Anastomosis Of Saphenous Vein Graft Research Articles

Symptomatic late saphenous vein graft failure in coronary artery bypass surgery.

Coronary artery bypass grafting for advanced coronary artery disease is a well-established procedure with excellent long-term results. The issue of saphenous vein graft (SVG) performance and its relation to clinical symptoms and thereby the potential for improvement by using superior grafts are still not fully understood. We aim to estimate the contribution of late SVG failure to the long-term outcome. A study population operated between 1997 and 2020, with an internal thoracic artery with a single distal anastomosis and 1, 2 or 3 distal SVG anastomoses, was isolated from the Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies registry. Data regarding postoperative clinically driven coronary angiography and status of bypass grafts were collected. The study population consisted of 44 951 patients. Clinically driven angiography occurred in 10.1% (9.5-10.8), 7.9% (7.6-8.3) and 7.1% (6.7-7.5), respectively, of patients within 3 years and 23.6% (22.6-24.5), 20.0% (19.5-20.6) and 17.5% (16.9-18.2), respectively, of patients within 10 years after surgery. Excluding the first 3 postoperative years, no failed SVGs were found in >75%, 60% and 45%, respectively, of cases when an angiography was performed in the first 10 years after surgery. The results suggest that the risk of symptomatic graft failure due to vein graft disease during the first 10 years after surgery is in the range of 1-2% for every grafted coronary vessel and provide an estimate for the upper limit of the improvements in results that could be achieved by replacing SVGs with superior grafts.

Individual Versus Sequential Saphenous Vein Grafts for on-Pump Coronary Artery Bypass Grafting - Does Smaller Coronaries in Indians Affect Graft Choice? - A Mid-Term Patency Comparison Study.

PurposeAlthough multiarterial grafting or bilateral mammary artery use is being increasingly emphasized for contemporary coronary artery bypass grafting (CABG) practice, saphenous vein graft (SVG) still accounts for 80% of all CABG conduits (Park et al., 2020) [1]. In India, both the individual and sequential saphenous grafting techniques are used arbitrarily, and there has not been a study that compares the mid-term patency of these two. This is specially relevant in view of smaller coronaries in Indians than the Caucasian counterparts. This study aims to compare the patency for on pump CABG’s.MethodsIn the present study, 323 patients underwent either sequential (group A, N = 151 grafts, each graft having two anastomoses each) or individual (group B, N = 344 grafts) saphenous vein CABG, between February 2014 and June 2017. The SVG anastomoses were created on obtuse marginal (OM1/OM2) and posterior descending artery (PDA). The graft patency of the vein grafts as well as the left internal mammary artery were assessed by serial coronary angiograms.ResultsResults were evaluated at 6 months, 1, 2 and 3 years post operatively. Group A showed a higher graft patency at 3 years at 80.8%, and group B, 67.1% (P = 0.002). Also, anastomoses on sequential conduits had overall better patency rates at three years (77.2% vs 67.2%, P = 0.005). The groups showed similar results at one year post operatively.ConclusionsSequential bypass grafts were associated with superior mid-term patency compared with individual grafts. These findings suggest the more favourable results of sequential bypass grafting to be attributed to the enhanced flow haemodynamics.

Cold Agglutinin Autoantibodies in a Patient without a Visible Coronary Sinus Ostium: Strategies for Myocardial Protection without Using Retrograde Cardioplegia

The presence of cold agglutinins (CA) during cardiac surgery with cardiopulmonary bypass usually creates the need for an altered surgical plan. In this case, the CA were discovered after the initiation of bypass, limiting the time, and cardioplegia solutions that could be used in the new approach. The inability to cannulate the coronary sinus with a retrograde cardioplegia catheter excluded the standard approach to myocardial preservation with CA of using continuous warm blood. For this case, we used intermittent cold crystalloid delivered via the antegrade needle for the first half of the procedure and through the saphenous vein graft anastomosis during the aortic valve portion of the cross-clamp period.

Monitoring diastolic dysfunction using a simplified algorithm in patients undergoing off-pump coronary artery bypass grafting surgery.

