Saphenous vein as a composite graft from the internal thoracic artery

Surgical Myocardial Revascularization with a Composite T-graft from the Left Internal Mammary Artery-Comparison of the Great Saphenous Vein with the Radial Artery

BACKGROUND

 Composite T-grafts between left internal mammary artery (LIMA) and radial artery (RA) are a common concept in complete arterial myocardial revascularization. The aim of the present study was to investigate whether the use of the great saphenous vein (SV) instead of RA leads to comparably good results in terms of outcome in this context.

METHODS

 Patients who underwent myocardial revascularization with a T-graft using RA or a segment of SV to the right coronary artery or circumflex artery between the beginning of 2014 and the end of 2019 at the Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel were included. To minimize surgical variation, only patients were observed by a single senior surgeon in the department. Exclusion criteria were previous cardiac surgery, preoperative extracorporeal circulatory support, off-pump surgery, additional aortocoronary bypasses, and cardiac combination procedures.

RESULTS

 A total of 115 patients were studied. In 55 patients, the T-graft was placed between the LIMA and SV, and in 60 patients, the T-graft was placed between the LIMA and RA. Patients in the SV group were older (70.6 ± 7.8 vs. 58.5 ± 10.0 years; p < 0.001), suffered more frequently from non-ST elevation myocardial infarction (12.7 vs. 1.7%; p = 0.027), arterial hypertension (83.6 vs. 61.7%; p = 0.009), and atrial fibrillation (18.2 vs. 1.7%; p = 0.003). They were less likely to be active smokers (16.4 vs. 38.3%; p = 0.009) and less likely to have a history of variceal surgery (0 vs. 15.0%; p = 0.003). Calcification of the ascending aorta was also found more frequently in the saphenous group (18.2 vs. 3.3%, p = 0.009). Operative times and number of distal anastomoses did not differ significantly between the two groups. Postoperative deliriums (16.7 vs. 5.0%; p = 0.043) were observed more frequently in venous patients. Wound healing disorders of the leg (11.1 vs. 0%; p = 0.011) did only occur in SV group and wound infections of the arm only in the RA group. Complete follow-up was achieved in 74.8% of cases. Median follow-up was 60.3 (39.6; 73.2) months. Serious adverse cardiac-cerebral events (19.0 vs. 22.7%; p = 0.675) and mortality (14.5 vs. 6.7%; p = 0.167) did not differ significantly between the groups at follow-up. Myocardial infarction (0 vs. 2.5%; p = 1.000) and stroke (0 vs. 7.5%; p = 0.245) were observed exclusively in RA group. Percutaneous coronary intervention was required in single patients of RA group (0 vs. 15.0%; p = 0.028). No patient from either group underwent repeat coronary artery bypass grafting (CABG). The patients of SV group had angiographically competent grafts and open anastomoses. Graft failure was noted in a single patient in RA group, in which case both grafts and native coronary vessels were stented. Kaplan-Meier analysis revealed no significant survival disadvantage for SV group compared with RA group.

CONCLUSION

 CABG with a composite T-graft between LIMA and a segment of SV may be comparable to bypass surgery with a composite T-graft between LIMA and RA. This might be true in terms of morbidity and mortality over an intermediate-term observation period. The results of our studies give rise to the hypothesis that the decision not to perform aortic bypass anastomosis may be more important than the choice of graft material.

The impact of perivascular tissue preservation on 5-year patency of saphenous vein composite grafts

OBJECTIVES

This retrospective study was conducted to evaluate the impact of saphenous vein (SV) harvesting with versus without perivascular tissue on the 5-year angiographic patency in coronary artery bypass grafting.

METHODS

Among the 944 patients who received coronary artery bypass grafting between 2010 and 2015, 579 patients who received off-pump coronary artery bypass grafting using 1 SV as a Y-composite graft based on the in situ left internal thoracic artery were enrolled. SV harvesting was performed using no-touch technique without perivascular tissue (the NoPVT group) in 342 patients and with perivascular tissue (the PVT group) in 237 patients. Follow-up duration was 84.0 months (interquartile range 66.5-105.4). Propensity score matching was performed, and long-term clinical outcomes and angiographic patency were compared.

RESULTS

The average number of distal anastomoses per patient was comparable between the groups, although more SV grafts were anastomosed to left anterior descending territory in the PVT group than in the NoPVT group. Overall survival and cumulative incidence of cardiac death were comparable between the groups, whereas cumulative incidence of target vessel revascularization (1.3% vs 4.3% at 5 year, P = 0.009) and that of major adverse cardiac events (7.3% vs 9.9% at 5 year, P = 0.035) were lower in the PVT group than in the NoPVT group. One-year and 5-year angiographic patency rates of the SV grafts were higher in the PVT group than in the NoPVT group [97.0% vs 91.7% (P = 0.004) and 96.3% vs 89.9% (P = 0.007), respectively].

CONCLUSIONS

SV grafts harvested using no-touch technique with perivascular tissue further improved the 5-year patency of SV composite grafts compared with those without perivascular tissue.

