Saphenous Vein Graft Failure Research Articles

Saphenous Vein Graft Interventions

Saphenous vein graft (SVG) percutaneous coronary intervention (PCI) currently accounts for approximately 6% of all PCIs and is associated with increased risk for distal embolization and subsequent SVG failure compared with native coronary artery PCI. To minimize the risk for distal embolization, embolic protection devices should be used during SVG PCI when technically feasible. To minimize the risk for in-stent restenosis and the need for repeat PCI, drug eluting stents should be utilized in patients without contraindications to long-term antiplatelet therapy. Treating native coronary artery lesions is preferable to SVG PCI when technically feasible.

The Impact of Vessel Clamps on Endothelial Integrity and Function of Saphenous Vein Grafts

Saphenous vein graft (SVG) failure can be associated with endothelial damage during coronary artery bypass grafting (CABG). Endothelial damage may develop after application of occlusive vessel clamps on SVGs. This study was designed to investigate the effect of plastic and metal clamps on the endothelial integrity and function of SVGs. Saphenous vein samples were obtained from 10 consecutive patients, who underwent an elective CABG using SVG. Plastic (group 1) and metal (group 2) clamps were sequentially applied on the vein. Each set of clamps (1 plastic and 1 metal) was removed and sampled at 5, 15, and 30 min, respectively. A short SVG segment was removed as control. The samples were fixed for histopathologic study using hematoxylin-eosin staining and immunostaining for endothelial nitric oxide synthase (eNOS) expression. In each group, endothelial, elastic tissue, muscular layer, and adventitial changes were investigated under light microscope and compared using a histologic scoring system. The intensity of eNOS expression was assessed using histochemical scoring system. In both groups, histopathologic examinations showed progressive endothelial damage in the zones of clamp application, compared with the control group (P<0.001). Histopathologic changes were more favorable with the metal clamps, compared with the plastic clamps, at 5 and 15 min. No significant increase in endothelial damage occurred after 15 min. The eNOS immunoreactivity of SVGs significantly decreased in the damaged areas of the endothelium (P<0.05). In metal clamps, the intensity of eNOS immunostaining was significantly high at 5 min, compared with plastic clamps (P<0.05). However, the intensity of eNOS expression in metal clamps was significantly lower than plastic clamps at 15 min (P<0.05). No significant difference was observed between the groups at 30 min. The endothelial cells can be better preserved with short-term application of SVGs with metal clamps rather than plastic clamps. These findings suggest that temporary use of metal clamps can be preferred without major effects on vascular integrity and function.

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

Five-Year Follow-up of the Plaque Sealing With Paclitaxel-Eluting Stents vs Medical Therapy for the Treatment of Intermediate Nonobstructive Saphenous Vein Graft Lesions (VELETI) Trial

BackgroundVery few data exist on the long-term follow-up of patients with intermediate nonobstructive saphenous vein graft (SVG) lesions. The purpose of this study was to evaluate the 5-year clinical outcomes of the patients enrolled in the Moderate Vein Graft Lesion Stenting With the Taxus Stent and Intravascular Ultrasound (VELETI) and the factors associated with SVG disease progression and outcomes. MethodsPatients with ≥ 1 intermediate SVG lesion (30%-60% diameter stenosis) were randomized to either stenting the SVG lesion with a paclitaxel-eluting stent (PES group, n = 30) or to medical treatment alone (MT group, n = 27). All patients were followed yearly up to 5 years. ResultsMajor adverse cardiac events (MACEs) (cardiac death, myocardial infarction [MI], revascularization) related to the target SVG lesion tended to be lower in the PES group (17% vs 33%; P = 0.146) due to a lower lesion revascularization rate (13% vs 33%; P = 0.072), with no difference in cardiac death or MI between groups. MACEs related to the target SVG and global MACEs were similar between groups (P > 0.20 for both). A higher cholesterol level at baseline was the only independent predictive factor of MACEs related to the target SVG (P = 0.016). ConclusionsOver a 5-year period, one third of intermediate lesions in old SVGs progressed, leading to a cardiac event. Stenting these lesions with PESs tended to improve clinical outcomes by reducing lesion progression but not SVG failure. Higher cholesterol levels were associated with SVG disease progression and clinical events. This pilot study provides the basis for a larger trial to determine the efficacy of intermediate SVG lesion plaque sealing.

Does prior coronary artery bypass grafting affect percutaneous chronic total occlusion revascularization?

