial-like pressure was observed. This consisted in a marked geometrical remodeling, in the suppression of Tissue Inhibitor of Metallo-Protease-1, in the enhanced expression of TGF-β1 and BMP-2 mRNAs and, finally, in the upregulation of microRNAs-138/200b/200c. In addition, the veins exposed to arterial-like pressure showed an increase in the density of the adventitial vasa vasorum and of cells co-expressing NG2, CD44 and SM22α markers in the adventitia. Cells with nuclear expression of Sox-10, a transcription factor characterizing multipotent vascular stem cells, were finally found in adventitial vessels. Our findings suggest, for the first time, a role of arterial-like wall strain in the activation of pro-pathologic pathways resulting in adventitial vessels growth, activation of vasa vasorum cells, and upregulation of specific gene products associated to vascular remodeling and inflammation.
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Affiliation(s)
- Francesca Prandi
- Unità di Ingegneria Tissutale, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Marco Piola
- Politecnico di Milano, Dipartimento di Elettronica, Informazione e Bioingegneria, Milan, Italy
| | - Monica Soncini
- Politecnico di Milano, Dipartimento di Elettronica, Informazione e Bioingegneria, Milan, Italy
| | - Claudia Colussi
- Istituto di Patologia Medica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Yuri D’Alessandra
- Unità di Immunologia e Genomica Funzionale, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Eleonora Penza
- II Divisione di Cardiochirurgia, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Marco Agrifoglio
- Dipartimento di Scienze Cliniche e di Comunità, Università di Milano, Milan, Italy
| | | | - Gianluca Polvani
- Dipartimento di Scienze Cliniche e di Comunità, Università di Milano, Milan, Italy
| | - Carlo Gaetano
- Division of Cardiovascular Epigenetics, Goethe University, Frankfurt-am-Main, Germany
| | | | - Maurizio Pesce
- Unità di Ingegneria Tissutale, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- * E-mail:
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Tribble C, Urencio M. Open saphenous vein harvest. J Am Coll Surg 2015; 220:e35-9. [PMID: 25601657 DOI: 10.1016/j.jamcollsurg.2014.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 11/26/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Curt Tribble
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA.
| | - Miguel Urencio
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS
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Herbst M, Hölzenbein TJ, Minnich B. Characterization of the vasa vasorum in the human great saphenous vein: a scanning electron microscopy and 3D-morphometry study using vascular corrosion casts. MICROSCOPY AND MICROANALYSIS : THE OFFICIAL JOURNAL OF MICROSCOPY SOCIETY OF AMERICA, MICROBEAM ANALYSIS SOCIETY, MICROSCOPICAL SOCIETY OF CANADA 2014; 20:1120-1133. [PMID: 24913662 DOI: 10.1017/s1431927614001287] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The vasa vasorum (VV) of explanted segments of the human great saphenous vein (Vena saphena magna; HGSV), harvested during dissection for coronary bypass grafts or diseased vein segments from the "Salzburger Landesklinikum," were studied by scanning electron microscopy and three-dimensional morphometry of microvascular corrosion casts. The main objective of this study was to examine the VV's structural arrangement in order to find the most vital segments of the HGSV and in turn to improve the results of coronary bypass surgeries. The study presents a meticulous analysis of the whole microvascular system of the VV of the HGSV and its three-dimensional arrangement. It is one of the first studies yielding detailed quantitative data on geometry of the VV of the HGSV. A detailed insight into different vascular parameters such as vessel diameter, interbranching, intervascular distances, and branching angles at different levels of the VV's angioarchitecture and in different parts of the HGSV in health and disease is given. Further, the geometry of bifurcations was examined in order to compute the physiological optimality principles of this delicate vascular system based on its construction, maintenance, and function.
