Single Vein Grafts Research Articles

Importance of Limb Severity on Primary Graft Patency of Ipsilateral Single Saphenous Vein Grafts for Lower Extremity Artery Bypass in Chromic Limb-threatening Ischemia

Approximately 30% of infrainguinal vein bypasses fail within 2 years after placement. A previous study demonstrated limb severity influenced cellular responses of saphenous veins used for lower extremity arterial bypass. The aim of this study was to assess the impact of wound, ischemia, and foot infection (WIfI) on primary graft patency of ipsilateral saphenous vein grafts. This is a retrospective, observational cohort study of autogenous vein bypass for chromic limb-threatening ischemia. Between 2014 and 2019, 201 (of 253) limbs receiving ipsilateral single great saphenous vein grafts were enrolled as research subjects. The outcome of interest was loss of primary graft patency >1 month after surgery because of occlusion or intervention for graft stenosis. Perioperative graft failure due to technical error successfully repaired by revision surgery were included; however, perioperative unrepaired failed graft and patients dying within 30 days after surgery were excluded, leaving 191 vein grafts for analysis of 2-year primary graft patency. Factors associated with loss of graft patency were predicted by Cox regression modeling based on patients’ background and limb severity. Seventy-six grafts (40%) lost primary patency at 2 years after surgery. The highest stage of WIfI classification had significantly lower primary graft patency than a bundle of other lower stages (49% vs 66%; P = .04). When focusing on the three factors of WIfI, higher wound grade (2 and 3) significantly impaired graft patency compared with lower grade (49% vs 68%; P = .016) and existence of foot infection (grade 1-3) also impaired primary graft patency rate (49% vs 63%; P < .05). There was a trend to lower patency for ischemia grade 3 than grade 2 (54% vs 65%; P = .06). Female sex (hazard ratio [HR], 1.6; 95% confidence interval [CI], 1.0-2.6; P = .04), chronic heart failure (HR, 2.0; 95% CI, 1.2-3.2; P < .01), higher wound grade (HR, 1.9; 95% CI, 1.1-3.1; P = .01) were significant by multivariate analysis. Intriguingly, the impact of wound and foot infection grade on loss of primary patency was not significant for men (n = 129 limbs) (P = .35 for wound and P = .30 for foot infection); however, it was for women (n = 62 limbs) (P = .018 for wound and P = .059 for foot infection). Limb severity as classified by WIfI, especially wound grade, was associated with loss of primary graft patency. This impact was weighted in women, not men; hence, further basic investigation will be needed with focus on differing cellular responses of saphenous vein stratified by sex.

Non-reversed bifurcated vein graft improves time to healing in ischemic patients undergoing lower limb distal bypass.

Bifurcated vein grafts have been described in reconstructive microsurgery. No comparative studies have been published in lower limb arterial revascularization. The aim of this study was to compare non-reversed bifurcated vs. single vein graft in patients with critical limb-threatening ischemia (CLTI) undergoing lower limb distal bypass. Between January 2015 and December 2021 193 CLTI patients have been treated at our center with vein bypass, and distal anastomosis on infrapopliteal vessels; 137 patients (71%) received a single graft (Group SIN), and 56 patients (29%) had a bifurcated bypass (Group BIF). Primary outcomes measures were time to healing, primary patency, primary assisted patency, secondary patency, and limb salvage. Two-year outcomes according to Kaplan-Meier curves were evaluated and compared. Both groups were homogeneous in terms of demographic data, preoperative risk factors, and clinical presentation except for an elderly age in Group BIF (77.5 vs. 71.5 years; P<0.001). Intraoperative technical success was achieved in all patients. Overall median duration of follow-up was 19 months (interquartile range 9-36). Wound healing did not differ between the two groups (77.4% Group SIN vs. 73.2% Group BIF; P=0.33). Mean time to healing was faster in Group BIF (2.4 vs. 6.8 months; P<0.001). At 2-year follow-up there were no differences between the two groups in terms of primary patency (71.4% Group SIN vs. 54% Group BIF; P=0.10), primary assisted patency (81.7% Group SIN vs. 76.4% Group BIF; P=0.53), secondary patency (85.1% Group SIN vs. 80.9% Group BIF; P=0.79), and limb salvage (92.3% Group SIN vs. 87.2% Group BIF; P=0.64). Bifurcated graft improved time to healing in CLTI patients undergoing infrapopliteal non-reversed vein bypass. Two-year overall patencies and limb salvage did not differ accordingly to vein graft configuration (single vs. bifurcated).