Context:Left ventricle diastolic dysfunction (LVDD) is gaining importance as useful marker of mortality and morbidity in cardiac surgical patients. Different algorithms have been proposed for the intraoperative grading of DD. Knowledge of the particular grade of DD has clinical implications with the potential to modify therapy, but there is a paucity of literature on the role of diastolic function evaluation during off-pump coronary artery bypass grafting (OPCABG) surgery.Aims:The aim of this study was to monitor changes in LVDD using simplified algorithm proposed by Swaminathan et al. in patients undergoing OPCABG.Settings and Design:The study was conducted in a tertiary care level hospital; this was a prospective, observational study.Subjects and Methods:Fifty consecutive patients undergoing OPCABG were enrolled. Hemodynamic and echocardiographic parameters were measured at 6 stages in every patient namely after anesthetic induction (baseline), during left internal mammary artery (LIMA) to left anterior descending (LAD) grafting (LIMA → LAD), saphenous vein graft (SVG) to obtuse marginal (OM) grafting (SVG → OM), SVG to posterior descending artery (PDA) grafting (SVG → PDA), during proximal anastomosis of SVG to aorta, and postprotamine. The patients were classified in grades of LVDD as per simplified algorithm proposed by Swaminathan et al. using only intraoperatively measured E and E’.Results:The success rate of measurement and classification of LVDD was 98.92% (277 out of 280 measurements). The grades of LVDD varied significantly as per surgical steps with maximum downgrading occurring during OM and LAD grafting. During OM grafting, none of the patients had normal diastolic function while 29% of patients exhibited restrictive pattern (Grade 3 LVDD). Patients with normal baseline LV diastolic function also exhibited downgrading during OM and LAD grafting. Postprotamine, 37% of patients with normal baseline diastolic function continued to exhibit some degree of DD.Conclusions:The LVDD changes dynamically during various stages of OPCABG, which can be successfully monitored with simplified algorithm.

Coronary Artery Bypass Grafting Using Side-to-Side Anastomosis with Distal End Clipping of the Saphenous Vein Graft

Although the Saphenous Vein Graft (SVG) is commonly grafted to the coronary artery with an end-to-side anastomotic technique, there is often a significant mismatch between the diameters of the SVG and the coronary artery, which may cause SVG failure. To overcome such a drawback of the standard end-to-side SVG anastomosis, we introduce a novel side-to-side anastomosis with distal end clipping of the SVG in coronary artery bypass grafting. The long-term outcome of Coronary Artery Bypass Grafting (CABG) depends predominantly on graft patency. Although an arterial graft is preferably used to improve long-term graft patency, a Saphenous Vein Graft (SVG) is also still widely used as a second bypass graft. The reported SVG patency ranging from 25% to >50% within 10 years was inferior to that of an arterial graft, despite considerable efforts to prevent SVG failure. Although the SVG is commonly grafted to the coronary artery with an end-to-side anastomotic technique, there is often a significant mismatch between the diameters of the SVG and the coronary artery, which may cause SVG failure. Moreover, the end-to-side anastomotic configuration has been reported to have an adverse effect on local hemodynamics, resulting in intimal hyperplasia in the long-term. The intimal hyperplasia, which is a major cause of late graft failure, has been shown to occur predominantly at the toe, heel, and bed of the host coronary artery around the distal anastomosis

Inadvertent anastomosis of saphenous vein graft to a cardiac vein detected with coronary computed tomographic angiography

A 34-year-old man with a prior history of Hodgkin's disease and coronary artery bypass surgery for radiation-induced left main disease presented with persistent chest pain. Cardiac catheterization showed near simultaneous filling of the venous system during arterial injection and could not precisely delineate the insertion point of the vein graft anastamosis to the diagonal branch, and the patient was referred for coronary computed tomography angiography (CTA). CTA demonstrated that the anastamosis of the graft was with a cardiac vein. This case illustrates the valuable complementary role of both angiographic methodologies in confirming a complex anatomic diagnosis.

