Early Saphenous Vein Graft Failure Research Articles

Development of a risk score for early saphenous vein graft failure: An individual patient data meta-analysis

ObjectivesEarly saphenous vein graft (SVG) occlusion is typically attributed to technical factors. We aimed at exploring clinical, anatomical, and operative factors associated with the risk of early SVG occlusion (within 12 months postsurgery). MethodsPublished literature in MEDLINE was searched for studies reporting the incidence of early SVG occlusion. Individual patient data (IPD) on early SVG occlusion were used from the SAFINOUS-CABG Consortium. A derivation (n = 1492 patients) and validation (n = 372 patients) cohort were used for model training (with 10-fold cross-validation) and external validation respectively. ResultsIn aggregate data meta-analysis (48 studies, 41,530 SVGs) the pooled estimate for early SVG occlusion was 11%. The developed IPD model for early SVG occlusion, which included clinical, anatomical, and operative characteristics (age, sex, dyslipidemia, diabetes mellitus, smoking, serum creatinine, endoscopic vein harvesting, use of complex grafts, grafted target vessel, and number of SVGs), had good performance in the derivation (c-index = 0.744; 95% confidence interval [CI], 0.701-0.774) and validation cohort (c-index = 0.734; 95% CI, 0.659-0.809). Based on this model. we constructed a simplified 12-variable risk score system (SAFINOUS score) with good performance for early SVG occlusion (c-index = 0.700, 95% CI, 0.684-0.716). ConclusionsFrom a large international IPD collaboration, we developed a novel risk score to assess the individualized risk for early SVG occlusion. The SAFINOUS risk score could be used to identify patients that are more likely to benefit from aggressive treatment strategies.

Impact of glucose control on early vein graft failure after coronary artery bypass grafting: one-month angiographic results.

To identify factors that determine early saphenous vein graft failure (VGF) within 1 month after coronary artery bypass grafting (CABG). Seven hundred forty-nine consecutive patients underwent primary isolated CABG with saphenous vein grafts at three Japanese centres from 1 January 2005 to 31 December 2014. According to angiographic findings within 1 month of CABG surgery, 63 patients (8.4%) developed early VGF. We examined the relationships between variables and early VGF by using multivariable logistic regression analysis. The preoperative clinical characteristics were similar between patients with and without early VGF, except for median preoperative haemoglobin A1c levels, which were significantly higher among patients with early VGF (6.7 vs 6.4%, P = 0.046). Additionally, anastomosis to the vessel with chronic total obstruction was performed more frequently among patients with early VGF (22/63 [34.9%] vs 140/686 [20.4%], P = 0.007), and myocardial infarction during the hospital admission occurred more frequently among patients with early VGF (4/63 [6.3%] vs 2/686 [0.3%], P < 0.0001). Results of multivariable analysis showed that the preoperative haemoglobin A1c level was associated with early VGF (odds ratio per unit increase, 1.30; 95% confidence interval, 1.06-1.60; P = 0.013). An increased preoperative haemoglobin A1c level was strongly associated with early VGF after CABG. Thus, VGF happened more frequently in patients with poorly controlled diabetes mellitus.