No-Touch Sequential Saphenous Venous Harvesting Technique in Off-Pump Bypass Surgery: A Retrospective Study.

BackgroundIn the mid-1990s, the Swedish expert team proposed saphenous vein graft (SVG) harvesting with pedicle tissue. The short-term and long-term patency rates of the great saphenous vein obtained by the no-touch (NT) were higher than those obtained by the conventional (CON). In the past, NT harvesting was mainly used in on-pump coronary artery bypass grafting (CABG), and vein grafts were mostly single vein grafts. In this study, we retrospectively analyzed the safety and effectiveness of sequential vein grafts using NT harvesting in off-pump CABG.MethodsFrom 2017 to 2019, a total of 505 patients were included in the study. There were 150 patients in the NT group and 355 patients in the CON group. After applying propensity score matching (1:1 matching), 148 patients were included in each group. Baseline data, graft patency, post-operative complications, leg wound complications and 1-year major adverse cardiac and cerebrovascular events (MACCEs) were compared between the two groups.ResultsThere was no significant difference in the patency rate of sequential venous grafts between the two groups 1 year after the operation either before [NT: 7.1% (10/141) vs. CON: 11.5% (38/331), p = 0.149) or after matching (NT: 7.1% (10/140) vs. CON: 7.3% (9/124), p = 0.971]. There was no significant difference in the composite clinical endpoint between the two groups either before [NT: 3 (2.3%) vs. CON: 9 (2.8%), p = 1.000] or after matching [NT: 3 (2.3%) vs. CON: 3 (2.5%), p = 1.000]. There were differences in leg wound complications between the two groups both before [NT: 9 (6.9%) vs. CON: 6 (1.9%), p = 0.007] and after matching [NT: 9 (6.9%) vs. CON: 2 (1.7%), p = 0.043].ConclusionsThe application of the NT harvesting in off-pump CABG with sequential vein grafts is safe and effective. NT method has disadvantages in leg wound.

Bilateral internal thoracic artery use in two-vessel disease does not increase the perioperative risk—A propensity score matched analysis

BackgroundBilateral internal thoracic arteries (BITA) are uncommonly used in the every-day practice due to safety concerns and technical challenges with Y-grafts. We hypothesized that in-situ BITA use during coronary artery by-pass grafting (CABG) for two vessel disease is equally safe to standard strategy with left internal thoracic artery-left anterior descending artery revascularization and venous graft to other target vessels.MethodsA propensity score matched analysis was used to compare elective on-pump CABG patients who received in-situ BITA (BITA-group), versus left internal thoracic artery graft to the left anterior descending artery plus vein (SITA-group). Primary end points were 30-days all-cause-mortality, major adverse cardiac events and incidents and deep sternal wound infections.ResultsA total of 50 matched pairs (c-statistics 0.769) were selected from patients operated on between January 2015 and April 2020 using BITA (n = 50) and SITA (n = 2170). There were no inter-group differences in demographics and basic clinical characteristics. The total operation time was longer in the BITA-group (4.0 vs 3.6 hours; p = 0.004). The rate of complete revascularization was similar, as was median aortic cross-clamp time, median extracorporeal circulation time, rate of re-explorations for bleeding, deep sternal wound infections or length of stay. One patient died in BITA group, 3 days after surgery, from a non-cardiac cause. After 36 months, the survival rate was 98% for BITA-group and 96% for controls (log-rank, p = 0.577).ConclusionsIn-situ use of BITA during coronary revascularization for two-vessel disease is as safe and effective, as use of single ITA and vein graft. In-situ strategy abolishes allows to avoid the technically demanding composite graft configuration.

