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Sajja LR, Kamtam DN, Sreeramula SK, Beri P. Current practice of saphenous vein graft harvesting in coronary artery bypass graft surgery: an Indian survey. Indian J Thorac Cardiovasc Surg 2023; 39:115-124. [PMID: 36785598 PMCID: PMC9918654 DOI: 10.1007/s12055-022-01441-z] [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: 08/18/2022] [Revised: 10/31/2022] [Accepted: 11/03/2022] [Indexed: 12/23/2022] Open
Abstract
Purpose The treatment of occluded saphenous vein graft (SVG) is challenging, and thus preventing the graft occlusion is of utmost importance. However, despite its recognized importance, a paucity of data exists regarding how SVGs are handled and preserved. Hence, this survey was conducted to document the techniques of vein graft preservation and handling among cardiac surgeons in India. Methods The survey had 26 questions regarding vein graft usage, harvesting, handling, and preservation techniques. Three hundred cardiac surgeons across India participated in this survey between March 2019 and July 2019. Results Responses were received from 215 (71.6%) surgeons across 13 states. Around 87% of respondents reported that ≥ 76% of veins were harvested by the open technique. Among the respondents, around 67% used one SVG in ≥ 96% of their patients, 45% used two SVGs in ≥ 86% of their patients, and 38% used ≥ 3 SVGs in < 25% of their patients, respectively. Around 54%, 27%, 9%, and 9% of respondents used autologous whole blood, saline solution, pH-buffered solution, and other solutions, respectively. In addition, 96.74% of respondents heparinized their vein graft preservation solutions, and 98.14% preserved the solution at room temperature. 34.88% and 83.26% of respondents used dual antiplatelet therapy (DAPT) before and after surgery in ≥ 76% of their patients, respectively. 63.26% of the surgeons reported that the patients received DAPT for > 12 months. Conclusion There is a significant variance in the process of vein harvesting, preservation, handling, and antiplatelet therapy protocols among various cardiac surgeons across India. Therefore, there is a need for standardization in the practice of vein harvesting.
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Affiliation(s)
- Lokeswara Rao Sajja
- Department of Cardiothoracic Surgery, Star Hospitals, Road No. 10, Banjara Hills, Hyderabad, 500034 Telangana India
- Present Address: Division of Clinical Research in Cardiovascular Medicine/Surgery, Sajja Heart Foundation, Srinagar Colony, Hyderabad, 500073 India
| | - Devanish Narasimhasanth Kamtam
- Present Address: Division of Clinical Research in Cardiovascular Medicine/Surgery, Sajja Heart Foundation, Srinagar Colony, Hyderabad, 500073 India
| | - Sateesh Kumar Sreeramula
- Present Address: Division of Clinical Research in Cardiovascular Medicine/Surgery, Sajja Heart Foundation, Srinagar Colony, Hyderabad, 500073 India
| | - Prashanthi Beri
- Present Address: Division of Clinical Research in Cardiovascular Medicine/Surgery, Sajja Heart Foundation, Srinagar Colony, Hyderabad, 500073 India
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Ladak SS, McQueen LW, Layton GR, Aujla H, Adebayo A, Zakkar M. The Role of Endothelial Cells in the Onset, Development and Modulation of Vein Graft Disease. Cells 2022; 11:3066. [PMID: 36231026 PMCID: PMC9561968 DOI: 10.3390/cells11193066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/22/2022] [Accepted: 09/26/2022] [Indexed: 01/23/2023] Open
Abstract
Endothelial cells comprise the intimal layer of the vasculature, playing a crucial role in facilitating and regulating aspects such nutrient transport, vascular homeostasis, and inflammatory response. Given the importance of these cells in maintaining a healthy haemodynamic environment, dysfunction of the endothelium is central to a host of vascular diseases and is a key predictor of cardiovascular risk. Of note, endothelial dysfunction is believed to be a key driver for vein graft disease-a pathology in which vein grafts utilised in coronary artery bypass graft surgery develop intimal hyperplasia and accelerated atherosclerosis, resulting in poor long-term patency rates. Activation and denudation of the endothelium following surgical trauma and implantation of the graft encourage a host of immune, inflammatory, and cellular differentiation responses that risk driving the graft to failure. This review aims to provide an overview of the current working knowledge regarding the role of endothelial cells in the onset, development, and modulation of vein graft disease, as well as addressing current surgical and medical management approaches which aim to beneficially modulate endothelial function and improve patient outcomes.
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Affiliation(s)
| | | | | | | | | | - Mustafa Zakkar
- Department of Cardiovascular Sciences, Clinical Science Wing, University of Leicester, Glenfield Hospital, Leicester LE3 9QP, UK
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3
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Hoenicka M, Sabau M, Liebold A, Hofmann HS, Ried M. Preservation of Adrenoceptor and Endothelin Receptor Mediated Vasoconstriction and of Endothelium-Dependent Relaxation after Cold Storage of Explanted Blood Vessels for ex vivo Analyses. J Vasc Res 2022; 59:303-313. [PMID: 35728582 DOI: 10.1159/000524922] [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: 02/02/2022] [Accepted: 04/28/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Adrenoceptor and endothelin (ET) receptor-mediated vasoconstriction as well as endothelium-dependent vasodilation of human saphenous veins were compared before and after 20 h of cold storage. METHODS Contractile responses to potassium chloride (KCl), norepinephrine (NE), and ET-1 as well as vasodilator responses to acetylcholine (ACh) were evaluated. RESULTS Storage in HEPES-supplemented Dulbecco's modified Eagle's medium (HDMEM) diminished KCl induced contractile forces to 71% (p = 0.002) and NE induced contractions to 80% (p = 0.037), in contrast to HEPES-supplemented Krebs-Henseleit solution (HKH) and TiProtec solution. KCl-normalized NE contractions were not affected by storage. NE EC50 values were slightly lower (7.1E-8 vs. 7.5E-8, p = 0.019) after storage in HKH, with no changes after storage in the other solutions. Endothelium-dependent responses to ACh were not affected by storage. ET-1 induced contractions were attenuated after storage in HDMEM (77%, p = 0.002), HKH (75%, p = 0.020), and TiProtec (73%, p = 0.010) with no changes in normalized constrictions. ET-1 EC50 values were not affected by storage. CONCLUSION Loss of contractility after storage in HDMEM may reflect the lower content of dextrose. There was no specific attenuation of adrenoceptor, ET-receptor, or ACh receptor mediated signal transduction after storage in any of the media. HKH or TiProtec are equally suitable cold storage solutions for ex vivo measurements.
