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Wang H, Williams KM, Elde S, Bulterys PL, Thakore AD, Lucian HJ, Farry JM, Mullis DM, Zhu Y, Paulsen MJ, Woo YJ. Trimmed central venous catheters do not increase endothelial injury in an ovine model. J Vasc Access 2024; 25:1180-1186. [PMID: 36765464 DOI: 10.1177/11297298231153716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
INTRODUCTION Central venous catheters (CVCs) are often trimmed during heart transplantation and pediatric cardiac surgery. However, the risk of endothelial injury caused by the cut tip of the CVC has not been evaluated. We hypothesized that there is no difference in the degree of endothelial injury associated with trimmed CVCs versus standard untrimmed CVCs. METHODS In four adult male sheep, the left external jugular vein was exposed in three segments, one designated for an untouched control group, one for the trimmed CVC group, and one for the untrimmed CVC group. Trimmed and untrimmed CVC tips were rotated circumferentially within their respective segments to abrade the lumen of the vein. The vein samples were explanted, and two representative sections from each sample were analyzed using hematoxylin and eosin (H&E) staining, as well as with immunohistochemistry against CD31, von Willebrand factor (vWF), endothelial nitric oxide synthase (eNOS), and caveolin. Higher immunohistochemical stain distributions and intensities are associated with normal health and function of the venous endothelium. Data are presented as counts with percentages or as means with standard error. RESULTS H&E staining revealed no evidence of endothelial injury in 6/8 (75%) samples from the untouched control group, and no injury in 4/8 (50%) samples from both the trimmed and untrimmed CVC groups (p = 0.504). In all remaining samples from each group, only mild endothelial injury was observed. Immunohistochemical analysis comparing trimmed CVCs versus untrimmed CVCs revealed no difference in the percentage of endothelial cells staining positive for CD31 (57.5% ± 7.2% vs 55.0% ± 9.2%, p = 0.982), vWF (73.8% ± 8.0% vs 62.5% ± 9.6%, p = 0.579), eNOS (66.3% ± 4.2% vs 63.8% ± 7.5%, p = 0.962), and caveolin (53.8% ± 5.0% vs 51.3% ± 4.4%, p = 0.922). There were no significant differences between the groups in the distributions of stain intensity for CD31, vWF, eNOS, and caveolin. CONCLUSION Trimmed CVCs do not increase endothelial injury compared to standard untrimmed CVCs.
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Affiliation(s)
- Hanjay Wang
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Kiah M Williams
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Stefan Elde
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | | | - Akshara D Thakore
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Haley J Lucian
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Justin M Farry
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Danielle M Mullis
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Yuanjia Zhu
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
- Department of Bioengineering, Stanford University, Stanford, CA, USA
| | - Michael J Paulsen
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
- Department of Bioengineering, Stanford University, Stanford, CA, USA
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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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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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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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5
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6551535. [DOI: 10.1093/ejcts/ezac144] [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: 02/14/2022] [Accepted: 02/17/2022] [Indexed: 11/13/2022] Open
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Sawaby A, Maklad S, Atta I, El Abd A, Mady MM, Solaiman A. Evaluation of the efficacy of foam sclerosant after addition of glycerine on human great saphenous vein: histological and immunohistochemical study. Ann R Coll Surg Engl 2021; 103:452-458. [PMID: 33851890 DOI: 10.1308/rcsann.2020.7130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Several treatment modalities have been postulated to improve the efficacy of varicose vein treatment. Addition of glycerine to the sclerosing material has been documented to increase its viscosity and subsequently prolong the duration of stability, in addition to the direct sclerosing effect of glycerine. This histological and immunohistochemical study investigated the efficacy of addition of glycerine 72% to sclerotherapy on the human varicose vein. METHODS After surgical stripping of great saphenous veins, three equal segments were resected between two clamps. Specimen 1 was injected with saline only, specimen 2 was exposed to foam sclerosant 2%, and specimen 3 was exposed to a mixture of foam sclerosant 2% and glycerine 72%. All segments were left for 5min. Vein segments were then processed for histological and immunohistochemical study. RESULTS Microscopically, haematoxylin and eosin-stained specimen 1 showed endothelial swelling, cytoplasmic eosinophilia and pyknotic nuclei. The media showed sarcoplasm vacuolisation and necrosis. Specimen 3 showed hypereosinophilic sarcoplasm of the smooth muscle fibres. Oedema was less evident, with a relative decrease in the thickness of the wall compared with specimen 2. Immunohistochemically, the expression of smooth muscle actin was weak in specimen 3 compared with specimens 1 and 2. Expression of CD31 antibody was much reduced in specimen 2 which showed conserved islands of endothelial cells. By contrast, there was a complete loss of endothelial cells in specimen 3. CONCLUSION Addition of glycerine 72% to foam sclerosant has a more damaging effect on human vein wall.