Gender Disparities in Presentation, Operative Characteristics, and Clinical Outcomes After Lower Extremity Bypass for Peripheral Artery Disease

Despite data suggesting greater rates of functional decline and worse clinical outcomes for women compared with men after invasive treatment of peripheral artery disease (PAD), women are underrepresented in contemporary PAD studies. We used Vascular Quality Initiative (VQI) data to evaluate gender differences in presentation, treatment, and clinical outcomes after lower extremity bypass (LEB) for PAD. Patients with data in the VQI database who had undergone LEB for claudication or chronic limb-threating ischemia (CLTI) from 2010 to 2019 were included. Descriptive statistics and competing risks survival analyses were performed. A total of 36,289 patients (33% female) had undergone LEB during the study period. Compared with men, the women were more likely to be older (mean age, 68 ± 12 years vs 66 ± 11 years), black (21% vs 15%), and diabetic (53% vs 51%; P < .001 for all). Women were also more likely to have a preoperative ankle brachial index of <0.40 (38% vs 30%; P < .001) and CLTI (75% vs 71%; P < .001) compared with men (Table I). The women were less likely to have undergone LEB to the tibial/peroneal arteries (35% vs 44%; P < .001) or a single segment vein graft (47% vs 54%; P < .001). Despite the shorter operative times and less blood loss, the women had longer hospital stays (mean, 6.4 ± 11.3 days vs 5.8 ± 8.2 days; P < .001) and greater rates of major adverse cardiovascular events (4.2% vs 3.7%; P < .001) compared with the men (Table II). At discharge, the women were less likely to be independently ambulatory (35% vs 42%; P < .001) and less likely to be prescribed a statin (78% vs 82%; P < .001; Table II). The overall 2-year cumulative incidence of major adverse limb events (MALE; major amputation, graft revision/thrombectomy, occlusion) was 47.7% (95% confidence interval, 46.6%-48.7%). In a hierarchical multivariable model that included age, diabetes, race, renal failure, previous bypass, CLTI, and tibial/peroneal distal target, female gender was significantly and independently associated with MALE (hazard ratio, 1.17; 95% confidence interval, 1.11-1.24; Figs 1 and 2). Women undergoing LEB for PAD have more advanced disease at surgery, worse cardiovascular outcomes, and a greater risk of MALE compared with men, despite having more proximal graft targets and shorter operative times. A better understanding of gender differences is critical for improving outcomes and providing optimal care for women with PAD.Table IBaseline patient characteristicsCharacteristicMale (n = 24,301)Female (n = 11,988)P valueAge, years66.3 ± 10.667.7 ± 11.7<.001Black race3729 (15)2539 (21)<.001Current smoker10,219 (42)4445 (37)<.001Diabetes12,325 (51)6349 (53)<.001Hypertension21,427 (88)10,736 (90)<.001Coronary artery disease11,101 (46)4553 (38)<.001Preoperative statin18,087 (75)8545 (72)<.001Preoperative ABI <0.45362 (30)3395 (38)<.001Critical limb ischemia17,014 (71)8932 (75)<.001ABI, Ankle brachial index.Data presented as mean ± standard deviation or number (%). Open table in a new tab Table IIOperative characteristics and short-term outcomesVariableMale (n = 24,301)Female (n = 11,988)P valueOperative characteristics<.001 Tibial/peroneal graft recipient10,610 (44)4202 (35) Single segment vein graft13,202 (54)5668 (47) Operative time, minutes241 ± 113233 ± 111Short-term outcomes<.001 Postoperative LOS, days5.8 ± 8.26.4 ± 11.3 Death, MI, or stroke before DC894 (3.7)507 (4.2) Major adverse limb event before DC1371 (5.7)826 (6.9) Independently ambulatory at DC10,070 (42)4153 (35) Statin on DC19,858 (82)9307 (78)LOS, Length of stay; MI, myocardial infarction.Data presented as number (%) or mean ± standard deviation. Open table in a new tab Fig 2Competing risks regression for major adverse limb events (MALE) stratified by gender.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Blood consumption in total arterial coronary artery bypass grafting