Chronic totally occluded coronary arteries are commonly encountered and often referred to as the “final frontier of interventional cardiology” [1]. Despite recent advances in wires, catheters, devices and techniques, this lesion subset remains the most technically challenging in the current era of interventional cardiology. Prior coronary artery bypass graft (CABG) surgery further increases the complexity of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) and many of these special considerations are highlighted in this article. CTOs are commonly discovered among patients referred for coronary angiography. In a large Canadian catheterization registry 18% of patients were found to have at least one CTO [2]. While CTOs are common among all patients referred for angiography, those with prior CABG represent a population with very high CTO prevalence. Approximately half of post-CABG patients undergoing coronary angiography have an unrevascularized CTO [2]. Among CTOs identified during coronary angiography, PCI is attempted in only 10–13%, and the CTOs successfully revascularized by PCI are a mere 7% [2,3]. In the SYNTAX trial, successful revascularization was achieved in only 49.4% of CTOs in the PCI cohort and 68.1% of CTOs in the surgical cohort on a per-lesion basis [4]. This observation suggests that CTO revascularization remains a challenge not only for interventionalists, but also for surgeons. However, the presence of a CTO, particularly in the setting of multivessel disease remains one of the strongest predictors of referral for CABG [3]. While the patency of the left internal mammary artery is over 90% at 10 years post-CABG, the per-patient incidence of 1-year saphenous vein graft (SVG) failure (defined as stenosis

Neutrophil–Lymphocyte Ratio is a Predictor of Saphenous Vein Graft Patency in Patients Undergoing Coronary Artery Bypass Surgery

We read the article ‘‘Preoperative Neutrophil–Lymphocyte Ratio and Saphenous Vein Graft Patency After Coronary Artery Bypass Grafting’’ by Tasoglu et al. They aimed to investigate the predictive value of preoperative neutrophil–lymphocyte (N/L) ratio in postoperative saphenous vein graft (SVG) patency in patients undergoing coronary artery bypass grafting (CABG) surgery. They showed that the N/L ratio is a powerful and independent predictor of further SVG failure after CABG. Patients in the highest tertile of N/L ratio were at greater risk. The study is successful in planning and presenting the results. We believe that these findings will enlighten further studies about the postoperative SVG patency and the N/L ratio. Thanks to the authors for their contribution Coronary lesion severity should be examined using both anatomical and physiological myocardial ischemia methods. Although coronary angiography is the conventional gold standard anatomical evaluation method, intravascular ultrasound and optical coherence tomography give useful information about the severity of coronary artery stenosis. Additionally, fractional flow reserve value has also become a necessary tool for the functional severity of coronary artery stenosis recently. All of these methods should be used together to evaluate the severity of coronary artery stenosis. Routine peripheral blood counts may be helpful in patients with postoperative SVG patency undergoing CABG surgery. White blood cell (WBC) count is one of the useful inflammatory biomarkers in clinical practice. Although WBC is in the normal range, subtypes of WBC like N/L ratio may predict cardiovascular mortality. The N/L ratio is a readily measurable laboratory marker used to evaluate systemic inflammation. Because of uncontrolled hypertension, uncontrolled diabetes mellitus, metabolic syndrome, left ventricular dysfunction or hypertrophy, acute coronary syndromes, valvular heart disease, congenital heart disease, abnormal thyroid function tests, renal or hepatic dysfunction, known malignancy, local or systemic infection, previous history of infection (<3 months), inflammatory diseases, and any medication related to inflammatory condition of patients, the measurement of N/L ratio can be potentially affected in all of the above conditions. For these reasons, it would be better if the authors had mentioned these factors. Finally, not only the N/L ratio but also the mean platelet volume, red cell distribution width, uric acid, a g-glutamyl transferase, and carotid intima–media thickness are easy methods to assess the SVG patency in patients with CABG. These markers might be useful in clinical practice. In conclusion, we strongly believe that those findings obtained from the current study will lead to further large-scale studies examining the relationship between the N/L ratio and the SVG patency in patients with CABG. However, one should keep in mind that the N/L ratio alone without other inflammatory markers may not give exact information to clinicians about the inflammatory status and SVG patency of the patients. So, from that point of view we think that it should be evaluated accompanied with other serum inflammatory markers.

Inhibition of vein graft stenosis with a c-jun targeting DNAzyme in a cationic liposomal formulation containing 1,2-dioleoyl-3-trimethylammonium propane (DOTAP)/1,2-dioleoyl-sn-glycero-3-phosphoethanolamine (DOPE).