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Affiliation(s)
- Markus Hoenicka
- Department of Cardiothoracic and Vascular Surgery, Ulm University Medical Center, Ulm, Germany
| | - Marius Sabau
- Department of Cardiothoracic and Vascular Surgery, Ulm University Medical Center, Ulm, Germany
| | - Andreas Liebold
- Department of Cardiothoracic and Vascular Surgery, Ulm University Medical Center, Ulm, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Michael Ried
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
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4
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Lidocaine effects on coagulation assessed by whole blood rotational thromboelastometry. Blood Coagul Fibrinolysis 2021; 32:115-121. [PMID: 33443924 DOI: 10.1097/mbc.0000000000001002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Lidocaine may be beneficial when added in solutions for the preservation of vascular grafts or solid organs as it has anti-inflammatory, endothelial protective, and antithrombotic effects. However, the mechanisms of lidocaine-induced changes in hemostasis were not elucidated until now. The aim of the study was to examine the effect of increasing concentrations of lidocaine on coagulation parameters and blood-clotting kinetics using velocity curves of clot formation assessed by rotational thromboelastometry. Ex-vivo blood coagulation using whole blood from healthy volunteers was studied with rotational thromboelastometry. For each volunteer, four assays were performed: saline control and samples with lidocaine end blood concentrations of 0.3, 0.6, and 0.9%. In this in-vitro study, whole blood from 15 healthy volunteers was used. Lidocaine concentration of 0.3% prolonged the initiation phase of clotting without significant differences in the propagation phase or clot stability and inhibited clot lysis compared with the control group. Higher lidocaine concentrations (0.6 and 0.9%) resulted in prolongation of both initiation and propagation phases and decreased clot firmness compared with the control group. Lysis was significantly increased only in the 0.6% lidocaine group compared with control. Although lidocaine concentration of 0.3% only delays coagulation initiation, the 0.6% concentration inhibits all phases of hemostasis and increases clot lysis compared with control. Higher lidocaine concentration results in very weak clot formation with very low lysis visible on thromboelastometry. More research is needed to explain the effects of lidocaine on clotting kinetics.
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Kimicata M, Swamykumar P, Fisher JP. Extracellular Matrix for Small-Diameter Vascular Grafts. Tissue Eng Part A 2020; 26:1388-1401. [PMID: 33231135 PMCID: PMC7759287 DOI: 10.1089/ten.tea.2020.0201] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/11/2020] [Indexed: 01/15/2023] Open
Abstract
To treat coronary heart disease, coronary artery bypass grafts are used to divert blood flow around blockages in the coronary arteries. Autologous grafts are the gold standard of care, but they are characterized by their lack of availability, low quality, and high failure rates. Alternatively, tissue-engineered small-diameter vascular grafts made from synthetic or natural polymers have not demonstrated adequate results to replace autologous grafts; synthetic grafts result in a loss of patency due to thrombosis and intimal hyperplasia, whereas scaffolds from natural polymers are generally unable to support the physiological conditions. Extracellular matrix (ECM) from a variety of sources, including cell-derived, 2D, and cannular tissues, has become an increasingly useful tool for this application. The current review examines the ECM-based methods that have recently been investigated in the field and comments on their viability for clinical applications.
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Affiliation(s)
- Megan Kimicata
- Department of Materials Science and Engineering, University of Maryland, College Park, Maryland, USA
- Center for Engineering Complex Tissues, and University of Maryland, College Park, Maryland, USA
| | - Prateek Swamykumar
- Center for Engineering Complex Tissues, and University of Maryland, College Park, Maryland, USA
- Fischell Department of Bioengineering, University of Maryland, College Park, Maryland, USA
| | - John P. Fisher
- Center for Engineering Complex Tissues, and University of Maryland, College Park, Maryland, USA
- Fischell Department of Bioengineering, University of Maryland, College Park, Maryland, USA
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Sandner SE, Pachuk CJ, Aschacher T, Milojevic M, Caliskan E, Emmert MY. Endothelial damage inhibitors for improvement of saphenous vein graft patency in coronary artery bypass grafting. Minerva Cardioangiol 2020; 68:480-488. [PMID: 32326681 DOI: 10.23736/s0026-4725.20.05234-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The saphenous vein graft (SVG) remains the most commonly used conduit in coronary artery bypass grafting (CABG). In light of this further research must be aimed at the development of strategies to optimize SVG patency and thereby improve both short- and long-term outcomes of CABG surgery. SVG patency in large part depends on the protection of the structural and functional integrity of the vascular endothelium at the time of conduit harvesting, including optimal storage conditions to prevent endothelial damage. This review provides an overview of currently available storage and preservation solutions, including novel endothelial damage inhibitors, and their role in mitigating endothelial damage and vein graft failure.
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Affiliation(s)
- Sigrid E Sandner
- Division of Cardiac Surgery, Department of Surgery, Medical University Vienna, Vienna, Austria -
| | | | - Thomas Aschacher
- Division of Cardiac Surgery, Department of Surgery, Medical University Vienna, Vienna, Austria
| | - Milan Milojevic
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands.,Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Etem Caliskan
- Department of Cardiovascular Surgery, Charite University of Medicine, Berlin, Germany.,Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin, Berlin, Germany
| | - Maximilian Y Emmert
- Department of Cardiovascular Surgery, Charite University of Medicine, Berlin, Germany.,Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin, Berlin, Germany
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Papakonstantinou NA, Sykaras AG, Vourlakou C, Goudevenos J, Papadopoulos G, Apostolakis E. Cardioplegic storage solution: Is it the guardian of saphenous vein graft endothelium? J Card Surg 2020; 35:996-1003. [PMID: 32207185 DOI: 10.1111/jocs.14519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Despite their suboptimal long-term patency, saphenous vein grafts are the most widely used conduits to achieve complete revascularization during coronary artery bypass grafting (CABG). Although vein storage critically impairs endothelial integrity, contradictory data concerning optimal storage solutions exist. The aim of this study is to explore any in vitro impact of cardioplegic solutions and temperature on vein grafts endothelial integrity during their storage. MATERIALS AND METHODS A single-center, prospective trial including 40 consecutive patients was conducted. Eligibility criteria included patients submitted to CABG receiving at least one vein graft. An excess segment of the graft was harvested and divided into four different parts. Each one of them was stored under different conditions; either in a conventional heparin-enriched blood solution or in a cardioplegic solution, at room temperature (20°C-22°C) and in the refrigerator (5°C). Endothelial integrity was evaluated via immunohistochemistry using an antibody against CD31. RESULTS Endothelial integrity (measured in a scale from 1-worst to 5-best) was significantly better after cardioplegic solution storage (2.83 ± 0.15 and 3.10 ± 0.13 in cold and room temperature, respectively) compared with storage in conventional solutions (2.23 ± 0.16 and 2.0 ± 0.15 in cold and room temperature, respectively). A significant effect of cardioplegic storage solution, as well as of cold temperature and cardioplegic solution interaction on endothelial preservation was reported, whereas storage temperature did not prove a significant factor by its own. CONCLUSIONS Cardioplegic storage solutions result in significantly better endothelial preservation compared with conventional heparin-enriched blood solutions. The association with superior clinical outcomes remains to be proved.