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Affiliation(s)
| | | | - I Atta
- Kafr El Sheikh University, Egypt
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Abstract
Coronary artery bypass grafting is the most common cardiac surgical procedure performed worldwide and the long saphenous vein the most common conduit for this. When performed as an open vein harvest (OVH), the incision on each leg can be up to 85cm long, making it the longest incision of any routine procedure. This confers a high degree of morbidity to the procedure. Endoscopic vein harvest (EVH) methods were popularised over two decades ago, demonstrating significant benefits over OVH in terms of leg wound complications including surgical site infections. They also appeared to hasten return to usual activities and wound healing and became popular particularly in North America. Subgroup analyses of two trials designed for other purposes created a period of uncertainty between 2009–2013 while the impact of endoscopic vein harvesting on vein graft patency and major adverse cardiac events was scrutinised. Large observational studies debunked the findings of increased mortality in the short-term, allowing practitioners and governing bodies to regain some confidence in the procedure. A well designed, adequately powered, randomised controlled trial published in 2019 also definitively demonstrated that there was no increase in death, myocardial infarction or repeat revascularisation with endoscopic vein harvest. Endoscopic vein harvest is a Class IIa indication in European Association of Cardio-Thoracic Surgery (EACTS) and a Class I indication in International Society of Minimally Invasive Cardiac Surgery (ISMICS) guidelines.
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Affiliation(s)
- Enoch Akowuah
- Department of Cardiac Surgery, James Cook University Hospital, South Tees NHS, Foundation Trust, Middlesbrough, UK
| | - Daniel Burns
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Joseph Zacharias
- Department of Cardiothoracic Surgery, Blackpool Victoria Hospital, Blackpool, UK
| | - Bilal H Kirmani
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
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8
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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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9
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Lucchese G, Jarral OA. Endoscopic vein harvest: benefits beyond (a) reasonable doubt? J Thorac Dis 2019; 11:S1342-S1345. [PMID: 31245128 DOI: 10.21037/jtd.2019.04.06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Omar A Jarral
- Department of Cardiac Surgery, St. Thomas' Hospital, London, UK
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10
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Kodia K, Patel S, Weber MP, Luc JGY, Choi JH, Maynes EJ, Rizvi SSA, Horan DP, Massey HT, Entwistle JW, Morris RJ, Tchantchaleishvili V. Graft patency after open versus endoscopic saphenous vein harvest in coronary artery bypass grafting surgery: a systematic review and meta-analysis. Ann Cardiothorac Surg 2018; 7:586-597. [PMID: 30505742 DOI: 10.21037/acs.2018.07.05] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Saphenous vein grafts (SVG) are a commonly used conduit for coronary artery bypass graft (CABG) surgery and can be harvested by either an open or endoscopic technique. Our goal was to evaluate long-term angiographic and clinical outcomes of open compared to endoscopic SVG harvest for CABG. Methods Electronic search was performed to identify all studies in the English literature that compared open and endoscopic SVG harvesting for CABG with at least one year of follow-up. The primary outcome was graft patency. Secondary outcomes included perioperative morbidity and mortality. Results Of 3,255 articles identified, a total of 11 studies were included for analysis. Of 18,131 patients, 10,873 (60%) patients underwent open SVG harvest and 7,258 (40%) patients underwent endoscopic SVG harvest. The mean age of patients was 65 years and 87% were male. The overall mean follow-up period was 2.6 years. During follow-up, patients who underwent open SVG harvest had superior graft patency per graft [open 82.3% vs. endoscopic 75.1%; OR: 0.61 (95% CI, 0.43-0.87); P=0.01], but higher rates of overall wound complications in the immediate post-operative period [open 3.3% vs. endoscopic 1.1%; OR: 0.02 (95% CI, 0.01-0.06); P<0.001]. Patients who underwent open SVG harvest had higher postoperative 30-day mortality [open 3.4% vs. endoscopic 2.1%; OR: 0.59 (95% CI, 0.37-0.94); P=0.03], but no significant difference in overall mortality [open 4.9% vs. endoscopic 4.9%; OR: 0.34 (95% CI, 0.50-1.27); P=0.34]. Conclusions Patients who underwent an open SVG harvest technique had improved graft patency and comparable overall mortality to endoscopic SVG harvest at average follow-up time of 2.6 years. Patients with open SVG harvest had higher rates of early wound complications and postoperative 30-day mortality, however, there was no difference in overall mortality.