How I do it: Traction of Ascending Aorta with Starfish Heart Positioner During Proximal Saphenous Vein Graft Anastomosis Using the PAS-Port System in Off-Pump Coronary Artery Bypass Grafting

The PAS-Port system allows for the rapid deployment of a clampless proximal anastomosis between a saphenous vein graft and the aorta. We have developed a simple technique of establishing traction of the ascending aorta with the Starfish heart positioner during proximal saphenous vein anastomosis using the PAS-Port system in off-pump coronary artery bypass grafting.

Diagnostic and Surgical Approach to a Descending Thoracic Aorta Saccular Aneurysm Case

Descending aorta saccular aneurysms are seen less than fusiform aneurysms. All symptomatic saccular aneurysms must be operated. In this study, we present a saccular aneurysm case developed at the descending aorta 1 year after a motor vehicle crash. Following an aorta-LAD saphenous vein graft anastomosis performed in beating heart, the aneurysm neck was closed with a Dacron patch under deep hypothermic circulatory arrest. All signs and symptoms removed dramatically after the operation. Regarding this case, we recommend that the surgical treatment must be performed in accordance with localization and specialties of aortic aneurysms.

Protecting the Crossover Right Internal Thoracic Artery Bypass Graft With a Pedicled Thymus Flap

The right internal thoracic artery graft is placed in jeopardy during repeat sternotomy as it crosses the aorta anteriorly to reach its left-sided coronary targets. We have devised a way of protecting it by means of a pedicled flap taken from the thymic remnants. The flap is easily developed without unduly increasing operative time and morbidity, and it is expected to prevent inadvertent injuries to the graft in the case of mediastinal reentry. Starting in 1999, suitable flaps were obtained in 955 of 1,034 patients (92.4%) receiving an anteaortic crossover right internal thoracic artery-to-coronary graft in our division.

Perioperative Patency of Coronary Artery Bypass Grafting is Not Influenced by Off-Pump Technique

Some concerns have been raised about technical accuracy and quality of distal anastomoses in off-pump myocardial revascularization (OPCAB), which could affect graft patency. Transit-time flowmetric results and clinical, enzymatic, and echocardiographic findings from 201 consecutive isolated on-pump coronary artery bypass graft cases (cardiopulmonary bypass coronary artery bypass grafting; group A) were compared with 96 consecutive OPCAB (group B) cases performed at our institution between January 2003 and December 2004. Maximum, mean, minimum flow, and pulsatility index were compared, stratifying the two groups according to graft type and coronaries revascularized. Graft flow reserve was evaluated in patients undergoing preoperative intraaortic balloon pump during baseline conditions and at a 1 to 1 ratio of intraaortic balloon pump augmentation. No differences were recorded between the two groups in hospital mortality, perioperative myocardial infarction, postoperative enzymatic leakage, echocardiographic recovery, or hospital stay (p = not significant). Off-pump coronary artery bypass and cardiopulmonary bypass coronary artery bypass grafting demonstrated similar intraoperative maximum (75.8 +/- 10.4 mL/min vs 82.3 +/- 15.8; p = 0.190), mean (50.1 +/- 13.3 vs 46.3 +/- 7.7; p = 0.420), minimum flow (12.7 +/- 5.3 vs 11.9 +/- 5.4; p = 0.811), and pulsatility index (2.9 +/- 0.2 vs 2.6 +/- 0.8; p = 0.360). After stratifying the population according to graft type, no differences were detected between the two groups in transit-time flowmetric results of left internal mammary artery, radial artery, and single and sequential saphenous vein grafts. A one to one ratio of intraaortic balloon pump augmentation did not result in any difference in graft flow reserve when left internal mammary artery (p = 0.699), radial artery (p = 0.066), and saphenous vein graft anastomoses (p = 0.772) were considered. Off-pump coronary artery bypass grafting and cardiopulmonary bypass coronary artery bypass grafting demonstrated similar clinical, biochemical, and transit-time flowmetric results, as well as comparable graft flow reserve. These data exclude a lower anastomotic quality in off-pump coronary artery bypass grafting.