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Affiliation(s)
- Nikolaos A Papakonstantinou
- Cardiothoracic Surgery Department, General Hospital of Athens "Evangelismos", Athens, Greece.,Cardiothoracic Surgery Department, School of Medicine, University Hospital of Ioannina, Greece
| | - Alexandros G Sykaras
- Department of Pathology, General Hospital of Athens "Evangelismos", Athens, Greece
| | - Christina Vourlakou
- Department of Pathology, General Hospital of Athens "Evangelismos", Athens, Greece
| | - John Goudevenos
- Department of Cardiology, School of Medicine, University Hospital of Ioannina, Greece
| | - Georgios Papadopoulos
- Department of Anesthesiology, School of Medicine, University Hospital of Ioannina, Greece
| | - Efstratios Apostolakis
- Cardiothoracic Surgery Department, School of Medicine, University Hospital of Ioannina, Greece
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8
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Saphenous vein grafts in contemporary coronary artery bypass graft surgery. Nat Rev Cardiol 2019; 17:155-169. [DOI: 10.1038/s41569-019-0249-3] [Citation(s) in RCA: 128] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/30/2019] [Indexed: 12/14/2022]
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9
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Chen SW, Chu Y, Wu VCC, Tsai FC, Nan YY, Lee HF, Chang CH, Chu PH, Wu S, Lin PJ. Microenvironment of saphenous vein graft preservation prior to coronary artery bypass grafting. Interact Cardiovasc Thorac Surg 2019; 28:71-78. [PMID: 29986023 DOI: 10.1093/icvts/ivy201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 06/18/2018] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES The best preservation solution for a free vascular graft prior to coronary artery bypass grafting (CABG) remains controversial. The aim of this investigation was to evaluate the microenvironment of the human saphenous vein graft when preserved in normal saline (NS) solution or autologous heparinized whole blood (AWB). METHODS Between January 2014 and December 2014, 21 patients who underwent CABG were enrolled and a total of 162 saphenous vein graft rings were collected. NS and AWB were used to investigate the influence of the microenvironment. The hypoxia, oxidative stress and vascular apoptosis were assayed by western blot, and endothelial integrity was assessed by immunohistochemical analysis. RESULTS The level of PaO2 in AWB was lower than that in NS (median: 100.5 mmHg vs 185.8 mmHg, P = 0.004). This hypoxic condition led to the production of more hypoxia-inducible factor-1 (median: 60.1% vs 15.1%, P = 0.008) and endothelial nitric oxide synthase (median: 52.6% vs 25%, P = 0.046) within 30 min of preservation time. The fact that higher levels of glutathione peroxidase resulted in the preservation of AWB suggests that it is beneficial to boost the vascular antioxidant defense with lower levels of NOX2. AWB led to increased Bcl-2, reduced cytochrome c and cleaved 85 kDa poly ADP-ribose polymerase apoptotic fragments. CONCLUSIONS We concluded that AWB possesses a microenvironment that is superior to that of NS for saphenous vein graft preservation prior to CABG.
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Affiliation(s)
- Shao-Wei Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yen Chu
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Medical Research and Development, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Victor Chien-Chia Wu
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Feng-Chun Tsai
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Yun Nan
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan, Taiwan
| | - Hsin-Fu Lee
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Chih-Hsiang Chang
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pao-Hsien Chu
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Semon Wu
- Department of Life Science, Chinese Culture University, Taipei, Taiwan
| | - Pyng-Jing Lin
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan, Taiwan
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The effect of storage solutions on endothelial function and saphenous vein graft patency. Indian J Thorac Cardiovasc Surg 2018; 34:258-265. [PMID: 33060947 DOI: 10.1007/s12055-018-0720-5] [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: 05/31/2018] [Revised: 07/11/2018] [Accepted: 07/16/2018] [Indexed: 10/28/2022] Open
Abstract
Vein graft failure is a complex mechanism that can be triggered immediately after surgical harvesting. Storage solutions have a major role in preventing endothelial cell damage during harvesting. While normal saline is still widely used, buffered solutions seem to better preserve endothelial integrity and function. This review aims to summarize the current literature surrounding vein graft storage solutions.
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11
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Ben Ali W, Bouhout I, Perrault LP. The effect of storage solutions, gene therapy, and antiproliferative agents on endothelial function and saphenous vein graft patency. J Card Surg 2018; 33:235-242. [DOI: 10.1111/jocs.13608] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Walid Ben Ali
- Department of Cardiac Surgery; Montreal Heart Institute; Quebec Canada
| | - Ismail Bouhout
- Department of Surgery; Université de Montréal; Quebec Canada
| | - Louis P. Perrault
- Department of Cardiovascular Surgery; Montreal Heart Institute; Quebec Canada
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12
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Woodward LC, Antoniades C, Taggart DP. Intraoperative Vein Graft Preservation: What Is the Solution? Ann Thorac Surg 2016; 102:1736-1746. [DOI: 10.1016/j.athoracsur.2016.05.097] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 05/14/2016] [Accepted: 05/23/2016] [Indexed: 12/31/2022]
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13
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Winkler B, Reineke D, Heinisch PP, Schönhoff F, Huber C, Kadner A, Englberger L, Carrel T. Graft preservation solutions in cardiovascular surgery. Interact Cardiovasc Thorac Surg 2016; 23:300-9. [DOI: 10.1093/icvts/ivw056] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 02/10/2016] [Indexed: 01/28/2023] Open
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14
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Barner HB, Farkas EA. Conduits for coronary bypass: vein grafts. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2012; 45:275-86. [PMID: 23130300 PMCID: PMC3487010 DOI: 10.5090/kjtcs.2012.45.5.275] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 08/16/2012] [Accepted: 08/17/2012] [Indexed: 11/23/2022]
Abstract
The saphenous vein has been the principal conduit for coronary bypass grafting from the beginning, circa 1970. This report briefly traces this history and concomitantly presents one surgeons experience and personal views on use of the vein graft. As such it is not exhaustive but meant to be practical with a modest number of references. The focus is that of providing guidance and perspective which may be at variance with that of others and recognizing that there may be many ways to accomplish the task at hand. Hopefully the surgeon in training/early career may find this instructive on the journey to surgical maturity.