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Affiliation(s)
- Karishma Kodia
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Sinal Patel
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Matthew P Weber
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jessica G Y Luc
- Division of Cardiovascular Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jae Hwan Choi
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Elizabeth J Maynes
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Dylan P Horan
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - H Todd Massey
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - John W Entwistle
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Rohinton J Morris
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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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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Suarez-Pierre A, Terasaki Y, Magruder JT, Kapoor A, Grant MC, Lawton JS. Complications of CO 2 insufflation during endoscopic vein harvesting. J Card Surg 2017; 32:783-789. [PMID: 29169212 DOI: 10.1111/jocs.13249] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Over the past few decades, the use of endoscopic harvest of the saphenous vein has gained popularity due to a significant reduction in rates of wound infection and improved cosmesis. The widespread adoption of this technique has introduced a set of complications associated with the use CO2 insufflation which facilitates exposure during the vein harvest. We describe a case of pneumoperitoneum with systemic acidosis and subcutaneous air following endoscopic vein harvest for coronary artery bypass grafting and review the complications that may arise from CO2 insufflation during endoscopic vein harvesting.
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Affiliation(s)
- Alejandro Suarez-Pierre
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yusuke Terasaki
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - J Trent Magruder
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Anubhav Kapoor
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer S Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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13
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Randomized Study Comparing the Effect of Carbon Dioxide Insufflation on Veins Using 2 Types of Endoscopic and Open Vein Harvesting. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2017; 12:320-328. [PMID: 29016381 DOI: 10.1097/imi.0000000000000405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to assess whether the use of carbon dioxide insufflation has any impact on integrity of long saphenous vein comparing 2 types of endoscopic vein harvesting and traditional open vein harvesting. METHODS A total of 301 patients were prospectively randomized into 3 groups. Group 1 control arm of open vein harvesting (n = 101), group 2 closed tunnel (carbon dioxide) endoscopic vein harvesting (n = 100) and Group 3 open tunnel (carbon dioxide) endoscopic vein harvesting (open tunnel endoscopic vein harvesting) (n = 100). Each group was assessed to determine the systemic level of partial arterial carbon dioxide, end-tidal carbon dioxide, and pH. Three blood samples were obtained at baseline, 10 minutes after start of endoscopic vein harvesting, and 10 minutes after the vein was retrieved. Vein samples were taken immediately after vein harvesting without further surgical handling to measure the histological level of endothelial damage. A modified validated endothelial scoring system was used to compare the extent of endothelial stretching and detachment. RESULTS The level of end-tidal carbon dioxide was maintained in the open tunnel endoscopic vein harvesting and open vein harvesting groups but increased significantly in the closed tunnel endoscopic vein harvesting group (P = 0.451, P = 0.385, and P < 0.001). Interestingly, partial arterial carbon dioxide also did not differ over time in the open tunnel endoscopic vein harvesting group (P = 0.241), whereas partial arterial carbon dioxide reduced significantly over time in the open vein harvesting group (P = 0.001). A profound increase in partial arterial carbon dioxide was observed in the closed tunnel endoscopic vein harvesting group (P < 0.001). Consistent with these patterns, only the closed tunnel endoscopic vein harvesting group demonstrated a sudden drop in pH over time (P < 0.001), whereas pH remained stable for both open tunnel endoscopic vein harvesting and open vein harvesting groups (P = 0.105 and P = 0.869, respectively). Endothelial integrity was better preserved in the open vein harvesting group compared with open tunnel endoscopic vein harvesting or closed tunnel endoscopic vein harvesting groups (P = 0.012) and was not affected by changes in carbon dioxide or low pH. Significantly greater stretching of the endothelium was observed in the open tunnel endoscopic open tunnel endoscopic vein harvesting group compared with the other groups (P = 0.003). CONCLUSIONS This study demonstrated that the different vein harvesting techniques impact on endothelial integrity; however, this does not seem to be related to the increase in systemic absorption of carbon dioxide or to the pressurized endoscopic tunnel. The open tunnel endoscopic harvesting technique vein had more endothelial stretching compared with the closed tunnel endoscopic technique; this may be due to manual dissection of the vein. Further research is required to evaluate the long-term clinical outcome of these vein grafts.