BackgroundAccumulating evidence consistently demonstrates that blood transfusion in cardiac surgery is related to decreased short- and long-term survival. We aimed to evaluate periprocedural blood loss and transfusion rates in elective, isolated total arterial coronary artery bypass grafting (CABG) using exclusively skeletonized bilateral internal mammary arteries (IMAs).MethodsWe identified 1011 consecutive patients with coronary artery disease who underwent CABG between 1/2007 and 12/2014. Of them, 595 patients who presented preoperative hemoglobin levels >9md/dl and underwent elective, isolated CABG for multi-vessel coronary artery disease were included in the study population. 419 patients (70.4%) received total arterial CABG using skeletonized bilateral IMAs, in 176 patients (29.6%) mixed CABG (single IMA & saphenous vein) was performed. Propensity score adjustment using 16 variables was applied to control for treatment effect.ResultsIn patients undergoing total arterial CABG, heterologous blood transfusion could be avoided in 87.8% of all cases. Propensity score adjusted results showed a significantly lower incidence of erythrocyte concentrate transfusion in patients undergoing total arterial CABG compared to mixed CABG (odds ratio 2.74, 95% confidence interval 1.38–5.43, P = 0.004). There were no statistically significant differences in the rates of thrombocyte concentrate (P = 0.39) and fresh frozen plasma transfusions (P = 0.07).ConclusionsIn this study, patients who underwent elective, isolated total arterial CABG using exclusively skeletonized bilateral IMAs showed reduced transfusion rates of erythrocyte concentrates compared to mixed CABG using a combination of single IMA and saphenous vein grafts. No evidence for a higher incidence of complications was found with a total arterial approach.

Comparison of blood flow in single and sequential vein grafts during off-pump coronary artery bypass.

The use of sequential anastomoses in coronary artery bypass grafting (CABG) is still controversial. This study aimed to evaluate the mean blood flow (MBF) rate and pulsatility index (PI) of single and sequential saphenous vein grafts to the posterior descending artery (PDA) in the same patient during off-pump CABG (OPCABG). Sequential saphenous vein grafts were used to bypass the diagonal artery (Diagonal) (side-by-side), obtuse marginal artery (OM) (side-by-side) and PDA (end-to-side). The anastomoses of Diagonal and OM were temporarily occluded with bulldog clamps, making the sequential graft a "single" graft to PDA. The MBF and PI of this "single" graft to PDA were measured with transit-time flow measurement (TTFM). Then the bulldog clamps were removed and the MBF and PI of sequential graft to PDA were measured again and compared to those of the "single" graft in the same patient. Anastomoses were evaluated with coronary CT angiogram at 6 months. A total of 128 patients with triple vessel disease were enrolled (96 men; mean age, 66.0±8.0 years; range, 54-80 years). The MBF of the "single" vs. sequential graft to PDA was 20.6±9.1 vs. 21.4±10.1 mL/min (P=0.472). The PI of 'single graft' vs. sequential graft to PDA was 1.7±0.6 vs. 1.7±0.5 (P=0.941). The patency of all grafts was good in all patients after 6 months of follow-up. There were no hydrodynamic differences between single and sequential grafts to PDA in OPCABG.

Correction: Are two internal thoracic grafts better than one in patients with chronic obstructive lung disease? Analysis of 387 cases between 1996-2011.

[This corrects the article DOI: 10.1371/journal.pone.0201227.].

OC26 EXTERNAL STENTING OF VEIN GRAFTS IN OFF PUMP CORONARY BYPASS SURGERY AND SEQUENTIAL GRAFTING: INTERMEDIATE RESULTS FROM A SINGLE CENTER PROSPECTIVE STUDY

