Vein Graft Research Articles

Infrapopliteal Bypass In Patients On Dialysis: Patency And Survival.

Portugal has one of the highest prevalence of patients on a regular dialysis program. This population has a higher incidence of peripheral arterial disease with higher rates of postoperative morbidity and mortality. Our goal was to compare outcomes between dialysis and non-dialysis patients with chronic limb threatening ischemia (CLTI) submitted to infrapopliteal bypass. A retrospective single-center study of infrapopliteal bypass for CLTI was performed between 2012 and 2019. Patients were divided in two groups based on dialysis status (group 1 incorporated patients on dialysis). Primary end point was 1-year freedom from CLTI. Secondary end points were limb-salvage, survival and primary (PP) and tertiary patency (TP) rates at 3 years of follow-up. A total of 352 infrapopliteal bypasses were performed in 310 patients with CLTI. Fourteen percent of the revascularizations were performed on dialysis patients (48/352). Median age was 73 years (interquartile range - IQR 15) and 74% (259/352) were male. Median follow-up was 26 months (IQR 42). Overall, 92% (325/352) had tissue loss and 44% (154/352) had some degree of infection. The majority of revascularization procedures were performed with vein grafts (61%, 214/352). The 30-day mortality was 4% (11/310), with no difference between groups (p = 0.627). Kaplan-Meier analysis showed no difference between groups regarding freedom from CLTI (76% vs. 79%; HR 0.96, CI 0.65-1.44, p=0.857), limb-salvage (70% vs. 82%; HR 1.40, CI 0.71-2.78, p=0.327) and survival (62% vs. 64%; HR 1.08, CI 0.60-1.94, p=0.799). PP rates were 39% in group 1 and 64% in group 2 (HR 1.71, CI 1.05-2.79, p=0.030). TP rates were not different between groups (57% and 78%; HR 1.79, CI 0.92-3.47, p=0.082). Infrapopliteal bypass for CLTI, on dialysis patients, resulted in lower PP rates. No differences were observed in freedom from CLTI, TP, limb salvage and survival.

Amputated Digit Replantations: Critical Digit Ischemia Timing, Temperature, and Other Predictors of Survival.

A common consideration for replantation success is the ischemia time following injury and the preservation temperature. A classic principle within the hand surgery community describes 12 hours of warm ischemia and 24 hours of cold ischemia as the upper limits for digit replantation; however, these limits are largely anecdotal and based on older studies. We aimed to compare survival data from the large body of literature to aid surgeons and all those involved in the replantation process in hopes of optimizing success rates. The PubMed database was queried on April 4th, 2023, for articles that included data on digit replantation survival in terms of temperature of preservation and ischemia time. All primary outcomes were analyzed with the Mantel-Haenszel method within a random effects model. Secondary outcomes were pooled and analyzed using the chi-square statistic. Statistical analysis and forest plot generation were completed with RevMan 5.4 software with odds ratios calculated within a 95% confidence interval. Our meta-analysis identified that digits preserved in cold ischemia for over 12 hours had significantly higher odds of replantation success than the amputated digits replanted with 0-12 hours of warm ischemia time ( P ≤ 0.05). The odds of survival in the early (0-6 hours) replantation group were around 40% greater than the later (6-12 hours) replantation group ( P ≤ 0.05). Secondary outcomes that were associated with higher survival rates included a clean-cut amputation, increased venous and arterial anastomosis, a repair that did not require a vein graft, and replants performed in nonsmokers ( P ≤ 0.05). Overall, these findings suggest that when predicting digit replantation success, time is of the essence when the digit has yet to be preserved in a cold environment. This benefit, however, is almost completely diminished when the amputated digit is appropriately maintained in a cold environment soon after injury. In conclusion, our results suggest that there is potential for broadening the ischemia time limits for digit replant survival outlined in the literature, particularly for digits that have been stored correctly in cold ischemia.

Alternative vein bypass in octogenarians with chronic limb-threatening ischaemia.