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Affiliation(s)
- Hendrick B Barner
- Division of Cardiothoracic Surgery, St. Louis University Hospital, USA
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15
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Tsakok M, Montgomery-Taylor S, Tsakok T. Storage of saphenous vein grafts prior to coronary artery bypass grafting: is autologous whole blood more effective than saline in preserving graft function? Interact Cardiovasc Thorac Surg 2012; 15:720-5. [PMID: 22753436 DOI: 10.1093/icvts/ivs275] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: 'Is storage of saphenous vein grafts in autologous whole blood prior to coronary artery bypass grafting (CABG) more effective than storage in saline in preserving graft function?' Altogether more than 580 papers were found using the reported search, of which, 10 represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Preservation of the vein graft endothelium during graft preparation is of well-recognized importance in forestalling graft occlusion and saphenous vein graft disease following CABG, however, the different preservation capabilities of saline vs autologous whole blood are not well validated. Although there is a complete lack of randomized clinical trials addressing this issue, some studies using basic in vitro techniques and animal models can be extrapolated to answer the clinical question in hand. All are consistent in demonstrating the detrimental effects of saline on vascular endothelium and therefore graft patency, but there is some disagreement in the literature as to whether autologous whole blood is superior as a storage medium. Though three well-designed studies suggest preserved endothelial function when saphenous vein grafts are stored in saline compared with storage in autologous whole blood, data from other studies are unimpressive, with two studies showing no difference. Furthermore, two elegant experiments that seek to mimic in vivo conditions by comparing outcomes postarterialization show no benefit of prior storage in autologous whole blood, despite the initial better-preserved endothelium. Instead, some notice should be taken of alternative storage solutions such as the University of Wisconsin solution, as some early studies suggest that it may be advantageous over both blood and crystalloid solution.
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Affiliation(s)
- Maria Tsakok
- Green Templeton College, University of Oxford, Oxford, UK.
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16
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Viaro F, Capellini VK, Celotto AC, Carlotti CG, Rodrigues AJ, Reis GS, dos Santos Augusto V, Evora PRB. Immunohistochemical evaluation of three nitric oxide synthase isoforms in human saphenous vein exposed to different degrees of distension pressures. Cardiovasc Pathol 2010; 19:e211-20. [DOI: 10.1016/j.carpath.2009.11.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2009] [Revised: 10/19/2009] [Accepted: 11/11/2009] [Indexed: 10/20/2022] Open
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17
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Aspirin in coronary artery bypass surgery: new aspects of and alternatives for an old antithrombotic agent. Eur J Cardiothorac Surg 2008; 34:93-108. [PMID: 18448350 DOI: 10.1016/j.ejcts.2008.03.023] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2008] [Revised: 03/10/2008] [Accepted: 03/19/2008] [Indexed: 12/29/2022] Open
Abstract
The success of coronary artery bypass graft surgery (CABG) depends mainly on the patency of the graft vessels. Aortocoronary vein graft disease is comprised of three distinct but interrelated pathological processes: thrombosis, intimal hyperplasia and atherosclerosis. Early thrombosis is a major cause of vein graft attrition during the first month after CABG, while during the remainder of the first year, intimal hyperplasia forms a template for subsequent atherogenesis, which thereafter predominates. Platelets play a crucial role in the pathophysiology of graft thrombosis and aspirin is the primary antiplatelet drug that has been shown to improve vein graft patency within the first year after CABG. Nevertheless, a significant number of grafts still occlude in the early postoperative period despite 'appropriate' aspirin treatment. Moreover, laboratory investigations showed that the expected inhibition of platelet function is not always achieved. This has been called 'aspirin nonresponse' or 'aspirin resistance', although a uniform definition is lacking. The finding that a considerable number of patients show an impaired antiplatelet effect of aspirin after CABG brought new insight into the discussion concerning poor patency rates of bypass grafts: the early period after CABG shows a coincidence of an increased risk for bypass thrombosis (amongst others, due to platelet activation and endothelial cell disruption of the graft) and an increased prevalence of aspirin resistance. Hitherto, the underlying mechanisms of aspirin resistance are uncertain and largely hypothetical; amongst others, increased platelet turnover, enhanced platelet reactivity, systemic inflammation, and drug-drug interaction are discussed. Up to now available data concerning the clinical outcome of aspirin resistant CABG patients are limited, and there is evidence that platelets of patients with graft thrombosis are more likely to be resistant to aspirin compared with patients without thrombotic events. Many publications concerning aspirin resistance are available today, but reports addressing this topic in CABG patients are sparse. This review summarises recent insights into the antiplatelet treatment after CABG and describes the clinical benefit, but also the therapeutic failure of the well-established drug aspirin. Moreover, possible pharmacological approaches to improve antithrombotic therapy in aspirin nonresponders among CABG patients are discussed.
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Mureebe L, Graham JA, Bush RL, Silver D. Risk of Heparin-Induced Thrombocytopenia from Heparin-Bonded Vascular Prostheses. Ann Vasc Surg 2007; 21:719-22. [DOI: 10.1016/j.avsg.2007.07.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2007] [Revised: 06/13/2007] [Accepted: 07/15/2007] [Indexed: 11/17/2022]
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Loesch A, Dashwood MR, Souza DSR. Does the method of harvesting the saphenous vein for coronary artery bypass surgery affect venous smooth muscle cells? iNOS immunolabelling and ultrastructural findings. Int J Surg 2006; 4:20-9. [PMID: 17462310 DOI: 10.1016/j.ijsu.2005.11.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2005] [Revised: 11/10/2005] [Accepted: 11/19/2005] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Coronary artery bypass surgery (CABG) using conventionally harvested saphenous vein (SV) as a graft is characterised by a high graft failure rate. It is believed that vein handling during harvesting is responsible for this, as damage to the vein's structure including its sources of endothelial nitric oxide synthase (eNOS) is apparent. Here we investigated the distribution of inducible nitric oxide synthase (iNOS) in conventionally harvested SV grafts and grafts prepared by a less-invasive 'no-touch' technique for CABG. Focus was on vascular smooth muscle cells (VSMCs). PATIENTS AND METHODS Six patients undergoing CABG were selected for the study; their SVs were harvested as grafts by conventional and 'no-touch' techniques and subsequently examined using fluorescent and transmission electron microscopy combined with immunolabelling to detect iNOS and structural changes in the grafts at the time of implantation. RESULTS The following were observed in conventionally harvested grafts: (i) damage to the VSMCs and (ii) induction of iNOS in these cells, (iii) heterogeneity of VSMCs-the presence of iNOS-positive and iNOS-negative VSMCs which were also (iv) in close contact with each other. In contrast, no damage to VSMCs and no expression of iNOS in these cells were observed in the 'no-touch' SV preparations. CONCLUSIONS The harvesting procedure influences the structure of VSMCs and the expression of iNOS in SV graft at the time of implantation. Whether rapid stimulation of iNOS in VSMCs in conventional SV grafts has a protective or harmful effect on the graft patency remains to be determined.
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Affiliation(s)
- Andrzej Loesch
- Department of Anatomy and Developmental Biology, Royal Free and University College Medical School, Hampstead Campus, Rowland Hill Street, Hampstead, London NW3 2PF, UK.