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Krishnamoorthy B, Critchley WR, Nair J, Malagon I, Carey J, Barnard JB, Waterworth PD, Venkateswaran RV, Fildes JE, Caress AL, Yonan N. Randomized Study Comparing the Effect of Carbon Dioxide Insufflation on Veins using 2 Types of Endoscopic and Open Vein Harvesting. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2017. [DOI: 10.1177/155698451701200502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Bhuvaneswari Krishnamoorthy
- Department of Cardiothoracic Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
- Faculty of Health and Social Care, Edge Hill University, Ormskirk, Lancashire, United Kingdom
| | - William R. Critchley
- Manchester Collaborative Centre for Inflammation Research, Faculty of Medical and Human Sciences, University of Manchester, Manchester, United Kingdom
| | - Janesh Nair
- Manchester Collaborative Centre for Inflammation Research, Faculty of Medical and Human Sciences, University of Manchester, Manchester, United Kingdom
| | - Ignacio Malagon
- Department of Cardiothoracic Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - John Carey
- Department of Cardiothoracic Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - James B. Barnard
- Department of Cardiothoracic Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Paul D. Waterworth
- Department of Cardiothoracic Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Rajamiyer V. Venkateswaran
- Department of Cardiothoracic Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - James E. Fildes
- Manchester Collaborative Centre for Inflammation Research, Faculty of Medical and Human Sciences, University of Manchester, Manchester, United Kingdom
| | - Ann L. Caress
- School of Nursing and Midwifery, The University of Manchester, Manchester, United Kingdom
| | - Nizar Yonan
- Department of Cardiothoracic Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
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15
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Krishnamoorthy B, Critchley WR, Thompson AJ, Payne K, Morris J, Venkateswaran RV, Caress AL, Fildes JE, Yonan N. Study Comparing Vein Integrity and Clinical Outcomes in Open Vein Harvesting and 2 Types of Endoscopic Vein Harvesting for Coronary Artery Bypass Grafting: The VICO Randomized Clinical Trial (Vein Integrity and Clinical Outcomes). Circulation 2017. [PMID: 28637880 DOI: 10.1161/circulationaha.117.028261] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Current consensus statements maintain that endoscopic vein harvesting (EVH) should be standard care in coronary artery bypass graft surgery, but vein quality and clinical outcomes have been questioned. The VICO trial (Vein Integrity and Clinical Outcomes) was designed to assess the impact of different vein harvesting methods on vessel damage and whether this contributes to clinical outcomes after coronary artery bypass grafting. METHODS In this single-center, randomized clinical trial, patients undergoing coronary artery bypass grafting with an internal mammary artery and with 1 to 4 vein grafts were recruited. All veins were harvested by a single experienced practitioner. We randomly allocated 300 patients into closed tunnel CO2 EVH (n=100), open tunnel CO2 EVH (n=100), and traditional open vein harvesting (n=100) groups. The primary end point was endothelial integrity and muscular damage of the harvested vein. Secondary end points included clinical outcomes (major adverse cardiac events), use of healthcare resources, and impact on health status (quality-adjusted life-years). RESULTS The open vein harvesting group demonstrated marginally better endothelial integrity in random samples (85% versus 88% versus 93% for closed tunnel EVH, open tunnel EVH, and open vein harvesting; P<0.001). Closed tunnel EVH displayed the lowest longitudinal hypertrophy (1% versus 13.5% versus 3%; P=0.001). However, no differences in endothelial stretching were observed between groups (37% versus 37% versus 31%; P=0.62). Secondary clinical outcomes demonstrated no significant differences in composite major adverse cardiac event scores at each time point up to 48 months. The quality-adjusted life-year gain per patient was 0.11 (P<0.001) for closed tunnel EVH and 0.07 (P=0.003) for open tunnel EVH compared with open vein harvesting. The likelihood of being cost-effective, at a predefined threshold of £20 000 per quality-adjusted life-year gained, was 75% for closed tunnel EVH, 19% for open tunnel EVH, and 6% for open vein harvesting. CONCLUSIONS Our study demonstrates that harvesting techniques affect the integrity of different vein layers, albeit only slightly. Secondary outcomes suggest that histological findings do not directly contribute to major adverse cardiac event outcomes. Gains in health status were observed, and cost-effectiveness was better with closed tunnel EVH. High-level experience with endoscopic harvesting performed by a dedicated specialist practitioner gives optimal results comparable to those of open vein harvesting. CLINICAL TRIAL REGISTRATION URL: https://www.isrctn.com. International Standard Randomised Controlled Trial Registry Number: 91485426.
