Derek Filbey

High early patency of saphenous vein graft for coronary artery bypass harvested with surrounding tissue

BACKGROUND Surgical trauma to the saphenous vein, used as a conduit for coronary artery bypass grafting, affects their occlusion rate. This study evaluates the early patency of saphenous vein grafts harvested with a pedicle of surrounding tissue that protects the vein from spasm and trauma. METHODS Fifty-two patients underwent coronary artery bypass grafting with saphenous veins harvested with surrounding tissue. Forty-five patients, who received a total of 124 vein grafts and 42 left internal mammary arteries, underwent angiographic follow-up at a mean of 18 months (9 to 24 months). RESULTS Patency for saphenous vein grafts was 95.4% and for left internal mammary arteries, it was 93.3%. Twenty-nine of 30 (96.7%) vein grafts anastomosed to arteries 2.0 mm or more, 65 of 67 (97%) grafts to 1.5 mm, and 10 of 13 (77%) anastomosed to 1-mm arteries were patent. Nineteen of 22 (86.4%) vein grafts with flow rates 20 mL/min or less, 32 of 34 (94.1%) with flow between 20 and 40 mL/min, and 50 of 51 (98%) with flow more than 40 mL/min were patent. Other registered surgical and clinical factors did not contribute to vessel occlusion. CONCLUSIONS Early patency rate of saphenous veins harvested with surrounding tissue is very high, even in saphenous vein grafts demonstrating low blood flow. Preservation of graft endothelium using our harvesting technique may be the explanation of this success.

The "no-touch" harvesting technique for vein grafts in coronary artery bypass surgery preserves an intact vasa vasorum.

OBJECTIVES Our objective was to evaluate the impact of vein graft harvesting technique on structure and function of vasa vasorum. METHODS Paired segments of great saphenous veins harvested either with conventional harvesting technique or no-touch technique were obtained from 9 consecutive patients undergoing coronary artery bypass grafting. Quantitative measurements, using immunohistochemistry and morphometry, were performed. Ultrastructural analyses of vasa vasorum were performed with electron microscopy. Video footage of superficial vasa vasorum in an implanted saphenous vein graft harvested with the no-touch technique was captured during a coronary bypass operation and is presented for online viewing. RESULTS The total area of vasa vasorum in vein grafts harvested with the conventional technique was significantly reduced both in the media (P = .007) and in the adventitia (P = .014) compared with vein grafts harvested with the no-touch technique. Ultrastructural findings indicated that the no-touch technique preserved an intact vasa vasorum whereas the conventional technique did not. Video footage showed retrograde flow in the vasa vasorum in vein graft harvested with the no-touch technique. CONCLUSIONS These findings show that the no-touch technique for saphenous vein graft harvesting for coronary bypass grafting preserves an intact vasa vasorum. This could represent one of the mechanisms underlying the improved patency of saphenous vein grafts harvested with this technique.

Prognostic Factors for the Survival of Surgically Treated Patients for Non-Small Cell Lung Cancer

The survival and outcome rates of 284 patients who underwent surgical treatment for non-small cell lung cancer were assessed retrospectively. Resectability rate was 94.1%, hospital mortality 3.9% (n=11) and the mortality rates in patients who underwent pneumonectomy or lobectomy were 8.9% and 0.6%, respectively. The overall 5-year survival was 43.6%. Female gender, earlier stages of disease and a complete resection were strongly predictive for a long-term survival. Women in stage IA disease had a 5-year survival rate of 92.7%. The 5-year survival rate for patients in stages IIIA and N2 disease who underwent a complete resection was 21.9%, and 9% for those who did not undergo a complete resection. It is concluded that the best surgical results were observed in women who were operated on at an early stage of disease. A complete resection also contributed to a better outcome, even for patients in stage IIIA and N2 disease.

No touch vein harvesting technique for CABG improves the long-term clinical outcome.