Matricryptin p1158/59 Modulates Vascular Remodeling During Carotid Artery Bypass

When atherosclerosis develops in the coronary arteries, blood flow is compromised and disease progression increases the risk of myocardial infarction. Saphenous vein (SV) is the most common conduit used for coronary artery bypass grafting; however, its long‐term patency and survival rates are not ideal. One year after surgery, 10% to 20% of SV grafts fail, from 1–5 years an additional 5% to 10% fail, and from 6–10 years, an added 20% to 25% fail. Early SV graft failure is mainly due to thrombosis (graft spasm) or technical error, whereas longer‐term failure results from neointimal hyperplasia. p1158/59 is a collagen‐derived matricryptin shown to facilitate tissue regeneration through targeted basement membrane protein deposition and vascularization. Accordingly, we hypothesized that p1158/59 SV treatment, prior to grafting, would modulate early vascular remodeling by modifying basal lamina composition and modulating intima growth, consistent with better graft patency.A canine model of carotid artery bypass was used. Animals (n=12; 25–35 kg) were anesthetized, intubated, and ventilated with 1–3% isoflurane, oxygen, and room air. A lateral hind limb incision was made and approximately 12–15 cm (in situ) of SV harvested. One half of the SV served as control (vehicle‐treated) and the other half was treated with p1158/59 (1 μM; 1.5 h). Vehicle‐ and p1158/59‐treated veins were anastomosed end‐to‐side into the right and left common carotid arteries respectively. Once graft patency was established, the native artery was divided, all surgical wounds repaired, and animals recovered. Ten days later, SV grafts were removed and tissue stored for gene and protein expression and histological assessments.Of the 12 SV vehicle grafts, 2 were thrombosed and 10 were patent; 6 of the patent grafts were heavily encapsulated. In the p1158/59‐treated group, 2 grafts were thrombosed with one continuing to show a weak pulse. Of the other 10 treated SV grafts, 4 were encapsulated; however, the level of adhesions was fewer as compared to the respective vehicle graft. There was no difference in lumen area between vehicle and p1158/59 groups (1.20×106±0.11×106 μm2 versus 1.33×106±0.12×106 μm2). Gene array revealed increased expression of the pro‐angiogenic factors EGF, HGF, and TGF‐β3 in the p1158/59 groups (all p&lt;0.05 versus vehicle). Aminopeptidase N, known to regulate the biological activity of various peptides and to be highly expressed in macrophages with elevated phagocytic function, was also overexpressed in the p1158/59‐treated SV grafts when compared to vehicle (p&lt;0.05). Histological analysis revealed similar expression of vascular elastin between groups but increased levels of collagen in the p1158/59‐treated group in the distal area of the graft when compared to vehicle (p&lt;0.05).Our data suggest p1158/59 reduced graft encapsulation and adhesion formation after 10 days of SV engraftment and modulated vascular collagen remodeling.Support or Funding InformationWe acknowledge support from the American Heart Association 14SDG18860050

THE EFFECT OF ADDING CLOPIDOGREL OR WARFARIN TO THE GOLD STANDARD, ASPIRIN, ON THE RATE OF REPEAT CORONARY ANGIOGRAPHY AND EARLY SAPHENOUS VEIN GRAFT FAILURE

CABG is known to improve patient’s survival and alleviate symptoms of angina. Early saphenous vein graft failure (ESVGF), from acute thrombosis, is seen in 15-45 % of implanted grafts within the first year, a major cause of morbidity and mortality. Current guidelines recommend the sole use of

Hinge Motion and Excessive Negative Remodeling as a Cause of Early Saphenous Vein Graft Failure

A 56-year-old male patient underwent a coronary artery bypass graft operation (CABG) using the left internal thoracic artery and saphenous vein graft (SVG) for severe coronary artery disease. Fourteen months later, he was admitted to our hospital because of recurrent angina. A coronary angiogram

Cut-Off Values for Transit Time Flowmetry: Are the Revision Criteria Appropriate?

Graft Imaging to Improve Patency (GRIIP), a single-center, randomized blinded clinical trial, reported that intraoperative graft assessment with graft revision according to a priori criteria of transit time flowmetry (TTF) and intraoperative fluorescent angiography did not improve graft patency at one year after coronary artery bypass grafting (CABG) when compared with standard intraoperative management. The objective of this study is to investigate whether other TTF values are more predictive of the saphenous vein graft (SVG) failure and/or clinical outcomes. This is a case control retrospective study of 65 SVGs from 44 patients from GRIIP. Study outcomes were graft patency at 12 months and major adverse cardiac events (MACE; death, myocardial infarction, repeat revascularization). Twenty-two SVGs were occluded. In receiver operating characteristic curve analysis, TTF mean flow was significantly predictive of one-year SVG failure (area under the curve = 0.698, p < 0.01), and 31 mL/min was the best cut-off value (p = 0.017, sensitivity 63.6%, specificity 67.4%). The risk of graft occlusion was 14/28, 50% for grafts with mean flow <31 mL/min and 8/37, 21.6% for grafts with mean flow ≥ 31 mL/min. In logistic regression models, mean flow was a significant predictor of early SVG failure (Odds Ratio 0.95 [0.91-0.99] per mL/min, p = 0.014) whereas other TTF values, patient comorbidities, and/or medication at discharge were not. However, TTF values were not predictive of MACE. TTF can identify non-functional grafts during CABG, but is of questionable value to improve one-year graft patency.