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Affiliation(s)
- Bhuvaneswari Krishnamoorthy
- From Departments of Cardiothoracic Surgery (B.K., R.V.V., N.Y.) and Medical Statistics (J.M.), University Hospital of South Manchester NHS Foundation Trust, United Kingdom; Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (W.R.C., B.K.), Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (J.E.F.), Manchester Centre for Health Economics (A.J.T., K.P.), and School of Nursing and Midwifery (A.L.C.), University of Manchester, United Kingdom; and Faculty of Health and Social Care, Edge Hill University, Ormskirk, Lancashire, United Kingdom(B.K.).
| | - William R Critchley
- From Departments of Cardiothoracic Surgery (B.K., R.V.V., N.Y.) and Medical Statistics (J.M.), University Hospital of South Manchester NHS Foundation Trust, United Kingdom; Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (W.R.C., B.K.), Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (J.E.F.), Manchester Centre for Health Economics (A.J.T., K.P.), and School of Nursing and Midwifery (A.L.C.), University of Manchester, United Kingdom; and Faculty of Health and Social Care, Edge Hill University, Ormskirk, Lancashire, United Kingdom(B.K.)
| | - Alexander J Thompson
- From Departments of Cardiothoracic Surgery (B.K., R.V.V., N.Y.) and Medical Statistics (J.M.), University Hospital of South Manchester NHS Foundation Trust, United Kingdom; Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (W.R.C., B.K.), Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (J.E.F.), Manchester Centre for Health Economics (A.J.T., K.P.), and School of Nursing and Midwifery (A.L.C.), University of Manchester, United Kingdom; and Faculty of Health and Social Care, Edge Hill University, Ormskirk, Lancashire, United Kingdom(B.K.)
| | - Katherine Payne
- From Departments of Cardiothoracic Surgery (B.K., R.V.V., N.Y.) and Medical Statistics (J.M.), University Hospital of South Manchester NHS Foundation Trust, United Kingdom; Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (W.R.C., B.K.), Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (J.E.F.), Manchester Centre for Health Economics (A.J.T., K.P.), and School of Nursing and Midwifery (A.L.C.), University of Manchester, United Kingdom; and Faculty of Health and Social Care, Edge Hill University, Ormskirk, Lancashire, United Kingdom(B.K.)
| | - Julie Morris
- From Departments of Cardiothoracic Surgery (B.K., R.V.V., N.Y.) and Medical Statistics (J.M.), University Hospital of South Manchester NHS Foundation Trust, United Kingdom; Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (W.R.C., B.K.), Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (J.E.F.), Manchester Centre for Health Economics (A.J.T., K.P.), and School of Nursing and Midwifery (A.L.C.), University of Manchester, United Kingdom; and Faculty of Health and Social Care, Edge Hill University, Ormskirk, Lancashire, United Kingdom(B.K.)