Coronary artery bypass grafting (CABG) is among the most commonly performed heart surgical procedures. Saphenous vein graft failure due to stenosis impedes the longer-term success of CABG. A key cellular event in the process of vein graft stenosis is smooth muscle cell hyperplasia. In this study, we evaluated the effect of a DNAzyme (Dz13) targeting the transcription factor c-Jun in a rabbit model of vein graft stenosis in a cationic liposomal formulation containing 1,2-dioleoyl-3-trimethylammonium propane (DOTAP)/1,2-dioleoyl-sn-glycero-3-phosphoethanolamine (DOPE). Dz13 in DOTAP/DOPE has undergone preclinical toxicological testing, and a Phase I clinical trial we recently conducted in basal cell carcinoma cancer patients demonstrates that it is safe and well tolerated after local administration. Effects of Dz13 in a formulation containing DOTAP/DOPE on smooth muscle cell (SMC) growth and c-Jun expression were assessed. Dz13 transfection was determined by cellular uptake of carboxyfluorescein-labeled Dz13. Autologous jugular vein to carotid artery transplantation was performed in New Zealand White rabbits to investigate the effect of the Dz13 in DOTAP/DOPE formulation on intimal hyperplasia. Dz13/DOTAP/DOPE reduced SMC proliferation and c-Jun protein expression in vitro compared with an impotent form of Dz13 bearing a point mutation in its catalytic domain (Dz13.G>C). The Dz13(500 μg)/DOTAP/DOPE formed lipoplexes that were colloidally stable for up to 1h on ice (0°C) and 30 min at 37°C, allowing sufficient uptake by the veins. Dz13 (500 μg) inhibited neointima formation 28 d after end-to-side transplantation. This formulation applied to veins prior to transplantation may potentially be useful in efforts to reduce graft failure.

Saphenous Vein Graft Failure After Coronary Artery Bypass Surgery

To review our current understanding of the epidemiology and pathogenesis of vein graft failure (VGF), give an overview of current preventive and interventional measures, and explore strategies that may improve vein graft patency. VGF and progression of native coronary artery disease limit the long-term efficacy of coronary artery bypass graft surgery. We reviewed the published literature on the pathophysiology, prevention, and/or treatment of VGF by searching the MEDLINE (January 1, 1966-January 1, 2012), EMBASE (January 1, 1980-January 1, 2012), and Cochrane (January 1, 1995-January 1, 2012) databases. In addition, we reviewed references from the selected articles for studies not identified in the initial search. Basic science and clinical studies were included; non-English language publications were excluded. Acute thrombosis, neointimal hyperplasia, and accelerated atherosclerosis are the 3 mechanisms that lead to VGF. Preventive measures include matching and quality assessment of conduit and target vessel, lipid-lowering drugs, antithrombotic therapy, and cessation of smoking. Treatment of VGF includes medical therapy, percutaneous intervention, and redo coronary artery bypass graft surgery. In patients undergoing graft intervention, the use of drug-eluting stents, antiplatelet agents, and embolic protection devices may improve clinical outcomes. Despite advances in management, VGF remains one of the leading causes of poor in-hospital and long-term outcomes after coronary artery bypass graft surgery. New developments in VGF prevention such as gene therapy, external graft support, fully tissue-engineered grafts, hybrid grafts, and synthetic conduits are promising but unproven. Future efforts to reduce VGF require a multidisciplinary approach with a primary focus on prevention.

Preoperative Neutrophil–Lymphocyte Ratio and Saphenous Vein Graft Patency After Coronary Artery Bypass Grafting

The aim of the present study was to investigate the predictive value of preoperative neutrophil-lymphocyte ratio (NLR) in postoperative saphenous vein graft patency in patients undergoing coronary artery bypass grafting (CABG) surgery. We retrospectively analyzed 444 patients who had undergone CABG and a further control coronary angiography due to recurrence of symptoms. The patients were divided into tertile groups according to the NLR. The primary end point was 50% saphenous vein graft stenosis or more or complete occlusion. The saphenous vein graft failure in the 3 groups based on NLR was 33%, 66.2%, and 79.1%, in the low-, middle- and high-risk groups, respectively. In multivariate regression modeling, current smoker, diabetes mellitus, target artery diameter <1.5 mm, and NLR independently predicted saphenous vein graft patency in patients after CABG. Preoperative NLR is clearly an independent predictor of saphenous vein graft patency in patients after CABG.