Abstract Background: External stenting of vein grafts has been shown to reduce graft disease by mitigating intimal hyperplasia and improving flow pattern in on-pump single vein graft context. Aim of study is to evaluate usability and clinical outcome of external stenting also in patients undergoing beating-heart sequential grafting receiving multiple external stents per patient. Methods: Thirty patients undergoing CABG had the venous grafts supported with VEST (VascularGraftSolutions, Israel) and were prospectively followed-up via phone call and/or visit every 6 months. Major Adverse Cardiac and Cerebrovascular Events (MACCE) were recorded. Planned follow-up is 5 years. Results: Mean age was 69.0, 86.7% were males, mean Euroscore and ejection fraction were 5.40% ± 4.92% and 56.8% ± 7.4. Veins were harvested in an open manner. Average number of grafts per patient was 3.2. Each patient had either single vein graft (n = 20), or sequential vein grafts (n = 10) supported with VEST. All patients were discharged alive from the hospital after surgery. One patient experienced transient ischemic attack during in-hospital stay and fully recovered before discharge. Follow up was complete for all patients, mean follow time of 16 months (range 1–31 months). During the follow up period, MACCE rate were 0% and no additional adverse events were reported. CT angiography performed to patients arriving at 1 year follow-up confirmed all grafts were patent. Conclusions: External stenting of saphenous vein grafts is technically feasible in off pump CABG procedures and sequential grafting. Intermediate follow up of up to 30 months suggest that it's safe and not associated with major clinical events.

How I deploy arterial grafts

There are currently around one million coronary artery bypass graft (CABG) procedures performed worldwide annually and despite two decades of evidence to support the use of a second arterial graft, if not total arterial grafting, the stark reality is that in contemporary practice 80% of all grafts used for CABG are saphenous vein grafts (SVG). The following description of how I deploy arterial grafts has been developed over more than two decades of clinical practice and largely self-taught by a process of "trial and error" and most importantly dictated by "ease of use" rather than personal robust angiographic data of long-term patency (although there is other such existing data in the literature for some of these techniques). The fact that there are numerous potential variants of deploying multiple arterial grafts underpins the fact that there is no single operation that is ideal in every patient-it is not a case of "one size fits all" as would be the situation for the use of a single internal thoracic artery (ITA) and supplemental vein grafts.

OP-162 - Propensity -Matched Comparison of Bilateral İnternal Mammary Arteries Only Versus Single Mammary Artery and Supplemental Vein Grafts for Left-sided Target Vessels: A 20- Year Follow-Up Study

OP-162 - Propensity -Matched Comparison of Bilateral İnternal Mammary Arteries Only Versus Single Mammary Artery and Supplemental Vein Grafts for Left-sided Target Vessels: A 20- Year Follow-Up Study

Late Survival of Left Internal Mammary Artery-Radial Artery-Y Graft Compared to Single Internal Mammary Artery and Saphenous Vein Grafts in Coronary Bypass Surgery

Late Survival of Left Internal Mammary Artery-Radial Artery-Y Graft Compared to Single Internal Mammary Artery and Saphenous Vein Grafts in Coronary Bypass Surgery

Results of Infrainguinal Bypass with a Composite Graft Combining Polytetrafluoroethylene and Vein Graft in Absence of Appropriate Saphenous Vein Graft.

PurposeUse of a composite graft combining a polytetrafluoroethylene graft with an autogenous vein is an option for limb salvage in the absence of an adequate single segment vein graft. We aimed to investigate the results of infrainguinal bypass with a composite graft.Materials and MethodsWe retrospectively reviewed 11 infrainguinal arterial bypasses on 11 limbs which underwent surgery from March 2012 to November 2016.ResultsCritical limb ischemia was common (63.6%) indication of bypass surgery and most (90.9%) of the patients had history of failed previous treatment including endovascular treatment (36.4%) and bypass surgery (72.7%). At the 2 years after graft implantations, primary patency and amputation-free survival of below-knee bypasses using composite graft were 73% and 76%, respectively.ConclusionInfrainguinal arterial bypasses with composite graft had an acceptable patency. In patients without other alternative conduits for revascularization, bypass with a composite graft can be an option.

The no-touch saphenous vein graft in elderly coronary bypass patients with multiple comorbidities is a promising conduit to substitute the left internal thoracic artery