| | - Rajamiyer V Venkateswaran
- From Departments of Cardiothoracic Surgery (B.K., R.V.V., N.Y.) and Medical Statistics (J.M.), University Hospital of South Manchester NHS Foundation Trust, United Kingdom; Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (W.R.C., B.K.), Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (J.E.F.), Manchester Centre for Health Economics (A.J.T., K.P.), and School of Nursing and Midwifery (A.L.C.), University of Manchester, United Kingdom; and Faculty of Health and Social Care, Edge Hill University, Ormskirk, Lancashire, United Kingdom(B.K.)
| | - Ann L Caress
- From Departments of Cardiothoracic Surgery (B.K., R.V.V., N.Y.) and Medical Statistics (J.M.), University Hospital of South Manchester NHS Foundation Trust, United Kingdom; Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (W.R.C., B.K.), Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (J.E.F.), Manchester Centre for Health Economics (A.J.T., K.P.), and School of Nursing and Midwifery (A.L.C.), University of Manchester, United Kingdom; and Faculty of Health and Social Care, Edge Hill University, Ormskirk, Lancashire, United Kingdom(B.K.)
| | - James E Fildes
- From Departments of Cardiothoracic Surgery (B.K., R.V.V., N.Y.) and Medical Statistics (J.M.), University Hospital of South Manchester NHS Foundation Trust, United Kingdom; Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (W.R.C., B.K.), Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (J.E.F.), Manchester Centre for Health Economics (A.J.T., K.P.), and School of Nursing and Midwifery (A.L.C.), University of Manchester, United Kingdom; and Faculty of Health and Social Care, Edge Hill University, Ormskirk, Lancashire, United Kingdom(B.K.)
| | - Nizar Yonan
- From Departments of Cardiothoracic Surgery (B.K., R.V.V., N.Y.) and Medical Statistics (J.M.), University Hospital of South Manchester NHS Foundation Trust, United Kingdom; Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (W.R.C., B.K.), Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (J.E.F.), Manchester Centre for Health Economics (A.J.T., K.P.), and School of Nursing and Midwifery (A.L.C.), University of Manchester, United Kingdom; and Faculty of Health and Social Care, Edge Hill University, Ormskirk, Lancashire, United Kingdom(B.K.)
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Wheeler AR, Kendrick DE, Allemang MT, Gosling AF, Kim AH, Hausladen A, Kashyap VS. Endothelial Function Is Preserved in Veins Harvested by Either Endoscopic or Surgical Techniques. Ann Vasc Surg 2017; 44:317-324. [PMID: 28495542 DOI: 10.1016/j.avsg.2017.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 05/01/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Endoscopic vein harvest for lower extremity arterial bypass grafting has been questioned due to concern for endothelial damage during procurement. We sought to compare nitric oxide (NO)-mediated endothelial-dependent relaxation (EDR) in vein segments harvested using open surgical techniques (OH) versus endoscopic vein harvest (EH) techniques. METHODS Saphenous vein segments were harvested for lower extremity bypass, and a single, minimally handled section of saphenous vein, free of branches, was taken from the end of the graft. Four 4-mm venous ring segments were then cut and mounted on force transducers. Segments were mounted in 37° oxygenated Krebs-Henseleit solution and maximally contracted using KCl. Individual ring segments that did not react to KCl were excluded from the study. Norepinephrine (NE) was used to achieve submaximal contraction. EDR was determined using increasing concentrations of bradykinin (BDK). Endothelial-independent relaxation (EIR) was confirmed using sodium nitroprusside. Two-way analysis of variance (ANOVA) was used to analyze differences between harvest techniques across BDK concentration and a Student's t-test was used to analyze single comparisons. RESULTS Vein segments harvested from patients (n = 13) led to 28 viable rings that exhibited a positive reaction to KCl (11 rings; 5 patients EH vs. 17 rings; 8 patients OH). Both vein groups achieved moderate relaxation to maximal BDK concentration, [10-6 M]; (49.5% EH vs. 40.55% OH, P = 0.270). Analysis by 2-way ANOVA for mean % relaxation for BDK concentration [10-11-10-6 M] showed improved EDR in EH samples compared with OH (P = 0.029). Mean nitrite/nitrate (NO(x)) tissue bath concentration measurements post-BDK were 139.8 nM (EH) vs. 97.2 nM (OH; P = 0.264). Histology and positive factor VIII immunohistochemistry staining provided evidence for the presence of intact endothelium in our sample segments. EIR was preserved and was similar in the two groups. CONCLUSIONS Endothelial function is preserved when utilizing endoscopic harvesting techniques. The advantages of minimally invasive vein procurement for lower extremity bypass can be obtained without concern for damaging venous endothelium.