Octogenarians are regarded as one of the frailest patient groups among the chronic limb-threatening ischaemia population with high perioperative morbidity and mortality rates. As a result, alternative vein bypass surgery in the absence of sufficient great saphenous vein is often not considered as a potential treatment option. The aim of this study was to compare the results of octogenarians undergoing alternative vein bypass surgery due to chronic limb-threatening ischaemia to younger patients. A single-centre retrospective analysis of patients undergoing bypass surgery for chronic limb-threatening ischaemia with alternative autologous vein grafts between 1997 and 2018 was performed. Patients aged over 80 years were compared with those under 80 years. Graft patency rates were assessed and a risk factor analysis for limb loss was performed. In total, 592 patients underwent bypass surgery during the study interval. Twenty-one per cent (n = 126) of patients were 80 years or older. At 4 years, primary, primary-assisted and secondary patency as well as limb salvage rates were not significantly different between the two groups (46% versus 50%, 60% versus 66%, 69% versus 72%, 72% versus 77%, for octogenarians versus non-octogenarians respectively). Major amputations were performed in 27 (21%) octogenarians and 91 (20%) non-octogenarians (P = 0.190). No higher 30-day and long-term mortality rates nor morbidity rates were detected in the octogenarian group with a median follow-up time of 27 (interquartile range 12-56) months. Minor amputation, the reason for alternative vein grafts, as well as the profunda femoris artery as proximal origin of the bypass were risk factors for limb loss in the postoperative course. Alternative vein bypass surgery in octogenarians with chronic limb-threatening ischaemia is safe and effective in terms of patency rates, limb salvage and survival compared with younger patients in the absence of sufficient great saphenous vein. Age alone should not be a deterrent from performing bypass surgery.

Endovascular Transvenous versus Open Femoropopliteal Bypass.

Background and Objectives: Lower extremity arterial disease is one of the most prevalent manifestations of atherosclerosis. The results from numerous studies regarding the best revascularization method of an occluded superficial femoral artery have been conflicting. The aim of this study was to compare the patency of transvenous endovascular with open femoropopliteal bypass, both with vein and prosthetic grafts. To our knowledge, a direct patency comparison between transvenous endovascular and open femoropopliteal bypass has not been published. This could help elucidate which method is preferable and in which cases. Materials and Methods: Patients with complex TASC-C and D SFA lesions were offered endovascular transvenous or open bypass. A total of 384 consecutive patients with PAD requiring surgical treatment were evaluated for inclusion in this study. Three-year follow-up data were collected for 52 endovascular procedures, 80 prosthetic grafts, and 44 venous bypass surgeries. Bypass patency was investigated by Duplex US every 6 months. Kaplan-Meier plots were used to analyze primary, primary-assisted, and secondary patency for endovascular transvenous, autovenous, and prosthetic bypasses. Results: Primary, primary-assisted, and secondary patency in venous group at 3 years was 70.5%, 77.3%, and 77.3%, respectively. In the endovascular transvenous group, primary, primary-assisted, and secondary patency at 3 years was 46.2%, 69.2%, and 76.9%, respectively. The lowest patency rates at 3 years were noted in the prosthetic graft group with 22.5% primary, 26.6% primary-assisted, and 28.2% secondary patency. Conclusions: The saphenous vein is the best graft to perform in above-the-knee femoropopliteal bypass. Transvenous endovascular bypass is a viable option with comparable primary-assisted and secondary patency. Primary patency is substantially lower for endovascular transvenous compared to venous bypass. Patients treated with endovascular transvenous bypass will require a significant number of secondary procedures to provide optimal patency. Prosthetic grafts should only be used if no other option for bypass is available.

