Abstract
The human saphenous vein (HSV) remains the most common conduit for peripheral and aortocoronary bypass operations in the United States (1, 2), with ever improving, though suboptimal long-term patency rates. The mishandling of vein grafts during explantation, preparation, and autotransplantation is gaining attention as a source of injury portending increased short-term thrombosis as well as acceleration of neointimal formation, the most common cause of vein graft failure from 2 months to 2 years postoperatively (3, 4). The handling of vein grafts during the explantation has been thoughtfully addressed, as “no-touch” open harvest has emerged as an approach stressing a minimization of trauma to tissue handling. In “no-touch” harvesting, the graft is removed with a pedicle of surrounding tissue. This has been shown to maintain structural and functional integrity of all cell layers, prevent spasm (5), and improve graft patency (6, 7), while conferring protection from subsequent intraoperative manipulations (8, 9). Nonetheless, once HSV has been fully explanted, manipulations to the conduit are routinely performed to make the anastomosis technically simpler and safer. The most well-characterized and injurious of these intraoperative manipulations is intraluminal radial distension (10). HSV is routinely cannulated and distended using a handheld syringe to infuse a solution or autologous blood, which dilates the vein. This procedure serves to disrupt any valves, increase the luminal diameter, identify leaks or injuries, prevent spasm, and ultimately, facilitate an easier anastomosis (11, 12). It is the opinion of the authors that this practice should be done with great care, emphasizing minimization of distension pressure using either controlled distension or a tool, such as a pressure release valve. While not conclusive, existing data strongly suggest that mitigation of distension-induced graft injury may prevent both early and delayed graft failure due to thrombosis and neointimal hyperplasia, respectively.
Highlights
The human saphenous vein (HSV) remains the most common conduit for peripheral and aortocoronary bypass operations in the United States [1, 2], with ever improving, though suboptimal long-term patency rates
Toll-like receptors TLR2 and TLR4 were both increased in distended HSV, in direct proportion to luminal distension pressures
While only a few key offenders are summarized there are a host of other adhesion molecules, toll-like receptors, and scavenger receptors that are ostensibly overexpressed in distended HSV, those that are regulated by nuclear factor-κB (NF-κB) translocation [24]
Summary
The human saphenous vein (HSV) remains the most common conduit for peripheral and aortocoronary bypass operations in the United States [1, 2], with ever improving, though suboptimal long-term patency rates. In “no-touch” harvesting, the graft is removed with a pedicle of surrounding tissue This has been shown to maintain structural and functional integrity of all cell layers, prevent spasm [5], and improve graft patency [6, 7], while conferring protection from subsequent intraoperative manipulations [8, 9]. HSV is routinely cannulated and distended using a handheld syringe to infuse a solution or autologous blood, which dilates the vein. This procedure serves to disrupt any valves, increase the luminal diameter, identify leaks or injuries, prevent spasm, and facilitate an easier anastomosis [11, 12]. While not conclusive, existing data strongly suggest that mitigation of distension-induced graft injury may prevent both early and delayed graft failure due to thrombosis and neointimal hyperplasia, respectively
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