Venous Conduits Research Articles

Impact of preoperative quantitative flow ratio on long term coronary artery bypass grafts patency

Abstract Background Preoperative fractional flow reserve (FFR) in the native coronaries is a known predictor of long-term graft patency after coronary artery bypass graft (CABG) surgery. Quantitative flow ratio (QFR) is an angiogram-based functional assessment tool of coronary stenoses. Its predictive value of graft patency is unknown. Purpose To investigate the impact of preoperative QFR value on long-term graft patency after CABG. Methods In this retrospective multicentric study we included consecutive patients treated with CABG between 2011 and 2022, with available coronary angiogram before and at any timepoint after CABG. Three-vessel QFR analysis of the preoperative angiography has been performed. Follow-up angiography was checked for graft patency. Only vessels entered the analysis for which baseline QFR was appropriate and which has been bypassed. Results 400 patients were included with mean age of 67±8 years. They received on average 2.0±0.9 bypasses. 788 coronaries and bypasses were analyzed, among the latter 455 were arterial and 333 were veins. 37% were placed on LAD, 26% on RCA and 26% on the LCx. Stenosis severity at baseline was 73±22% with a QFR value of 0.68±0.30. Follow-up angiographies were performed at 34±29 months. Overall graft patency was 83%, with higher occlusion rate for venous than arterial conduits (27% vs 9%, respectively; HR 3.9 [2.60-5.88]). Occlusion rate was lower for grafts implanted on QFR significant native vessels versus those, placed on non-significant ones (13% vs 30%, respectively; HR 2.86 [1.93-4.26]). Benefit was maintained for both, arterial (5% vs 22%, respectively; HR 5.23 [2.78-10.38]), as well as for venous conduits (24% vs 39%; HR 2.09 [1.21-3.50]). Conclusion QFR significantly predicts graft patency irrespective of whether the graft is arterial or venous. However, patency of venous grafts is poor, even if implanted on functionally significant native stenotic coronaries.Graft patency

Long-Term Outcomes of a Japanese Prospective Multicenter Registry Using a Heparin-Bonded Expanded Polytetrafluoroethylene Graft for Above-the-Knee Femoropopliteal Bypasses.

Despite the widespread use of PROPATEN®, a bioactive heparin-bonded expanded polytetrafluoroethylene graft, in bypass surgery, there are only a few reports of long-term results. We evaluated the long-term results of PROPATEN®use for above-knee femoropopliteal bypass (AKFPB). After PROPATEN®-based AKFPB, patients were prospectively registered at 20 Japanese institutions between July 2014 and October 2017 to evaluate long-term results. During the median follow-up of 76 months (interquartile range 36-88 months) for 120 limbs (in 113 patients; mean [±SD] age 72.7±8.1 years; 66.7% male; ankle-brachial index [ABI] 0.45±0.27; lesion length 26.2±5.7 cm; chronic limb-threatening ischemia in 45 limbs), there were 8 major amputations; however, clinical improvement was sustained (mean [±SD] ABI 0.87±0.23) and the Rutherford classification grade improved in 105 (87.5%) limbs at the latest follow-up. At 8 years, the primary patency, freedom from target-lesion revascularization, secondary patency, survival, and amputation-free survival, as estimated by the Kaplan-Meier method, were 66.3±4.8%, 71.5±4.4%, 86.5±3.4%, 53.1±5.0%, and 47.4±5.3%, respectively. This multicenter prospective registry-based analysis showed sustained excellent clinical improvement and secondary patency for up to 8 years following PROPATEN®-based AKFPB. PROPATEN®constitutes a durable and good revascularization option for complex superficial femoral artery lesions, especially when endovascular treatment is inappropriate or an adequate venous conduit is unavailable.

Two Decades of CABG in the UK: A Propensity Matched Analysis of Outcomes by Conduit Choice.