Rationale and design of a single-center randomized trial to compare the graft patency between the radial artery and the no-touch saphenous vein in coronary artery bypass grafting surgery (GRAFT-CAB Study)

Previous studies suggested only the radial artery and the No-touch (NT) technique were effective in reducing graft occlusion after coronary artery bypass grafting (CABG) surgery. However, there is no randomized trial comparing these 2 graft conduits. The optimum second conduit for CABG remains undetermined. This study is a prospective, single-center randomized clinical trial, aiming to compare the graft patency between the radial artery and the NT vein graft. All patients undergoing isolated CABG with left internal mammary artery (LIMA) plus at least 2 additional grafts will be considered eligible. About 774 cases (516 in the radial artery group and 258 in the NT vein group) will be enrolled in over 1 to 2 years. Participants will be randomized and allocated to two bypass strategies: the LIMA plus 1 radial artery and 1 conventional vein graft, or the LIMA plus 2 NT vein grafts. The primary outcome is graft occlusion at 1 year after CABG evaluated by CT angiography. The secondary outcomes include graft occlusion at 3 and 5 years and major adverse cardiac or cerebrovascular events at 1, 3, and 5 years follow-ups. This study will define whether or not the NT vein has a lower graft occlusion rate than the radial artery in short and mid-term follow-ups, and provide new evidence for the second conduit choice in CABG surgery. ClinicalTrials.gov NCT06014047. Registered on October 15th, 2023.

Extracranial-Intracranial Microsurgical Bypass Using a Y-Shaped Vein Graft From the Hand

While extracranial-intracranial (EC-IC) bypass is commonly performed by neurosurgeons with specific expertise in cerebrovascular surgery, they can also be performed together with microvascular plastic surgeons. At our institution, some EC-IC bypass cases have evolved to be performed by neurosurgeons and plastic surgeons in a combined approach. Given the plastic surgeons’ expertise and volume of experience in performing microvascular surgery, their skills are utilized in performing the donor vessel dissection as well as the bypass itself. This paper outlines a Canadian perspective on collaboration between plastic surgeons and neurosurgeons in performing EC-IC bypass along with a case report illustrating the use of a dorsal hand Y-shaped vein graft for EC-IC bypass, which has not been described in the literature to date.

Relationship between uric acid to albumin ratio and saphenous vein graft disease in patients with coronary artery bypass graft.

Saphenous vein graft disease (SVGD) remains a challenging issue for patients with coronary artery bypass grafting (CABG). It is associated with poor outcomes and atherosclerosis is the major cause of SVGD. Uric acid to albumin ratio (UAR) is a new marker which associated with cardiovascular mortality. We aim to evaluate the relationship between the SVGD and UAR. We retrospectively enrolled 237 patients who underwent elective coronary angiography (CAG) for stable angina or positive stress test results >1 year after CABG. The patients were divided into two groups; SVGD (+) patients and SVGD (-) patients. The SVGD was defined as presence of at least 50% stenosis in at least 1 SVG. UAR were significantly higher in the SVGD (+) group ( P < 0.001). Similarly, Hs-CRP, white blood cell count, and neutrophil count were significantly higher in SVGD (+) group ( P = 0.03, P = 0.027 P = 0.01, respectively). In multivariate logistic regression analysis, time interval after CABG [OR = 1.161, 95% confidence interval (CI) 1.078-1.250; P < 0.001] and UAR (OR = 2.691, 95% CI 1.121-6.459; P < 0.001) were found to be independent predictors of SVGD. Our results suggested that UAR could be a simple and available marker to predict SVGD in patients with CABG who underwent elective percutaneous coronary intervention.

Decellularized porcine vena cava grafts are fully repopulated after orthotopic implantation