ObjectivesWe investigated the patency rates of no-touch saphenous vein grafts anastomosed to the left anterior descending artery compared with the left internal thoracic artery. Further, we compared the patency of no-touch vein grafts to the left anterior descending artery with the patency of no-touch vein grafts to other coronary arteries. MethodsOf 2635 consecutive patients undergoing coronary artery bypass grafting between 2003 and 2008, 168 (6.3%) were given at least a saphenous vein graft to the left anterior descending artery to avoid harvesting complications in high-risk patients or in response to a left internal thoracic artery injury. A total of 97 patients were consecutively included after informed consent. A clinical examination and computed tomography angiography were performed on 91 patients at a mean of 6 (4-9) years. ResultsThe mean age of patients was 75.6 ± 8.5 years. Postoperatively, 88.7% of patients (86/97) were free of angina. The 91 examined patients had 163 grafts with 286 distal anastomoses. Crude patency, according to distal anastomoses, was 94.4% (270/286). The patency of single versus sequential no-touch vein grafts to the left anterior descending artery was 98% (50/51) versus 92.5% (37/40). The total patency rate was 95.6% (87/91), similar to the reported patency rate for the left internal thoracic artery. The no-touch grafts to the left anterior descending artery versus other coronaries had a patency of 95.6% (87/91) versus 93.8% (183/195), a high similarity confirmed by an equivalence analysis. ConclusionsIn elderly coronary bypass patients with multiple comorbidities, a no-touch saphenous vein graft is a promising substitute for the left internal thoracic artery.

The Use of Bilateral Internal Mammary Arteries for Coronary Revascularization in Patients with COPD: Is It a Good Idea?

The use of bilateral internal mammary arteries (BIMA) is limited worldwide, especially in patients with chronic obstructive pulmonary disease (COPD). Thus, we assessed the safety of the use of BIMA in COPD patients. From cohorts of 8846 patients operated on at our center for primary isolated multi-vessel coronary bypass operations between 2002 and 2012, we studied two propensity-matched groups of patients with COPD who received either single internal mammary artery and saphenous vein grafts (SIMA group: 137 patients) or exclusively BIMA (BIMA group: 137 patients). Preoperative data were similar regarding age (63.59 ± 10.62 versus 65.55 ± 9.61 years; P = .10), body mass index (BMI) (28.6 ± 4.71 versus 28.42 ± 3.86 kg/m2; P = .72), diabetes mellitus (32% versus 27%; P = .08), EuroSCORE (4.34 ± 2.23 versus 4.8 ± 2.52; P = .09) and ejection fraction (58.7 ± 13.08% versus 60.29 ± 14.13%; P = .32). No significant differences were noticed between the two groups regarding the number of peripheral anastomoses (3.07 ± 0.77 versus 3.06 ± 0.85; P = .90), total operation time (192.17 ± 43.06 versus 200.63 ± 39.24 min; P = .08), postoperative stroke (0.7% versus 0%; P = .29), myocardial infarction (2.92% versus 3.6%; P = .81), reintubation (2.9% versus 4.4%; P = .66), reexploration (0.7% versus 2.2%; P = .32), deep sternal wound infection (2.9% versus 3.6%; P = .81) and 30-day mortality (2.2% versus 2.9%; P = .77). However, postoperative blood loss (726.1 ± 468.35 versus 907 ± 890.58 mL; P = .03) was higher in the BIMA group. COPD patients can benefit from coronary artery revascularization with BIMA; however, postoperative blood loss can be higher using this technique.

Standard Surgical Skin Markers Should Be Avoided for Intraoperative Vein Graft Marking during Cardiac and Peripheral Bypass Operations.