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

Saphenous Vein Graft Disease

Saphenous vein graft (SVG) disease after coronary artery bypass grafting (CABG) occurs in three phases: thrombosis, intimal hyperplasia, and atherosclerosis. Within the first month, thrombosis plays a major role. From month 1 to month 12, intimal hyperplasia occurs. Beyond 12 months, atherosclerosis becomes the primary cause for late graft failure. Endothelial damage has been shown to be the major underlying pathophysiology of SVG disease. Many factors contribute to endothelial damage from the moment the vein is harvested to when the vein is grafted into an arterial environment. To address this disease process, various therapeutic modalities, from surgical methods to medical treatment, have been evaluated. Surgically, the technical method of harvesting the vein has been shown to affect SVG patency. From a pharmacologic perspective, only two guideline class I recommended medications, aspirin and statins, have been shown to improve short- and long-term SVG patency after CABG. Despite these surgical and medical advances, SVG disease remains a significant problem with 1-year patency rates of 89% dropping to 61% after 10 years. This review discusses the pathogenesis of SVG disease, predictors of SVG failure, and current surgical and pharmacologic therapies to address SVG disease, including possible future treatment.

Role of hemodynamic forces in the ex vivo arterialization of human saphenous veins

Human saphenous vein grafts are one of the salvage bypass conduits when endovascular procedures are not feasible or fail. Understanding the remodeling process that venous grafts undergo during exposure to arterial conditions is crucial to improve their patency, which is often compromised by intimal hyperplasia. The precise role of hemodynamic forces such as shear stress and arterial pressure in this remodeling is not fully characterized. The aim of this study was to determine the involvement of arterial shear stress and pressure on vein wall remodeling and to unravel the underlying molecular mechanisms. An ex vivo vein support system was modified for chronic (up to 1 week), pulsatile perfusion of human saphenous veins under controlled conditions that permitted the separate control of arterial shear stress and different arterial pressure (7 mm Hg or 70 mm Hg). Veins perfused for 7 days under high pressure (70 mm Hg) underwent significant development of a neointima compared with veins exposed to low pressure (7 mm Hg). These structural changes were associated with altered expression of several molecular markers. Exposure to an arterial shear stress under low pressure increased the expression of matrix metalloproteinase (MMP)-2 and MMP-9 and tissue inhibitor of metalloproteinase (TIMP)-1 at the transcript, protein, and activity levels. This increase was enhanced by high pressure, which also increased TIMP-2 protein expression despite decreased levels of the cognate transcript. In contrast, the expression of plasminogen activator inhibitor-1 increased with shear stress but was not modified by pressure. Levels of the venous marker Eph-B4 were decreased under arterial shear stress, and levels of the arterial marker Ephrin-B2 were downregulated under high-pressure conditions. This model is a valuable tool to identify the role of hemodynamic forces and to decipher the molecular mechanisms leading to failure of human saphenous vein grafts. Under ex vivo conditions, arterial perfusion is sufficient to activate the remodeling of human veins, a change that is associated with the loss of specific vein markers. Elevation of pressure generates intimal hyperplasia, even though veins do not acquire arterial markers. The pathological remodeling of the venous wall, which leads to stenosis and ultimately graft failure, is the main limiting factor of human saphenous vein graft bypass. This remodeling is due to the hemodynamic adaptation of the vein to the arterial environment and cannot be prevented by conventional therapy. To develop a more targeted therapy, a better understanding of the molecular mechanisms involved in intimal hyperplasia is essential, which requires the development of ex vivo models of chronic perfusion of human veins.

“bad things happen in threes”: A story of saphenous vein graft failure, stent fracture, and stent loss

“bad things happen in threes”: A story of saphenous vein graft failure, stent fracture, and stent loss

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.

Early angiographic evaluation after off-pump coronary artery bypass grafting

One of the potential drawbacks of off-pump coronary artery bypass is reduced patency compared with conventional coronary artery bypass. This study examined the systematic angiographic evaluation after off-pump coronary artery bypass. Of the 1604 consecutive patients who underwent off-pump coronary artery bypass over 6 years, 1422 (89%) who underwent postoperative angiography were analyzed. Generalized estimating equations logistic analyses were used to investigate potential predictors of graft failure (FitzGibbon B or O). Bilateral internal thoracic arteries were used in 78% of the patients. The mean number of distal anastomoses was 3.7±1.2. The in-hospital mortality rate was 0.4%. Recipient coronary diameter less than 1.5 mm (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.24-2.11) was an independent predictor of graft failure, whereas percent stenosis diameter greater than 75% (OR, 0.71; 95% CI, 0.53-0.93), sequential graft (OR, 0.69; 95% CI, 0.51-0.94), and left main disease (OR, 0.72; 95% CI, 0.53-0.96) were protective factors. In the subanalyses for each conduit, percent stenosis diameter was protective against left internal thoracic artery failure (OR, 0.61), whereas smaller recipient coronary diameter was associated with right gastroepiploic artery and saphenous vein graft failure (OR, 2.37 and 2.36, respectively). Left circumflex artery was associated with gastroepiploic artery graft failure, whereas sequential graft was again protective for the gastroepiploic artery (OR, 4.39 and 0.33, respectively). Smaller coronary diameter would be a predictor of graft failure, whereas percent stenosis diameter greater than 75%, sequential graft, and left main disease would be protective factors for off-pump bypass grafts.