Tissue-engineered organs, based on native extracellular matrix (ECM) scaffolds, could be a game changer in regenerative medicine applications. Decellularization technology provides such scaffolds with organ-typic ECM composition and architecture. Despite limitations such as the requirement of huge cell numbers and finding the optimal route of entry, recellularized scaffolds provide alternative grafts for transplantation. In this study we assessed whether decellularized scaffolds, when implanted, are repopulated from the adjacent tissue. Since the vasculature plays an important role in tissue functionality, our main focus was to evaluate in situ repopulation of decellularized veins in a pig model. For this, porcine inferior vena cava grafts were decellularized and orthotopically implanted in recipient pigs (n = 12). To evaluate possible immune responses to the scaffolds and to assess potential thrombus formation, cellular allogeneic vena cava grafts were transplanted in control pigs (n = 8). Within 28 days after implantation, the decellularized veins were fully recellularized with endothelial cells and smooth muscle cells. Quantitative histological analysis showed a comparable amount of smooth muscle actin in the repopulated decellularized grafts similar to the native IVC. Lymphocyte infiltrates representing signs of graft rejection were not detected in the pigs, as opposed to the control group that received the allogeneic grafts. The decellularized grafts provoked a higher incidence of thrombosis in comparison with allogeneic grafts (33.3 vs. 12.5%). With this study, we show efficient in situ repopulation of decellularized vein grafts. These findings are insightful and promising to further explore the use of decellularized tissue without the need for full pre-transplant recellularization.Graphical abstract

Free Flaps in Patients with Advanced Arteriosclerosis of the Tibial Vessels: Mini Vein Graft to the Peroneal Artery.

Lower extremity reconstruction with free flaps in patients with only peroneal artery runoff remains a challenge. Here, we present a novel technique for reconstruction of medial defects in the distal leg using a medial approach to the peroneal artery and a short interposition vein graft anastomosed end to side to the peroneal artery. A retrospective, single-center study was performed including all patients who underwent lower extremity reconstruction with free flaps anastomosed to the peroneal artery using a mini vein graft from November 2020 to March 2022. The primary outcome measure was limb salvage. Secondary endpoints were flap survival and postoperative complications. Seven patients received lower extremity free flap reconstruction with a mini vein graft to the peroneal artery. Flap loss rate was 0%. Limb salvage was achieved in five patients (71%). At 6-month follow-up, all patients were ambulatory. One patient died 1 month after surgery due to heart failure. Mini vein graft to the peroneal artery allows reliable and safe free flap reconstruction of distal leg defects in patients with only peroneal artery runoff.

Controlled antegrade and retrograde subintimal tracking (CART) for recanalisation of chronic total occlusions.

Controlled antegrade and retrograde subintimal tracking (CART) is rarely performed in contemporary chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We aimed to analyse the indications, procedural characteristics, and outcomes of CART at a high-volume CTO programme. We included all patients undergoing a retrograde CTO PCI in which CART was performed at our institution between January 2019 and November 2023. The primary endpoint was technical success. Of 1,582 CTO PCI, the retrograde approach was performed in 603 procedures (38.1%), and CART was used in 45 cases (7.5%). The mean age was 69.1±10.3 years, 93.3% were male, and prior coronary artery bypass graft surgery was present in 68.9%. The most common target CTO vessel was the right coronary artery (48.9%). Anatomical complexity was high (Multicentre CTO Registry of Japan [J-CTO] score of 3.6±0.9). The most common collateral used for CART was a saphenous vein graft (62.2%). Advanced calcium modification was required in 15.6% of cases. CART was successful in 73.3%. Technical and procedural success was 82.2%. Coronary perforation was diagnosed in 4 subjects (8.9%), but only 1 patient (2.2%) suffered tamponade and required pericardiocentesis. No other in-hospital major adverse cardiac events were diagnosed. CART is a useful technique in selected, very complex CTOs tackled with the retrograde approach. Success rates were high, while complication rates were low, considering the high anatomical complexity and baseline patient risk.

D-62 | Use of retrograde access via saphenous vein graft versus collaterals for recanalization of coronary chronic total occlusions: a meta-analysis

D-62 | Use of retrograde access via saphenous vein graft versus collaterals for recanalization of coronary chronic total occlusions: a meta-analysis

Abstract 1152: Hydrodissection Facilitates Endoscopic Vein Harvesting Of The Great Saphenous Vein For Coronary Artery Bypass Grafting