Background/Objectives: Grafting of LIMA to LAD has long been considered the gold-standard conduit choice for patients undergoing CABG. Despite this, the LSV remains the most used conduit by volume and some patients may not receive even a single arterial conduit. However, the outcomes in this group are not frequently explored. This study, therefore, compares in-hospital outcomes of patients who underwent CABG without any arterial conduits to those who received at least one arterial conduit. Methods: Retrospective propensity-matched database analysis of consecutive patients undergoing CABG in the UK between 1996 and 2019 using data from the National Adult Cardiac Surgery Audit. Results: 335,144 patients underwent CABG, with 6% receiving venous conduits only; matched outcomes are reported for 39,812 patients. In both unmatched and matched groups, we found a significant increase in mortality with the use of veins only (matched mortality 5.3% vs. 3.8%, p < 0.001) with estimated treatment effect for mortality OR 1.43, p < 0.001 (95% CI: 1.31-1.57). We also identified greater rates of post-operative dialysis, IABP insertion, and length of hospital stay in this group. Conclusions: We identified a significant increase in in-hospital mortality with the use of veins only compared to using at least one arterial graft to the LAD. While a single arterial graft should be prioritised wherever possible, venous revascularisation retains a critical role for specific patients. We must, therefore, continue to conduct research addressing the mechanisms underlying and propagating vein graft disease in order better to optimise outcomes for this niche patient group after CABG.

The Best Second Arterial Conduit for Coronary Artery Bypass Grafting: A Meta-Analysis of Reconstructed Individual Patient Data.

Multiple arterial conduit revascularization in coronary bypass surgery is being advocated over the use of venous conduits. However, there is a critical gap regarding the optimal sequence of arterial conduit selection following the left internal thoracic artery. This study is the first individual patient data meta-analysis, which aimed to compare the right internal thoracic artery (RITA) versus the radial artery (RA) as a second-best arterial conduit. A comprehensive literature search was conducted in MEDLINE, Embase, Scopus, and CENTRAL. A forward-backward citation check was performed to identify other relevant studies. The study protocol was registered in the PROSPERO (CRD42023455543). Eligible studies included randomized controlled trials and propensity-score-matched cohort studies reporting long-term outcomes (>3 years) after coronary bypass surgery using the RITA versus RA as the second arterial conduit after left internal thoracic artery. Overall, long-term survival between the RITA and RA groups showed no significant difference. Landmark analyses demonstrated the superiority of RITA as a second arterial conduit at 1 [hazard ratio (HR): 0.86 (95% CI, 0.75-0.99), P = 0.036], 2 [0.83 (95% CI, 0.72-0.96), P = 0.011], and 5 years [HR: 0.80 (95% CI, 0.68-0.95), P = 0.036] post-surgery. Freedom from major cardiovascular events was significantly higher using the RITA conduit [HR: 0.72 (95% CI, 0.59-0.89), P = 0.002]. This study supports the use of RITA, especially when used in a skeletonized in situ fashion, as a second choice following the left internal thoracic artery as it has the potential to enhance long-term survival and outcomes. Further research with standardized surgical techniques is warranted.

Comparative analysis of the efficiency of the use of various types of conduits during coronary artery bypass grafting

The OBJECTIVE was to compare efficiency of the use of various types of conduits during coronary artery bypass grafting (CABG).METHODS AND MATERIALS. The retrospective study included 282 patients, who underwent CABG, performed with different types of conduits. The average age of the patients was 63.2±8.5 years; the majority of 231 patients (81.9%) were male. Patients were separated in 3groups depending on the use of conduits: the first one included patients after bimammary coronary artery bypass grafting (n=77); the second one involved coronary artery bypass grafting using radial artery(n=87); the third one included patients with venous conduits (n=77). The main endpoint of the study was the development of conduit dysfunctions in the long-term period according to diagnostic coronary artery bypass grafting.RESULTS. The average follow-up time in the long-term period was 44.9±39 months. During this period, 198 patients underwent diagnostic coronary artery bypass grafting. According to the results of the analysis, the greatest effectiveness was observed in groups using arterial conduits – the left internal thoracic artery and radial artery. For example, the incidence of dysfunction of the left internal thoracic artery in the anterior artery basin was 8.2%; the incidence of dysfunction of radial artery in the right artery basin was 12.5 %, and in the obtuse marginal branch basin – 11.5 %; while the incidence of venous conduits’ dysfunction varied, reaching its maximum of 42.8 %.CONCLUSIONS. Thus, the greatest efficiency was observed when using the left and the right internal thoracic arteries, thereafter by the radial artery. The results of using venous conduits were lower.