One cause of early graft failure following coronary and peripheral vein grafting is kinking or mechanical twisting of the conduit. The blind tunneling necessitated in peripheral bypasses can lead to this consequence (1). In coronary artery bypass grafting (CABG), grafts to the posterior branches of the right or circumflex coronary arteries are placed to the back of the heart and are generally the longest aortocoronary grafts. These grafts are particularly prone to twisting and kinking. Additionally, single vein grafts to two or more coronary branches (“sequential vein grafts”) present special challenges with respect to maintenance of proper alignment (2, 3). The coronary vein graft failure rate at 1 year in the PRoject of Ex vivo Vein graft ENgineering via Transfection IV (PREVENT IV) cohort was 25%, suggesting that early graft failure is a significant problem (4, 5). The incidence of vein graft failure due to twisting or kinking is not well studied, though some reports estimate that obstructing lesions, including but not limited to twisting or kinking, account for 15–25% of early (<1 year) graft failures (6–8). Preparation and preservation techniques have advanced the field of solid organ allotransplantation, but vein graft failure rates suggest room for improvement in the handling of saphenous vein (SV) harvested for autotransplantation. Interventions for ex vivo graft treatment, including appropriate choice of preservation solution and minimization of manual pressure distension via chemical vasodilators such as papaverine, have been proposed (9–12). Additionally, the “no-touch” technique has emerged as a method of minimizing detrimental handling of graft during harvest with adventitial preservation (4, 13–15). Marking of the SV graft using a surgical skin marker in an “off-label” fashion represents another such preparation technique and is the most commonly employed method of preventing graft torsion (16). This marking allows for the maintenance of continuous alignment along the length of the vein in the same longitudinal plane. These lines provide a visible guide for surgeons to use during conduit routing and tunneling to avoid mechanical obstructions related to vein alignment (17). While operating rooms have adapted less traumatic methods of vein harvest, preservation, and distension, surgical skin marker use remains ubiquitous as the primary method to maintain graft orientation. The use of surgical skin markers during graft preparation is toxic to the tissue and impairs physiologic function (16). We argue that the data support avoidance of standard surgical skin markers for marking on vascular tissue; We further contend that brilliant blue FCF (for coloring food) may represent a viable alternative dye for intraoperative graft marking.

Total Arterial Revascularization

Total arterial revascularization (TAR) has been shown to improve both short- and long-term mortality in coronary artery bypass grafting patients when compared with a single internal thoracic artery (ITA) and vein grafts (Buxton, 2014; Zacharias, 2009). This benefit has been demonstrated in both younger and older (>70 years) patients (Habib, 2012). TAR typically uses bilateral ITA grafts, the left as a pedicled graft and the right either pedicled, free or as a Y graft. Skeletonization of the ITA grafts increases available length, decreases devascularization of the chest wall and may decrease sternal wound infection rates. Radial artery grafts are a very versatile conduit also commonly used in TAR. They are long enough to reach any target as an aortocoronary graft; alternatively, they lend themselves well to Y grafts, T grafts and sequential grafts.

Genetic variants associated with vein graft stenosis after coronary artery bypass grafting.

Vein graft stenosis after coronary artery bypass grafting (CABG) is common. Identifying genes associated with vein graft stenosis after CABG could reveal novel mechanisms of disease and discriminate patients at risk for graft failure. We hypothesized that genome-wide association would identify these genes. We performed a genome-wide association study on a subset of patients presenting for cardiac catheterization for concern of ischemic heart disease, who also underwent CABG and subsequent coronary angiography after CABG for clinical indications (n = 521). Cases were defined as individuals with ≥50% stenosis in any vein graft on any cardiac catheterization, and controls were defined as those who did not have vein graft stenosis on any subsequent cardiac catheterization. Multivariable logistic regression was used to assess the association between single nucleotide polymorphisms (SNPs) and vein graft stenosis. Sixty-nine percent of patients had vein graft failure after CABG. Seven SNPs were significantly associated with vein graft stenosis, including intronic SNPs in the genes PALLD (Rs6854137, P = 3.77 × 10(-6)), ARID1B (Rs184074, P = 5.97 × 10(-6)), and TMEM123 (Rs11225247, P = 8.25 × 10(-6)); and intergenic SNPs near the genes ABCA13 (Rs10232860, P = 4.54 × 10(-6)), RMI2 (Rs9921338, P = 6.15 × 10(-6)), PRM2 (Rs7198849, P = 7.27 × 10(-6)), and TNFSF4 (Rs17346536, P = 9.33 × 10(-6)). We have identified novel genetic variants that may predispose to risk of vein graft failure after CABG, many within biologically plausible pathways. These polymorphisms merit further investigation, as they could assist in stratifying patients with multi-vessel coronary artery disease, which could lead to alterations in management and revascularization strategy.