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20
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Black EA, Guzik TJ, West NE, Campbell K, Pillai R, Ratnatunga C, Channon KM. Minimally invasive saphenous vein harvesting: effects on endothelial and smooth muscle function. Ann Thorac Surg 2001; 71:1503-7. [PMID: 11383790 DOI: 10.1016/s0003-4975(01)02463-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND The long saphenous vein remains the commonest conduit used in coronary artery bypass grafting procedures. Surgical trauma during vein harvesting can cause endothelial and smooth muscle injury that has important implications for vein graft longevity. Minimally invasive vein harvesting is advocated to reduce wound morbidity. However, the functional consequences of increased handling and traction, with potentially detrimental effects, remain unknown. METHODS Forty patients were prospectively randomized into either a minimally invasive (minimal) or traditional (open) saphenous vein harvest group. Smooth muscle contractile function was assessed by responses to potassium chloride and phenylephrine. Endothelial cell function was assessed by responses to serial escalations in concentration of acetylcholine, bradykinin, calcium ionophore, sodium nitroprusside, and N-nitro-L-arginine using isometric tension studies. RESULTS Harvest times were similar for both groups. The total incision length in the minimal group was significantly shorter than in the open group. There were no differences in smooth muscle contractions to either receptor-independent or receptor-mediated agonists between the two groups. Similarly, vasorelaxation in response to both endothelium-dependent and endothelium-independent agonists were similar in both groups. CONCLUSIONS Minimally invasive saphenous vein harvesting is associated with similar medial smooth muscle and endothelial function as open harvesting. These findings suggest that minimally invasive harvesting techniques can be used without major detrimental effects on vascular integrity.
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Affiliation(s)
- E A Black
- Oxford Heart Centre and Department of Cardiovascular Medicine, John Radcliffe Hospital, University of Oxford, United Kingdom
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21
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Meyer DM, Rogers TE, Jessen ME, Estrera AS, Chin AK. Histologic evidence of the safety of endoscopic saphenous vein graft preparation. Ann Thorac Surg 2000; 70:487-91. [PMID: 10969668 DOI: 10.1016/s0003-4975(00)01503-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Endoscopic methods of saphenous vein procurement have recently been introduced. These techniques have been successful in limiting pain and wound complications, but less information on assessing potential trauma to the harvested vein segment is available. METHODS Fourteen male patients undergoing coronary artery bypass grafting were included in the study. Nine patients underwent endoscopic procurement of saphenous vein whereas 5 patients underwent procurement using standard open techniques. Histologic appearance and immunohistochemical studies (factor VIII:vWF [von Willebrand factor protein] and CD34) of the vein segments were reviewed in a blinded fashion. RESULTS On histologic analysis, no differences in the intima, media, or adventitia were found between endoscopically and conventionally obtained vein segments. Immunohistochemical staining for factor VIII:vWF and CD34 showed no differences between veins harvested by the two techniques. CONCLUSIONS Endoscopic saphenous vein harvesting does not appear to traumatize the vessel wall any more than open techniques. Longitudinal assessment is necessary to evaluate long-term patency in vein grafts procured using this method.
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Affiliation(s)
- D M Meyer
- Department of Surgery, University of Texas Southwestern Medical Center at Dallas, and Dallas Veterans Administration Medical Center, 75235-8879, USA.
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Affiliation(s)
- P Vallance
- Centre for Clinical Pharmacology, University College London.
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Alderman EL, Levy JH, Rich JB, Nili M, Vidne B, Schaff H, Uretzky G, Pettersson G, Thiis JJ, Hantler CB, Chaitman B, Nadel A. Analyses of coronary graft patency after aprotinin use: results from the International Multicenter Aprotinin Graft Patency Experience (IMAGE) trial. J Thorac Cardiovasc Surg 1998; 116:716-30. [PMID: 9806378 DOI: 10.1016/s0022-5223(98)00431-0] [Citation(s) in RCA: 201] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We examined the effects of aprotinin on graft patency, prevalence of myocardial infarction, and blood loss in patients undergoing primary coronary surgery with cardiopulmonary bypass. METHODS Patients from 13 international sites were randomized to receive intraoperative aprotinin (n = 436) or placebo (n = 434). Graft angiography was obtained a mean of 10.8 days after the operation. Electrocardiograms, cardiac enzymes, and blood loss and replacement were evaluated. RESULTS In 796 assessable patients, aprotinin reduced thoracic drainage volume by 43% (P < .0001) and requirement for red blood cell administration by 49% (P < .0001). Among 703 patients with assessable saphenous vein grafts, occlusions occurred in 15.4% of aprotinin-treated patients and 10.9% of patients receiving placebo (P = .03). After we had adjusted for risk factors associated with vein graft occlusion, the aprotinin versus placebo risk ratio decreased from 1.7 to 1.05 (90% confidence interval, 0.6 to 1.8). These factors included female gender, lack of prior aspirin therapy, small and poor distal vessel quality, and possibly use of aprotinin-treated blood as excised vein perfusate. At United States sites, patients had characteristics more favorable for graft patency, and occlusions occurred in 9.4% of the aprotinin group and 9.5% of the placebo group (P = .72). At Danish and Israeli sites, where patients had more adverse characteristics, occlusions occurred in 23.0% of aprotinin- and 12.4% of placebo-treated patients (P = .01). Aprotinin did not affect the occurrence of myocardial infarction (aprotinin: 2.9%; placebo: 3.8%) or mortality (aprotinin: 1.4%; placebo: 1.6%). CONCLUSIONS In this study, the probability of early vein graft occlusion was increased by aprotinin, but this outcome was promoted by multiple risk factors for graft occlusion.
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Affiliation(s)
- E L Alderman
- Division of Cardiovascular Medicine, Stanford University Medical Center, Calif 94305, USA
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Dattilo JB, Dattilo MP, Spratt JA, Matsuura J, Yager DR, Makhoul RG. Inducible nitric oxide synthase expression in human vein grafts. Am J Surg 1997; 174:177-80. [PMID: 9293839 DOI: 10.1016/s0002-9610(97)90078-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The patency of vascular reconstructive procedures is limited by the development of intimal hyperplasia (IH). Nitric oxide (NO) seems to be beneficial in abrogating this process. Currently, there is little information concerning inducible nitric oxide synthase (iNOS), the enzyme responsible for NO synthesis, and human vein grafts. The purpose of this study was to examine iNOS gene expression in human aortocoronary vein grafts (ACVG) and infrainguinal vein bypass grafts (IVG). METHODS Nonthrombosed sections from ACVG (n = 5), IVG (n = 5), and control saphenous vein (SV; n = 4) were harvested and processed for RNA isolation. Quantitative reverse transcription-polymerase chain reaction (RT-PCR) was performed on samples using 32P radioactively end labeled primers. Glyceraldehyde-3-phosphate-dehydrogenase (GAPDH) was the internal control, and results were expressed as iNOS pmol/GAPDH pmol. RESULTS There was a significant increase in the iNOS gene expression in the ACVG (0.049 +/- 0.01) when compared with IVG (0.019 +/- 0.001) or normal SV (0.011 +/- 0.002; P < or = 0.05). There was no significant difference between normal vein and the infrainguinal grafts. Sequencing of a fragment of the amplified 428 bp gene product confirmed 84% homology with the available gene bank human sequence. CONCLUSIONS This study proves that iNOS is expressed in human vein bypass grafts. Additionally, there is a significant elevation of iNOS message in human ACVGs compared with IVG or normal SV. This difference may be the result of the unique vascular beds supplied by these grafts. Ultimately, manipulation of iNOS expression may lead to therapies to alleviate IH in these grafts.