Perioperative management of aspirin resistance after off‐pump coronary artery bypass grafting: possible role for aprotinin

Aspirin is the only drug proven to reduce saphenous vein graft (SVG) failure, but aspirin resistance (ASA-R) frequently occurs after off-pump coronary artery bypass grafting (OPCAB). The factors, mechanism, and best means for preventing and/or treating ASA-R have not been established. This study hypothesizes that thrombin production during OPCAB stimulates this acquired ASA-R. A nonrandomized prospective cohort of 255 patients (n=465 SVG) who underwent OPCAB with varied use of aprotinin (21%) and different SVG preparation techniques (standard, 56% vs. low-pressure, 44%) was analyzed. A surplus SVG segment was obtained to assess endothelial integrity. ASA-R was determined at baseline, after surgery, and on Days 1 and 3 by three assays. The effects of aprotinin on thrombin responsiveness were analyzed by means of whole-blood aggregometry, SVG tissue factor (TF) activity, and transcardiac thrombin production (i.e., F1.2 levels in aorta versus coronary sinus). SVG patency was assessed on Day 5 with multichannel CT angiography. ASA-R developed in 42 percent of patients after OPCAB. Multivariate analysis showed that ASA-R, endothelial integrity, and target size independently predicted early SVG failure. Aprotinin use was associated with: 1) reduced postoperative ASA-R (15%); 2) decreased platelet (PLT) response to thrombin; 3) reduced TF activity within SVG segments; 4) decreased transcardiac thrombin gradient; and 5) improved SVG patency. ASA-R is a common post-OPCAB event whose frequency may be reduced by intraoperative use of aprotinin, possibly via TF and thrombin suppression. Improved perioperative PLT function after OPCAB may also inadvertently enhance the clinical relevance of these potential antithrombotic effects.

Role of Procurement-Related Injury in Early Saphenous Vein Graft Failure after Coronary Artery Bypass Surgery

Saphenous vein graft thrombosis after coronary artery bypass graft surgery is a poorly understood problem that lessens the benefits of this procedure. Recent studies highlight the importance of injury sustained at the time of saphenous vein graft procurement in the pathogenesis of acute graft thrombosis. In particular, damage to the graft endothelium that occurs secondary to ex vivo pressure distention, a common practice during vein harvest, leads to a loss of antithrombotic factors and increased activity of subendothelial prothrombotic factors. The prothrombotic potential of damaged grafts is further exacerbated by an ischemic storage interval and subsequent exposure to arterial flow conditions after grafting. A clearer understanding of the mechanisms by which endothelial disruption leads to acute saphenous vein graft thrombosis may result in interventions for improving our procurement techniques, interrupting the downstream effects of the damaged saphenous vein graft and/or discriminating damage that is beyond an acceptable threshold of thrombotic risk.

Relation of Early Saphenous Vein Graft Failure to Outcomes Following Coronary Artery Bypass Surgery

Up to 20% of saphenous vein grafts (SVGs) fail within 2 years of coronary artery bypass grafting (CABG). The long-term effects of early SVG failure on major clinical events remain undefined in contemporary patient populations. We sought to examine the relation between early SVG failure and long-term outcomes after CABG. Using the Duke Cardiovascular Databank, we examined baseline clinical and angiographic characteristics and clinical outcomes among patients who underwent catheterization 1 to 18 months after their first CABG from 1986 to 2004. Patients were classified on the basis of their worst SVG stenosis as having no (<25%), noncritical (25% to 74%), critical (75% to 99%), or occlusive (100%) SVG disease. Our primary outcome measure was the composite of death, myocardial infarction, or repeat revascularization after catheterization. Of 1,243 patients included in the analysis, 27.9% had no, 11.9% had noncritical, 20.8% had critical, and 39.3% had occlusive SVG disease. At 10 years, the corresponding adjusted composite event rates were 41.2%, 56.2%, 81.2%, and 67.1%, respectively (p <0.0001). Most events occurred immediately after catheterization in patients with critical and occlusive SVG disease and were primarily repeat revascularization. On multivariate analysis, critical, nonocclusive SVG disease was the strongest predictor of the composite outcome (hazard ratio 2.36, 95% confidence interval 2.00 to 2.79, p <0.0001). In conclusion, in contemporary clinical practice, early SVG failure is associated with worse long-term outcomes after CABG.