Coronary Artery Disease is the primary cause of mortality in the United States (US), ranking as the third leading cause of death globally. Coronary Artery Bypass Grafting (CABG) with left internal mammary artery to the left anterior descending artery is the gold standard for CABG with a patency rate of 90% at 15 years. The great saphenous vein (GSV) harvested by endoscopic vein harvesting (EVH) is the second most common vascular conduit used for CABG in the US. This is despite the poor long-term patency of this conduit due to vein graft failure (VGF). VGF is the number one technical problem associated with CABG, with 15-year patency rates of only 30 to 50%. While the "no touch" harvesting technique avoids VGF, with 15-year patency rates of 86%, it is technically demanding and results in increased leg wound healing, and not widely used. With this in mind, we developed the Minimally Invasive No Touch (MINT) technique that incorporates the best features of EVH and no touch. This procedure employs hydro dissection, a process that utilizes fluid pressure to gently harvest the GSV with minimal trauma. This approach effectively addresses two significant issues associated with using the GSV in CABG, namely VGF resulting from impaired endothelial function and excessive trauma to the GSV during the extended learning curve needed to master EVH. To evaluate this, harvesting was conducted by a PA, with over 2,000 standard EVH procedures. Our preliminary studies looked to evaluate the quality of GSVs harvested from patients using 1) standard EVH, 2) “no touch” harvesting techniques or 3) the MINT harvesting procedure, focused on evaluating the quality of the vessels by measuring the endothelial nitric oxide synthase (eNOS) activity and nitric oxide (NO) bioavailability. eNOS activity assays across harvested GSVs revealed a 3.4-fold increase in NO generation across MINT harvested samples compared to EVH and “no touch” samples, respectively. This data suggests that the GSVs harvested by the MINT procedure result in a structurally intact vein with elevated eNOS activity and NO bioavailability consistent with a functionally intact endothelium. Additional studies are necessary to uncover the array of vascular benefits associated with MINT GSV harvesting for CABG procedures.

Successful Intraoperative Salvage of a Venous Congested Deep Inferior Epigastric Perforator Flap Using a Cross-thoracic Saphenous Vein Graft.

For autologous breast reconstruction using the deep inferior epigastric perforator flap, the internal mammary vessels are a common choice for recipient vessels. However, if these vessels are discovered to be inadequate, this may require the utilization of alternative vessels for successful salvage. Here, we demonstrate the use of a venous conduit for flap salvage in a patient undergoing bilateral deep inferior epigastric perforator flap breast reconstruction. Intraoperative venous congestion was identified on the left side. A contributing factor was an unresolvable size discrepancy between the deep inferior epigastric and the internal mammary venae comitantes. A saphenous vein graft can be used to drain the donor inferior epigastric vein to the contralateral internal mammary venae comitantes. In this discussion, adequate venous drainage was obtained with this approach, and the flap remained viable with good Doppler signals without further complications over a year postoperatively.

Successful salvage of upper extremity following severe crush injury associated with vascular compromise using a supra thin free anterolateral thigh flap

Traumatic injuries of the upper limbs can often result in serious and challenging wounds involving multiple compartments such as skin, bone, tendons and neurovascular structures. These type of injuries of the upper extremity pose several challenges to the plastic surgeon. The main difficulty is to provide a stable, long lasting and aesthetically acceptable coverage that enables joints excursion so that patient can return to work at the earliest. Here, we present a case of 45 years old gentlemen who sustained severe crush injury associated with avulsed radial and ulnar artery of left upper limb following road traffic accident. At presentation, there was no pin prick in his hand and hand was pale. At first surgery, hand was revascularized using a vein graft in radial artery and skin grafting was done over the forearm defect as a temporary cover. After 12 hours, when the viability of hand was reassured, the defect was covered with free supra thin anterolateral thigh (ALT) flap. Patient’s hand and flap both survived and he was discharged in a satisfactory condition.

Risk factors for post-operative portal vein stenosis in pediatric liver transplantation: a single center case-control study.