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Affiliation(s)
- J B Dattilo
- Department of Surgery, Medical College of Virginia/Virginia Commonwealth University, Richmond 23298-0108, USA
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25
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Affiliation(s)
- J B Dattilo
- Department of Surgery, Medical College of Virginia/Virginia Commonwealth University, Richmond 23298-0108, USA
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26
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Anastasiou N, Allen S, Paniagua R, Chester A, Yacoub M. Altered endothelial and smooth muscle cell reactivity caused by University of Wisconsin preservation solution in human saphenous vein. J Vasc Surg 1997; 25:713-21. [PMID: 9129628 DOI: 10.1016/s0741-5214(97)70299-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE We have investigated the effect of University of Wisconsin (UW) solution at different temperatures on endothelial and smooth muscle cell function of the human saphenous vein to define the efficacy of UW solution as a preservation solution for saphenous vein conduits. METHODS Saphenous vein segments from 38 patients undergoing coronary artery bypass surgery were examined with an isolated organ bath technique to monitor changes in vessel reactivity. RESULTS Endothelial-dependent relaxations to acetylcholine were attenuated after incubation in UW solution at both 4 degrees C and 28 degrees C (p < 0.05, n = 10). In contrast, relaxations to sodium nitroprusside were unchanged after incubation in UW solution at both temperatures (n = 8). The responses to 90 mmol/L KCl were increased at both 4 degrees C and 28 degrees C, respectively. Tyrode's: 27.2% +/- 3.1% and 23.8% +/- 3.0%, UW: 64.7% +/- 8.0% and 73.1% +/- 11% (p < 0.001). In addition, the responses to 5-HT were enhanced at 4 degrees C and 28 degrees C (p < 0.05). In contrast, responses to noradrenaline were enhanced only at 28 degrees C compared with the responses after incubations in Tyrode's solution (p < 0.05, n = 6). Furthermore U46619 (0.3 nmol/L to 1 nmol/L) responses were augmented at 4 degrees C (p < 0.05, n = 7). The potency (pD2) values for each agonist were not significantly different after incubations in UW solution. CONCLUSIONS We conclude that UW solution produces attenuation of acetylcholine relaxations and temperature-dependent increased reactivity of smooth-muscle cell function in the isolated human saphenous vein. These studies document the complex interactions brought about by UW solution on the different components of the vascular wall that need to be elucidated further if this solution is to attain a place in vascular preservation.
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Affiliation(s)
- N Anastasiou
- Heart Science Centre, Imperial College of Science, Technology, and Medicine, Harefield Hospital, UK
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27
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Yang JA, He GW. Surgical preparation abolishes endothelium-derived hyperpolarizing factor-mediated hyperpolarization in the human saphenous vein. Ann Thorac Surg 1997; 63:429-33. [PMID: 9033314 DOI: 10.1016/s0003-4975(96)00900-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The impairment of the synthesis and release of endothelium-derived relaxing factors may be related to the high incidence of atherosclerosis and occlusion in saphenous vein grafts. This study focused on the effect of surgical preparation on one of the endothelium-derived relaxing factors, endothelium-derived hyperpolarizing factor, in the human saphenous vein. METHODS Human saphenous vein segments taken from patients undergoing coronary bypass were placed in an organ bath. A glass microelectrode was inserted into a smooth muscle cell. The membrane potential in response to acetylcholine (-9 to -5 log M) was measured in normal or surgically prepared saphenous vein with presence or absence of NG-nitro-L-arginine (300 mumol/L) and indomethacin (7 mumol/L). RESULTS The resting membrane potential was -71.28 +/- 1.91 mV (n = 7) with intact endothelium and -65.5 +/- 2.92 mV (n = 6, p > 0.05) without endothelium. Acetylcholine hyperpolarized membrane potential with intact endothelium (-90.57 +/- 1.48 mV, n = 7, p < 0.001), but not without endothelium (-69.67 +/- 2.93 mV, n = 6, p > 0.05). In the surgically prepared saphenous vein, acetylcholine did not hyperpolarize membrane potential (-71.83 +/- 3.84 mV versus the resting membrane potential of -69.50 +/- 3.53 mV, n = 6, p > 0.05). CONCLUSIONS The endothelium-derived hyperpolarizing factor plays a role in the human saphenous vein. The surgical preparation abolishes the endothelium-derived hyperpolarizing factor-mediated hyperpolarization in the saphenous vein. This study provides evidence of functional changes of endothelium by traditional surgical preparation from another point of view, and it may be related to the high incidence of occlusion in saphenous vein grafts.
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Affiliation(s)
- J A Yang
- Department of Surgery, University of Hong Kong, Grantham Hospital, Aberdeen, Hong Kong
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28
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Abstract
Arterial allografts, formerly called homografts, came into limited use in the 1940s and 1950s as arterial substitutes. Fresh allografts underwent rapid rejection. Preserved allografts had a longer but still limited clinical life. Allografts demonstrated that arterial replacement was a valid concept and led to the development of synthetic substitutes. Recent renewed interest is based on the need for graft replacements in re-do procedures and in an infected field. Even the best methods of graft procurement and preservation do not preserve normal endothelial and smooth muscle cell functions nor eliminate antigenicity. The biologic and economic costs of immune suppression to obtain a successful allograft for an ischaemic limb are presently unjustifiable. Transplantation between species (xenotransplantation) may be attainable via selective inhibition of the complement system avoiding full immunosuppression now required for organ transplantation. At present allografts may be an acceptable choice for the patient with (1) a critical need for revascularisation and with a life expectancy not exceeding that of the graft, (2) in urgent vascular trauma, and (3) where immunosuppression is contraindicated as in an infected surgical field. Except in most unusual circumstances allografts should not be used for (1) relief of claudication, (2) in the above mid-calf location and (3) anatomic locations where synthetic grafts are superior.