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Affiliation(s)
- Markus Herbst
- 1Department of Cell Biology,Division of Animal Structure & Function,Vascular & Exercise Biology Unit,University of Salzburg,5020 Salzburg,Austria
| | | | - Bernd Minnich
- 1Department of Cell Biology,Division of Animal Structure & Function,Vascular & Exercise Biology Unit,University of Salzburg,5020 Salzburg,Austria
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The effect of distension pressure on endothelial injury and vasodilatation response in saphenous vein grafts: conversion of a bypass graft to a dead pipe. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2014; 11:119-25. [PMID: 26336407 PMCID: PMC4283857 DOI: 10.5114/kitp.2014.43836] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 03/12/2014] [Accepted: 05/30/2014] [Indexed: 11/30/2022]
Abstract
Introduction Endothelial damage caused by high pressure applied for spasm relaxation during graft preparation is one of the most plausible theories explaining early graft failure. Aim of the study We aimed to demonstrate the extent of endothelial damage in saphenous vein grafts distended to different pressure levels by using immunohistochemical methods and in vitro tissue baths. Material and methods Saphenous vein grafts (SVGs) of 25 patients who underwent isolated elective CABG surgery were used in this study. By using a specific mechanism, SVGs were distended to five different pressure levels for two minutes: 0 mmHg, 50 mmHg, 100 mmHg, 200 mmHg, 300 mmHg. In vitro tissue baths and immunohistochemical examinations were performed. Results None of the grafts distended to 300 mmHg pressure were functional in the tissue bath system. The relaxation response to carbachol of SVGs distended to 0, 50, 100 and 200 mmHg was 97.87 ± 4.47%, 98.52 ± 3.95%, 93.78 ± 3.64%, and 30.87 ± 4.11%, respectively. There were no statistically significant differences in terms of relaxation responses between samples distended to 0, 50, and 100 mmHg (p = 0.490). The relaxation response of samples distended to 200 mmHg was significantly decreased (p = 0.021). The endothelia of samples distended to 0 mmHg were almost intact in CD31 staining. Endothelial cell loss occurred at all tested distension pressures at different degrees. Conclusion In vitro and immunohistochemical studies revealed that distending an SVG used for coronary artery bypass grafting with pressures of 100 mmHg or less results in less endothelial damage and increases graft patency.
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Piola M, Prandi F, Bono N, Soncini M, Penza E, Agrifoglio M, Polvani G, Pesce M, Fiore GB. A compact and automated ex vivo vessel culture system for the pulsatile pressure conditioning of human saphenous veins. J Tissue Eng Regen Med 2013; 10:E204-15. [PMID: 23897837 DOI: 10.1002/term.1798] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Revised: 04/29/2013] [Accepted: 07/08/2013] [Indexed: 11/05/2022]
Abstract
Saphenous vein (SV) graft disease represents an unresolved problem in coronary artery bypass grafting (CABG). After CABG, a progressive remodelling of the SV wall occurs, possibly leading to occlusion of the lumen, a process termed 'intima hyperplasia' (IH). The investigation of cellular and molecular aspects of IH progression is a primary end-point toward the generation of occlusion-free vessels that may be used as 'life-long' grafts. While animal transplantation models have clarified some of the remodelling factors, the pathology of human SV is far from being understood. This is also due to the lack of devices able to reproduce the altered mechanical load encountered by the SV after CABG. This article describes the design of a novel ex vivo vein culture system (EVCS) capable of replicating the altered pressure pattern experienced by SV after CABG, and reports the results of a preliminary biomechanical conditioning experimental campaign on SV segments. The EVCS applied a CAGB-like pressure (80-120 mmHg) or a venous-like perfusion (3 ml/min, 5 mmHg) conditioning to the SVs, keeping the segments viable in a sterile environment during 7 day culture experiments. After CABG-like pressure conditioning, SVs exhibited a decay of the wall thickness, an enlargement of the luminal perimeter, a rearrangement of the muscle fibres and partial denudation of the endothelium. Considering these preliminary results, the EVCS is a suitable system to study the mechanical attributes of SV graft disease, and its use, combined with a well-designed biological protocol, may be of help in elucidating the cellular and molecular mechanisms involved in SV graft disease.