The incidence of post-transplant poral vein stenosis (PVS) is higher in pediatric liver transplantation, probably resulting from various portal vein (PV) reconstruction methods or other factors. 332 patients less than 12 years old when receiving liver transplantation (LT) were enrolled in this research. Portal vein reconstruction methods include anastomosis to the left side of the recipient PV trunk (type 1, n = 170), to the recipient left and right PV branch patch (type 2, n = 79), using vein graft interposition (type 3, n = 32), or end-to-end PV anastomosis (type 4, n = 50). The incidence of PVS was analyzed in terms to different PV reconstruction methods and other possible risk factors. PVS occurred in 35 (10.5%) patients. Of the 32 patients using vein graft, 20 patients received a cryopreserved vein graft, 11 (55%) developed PVS, while the remaining 12 patients received a fresh iliac vein for PV interposition and none of them developed PVS. 9 patients whose liver donor was under 12 years old developed PVS, with an incidence of 18.8%. Cryopreserved vein graft interposition and a liver donor under 12 are independent risk factors for PVS in pediatric LT.

Immediate lymphatic reconstruction: Lessons learned over eight years

Immediate lymphatic reconstruction (ILR) is recognized as a surgical approach used to reduce the risk of developing secondary lymphedema, and evidence demonstrating the efficacy of ILR is favorable. Our Lymphatic Center has become a centralized location offering ILR for the risk-reduction in breast cancer-related lymphedema (BCRL) in New England. Over the course of our experience, we made several modifications and adapted our approach to enhance the operative success of this procedure. These include advancements in our use of indocyanine green (ICG) imaging to identify baseline lymphatic anatomical variation, utilization of fluorescein isothiocyanate for lymphatic vessel visualization, application of the lymphosome concept to guide arm injection sites, verification of anastomotic patency (using ICG), localization of reconstruction to guide radiation therapy, incorporation of intraoperative tools to facilitate better anatomic visualization of the axilla, and addition of a lower extremity vein graft to mitigate venous-related complications. Collecting information from each surgery in a standardized manner, including intraoperative lymphatic channel measurements, and deploying clips for possible future radiation exposure, enables future studies on ILR patient outcomes. In this contribution, we aimed to share our institutional modifications with the surgical community to facilitate further adoption, conversation, and advancement of ILR for the risk-reduction in BCRL.

Selecting conduits for coronary artery bypass grafting: caution regarding the right internal mammary artery

This narrative review summarizes the angiographic and clinical outcome results of the most common coronary artery bypass grafting (CABG) conduits. The left internal mammary artery is the preferred first conduit to bypass the left anterior descending artery due to superior long-term survival and graft patency. Recent studies suggest the radial artery may be the preferred second conduit for the circumflex or right coronary artery territories, challenging the belief that the right internal mammary artery is the best choice. Despite their historical high failure rates, saphenous vein grafts continue to be widely used as secondary conduits. Several recent studies report suboptimal rates of right internal mammary artery graft failure, with clinical outcomes comparable to or worse than saphenous veins. The suboptimal rates of RIMA graft failure may be attributed to several factors such as improvements in vein graft failure rates, the use of in situ and non-left anterior descending artery grafting configurations, and skeletonized harvesting techniques. While observational studies favor multiple over single arterial grafting, randomized studies are needed for confirmation. The ongoing Randomized comparison of the clinical Outcome of single vs. Multiple Arterial grafts (ROMA) trial aims to determine if multiple arterial grafting reduces major adverse cardiovascular events and mortality and how secondary conduit selection influences these outcomes. Greater adoption of arterial grafting strategies is likely to come from high-quality evidence of benefit and safety from ongoing and future large pragmatic trials.

Do T2DM and Hyperglycaemia Affect the Expression Levels of the Regulating Enzymes of Cellular O-GlcNAcylation in Human Saphenous Vein Smooth Muscle Cells?