Objectives. To investigate the long-term clinical outcome, averaging 8.5 years, of two saphenous vein harvesting techniques for CABG; no touch (NT) versus conventional (C). Design. In a randomized study, 49/52 in group NT and 44/52 in group conventional were evaluated for reangina, myocardial infarction, new revascularization, functional class, risk factors and medical treatment. The vein grafts and the native coronary arteries were correlated to the occurrence of reangina. Results. There were significantly more patients free from angina and in NYHA class I (67.3 versus 43.2%; p =0.02) in group NT compared to group C. No cardiac death was found in group NT versus three in group C. There were trends towards fewer patients with cardiac death or myocardial infarction (3.8 vs. 13.4%; p =0.16), more patients free from angina (75.5 vs. 63.6%; p =0.26) and fewer patients with graft occlusion (24.3 vs. 43.2% (p =0.14) in group NT. Conclusions. The results of the NT-technique are encouraging with no cardiac deaths, significantly more asymptomatic patients and a trend towards impact on hard clinical endpoints compared to the conventional technique.

The no-touch vein graft for coronary artery bypass surgery preserves the left ventricular ejection fraction at 16 years postoperatively: long-term data from a longitudinal randomised trial

Objectives To assess the left ventricular heart function and the clinical outcome 16 years after coronary artery bypass surgery. Design In a randomised trial, the no-touch (NT) vein graft in coronary artery bypass surgery has shown a superior patency rate, a slower progression of atherosclerosis and better clinical outcome compared to the conventional (C) vein graft at 8.5 years. All patients at mean time 16 years were offered an echocardiographic and clinical examination. Results In the NT-group 34 patients and in the C-group 31 patients underwent an echocardiography examination. A significantly better left ventricle ejection fraction was seen in the NT-group compared to the C-group (57.9% vs 49.4%; p=0.011). The size of the left atrium in NT was 21.7 cm2 compared to 23.9 cm2 in C; p=0.034. No patient in NT had atrial fibrillation compared to five patients in C (p=0.021). Patients with a brain natriuretic peptide value (BNP) ≥150 was 30% in NT compared to 38% in C. Total mortality was 25% in NT vs 27% in C. Cardiac-related deaths were 8% and 12% in NT and C respectively. Conclusions The NT vein graft preserves the left ventricular ejection fraction after 16 years. A smaller left atrium, a lower BNP and no atrial fibrillation indicates an improved diastolic left ventricular function in the NT-group. Trial registration The study is registered with clinicaltrials.gov (NCT01686100) and The Research and Development registry in Sweden (no. 102841).

Recent Strategies to Improve Graft Performance in Patients Undergoing Coronary Artery Bypass Surgery. Are Best Results Achieved by Improved Surgical Techniques of Graft Preparation

The patency rate of the saphenous vein (SV) used as a graft in patients undergoing coronary artery bypass surgery (CABG) is poor, with 15-25% grafts occluding within 1 year and over 50% patients requiring further (redo) surgery within 10 years.1 In order to investigate the strategies to reduce vein graft failure in patients undergoing CABG, the underlying pathology of the disease must first be established. The high prevalence of coronary heart disease in Western society has prompted surgeons to develop procedures to improve myocardial blood flow, and subsequently relieve the symptoms of angina pectoris along with other myocardial crises.2 One of the most significant advances in vascular surgery was the finding that venous conduits could be used as replacements for atherosclerotic arteries. Following the work of Alexis Carrel at the turn of the century, a venous graft was first used in 1906 to replace a popliteal aneurysm.2 Promising experimental results encouraged surgeons to apply this method to the coronary vessels. By the 1950s, at the Cleveland Clinic, Favaloro et al. had treated numerous cases of peripheral and renal artery reconstruction with venous conduits and employed this procedure in coronary vessels.3 Research efforts by Favaloro4 led to the development of CABG, a technique which has been used for almost four decades. The great SV of the leg is the conduit of choice for three main reasons. First, it is expendable as deeper vessels maintain blood flow to superficial tissues after its removal. Second, the extensive length of this vein allows for multiple grafts, and finally, its superficial position renders it easily accessible. A 10-year follow-up recatheterization of Favarolo’s first operation showed that both the graft and the bypassed right coronary artery remained patent.3 Such promising results reshaped the history of cardiac surgery and led to the rise of surgical revascularization in the treatment of ischemic heart disease.