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Affiliation(s)
- A D Callow
- Whitaker Cardiovascular Institute, Boston University Medical Center, University Hospital, Massachusetts, USA
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29
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Hausmann H, Merker HJ, Hetzer R. Pressure controlled preparation of the saphenous vein with papaverine for aortocoronary venous bypass. J Card Surg 1996; 11:155-62. [PMID: 8811411 DOI: 10.1111/j.1540-8191.1996.tb00032.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND METHODS In 21 patients intraoperatively receiving coronary revascularization, segments of the saphenous vein were prepared for aortocoronary bypass. Postoperatively, the endothelial intima was subjected to electron microscopy. Venous segments in which an intraluminal mean pressure of 263 mmHg +/- 52 mmHg had been measured during preparation were compared with venous segments that had been explanted with the aid of a venous protection bulldog and with pharmacological treatment through papaverine. RESULTS Those segments of high-pressure distension that had not been protected showed intimal damage with erythrocytes and thrombocytes. On the other hand, venous segments with low-pressure distension that had been protected in the described way during harvesting appeared similar to native veins. CONCLUSION We conclude that during the preparation of the saphenous vein for aortocoronary bypass surgery, the application of papaverine and the use of the venous protection bulldog clamp is effective in preventing pressure damage during preparation of the vein.
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Affiliation(s)
- H Hausmann
- Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin, Germany
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30
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Allen SP, Chester AH, Dzimiri NF, Duran CM, Yacoub M. Vascular biology of human saphenous veins. Ann Saudi Med 1995; 15:378-84. [PMID: 17590611 DOI: 10.5144/0256-4947.1995.378] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Affiliation(s)
- S P Allen
- National Heart and Lung Institute, London, Heart Science Centre Harefield Hospital, Harefield, Middlesex, U.K., Department of Cardiovascular Diseases, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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31
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Massa G, Ingemansson R, Sjöberg T, Steen S. Endothelium-dependent relaxation after short-term preservation of vascular grafts. Ann Thorac Surg 1994; 58:1117-22. [PMID: 7944762 DOI: 10.1016/0003-4975(94)90469-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
As the integrity of graft endothelium seems to be essential to successful long-term patency in coronary operations, its preservation demands the utmost care. The aim of the present study was to investigate the effects of currently used solutions on endothelium-dependent relaxation after short-term storage of vessels at room temperature or at 4 degrees C. The infrarenal rat aorta was selected for study because its use enabled standardization of the investigation, which was performed in organ baths on 672 vessel segments from 112 Sprague-Dawley rats. Stable vasoconstriction was obtained with the thromboxane analogue U-46619. Acetylcholine was used to elicit endothelium-dependent relaxation. The results obtained for vessels preserved for 2 hours were compared with those for autologous vessels studied immediately after harvesting. Vessel contractility was unaffected by the preservation solutions, except in the Ringer's acetate group, where it was reduced by 50% (p < 0.05). Endothelium-independent relaxation, tested with papaverine, was unaffected in all groups. Ringer's lactate, Krebs solution, and Perfadex (a low-potassium-dextran-glucose solution) did not significantly affect endothelium-dependent relaxation either at room temperature or at 4 degrees C, although a tendency to impaired relaxation was seen in these three groups after cold storage. Standard Ringer's solution and fresh heparinized blood each significantly reduced endothelium-dependent relaxation in vessels stored at room temperature (p < 0.05), but not in those stored at 4 degrees C. Endothelium-dependent relaxation was significantly reduced after storage in normal saline solution (p < 0.05) and in Ringer's acetate (p < 0.01), both at room temperature and at 4 degrees C.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- G Massa
- Department of Cardiothoracic Surgery, University Hospital, Lund, Sweden
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32
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Abstract
In the complex setting of cardiac surgery and cardiopulmonary bypass, several potent mediators are released that by interacting may cause clinical syndromes like coronary ischemia, systemic hypertension, pulmonary hypertension, and renal failure. One of the mediators is serotonin, released from aggregating platelets, and causing vasoconstriction by activating S2-serotonergic receptors, particularly in patients with an impaired endothelial function, as in atherosclerosis. The most important available specific S2-serotonergic receptor antagonist is ketanserin. If administered during or after cardiac surgery, ketanserin lowers systemic and pulmonary blood pressure, and improves peripheral and pulmonary perfusion without causing reflex tachycardia or an increase in pulmonary shunt fraction.
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Affiliation(s)
- P J Van der Starre
- Department of Cardiothoracic Anesthesiology and Intensive Care, Hospital De Weezenlanden, Zwolle, The Netherlands
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33
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Sanchez AM, Wooldridge TA, Boerboom LE, Olinger GN, Almassi GH, Rusch NJ. Comparison of saphenous vein graft relaxation between Plasma-Lyte solution and normal saline solution. J Thorac Cardiovasc Surg 1994. [DOI: 10.1016/s0022-5223(94)70421-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Underwood MJ, More R, Weeresena N, Firmin RK, De Bono DP. The effect of surgical preparation and in-vitro distension on the intrinsic fibrinolytic activity of human saphenous vein. EUROPEAN JOURNAL OF VASCULAR SURGERY 1993; 7:518-22. [PMID: 8405495 DOI: 10.1016/s0950-821x(05)80363-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The objective of this study was to assess the effect of distension on the intrinsic fibrinolytic activity of human saphenous vein during its preparation for use as a bypass conduit prior to coronary artery surgery. Fibrinolytic activity was studied using fibrin plate techniques and Chromogenic assays for extractable tPA and uPA. Samples were obtained from patients undergoing routine coronary surgery. Fibrinolytic activity was compared in control vein (untouched) vein that had been prepared for use as a bypass conduit (surgical dissection, ligation of side branches and careful but uncontrolled manual distension) and segments of dissected vein distended in vitro to pressures of 230 or 120 mmHg. Uncontrolled distension and distension to 230 mmHg impaired fibrinolytic activity as determined by areas of lysis on fibrin plates (p < 0.05), (p < 0.005), tPA activity (p < 0.005) (p < 0.005) and uPA activity (p < 0.05), (p < 0.005). Distension to 120 mmHg had no effect on the fibrinolytic activity of human saphenous vein. Impaired fibrinolytic activity caused by uncontrolled distension of saphenous vein prior to its use as a vascular conduit may contribute to early vein graft thrombosis and can be avoided using controlled distension to < 120 mmHg.