Internal Mammary Artery Graft Flow Steal by a Large Dialysis Arteriovenous Fistula Characterized by Electrical Storm

Background: Steal syndrome describes a condition in which a dilated vessel distal to a smaller artery attempts to compensate for decreased blood flow by “stealing” from the smaller artery. Steal syndrome is not uncommon and can be seen in certain physiologic and pathologic states. The classic example is an occluded atherosclerotic coronary artery resulting in a misdirection of blood flow into the open channels that have developed over time resulting in downstream ischemia. Case Report: A 66-year-old male fourteen years post 4-vessel coronary artery bypass grafting using his left internal mammary artery to bypass a stenotic segment of the left anterior descending artery, along with three saphenous venous conduits to the right coronary artery. He also had a stent placement by PCI. He was on dual antiplatelet therapy with aspirin and clopidogrel. An electrophysiology study revealed inducible VF and he underwent implantation of a dual chamber ICD 9 months prior to presentation. He experienced an unprovoked fall at home and a workup revealed the flow volume through the patient’s fistula increased to such a degree that the patient developed a steal syndrome from his left internal mammary artery graft. In addition, went into a state of electrical storm caused by ischemic damage to cardiac tissue distal to the graft. By ligating the fistula, the patient’s steal syndrome resolved and he did not suffer further ventricular arrhythmias. Conclusion: Both coronary bypass grafting and fistula formation are common and necessary interventions and providers should take care to monitor for interactions between these proposed interventions to best serve their patients without causing additional harm. Increased vascular flow through any portion of the body can induce a steal syndrome from an upstream region. Patients who undergo arteriovenous (AV) fistula placement may develop a steal syndrome from ipsilateral bypass grafts.

Therapeutic strategies based on non-ionizing radiation to prevent venous neointimal hyperplasia: the relevance for stenosed arteriovenous fistula, and the role of vascular compliance.

We have reviewed the development and current status of therapies based on exposure to non-ionizing radiation (with a photon energy less than 10 eV) aimed at suppressing the venous neointimal hyperplasia, and consequentially at avoiding stenosis in arteriovenous grafts. Due to the drawbacks associated with the medical use of ionizing radiation, prominently the radiation-induced cardiovascular disease, the availability of procedures using non-ionizing radiation is becoming a noteworthy objective for the current research. Further, the focus of the review was the use of such procedures for improving the vascular access function and assuring the clinical success of arteriovenous fistulae in hemodialysis patients. Following a brief discussion of the physical principles underlying radiotherapy, the current methods based on non-ionizing radiation, either in use or under development, were described in detail. There are currently five such techniques, including photodynamic therapy (PDT), far-infrared therapy, photochemical tissue passivation (PTP), Alucent vascular scaffolding, and adventitial photocrosslinking. The last three are contingent on the mechanical stiffening achievable by the exogenous photochemical crosslinking of tissular collagen, a process that leads to the decrease of venous compliance. As there are conflicting opinions on the role of compliance mismatch between arterial and venous conduits in a graft, this aspect was also considered in our review.

Use of the composite Y-shaped veno-venous bypass graft in coronary surgery

Introduction. This study was performed to assess the functional status of Y­shaped veno­venous bypass grafts in cases of lacking both arterial and venous material, as well as in patients with ascending aorta abnormalities, in order to perform the most adequate myocardial revascularisation. Material. The retrospective study performed in Scientific and Practical Center of Interventional Cardioangiology included 43 patients, who underwent surgery between 2017 and 2022. The main inclusion criterion for the study was coronary artery bypass grafting (CABG) with the use of Y­shaped venous conduits. The control bypass angiography was performed in average in 33 ± 8 months. All interventions were performed under normothermic cardiopulmonary bypass (CPB), and the average number of conduits per patient was 3.4. Results. Satisfactory functional status of the Y­shaped venous bypass grafts in the long­term (33 ± 8 months) period was observed in 86.1% of cases. At that, no cases of cerebrovascular accident were reported in the postoperative period, as well as no sternal infections in patients with insulin­dependent diabetes mellitus, and only one patient out of 20 patients with severe lower limb ischaemia had wound infection of the lower extremity (5%). Conclusions. Y­shaped veno­venous bypass grafts demonstrated quite acceptable long­term functional results in patients with ascending aorta abnormalities or conduit deficiency and they can be used to achieve the most adequate myocardial revascularisation. Keywords: CABG, Y­shaped bypass graft, venous conduit, aortic atheromatosis

Endothelial damage inhibitor preserves the integrity of venous endothelial cells from patients undergoing coronary bypass surgery.