Mechanical properties of cellulose: chitosan blends for potential use as a coronary artery bypass graft

The development of intimal hyperplasia is the major cause of failure of both autologous saphenous vein and synthetic coronary artery bypass grafts. This is partially due to graft-host vessel compliance mismatch. Cellulose and chitosan (CELL:CHIT) are both biocompatible, nontoxic, and naturally occurring biopolymers that have been used extensively for biomedical applications. Elastic properties of membranes made of CELL:CHIT blends with different ratios between each polymer were determined using uniaxial tests and the ratio that yielded the less stiff membrane was chosen to prepare a small diameter hollow tube. The presence of chitosan had a favorable impact on the elasticity of the membranes, where the CELL:CHIT 5:5 ratio showed the lowest Young’s modulus. Small diameter tubular constructs were fabricated using this optimal CELL:CHIT ratio and the compliance was determined on samples with different wall thickness and internal diameter. The compliance of the hollow tube with inner diameter of 4 mm and wall thickness of 1.2 mm was found to be 5.91%/mmHg × 10−2, which is higher than those of Dacron, expanded polytetrafluorethylene, and saphenous vein, but very close to that of human coronary artery. Burst strength tests revealed that the tubes can withstand at least 300 mmHg. Finally, the tubes showed satisfactory cell attachment property when myofibroblast cells adhered and proliferated on the lumen of the samples.

LONG-TERM PATENCY OF CORONARY ARTERY BYPASS VEIN GRAFTS HARVESTED ENDOSCOPICALLY: A META-ANALYSIS

Failure of saphenous vein grafts (SVG) used in CABG is associated with increased rates of late major adverse cardiac events: these include death, myocardial infarction and need for revascularization. In the last 10 years endoscopic vein harvest (EVH) has become the preferred method of venous conduit

Pathophysiology of saphenous vein graft failure: a brief overview of interventions

Coronary artery bypass graft surgery (CABG) is widely used for the treatment of atheromatous stenosis of coronary arteries. However, as many as 50% of grafts fail within 10 years after CABG due to neointima (NI) formation, a process involving the proliferation of vascular smooth muscle cells (VSMCs) and superimposed atherogenesis. To date no therapeutic intervention has proved successful in treating late vein graft failure. However, several diverse approaches aimed at preventing neointimal formation have been devised which have yielded promising results. In this review, therefore, we will summarise the pathophysiology of vein graft disease and then briefly consider interventional approaches to prevent late vein graft failure which include surgical technique, conventional pharmacology, external sheaths, cytostatic drugs and gene transfer.

Successful recanalization of chronic total occlusion by retrograde approach via grafts in cases with saphenous vein graft failure

Successful recanalization of chronic total occlusion by retrograde approach via grafts in cases with saphenous vein graft failure

Saphenous vein graft disease: causes, prevention, and contemporary treatment strategies

Coronary bypass graft surgery provides symptomatic relief and a long life expectancy for most patients with coronary artery disease who have suitable vessels. Although arterial conduits are becoming more popular, saphenous vein grafts (SVG) are still frequently used in coronary artery bypass surgery since they are readily available, especially in emergency situations. However, SVG tend to degenerate over time, as nearly half of them develop significant stenosis and nearly 40% of them become completely occluded within a decade. Treatment options for SVG failure include redo-surgery, percutaneous intervention, and/or medical therapy. However, challenges in maintaining graft patency (as a predictor of long-term survival) and interventional complications (e.g., distal embolization, ''no-reflow,'' and higher rates of periprocedural myocardial infarction) are still ongoing problems for cardiologists and cardiovascular surgeons. This review discusses the possible causes of graft failure and the contemporary approaches for improving outcomes in patients undergoing coronary artery bypass graft surgery with at least one SVG.