Protein O-GlcNAcylation, a dynamic and reversible glucose-dependent post-translational modification of serine and threonine residues on target proteins, has been proposed to promote vascular smooth muscle cell proliferation and migration events implicated in vein graft failure (VGF). Therefore, targeting the enzymes (glutamine fructose-6P amidotransferase (GFAT), O-GlcNAc transferase (OGT), and O-GlcNAcase (OGA)) that regulate cellular O-GlcNAcylation could offer therapeutic options to reduce neointimal hyperplasia and venous stenosis responsible for VGF. However, it is unclear how type 2 diabetes mellitus (T2DM) and hyperglycaemia affect the expression of these enzymes in human saphenous vein smooth muscle cells (HSVSMCs), a key cell type involved in the vascular dysfunction responsible for saphenous VGF. Therefore, our aim was to assess whether T2DM and hyperglycaemia affect GFAT, OGT, and OGA expression levels in HSVSMCs in vitro. Expression levels of GFAT, OGT, and OGA were determined in low-passage HSVSMCs from T2DM and non-T2DM patients, and in HSVSMCs treated for 48 h with hyperglycaemic (10 mM and 25 mM) glucose concentrations, by quantitative immunoblotting. Expression levels of OGT, OGA, and GFAT were not significantly different in HSVSMC lysates from T2DM patients versus non-T2DM controls. In addition, treatment with high glucose concentrations (10 mM and 25 mM) had no significant effect on the protein levels of these enzymes in HSVSMC lysates. From our findings, T2DM and hyperglycaemia do not significantly impact the expression levels of the O-GlcNAcylation-regulating enzymes OGT, OGA, and GFAT in HSVSMCs. This study provides a foundation for future studies to assess the role of O-GlcNAcylation on VGF in T2DM.

Influence of graft anastomosis and graft morphology on long-term patency of the saphenous vein after aortocoronary bypass.

Several factors are involved in the preservation of graft function after surgical myocardial revascularization. This follow-up study aimed to evaluate the effects of vein graft anastomosis and graft morphology on long-term graft patency a minimum of 10 years after aortocoronary bypass grafting.Setting and Cohorts. This was a sub-analysis of a study that enrolled patients after isolated bypass surgery at the University Hospital Ostrava in order to evaluate the long-term graft patency of the saphenous vein after endoscopic harvest, a minimum of 10 years after aortocoronary bypass grafting. Fifty angiograms, with a total of 90 grafts, after isolated myocardial revascularization were visualized using coronary computed tomography angiography, with 50% luminal stenosis or greater considered significant. The overall graft patency rate was 72.3%. The differences in occlusion rates between sequential and individual grafts were not statistically significant (P=0.156). All y-grafts were totally occluded. Graft and target artery diameters had a statistically significant influence on patency (P=1.000 and 0.381, respectively). Longer graft length and higher calcium scores were associated with statistically significant graft occlusion (P=0.033 and 0.005, respectively). Sequential grafts can be constructed safely, especially when the goal is complete myocardial revascularization.

Rapid progression of a coronary artery aneurysm caused by IgG4-related disease

BackgroundIgG4-related disease (IgG4-RD) is a recently recognized fibro-inflammatory disorder that can affect almost any organ. IgG4-RD has also been reported in coronary arteries as periarteritis. IgG4-related coronary periarteritis may cause coronary artery aneurysms, and IgG4-related coronary artery aneurysms (IGCAs) are life-threatening. We describe a case of a patient with IGCA that highlights the usefulness and limitations of various IGCA evaluation modalities and provides insight into disease pathophysiology. Case summaryA 60-year-old man with IgG4-RD diagnosed 2 years before and with IGCA at the proximal right coronary artery (RCA) on coronary angiography (CAG) 9 months prior to admission to the hospital presented with acute coronary syndrome. Emergent CAG revealed the rapid progression of IGCA at the RCA, an obstruction of the diagonal branch, and stenosis of the left anterior descending artery (LAD) and the high lateral branch (HL). The patient underwent percutaneous coronary intervention for the diagonal branch. The RCA aneurysm was resected and bypassed with a saphenous vein graft (SVG); coronary bypass grafting (left internal mammary artery to LAD and SVG to HL) was performed. Pathological findings showed inflammatory cell infiltration and disruption of the elastic plate. ConclusionIGCAs require careful follow-up with computed tomography scans for early detection of aneurysmal enlargement.