Early and midterm patency of the proximal anastomoses of saphenous vein grafts made with a Symmetry Aortic Connector System

The purpose of this study was to investigate (1) the early and midterm patency rates in saphenous vein grafts that were anastomosed with the Symmetry Aortic Connector System (St Jude Medical, Inc, St Paul, Minn) and (2) risk factors for graft occlusion. Thirty-one patients underwent off-pump coronary artery bypass grafting for proximal saphenous vein graft anastomoses with the aortic connector system. Intraoperative graft flow was studied with transit time flowmetry, and angiography was performed before discharge in 29 cases. Midterm (at least 1 year after the operation) saphenous vein graft patency was assessed by coronary angiography or 3-dimensional coronary computed tomography in 27 cases. Postoperative angiography demonstrated a 100% patency rate and no significant stenosis at the connector-anastomosed sites. The 1-year patency rate of the saphenous vein grafts with the aortic connector system was 92.6%, with 2 cases of saphenous vein graft occlusion. Both of these cases had low graft flow and poor left ventricular function documented during the operation. Once surgical errors had been ruled out, the 1-year patency rate of proximal saphenous vein grafts anastomosed with the aortic connector system was favorable. Poor left ventricular function and low graft flow during the operation were risk factors for midterm graft occlusion. Selection of the target vessel and its runoff may also be an important determinant of long-term patency.

A case of ostial stenosis with the PAS-Port proximal anastomosis system in off-pump coronary artery bypass grafting

The use of an automatic aortic connector device for proximal saphenous vein graft anastomoses eliminates the need for aortic clamping during off-pump coronary artery bypass grafting and may reduce the incidence of stroke in the elderly and in patients with severe aortic atherosclerosis. The PAS-Port proximal anastomotic system is a recently developed sutureless automatic saphenous vein graft anastomosis device. We used the system in thirteen patients. Overall handling, feasibility and safety of the device were satisfactory in our limited experience. However, one patient developed severe ostial and proximal graft stenosis in four months postoperative angiogram.

Decreased intermediate term patency of automated proximal anastomoses evaluated by sequential ultrafast CT

The Symmetrytrade mark aortic connector creates proximal anastomoses of saphenous vein grafts using a nitinol implant. The device avoids partial clamping and thus possibly reduces neurologic complications. To evaluate graft patency, a single surgeon randomised study was performed in our institution. Seventy-seven patients were randomised either to automated proximal anastomoses (group I, n=39, 61 vein grafts connected using the aortic connector, 47 as single, 15 as sequential bypasses) or controls (group II, n=38, 62 proximal anastomoses handsewn, 46 as single, 16 as sequential bypasses). Ultrafast CT-scans were performed on postoperative day 5 in 34 patients of group I and 16 patients of group II to evaluate early graft patency. Intermediate term patency was evaluated with ultrafast CT-scan in 30 patients of group I (46 grafts) and 25 patients of group II (39 grafts) 1 year after the operation. Two early graft occlusions were detected in group I (3.8%). In group II all evaluated grafts were patent 5 days after surgery. 11.4 months after surgery, seven out of 46 grafts were found occluded (15.2%) in group I. In the control group, only one occlusion was detected (2.6%). We observed a trend towards an increased occlusion rate 1 year after surgery with automated connector devices. For evaluation of long-term patency larger patient groups have to be evaluated. Other benefits of these devices have to be proven to promote their clinical application.