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Affiliation(s)
- M J Underwood
- University Department of Cardiology, Glenfield General Hospital, Leicester, U.K
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37
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Miller VM, Bergman R, Gloviczki P, Brockbank KG. Cryopreserved venous allografts: Effects of immunosuppression and antiplatelet therapy on patency and function. J Vasc Surg 1993. [DOI: 10.1016/0741-5214(93)90601-h] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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38
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He GW, Rosenfeldt FL, Angus JA. Pharmacological relaxation of the saphenous vein during harvesting for coronary artery bypass grafting. Ann Thorac Surg 1993; 55:1210-7. [PMID: 8494433 DOI: 10.1016/0003-4975(93)90036-h] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Spasm of the saphenous vein frequently occurs during harvesting from the leg and high-pressure distension is required to restore an adequate diameter for grafting. Forceful distention has been shown to damage the intima and media and may predispose to subsequent occlusion of the vein graft. Various pharmacologic vasodilators are capable of relaxing veins; in this study, we carried out a systematic investigation to determine the appropriate agents and concentrations for use during vein graft operations. In organ baths, human saphenous vein segments were contracted with potassium or a thromboxane mimetic, and vasodilator agents were then applied. Glyceryl trinitrate, 7.2 micrograms/mL, or papaverine hydrochloride, 11.9 micrograms/mL, caused 80% to 100% relaxation of contraction induced by potassium or thromboxane. Verapamil, 15.5 micrograms/mL, relaxed the potassium contraction by 100% and the thromboxane contraction by 75%. Comparison of the time course of action showed that glyceryl trinitrate had a rapid onset and a short duration of maximal action, whereas verapamil (like papaverine) had delayed onset and a long duration. A mixture of glyceryl trinitrate and verapamil combined rapid onset with long duration of action. We now use a mixture of glyceryl trinitrate and verapamil (pH 7.4) topically and intraluminally during harvesting of the saphenous vein to provide a relaxed conduit for coronary artery bypass grafting.
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Affiliation(s)
- G W He
- Baker Medical Research Institute, Melbourne, Australia
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39
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Abstract
The vascular endothelium is a complex modulator of a variety of biological systems and may well be the key to definitive success in the treatment of cardiovascular disorders. Surgically-induced endothelial injury may occur preoperatively during cardiac catheterization and intraoperatively from mechanical manipulation, ischemia, hypothermia, and exposure to cardioplegic solutions. The normal endothelium is antithrombogenic and yet promotes platelet aggregation and coagulation if injured. Vasospasm, occlusive intimal hyperplasia, and accelerated arteriosclerosis can also all occur as a result of endothelial injury. Furthermore, endothelial injury is harmful even in the absence of disruption of its monolayer integrity. Thus, preservation of the endothelium should be an additional objective for all cardiovascular surgeons. Synthetic vascular grafts, cardiac valves, and artificial ventricles do not spontaneously endothelialize and thus usually require some form of anticoagulation to maintain patency. Hence, endothelialization of prosthetic implants became an attractive concept. A number of different methods of obtaining an endothelial lining of prosthetic material has since been developed; these include facilitated endothelial cell migration, and endothelial cell seeding by using either venous or microvascular endothelial cells. Manipulating the endothelium might well provide the next major advancement for therapeutic and preventive measures for cardiovascular disease.
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Affiliation(s)
- P Zilla
- Department of Cardio-Thoracic Surgery, University of Cape Town, South Africa
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40
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Affiliation(s)
- B W Lytle
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Ohio
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41
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Aardal S, Helle KB, Svendsen E. In vitro responses to atrial natriuretic polypeptide in human vessels commonly used as aortocoronary bypass grafts. SCANDINAVIAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 1992; 26:135-41. [PMID: 1439644 DOI: 10.3109/14017439209099068] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Vascular effects of atrial natriuretic polypeptide (APII), i.e. the peptide hormone released from the atrial myocardium, were investigated in segments of the human internal thoracic artery (ITA) and saphenous vein (SV) with intact (+E) or injured (-E) endothelium. All segments were subject to several cycles of agonists in order to detect tachyphylactic or facilitatory responses. Opposite, indirect effects on the noradrenaline contracted ITA and SV were obtained in response to APII at a supranormal concentration (50 nM) which had no direct relaxing action on the isolated segments in vitro. In ITA the noradrenaline contractures in subsequent cycles were reduced to 41 +/- 21% (+E) and 28 +/- 9% (-E), but in SV they were enhanced to 211 +/- 115% (+E) and 483 +/- 242% (-E) of those before APII exposure. Thus under in vitro conditions ITA could be indirectly relaxed by APII via tachyphylactic effect on the noradrenaline contracture. SV, on the other hand, was markedly potentiated by APII in its noradrenaline response. In injured endothelium these opposite effects were aggravated.
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Affiliation(s)
- S Aardal
- Department of Physiology, University of Bergen, Norway
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Keller MW, Geddes L, Spotnitz W, Kaul S, Duling BR. Microcirculatory dysfunction following perfusion with hyperkalemic, hypothermic, cardioplegic solutions and blood reperfusion. Effects of adenosine. Circulation 1991; 84:2485-94. [PMID: 1659955 DOI: 10.1161/01.cir.84.6.2485] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Cardioplegic solutions have been used to enhance myocardial preservation during cardiac surgery. The benefits derived from preventing myocardial ischemia with cardioplegic solutions may, however, be countered by tissue damage that occurs when the myocardium is reperfused with oxygenated blood. Furthermore, cardioplegia-induced endothelial dysfunction may contribute to depressed myocardial function postoperatively. The endothelium of coronary arteries and vein grafts is damaged by crystalloid cardioplegic solutions. There is less known about the effects of cardioplegic solutions on the microvasculature. METHODS AND RESULTS The hypothesis that microvascular damage occurs following perfusion with hyperkalemic, crystalloid, cardioplegic solutions and blood reperfusion, leading to decreased blood flow and increased neutrophil accumulation, was tested in a model system. Intravital microscopic observations were performed during a 20-minute perfusion of the hamster cremaster muscle with cardioplegic solutions (10 degrees C) via the femoral artery with the iliac occluded and during a subsequent 2-hour blood reperfusion period (iliac open). Arteriolar vasoconstriction (27% decrease in diameter, p less than 0.05) and a 25% decrease in the density of perfused capillaries (p less than 0.05) occurred during reperfusion in hamsters receiving crystalloid cardioplegic solution (16 meq K+) compared to control hamsters (no cardioplegic solution given). Neutrophils accumulated on venular endothelium in treated animals (250% increase, p less than 0.05) and extravascularly (myeloperoxidase levels 2.0 +/- 0.4 U/g versus 1.3 +/- 0.3 U/g in control, p less than 0.05). The addition of adenosine (10(-4) M) and albumin (2 g%) to the cardioplegic perfusate, accompanied by the administration of adenosine (10(-4) M) during reperfusion, produced arteriolar vasodilation (34% diameter increase, p less than 0.05) and inhibited extravascular neutrophil accumulation (myeloperoxidase level of 1.5 +/- 0.2 U/g, p greater than 0.05 versus control). Capillary perfusion, however, was still significantly diminished (28% decrease, p less than 0.05.) CONCLUSIONS We conclude that injury manifest by decreased microvascular blood flow and increased neutrophil accumulation in tissues occurs after perfusion with hypothermic, hyperkalemic, crystalloid cardioplegic solutions and blood reperfusion. Adenosine seems to partially attenuate this injury by dilating arterioles and decreasing extravascular neutrophil accumulation.
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Affiliation(s)
- M W Keller
- Department of Medicine, University of Virginia Health Sciences Center, University of Virginia, Charlottesville 22908
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