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Affiliation(s)
- Marco Piola
- Politecnico di Milano, Dipartimento di Elettronica, Informazione e Bioingegneria, Milan, Italy
| | - Francesca Prandi
- Laboratorio di Ingegneria Tissutale Cardiovascolare, Centro Cardiologico Monzino-IRCCS, Milan, Italy
| | - Nina Bono
- Politecnico di Milano, Dipartimento di Elettronica, Informazione e Bioingegneria, Milan, Italy
| | - Monica Soncini
- Politecnico di Milano, Dipartimento di Elettronica, Informazione e Bioingegneria, Milan, Italy
| | - Eleonora Penza
- II Divisione di Cardiochirurgia, Centro Cardiologico Monzino-IRCCS, Milan, Italy
| | - Marco Agrifoglio
- Dipartimento di Scienze Cliniche e di Comunità, Università di Milano, Milan, Italy
| | - Gianluca Polvani
- Dipartimento di Scienze Cliniche e di Comunità, Università di Milano, Milan, Italy
| | - Maurizio Pesce
- Laboratorio di Ingegneria Tissutale Cardiovascolare, Centro Cardiologico Monzino-IRCCS, Milan, Italy
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46
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Kopjar T, Biočina B, Gašparović H. Radial artery or saphenous vein: a graft of second choice in coronary artery bypass surgery. J Thorac Cardiovasc Surg 2013; 145:1146-1147. [PMID: 23497948 DOI: 10.1016/j.jtcvs.2012.12.077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Accepted: 12/05/2012] [Indexed: 11/18/2022]
Affiliation(s)
- Tomislav Kopjar
- Department of Cardiac Surgery, University Hospital Centre Zagreb, School of Medicine University of Zagreb, Zagreb, Croatia
| | - Bojan Biočina
- Department of Cardiac Surgery, University Hospital Centre Zagreb, School of Medicine University of Zagreb, Zagreb, Croatia
| | - Hrvoje Gašparović
- Department of Cardiac Surgery, University Hospital Centre Zagreb, School of Medicine University of Zagreb, Zagreb, Croatia
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Southerland KW, Frazier SB, Bowles DE, Milano CA, Kontos CD. Gene therapy for the prevention of vein graft disease. Transl Res 2013; 161:321-38. [PMID: 23274305 PMCID: PMC3602161 DOI: 10.1016/j.trsl.2012.12.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Revised: 12/04/2012] [Accepted: 12/04/2012] [Indexed: 11/20/2022]
Abstract
Ischemic cardiovascular disease remains the leading cause of death worldwide. Despite advances in the medical management of atherosclerosis over the past several decades, many patients require arterial revascularization to reduce mortality and alleviate ischemic symptoms. Technological advancements have led to dramatic increases in the use of percutaneous and endovascular approaches, yet surgical revascularization (bypass surgery) with autologous vein grafts remains a mainstay of therapy for both coronary and peripheral artery disease. Although bypass surgery is highly efficacious in the short term, long-term outcomes are limited by relatively high failure rates as a result of intimal hyperplasia, which is a common feature of vein graft disease. The supply of native veins is limited, and many individuals require multiple grafts and repeat procedures. The need to prevent vein graft failure has led to great interest in gene therapy approaches to this problem. Bypass grafting presents an ideal opportunity for gene therapy, as surgically harvested vein grafts can be treated with gene delivery vectors ex vivo, thereby maximizing gene delivery while minimizing the potential for systemic toxicity and targeting the pathogenesis of vein graft disease at its onset. Here we will review the pathogenesis of vein graft disease and discuss vector delivery strategies and potential molecular targets for its prevention. We will summarize the preclinical and clinical literature on gene therapy in vein grafting and discuss additional considerations for future therapies to prevent vein graft disease.
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Affiliation(s)
- Kevin W Southerland
- Department of Surgery, Division of Surgical Sciences, Duke University Medical Center, Durham, North Carolina, USA
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