Vettath’s Anastamotic Obturator—Our Experience of 269 Proximal Anastomoses

Background. Coronary artery bypass grafting (CABG) has come full circle-it started as an off-pump affair, then became an on pump one and now we are trying to keep off the pump again. One of the main reasons for this has been the neurological sequelae subsequent to CABG. But neurological problems kept causing concern even in off-pump CABGs (OPCAB). Side clamping the aorta was thought to be the major factor and thus came the concept of ‘no touch proximal anastomoses’ onto the aorta (1). Though a variety of proximal anastamotic devices are available in the market, high cost is a matter of real concern in third world countries like India. Hence, this endeavor of ours to fabricate an anastamotic device of our own—‘the Vettath’s anastamotic obturator’ (VAO) for proximal anastomoses of saphenous vein grafts (SVG) onto the aorta. VAO is a stainless steel rod with three grooves and a guard at the end, which sinks into the aorta, through a punch hole, cordoned off by two wide purse string sutures. Methods. After trials on perfused animal heart models, we started using this device on humans. We have performed 269 proximal anastomoses using the VAO in 177 of our OPCAB patients in the past 1 year (till July 2003). Ninety-five of them had single top ends, 72 had 2 top ends and 10 had 3 top ends onto the aorta. We have used this on disease free islands on four patients with palpable aortic plaques. Initially all anastomoses were of the proximal first type (to ensure that the flow was adequate). Now-a-days, with confidence, distal first anastomoses are being performed. Results. We had no operative mortality in this group. None of our patients needed IABP support. One patient reported back with angina, after 3 months—he was studied and his grafts were found to be patent. All patients, except three, are being followed up till date and they are leading active symptom free and event free lives. Discussion. It is logical to think that avoidance of side clamp on the aorta reduces the risk of neurologic complications. Vettath’s anastamotic obturator is an indigenous, cheap and reusable alternative to the other costlier devices, which serve the same purpose. Though there is a small learning curve, results are gratifying and complications are few.

Off-pump coronary artery bypass in patients with Takayasu's disease

We report 2 patients with ostial stenoses of coronary arteries and heavy aortic calcification caused by Takayasu's disease in which severe angina was successfully relieved by off-pump coronary artery bypass grafting. In one case, visceral arteries such as the right gastroepiploic artery, the superior mesenteric artery, and the splenic artery were used as proximal blood sources of saphenous vein grafts. In another case, an aortic connector system was employed for proximal anastomoses of saphenous vein grafts. The use of off-pump coronary artery bypass grafting techniques should be considered in surgical coronary revascularization in patients with Takayasu's disease, thus leading to wide-spreading indication for the surgery.

Fatal complications after use of the symmetry aortic connector in coronary artery bypass surgery

During the last 2 years, 103 aortic saphenous vein graft anastomoses were performed in 68 patients undergoing off-pump coronary artery bypass by using the Symmetry Bypass System Aortic Connector. Of these patients, 2 died during the early postoperative period. In the first patient, after an episode of ventricular fibrillation and closed-chest cardiac massage, the sternum was opened and hemopericardium secondary to leakage of the proximal anastomotic device was found. The second patient died of ascending aortic dissection, the tear of which was likely to have originated from the proximal anastomotic site.

Initial results on the use of mechanical devices for proximal saphenous vein graft anastomoses: a clinical and angiographic evaluation

OBJECTIVE: To report on our initial clinical experience of the utilization of a mechanical anastomotic device (MAD) to perform saphenous vein graft to aorta anastomosis. METHOD: Between June 2002 and May 2003, 17 patients, including 13 male, with a mean age of 64.4 ± 9.4 years, were selected for coronary artery bypass grafting using MAD. A total of 49 anastomoses, 19 arterial and 30 vein grafts, were performed with a mean of 2.9 ± 0.5 anastomoses per patient. Eleven (36.7%) vein-graft anastomoses were performed with conventional sutures and 19 (63.3%) using MAD. The clinical evolution, enzymatic and electrocardiographic alterations as well as an angiographic study were analyzed in the postoperative period. RESULTS: Of the 17 patients, the mechanical device was used on 16 (94.1%). Six (37.5%) patients were operated on under cardiopulmonary bypass with a mean time of 102.9 ± 16.9 minutes. The postoperative evolution was satisfactory in all patients. No patient presented with enzymatic, myocardial infarction or other ischemic electrocardiographic alterations in the immediate postoperative period. Early postoperative angiography was performed in 9 (52.9%) patients. The anastomoses of the left internal thoracic artery to left anterior descending artery were patent in all cases. Of the 15 saphenous vein grafts studied, 11 (73.3%) were performed using MAD, 9 (81.8%) of which were patent. All the 4 conventionally sutured vein anastomoses were patent. No hospital deaths occurred. In the late follow-up, 88.2% of the patients were free of cardiac-related events. CONCLUSIONS: MAD for vein graft-to-aorta anastomosis proved to be feasible, but a wider analysis of the benefits of its utilization regarding operative time, aggression to the patient, patency of the grafts and final cost are necessary.