Clinical, angiographic, and intravascular ultrasound characteristics of early saphenous vein graft failure

Clinical, angiographic, and intravascular ultrasound characteristics of early saphenous vein graft failure

Clinical, angiographic, and intravascular ultrasound characteristics of early saphenous vein graft failure

ObjectivesWe sought to examine saphenous vein graft (SVG) lesions that fail within the first year after operation. BackgroundSaphenous vein grafts remain patent for approximately 10 years; however, up to 15% to 20% of SVGs become occluded within the first year. MethodsWe studied 100 patients who underwent percutaneous coronary intervention (PCI) for early (<1 year post-implantation) SVG failure lesions and compared them with a diabetes- and hypercholesterolemia-matched cohort of late SVG failures (>1 year). Coronary angiography and intravascular ultrasound images were analyzed. ResultsThe majority of patients in both groups were males who presented with unstable angina; 36% were diabetic. Graft ages were 6.0 ± 2.9 months and 105.4 ± 50.8 months, respectively. The early SVG failure lesion location was more often ostial or proximal (62% vs. 42%, respectively). Early SVG failures were angiographically smaller than late failures (reference: 2.47 ± 0.86 mm vs. 3.26 ± 0.83 mm, p < 0.001) but had similar lesion lengths. Intravascular ultrasound showed that early failure lesions had smaller proximal and distal reference lumen areas (7.3 ± 6.8 mm2vs. 10.6 ± 3.8 mm2, p = 0.026) and greater reference plaque burden than late failures (52.3% vs. 36.1%, p < 0.001). After PCI, 20.6% of early and 30.6% of late failure lesions had creatine kinase-myocardial band (CK-MB) greater than twice normal. ConclusionsEarly SVG failure is mostly proximal or ostial, lesions appear focal, and early SVGs appear smaller than late SVGs. Intravascular ultrasound shows significant reference segment plaque burden, suggesting more severe, diffuse SVG disease.

1120-66 Early saphenous vein graft failure: A predictor of poor outcomes after percutaneous coronary intervention

1120-66 Early saphenous vein graft failure: A predictor of poor outcomes after percutaneous coronary intervention

Ascending aortic atheroma assessed intraoperatively by epiaortic and transesophageal echocardiography

Background. The presence of ascending aortic atheroma is a known risk for systemic emboli or early saphenous vein graft failure if unrecognized at the time of cardiopulmonary bypass. Methods. This study prospectively compared intraoperative omniplane transesophageal echocardiography (TEE) and epiaortic ultrasound (EAU) images in 22 patients (6 women, 16 men, age 66 ± 8 years) before surgical manipulation of the ascending aorta. Atheroma lesion severity was scored: 1 = normal, 2 = nonprotruding intimal thickening (> 2 mm), 3 = atheroma less than 4 mm ± Ca++, 4 = atheroma greater than or equal to 4 mm ± Ca++, and 5 = any size mobile or ulcerated lesion ± Ca++. The ascending aorta between the aortic valve and innominate artery was divided into proximal, middle, and distal segments. A total of 66 segments were evaluated. Results. Although the overall agreement of scores between procedures was 75.8%, significantly more lesions were identified by EAU (15) than by TEE (5) ( p < 0.03). TEE failed to identify lesions in the middle and distal segments of the aorta with a score of more than 3. Conclusions. Although atheromatous lesions were identified in the ascending aorta by both ultrasound modalities, the results suggest that intraoperative EAU may have an advantage over TEE for surgeons assessing target sites for surgical procedures involving the ascending aorta.