Despite the success of coronary artery bypass graft (CABG) surgery using autologous saphenous vein grafts (SVGs), nearly 50% of patients experience vein graft disease within 10 years of surgery. One contributing factor to early vein graft disease is endothelial damage during short-term storage of SVGs in inappropriate solutions. Our aim was to evaluate the effects of a novel endothelial damage inhibitor (EDI) on SVGs from patients undergoing elective CABG surgery and on venous endothelial cells (VECs) derived from these SVGs. SVGs from 11 patients participating in an ongoing clinical registry (NCT02922088) were included in this study, and incubated with both full electrolyte solution (FES) or EDI for 1 h and then examined histologically. In 8 of 11 patients, VECs were isolated from untreated grafts, incubated with both FES and EDI for 2 h under hypothermic stress conditions and then analysed for activation of an inflammatory phenotype, cell damage and cytotoxicity, as well as endothelial integrity and barrier function. The EDI was superior to FES in protecting the endothelium in SVGs (74 ± 8% versus 56 ± 8%, P < 0.001). Besides confirming that the EDI prevents apoptosis in SVG-derived VECs, we also showed that the EDI temporarily reduces adherens junctions in VECs while protecting focal adhesions compared to FES. The EDI protects the connectivity and function of the SVG endothelium. Our data suggest that the EDI can preserve focal adhesions in VECs during short-term storage after graft harvesting. This might explain the superiority of the EDI in maintaining most of the endothelium in venous CABG surgery conduits.

436 Total Arterial Revascularisation Complicated by Unexpected Vasoconstrictor Requirements

Abstract Introduction The debate surrounding conduit selection in multi-vessel coronary artery bypass grafting (CABG) persists. Whilst combined arterial and venous conduits remains the gold standard approach, some studies report superior long-term outcomes with total arterial revascularisation (TAR). Case Description A 48-year-old male was admitted with acute coronary syndrome. Investigations demonstrated significant triple vessel coronary artery disease with preserved biventricular systolic function. He had no major comorbidities. He underwent uneventful urgent off-pump CABG x 3 with TAR. Conduits used were a skeletonised left internal mammary artery (LIMA) and a radial artery. They were anastomosed to make a Y configuration. The LIMA was anastomosed end-to-side to the mid-LAD and the radial artery was anastomosed side-to-side to the first obtuse marginal and end-to-side to the posterior descending artery. Post-operatively the patient had significant drain output, resulting in haemodynamic instability and a significant increase in vasoconstrictor requirements. This led to vasoconstrictive spasm of the arterial grafts and cardiac arrest ensued. The patient underwent emergency re-sternotomy and institution of cardiopulmonary bypass. The arterial grafts were removed, and the patient was re-grafted with three saphenous vein grafts. The patient was successfully discharged home in a stable condition on the tenth post-operative day. Discussion Careful management of post-operative complications in patients who underwent TAR is required in order to reduce the risk of arterial graft spasm. Pre-operative planning should include the consideration of alternative conduit strategies in patients where higher post-operative vasoconstrictor requirements are anticipated.

Early asymptomatic graft failure in coronary artery bypass grafting: a study based on computed tomography angiography analysis