Cirurgia de revascularização coronariana esquerda sem CEC e sem manuseio da aorta em pacientes acima de 75 anos: análise das mortalidades imediata e a médio prazo e das complicações neurológicas no pós-operatório imediato

INTRODUÇÃO: A circulação extracorpórea (CEC) e o manuseio da aorta ascendente (MAA) estão associados a alta incidência de acidente vascular cerebral (AVC) na cirurgia de revascularização do miocárdio (RM) em pacientes idosos. Esta complicação deve-se, sobretudo, ao MAA, por ocasião do pinçamento e despinçamento, quer para isolamento do coração do circuito de CEC, quer para realização das anastomoses dos enxertos na aorta ascendente. OBJETIVOS: Verificar mortalidades imediata e a médio prazo e a ocorrência de AVC no pós-operatório imediato (POI) em pacientes acima de 75 anos submetidos a cirurgia de revascularização do sistema coronariano esquerdo (SCE), sem CEC e sem MAA. MÉTODO: De janeiro de 2000 a abril de 2002, 40 pacientes acima de 75 anos (média 79,1 anos) foram submetidos a cirurgia de revascularização do SCE, com enxerto de artéria torácica interna esquerda (ATIE) para a artéria descendente anterior (DA), e enxerto(s) de veia safena magna oriundo(s) da ATIE para outro(s) ramo(s) da coronária esquerda (enxerto composto), sem CEC e sem MAA. Houve predominância do sexo masculino (67,5%). Foram realizados 89 enxertos (média 2,22 pontes por paciente), sendo 40 (44,94%) de ATIE e 49 (55,06%) de veia safena. A ocorrência de AVC foi avaliada por exames clínico e neurológico. RESULTADOS: Não foi observada ocorrência de AVC no grupo estudado. Não houve óbitos no POI. CONCLUSÃO: A cirurgia de revascularização do SCE em pacientes acima de 75 anos sem CEC e sem MAA pode ser realizada sistematicamente de modo a evitar a ocorrência de AVC, com baixa mortalidade.

Early clinical experience with a new sutureless anastomotic device for proximal anastomosis of the saphenous vein to the aorta

Background: Avoiding aortic side clamping in useful to avoid local particulate embolization. A device that allows a saphenous vein graft to be anastomosed to the aorta without aortic manipulation is clinically evaluated. Methods and results: From July 1999 to March 2000, 17 patients who underwent myocardial revascularization had an aorta–saphenous vein graft anastomosis performed by means of an aortic anastomotic device. Eight were operated on with cardiopulmonary bypass and 9 without. The proximal anastomoses created by the aortic anastomotic device were performed before the institution of cardiopulmonary bypass or before the related distal anastomosis was performed. In 11 patients transcranial Doppler ultrasound was used. In 1 (6%) patient the saphenous vein graft was not deployed, and in 2 (12%) a single suture was added for minor bleeding. None of the 11 patients evaluated with transcranial Doppler ultrasound had evidence of particulate embolization during the procedure. No patient died or was reoperated on for bleeding. Six (35%) patients had a postoperative angiogram 48 ± 26 days after the operation that showed widely patent proximal anastomoses. Conclusions: Use of an aortic anastomotic device allows a sutureless anastomosis to be created between the aorta and saphenous vein graft. The device could be used in totally endoscopic myocardial revascularization. A second-generation device is ready to solve the problems encountered and to increase the ease in handling the device. (J Thorac Cardiovasc Surg 2001;121:854-8)

Single Aortotomy for Multiple Aortocoronary Saphenous Vein Bypass Grafts

A new technique for the proximal anastomoses of saphenous vein grafts in coronary artery bypass operations is described. This technique has several advantages over existing methods and has been shown to be safe and satisfactory in 389 consecutive patients operated on between May, 1978, and May, 1981.