A rare cause of cardiac decompensation in a patient with left ventricular hypertrophy

Amyloidosis, a disease characterized by the deposition of extracellular proteinaceous material known as amyloid, commonly involves more than one organ system. When cardiac amyloidosis is the isolated or even the predominant manifestation of undiagnosed multiorgan amyloidosis, diagnose is often not confirmed until the late course of disease [1]. The different types of amyloidosis, e.g., AL, senile, familial or secondary amyloidosis, progress at different speeds, but if cardiac amyloidosis is present, the prognosis is determined by cardiac symptoms and complications [1, 2]. A 72-year-old woman was admitted with progressive dyspnoea on exertion during the last month (NYHA class III), unspecific chest discomfort and recurrent syncope (twice). Her previous history included cardiac surgery in 2005 with bioprosthetic aortic valve replacement, mitral valve repair, and aortocoronary bypass grafting (LIMA bypass to the LAD and single vein graft to the right coronary artery). The electrocardiogram documented bradycardic atrial fibrillation about 50/min, lost R-wave in V1–V4 with persistent ST-elevation in V1–V3 and T-wave inversion in I, II, III, aVF as well as V5–V6. Echocardiography confirmed normal aortic valve prosthesis and a mild regurgitation of the reconstructed mitral valve with adequate mitral valve opening area. However, a remarkable concentric left ventricular hypertrophy was detected (left ventricular mass index, 181 g/m; relative wall thickness, 0.8). The myocardial texture showed a striking ‘‘speckled’’ appearance involving both papillary muscles (Fig. 1a, b). Systolic and diastolic function was impaired in both the left and the right ventricle: The left ventricular ejection fraction (LV-EF 40 %) and peak systolic strain were significantly impaired. Right ventricular function as measured by tricuspid annular plane systolic excursion (TAPSE: 8 mm) was reduced. Echocardiographic examination of diastolic function pointed to elevated LV-enddiastolic pressures under the circumstances of atrial fibrillation: Emax. 1.8, deceleration time 144 ms, E/Em at lateral mitral annulus 25.9, E/Em at septal mitral annulus 53.3. An inconspicuous pericardium, the lack of a breathdependent flow pattern of the mitralor tricuspid valve inflow and higher lateral Em (7 cm/s) than septal Em (3 cm/s) made the diagnosis of constrictive pericarditis unlikely. For further tissue characterization, we performed cardiac magnetic resonance imaging (CMR) including late gadolinium enhancement (LGE). CMR confirmed left ventricular hypertrophy (Fig. 1c), atrial enlargement, reduced left ventricular ejection fraction and demonstrated bilateral pleural effusion. No focal or generalized edema, but increased global relative enhancement was present. Furthermore, LGE demonstrated a diffuse enhancement (Fig. 1d). It was impossible to perfectly null the left Electronic supplementary material The online version of this article (doi:10.1007/s00392-012-0478-5) contains supplementary material, which is available to authorized users.

Syncope: a rare manifestation of a common condition

A previously active, fi t, well 71-year-old man, presented to our cardiology department in January, 2011, with a recent history of syncope. This occurred suddenly on two separate occasions, with rapid recovery after a few seconds, but resulting in injury. There were no associated symptoms. Both events occurred after non-strenuous exertion, with one or two further episodes of pre-syncope while at rest. A working diagnosis of arrhythmic cardiogenic syncope was made. He had no exertional symptoms or additional risk factors for coronary disease. He took no medications. ECG corrected QT interval, echocardiography, and tilt table test were normal. A 24 h ambulatory ECG showed normal rhythm. Exercise treadmill testing was stopped at 7 min because of fatigue. There were no ECG changes and the target heart rate (220 minus age beats per min) was achieved. Nuclear myocardial perfusion scanning did not show any evidence of myocardial ischaemia. Since the most likely diagnosis was syncope caused by cardiac arrhythmia, arrangements were made for an implantable cardiac loop recording device (ILR) (Reveal, Medtronic, Minneapolis, USA). 1 month later our patient was urgently admitted to the cardiology department after experiencing an episode of pre-syncope. Interrogation of the loop recorder data (fi gure A) showed non sustained ventricular fi brillation preceded by ST segment depression. This fi nding raised the possibility of silent ischaemia triggering arrhythmia. Urgent coronary angiography showed clinically signifi cant stenosis in the left anterior descending (LAD) artery (fi gure B; see also appendix), and inpatient surgical revascularisation with a single vein graft to the LAD was undertaken without complication. 8 months after surgery the patient was well, taking aspirin, a β-blocker, and a