Graft Patency of No-Touch Saphenous Veins Used as Aortocoronary Bypass Grafts

Background

This study evaluated the early, 1-year, and 3-year graft patency rates and mid-term clinical outcomes after no-touch saphenous veins (NT-SVs) were used as aortocoronary grafts in coronary artery bypass grafting (CABG).

Methods

In total, 101 patients who underwent CABG using NT-SVs as aortocoronary grafts were included. The 2 most common indications for performing aortocoronary grafting with NT-SVs were unavailability of the left internal thoracic artery (n=36) and moderate lesions where flow competition was expected (n=27). Early (median, 1 day; interquartile range [IQR], 1-2 days), 1-year (median, 13 months; IQR, 11-16 months), and 3-year (median, 34 months; IQR, 27-41 months) graft angiography was performed in 98 (97.0%), 84 (83.2%), and 40 patients (39.6%), respectively. The median follow-up duration was 43 months (IQR, 13-76 months). Overall survival rates and the cumulative incidence of major adverse cardiac events were evaluated.

Results

The operative mortality rate was 2% (2 of 101 patients). Early postoperative patency rates for overall and aortocoronary NT-SV grafts were 98.2% (223 of 227 distal anastomoses) and 98.2% (164 of 167), respectively. The 1- and 3-year patency rates for aortocoronary SV grafts were 94.9% (131 of 138) and 90.6% (58 of 64), respectively. The overall survival rates at 5 and 10 years were 81.7% and 59%, respectively. The cumulative incidence of major adverse cardiac events at 5 and 10 postoperative years was 20.7% and 39%, respectively.

Conclusion

The feasibility of using NT-SVs as aortocoronary grafts in CABG was shown in this study, based on the graft patency rates up to 3 years and the mid-term clinical outcomes.

Anterolateral territory coronary artery bypass grafting strategies: a non-inferiority randomized clinical trial: the AMI-PONT trial

OBJECTIVES

The main objective was to assess whether a composite coronary artery bypass grafting strategy including a saphenous vein graft bridge to distribute left internal mammary artery outflow provides non-inferior patency rates compared to conventional grafting surgery with separated left internal mammary artery to left anterior descending coronary graft and aorto-coronary saphenous vein grafts to other anterolateral targets.

METHODS

All patients underwent isolated grafting surgery with cardiopulmonary bypass and received ≥2 grafts/patients on the anterolateral territory. The graft patency (i.e. non-occluded) was assessed using multislice spiral computed tomography at 1 year.

RESULTS

From 2012 to 2021, 208 patients were randomized to a bridge (n = 105) or conventional grafting strategy (n = 103). Patient characteristics were comparable between groups. The anterolateral graft patency was non-inferior in the composite bridge compared to conventional grafting strategy at 1 year [risk difference 0.7% (90% confidence interval -4.8 to 6.2%)]. The graft patency to the left anterior descending coronary was no different between groups (P = 0.175). Intraoperatively, the bridge group required shorter vein length for anterolateral targets (P < 0.001) and exhibited greater Doppler flow in the mammary artery pedicle (P = 0.004). The composite outcome of death, myocardial infarction or target vessel reintervention at 30 days was no different (P = 0.164).

CONCLUSIONS

Anterolateral graft patency of the composite bridge grafting strategy is non-inferior to the conventional grafting strategy at 1 year. This novel grafting strategy is safe, efficient, associated with several advantages including better mammary artery flow and shorter vein requirement, and could be a valuable alternative to conventional grafting strategies. Ten-year clinical follow-up is underway.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01585285.

The Anaortic Technique with Bilateral Internal Thoracic Artery Grafting - Filling the Gap in Coronary Artery Bypass Surgery

Coronary artery bypass grafting (CABG) has consolidated its role as the most effective procedure for treating patients with advanced atherosclerotic coronary artery disease, reducing the long-term risk of myocardial infarction and death compared to other therapies and relieving angina. Despite the recognized benefits afforded by surgical myocardial revascularization, a subset of higher-risk patients bears a more elevated risk of perioperative stroke. Stroke remains the drawback of conventional CABG and has been strongly linked to aortic manipulation (cannulation, cross-clamping, and side-biting clamping for the performance of proximal aortic anastomoses) and the use of cardiopulmonary bypass. Adoption of off-pump CABG (OPCAB) is demonstrated to lower the risk of perioperative stroke, as well as reducing the risk of short-term mortality, renal failure, atrial fibrillation, bleeding, and length of intensive care unit stay. However, increased risk persists owing to the need for the tangential ascending aorta clamping to construct the proximal anastomosis. The concept of anaortic (aorta no-touch) OPCAB (anOPCAB) stems from eliminating ascending aorta manipulation, virtually abolishing the risk of embolism caused by aortic wall debris into the brain circulation. The adoption of anOPCAB has been shown to further decrease the risk of postoperative stroke, especially in higher-risk patients, entailing a step forward and a refinement of outcomes provided by the primeval OPCAB technique. Therefore, anOPCAB has been the recommended technique in patients with cerebrovascular disease and/or calcification or atheromatous plaque in the ascending aorta and should be preferred in patients with high-risk factors for neurological damage and stroke.