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Affiliation(s)
- Adam R Wheeler
- Department of Vascular Surgery, University Hospitals, Cleveland, OH
| | | | - Matt T Allemang
- Department of Vascular Surgery, University Hospitals, Cleveland, OH
| | - Andre F Gosling
- Department of Vascular Surgery, University Hospitals, Cleveland, OH
| | - Ann H Kim
- Department of Vascular Surgery, University Hospitals, Cleveland, OH
| | - Alfred Hausladen
- Institute for Transformative Molecular Medicine, Case Western Reserve University School of Medicine, University Hospitals Case Medical Center, Cleveland, OH
| | - Vikram S Kashyap
- Department of Vascular Surgery, University Hospitals, Cleveland, OH.
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Full Mimicking of Coronary Hemodynamics for Ex-Vivo Stimulation of Human Saphenous Veins. Ann Biomed Eng 2016; 45:884-897. [PMID: 27752921 DOI: 10.1007/s10439-016-1747-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 10/05/2016] [Indexed: 01/25/2023]
Abstract
After coronary artery bypass grafting, structural modifications of the saphenous vein wall lead to lumen narrowing in response to the altered hemodynamic conditions. Here we present the design of a novel ex vivo culture system conceived for mimicking central coronary artery hemodynamics, and we report the results of biomechanical stimulation experiments using human saphenous vein samples. The novel pulsatile system used an aortic-like pressure for forcing a time-dependent coronary-like resistance to obtain the corresponding coronary-like flow rate. The obtained pulsatile pressures and flow rates (diastolic/systolic: 80/120 mmHg and 200/100 mL/min, respectively) showed a reliable mimicking of the complex coronary hemodynamic environment. Saphenous vein segments from patients undergoing coronary artery bypass grafting (n = 12) were subjected to stimulation in our bioreactor with coronary pulsatile pressure/flow patterns or with venous-like perfusion. After 7-day stimulation, SVs were fixed and stained for morphometric evaluation and immunofluorescence. Results were compared with untreated segments of the same veins. Morphometric and immunofluorescence analysis revealed that 7 days of pulsatile stimulation: (i) did not affect integrity of the vessel wall and lumen perimeter, (ii) significantly decreased both intima and media thickness, (iii) led to partial endothelial denudation, and (iv) induced apoptosis in the vessel wall. These data are consistent with the early vessel remodeling events involved in venous bypass adaptation to arterial flow/pressure patterns. The pulsatile system proved to be a suitable device to identify ex vivo mechanical cues leading to graft adaptation.
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18
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A prospective randomized trial of endoscopic versus open saphenous vein harvesting technique for coronary artery bypass graft surgery. Indian J Thorac Cardiovasc Surg 2016. [DOI: 10.1007/s12055-016-0432-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Abstract
PURPOSE OF REVIEW Over the past decade, there has been an increased adoption of minimally invasive techniques for saphenous vein and radial artery procurement during coronary artery bypass surgery, albeit concerns have been raised about the potential detrimental effects of the endoscopic approach when compared with the conventional 'open' technique. The aim of the present review is to analyse the current available techniques and evidence about the impact of an endoscopic approach on conduit quality and clinical outcomes. RECENT FINDINGS At present, the available techniques for endoscopic vessel harvesting can be based on a sealed or non-sealed concept, for both saphenous vein and radial artery procurement. Despite the proven advantages of a minimally invasive approach in terms of reduced incidence of wound complications, pain reduction and improved cosmetic results, some studies questioned the impact of this technique in terms of potential graft damage, thus impairing the longevity of the graft itself. SUMMARY Endoscopic conduit harvesting can be performed safely and effectively with the currently available techniques, albeit a careful knowledge of the pitfalls of each technique is mandatory. Since there is ample evidence in literature that a minimally invasive approach for saphenous vein and radial artery procurement is not associated with an increased risk of graft damage and related failure in the mid-long term, the endoscopic technique should be adopted as the approach of choice for saphenous vein and radial artery harvesting in coronary artery bypass graft surgery.
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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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