BackgroundAsymptomatic graft failure after coronary bypass grafting surgery (CABG) may have negative impact on the patients’ short- and long-term outcomes. Cardiac computed tomography angiography (CTA) has been proved to be another choice to detect graft failure besides coronary artery angiography in several studies. We aimed to identify the rate and predictors of asymptomatic graft failure detected by CTA before discharge.Methods and resultsA total of 955 grafts of 346 consecutive asymptomatic patients who received CTA examination after CABGs were included in this retrospective study from July 2017 to Dec 2019. We divided 955 grafts into the patent group and occluded group by CTA results. Logistic regression model at graft-level were established to determine predictors of the early asymptomatic graft occlusion. The overall asymptomatic graft failure rate was 4.71% (45/955), and there was no difference between the arterial and venous conduits in different target territories (P > 0.05). The logistic regression at graft-level analysis showed that female (OR 3.181, CI 1.58–6.40, P = 0.001), composite grafting (OR 6.762, CI 2.26–20.28, P = 0.001), pulse index value (OR 1.180, CI 1.08–1.29, P < 0.001) and new postoperative atrial fibrillation (POAF) (OR2.348, CI 1.15–4.78, P = 0.018) were independent risk factors that affect graft failure, while early postoperative dual-antiplatelet treatment with aspirin and clopidogrel was a protective factor (OR 0.403, CI 0.19–0.84, P = 0.015).ConclusionsEarly asymptomatic graft failure is associated with both patient and surgical factors including female gender, high PI value, composite graft strategy and the new POAF. However, the early dual- antiplatelet therapy with aspirin and clopidogrel may be useful for preventing graft failure.

Rivaroxaban in patients with symptomatic peripheral artery disease after lower extremity bypass surgery with venous and prosthetic conduits: Presented at the Seventy-fourth Annual Meeting of the Society for Vascular Surgery, San Diego, CA, August 18-21, 2021.

Rivaroxaban in patients with symptomatic peripheral artery disease after lower extremity bypass surgery with venous and prosthetic conduits: Presented at the Seventy-fourth Annual Meeting of the Society for Vascular Surgery, San Diego, CA, August 18-21, 2021.

Routine Completion Angiography for Infrainguinal Bypasses Using Prosthetic Conduit: No Effect on Postoperative Patency

Recent studies have demonstrated increased postoperative patency with the use of routine completion angiography for bypass using venous conduit. Compared to vein conduits, however, prosthetic conduits are less plagued by technical issues such as unlysed valves or arteriovenous fistulae. The effect of routine completion angiography on bypass patency in prosthetic bypasses has yet to be compared to the more traditional selective use of completion imaging. A retrospective review of all infrainguinal bypass procedures using prosthetic conduit completed at a single hospital system from 2001 to 2018 was performed. Demographics, comorbidities, intraoperative reintervention rates, and 30-day rates of graft thrombosis were analyzed. Statistical analysis included t-tests, chi-square tests, and cox regression. Four hundred and ninety-eight bypasses that were performed in 426 patients met inclusion criteria. Fifty-six (11.2%) bypasses were classified into the routine completion angiogram group compared to 442 (88.8%) into the no completion angiogram group. Patients who underwent routine completion angiograms had a rate of intraoperative reintervention of 21.4%. When comparing bypasses that underwent routine completion angiography versus no completion angiography, there were no significant differences in rates of reintervention (3.5% vs. 4.5%, P=0.74) or graft occlusion (3.5% vs. 4.7%, P=0.69) at 30-days postoperatively. Almost one-quarter of lower extremity bypasses using prosthetic conduit that undergo routine completion angiography undergo postangiogram bypass revision; however, this is not associated with an increased graft patency at 30 days postoperatively.

Angiographic Outcomes for Arterial and Venous Conduits Used in CABG.

Coronary artery bypass grafting is the most commonly performed cardiac surgical procedure. Conduit selection is crucial to achieving early optimal outcomes, with graft patency being likely the main driver to long-term survival. We present a review of current evidence on the patency of arterial and venous bypass conduits and of differences in angiographic outcomes.

Right Ventricular Function During Exercise After Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension.

Background Pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension improves resting hemodynamics and right ventricular (RV) function. Because exercise tolerance frequently remains impaired, RV function may not have completely normalized after PEA. Therefore, we performed a detailed invasive hemodynamic study to investigate the effect of PEA on RV function during exercise. Methods and Results In this prospective study, all consenting patients with chronic thromboembolic pulmonary hypertension eligible for surgery and able to perform cycle ergometry underwent cardiac magnetic resonance imaging, a maximal cardiopulmonary exercise test, and a submaximal invasive cardiopulmonary exercise test before and 6 months after PEA. Hemodynamic assessment and analysis of RV pressure curves using the single-beat method was used to determine load-independent RV contractility (end systolic elastance), RV afterload (arterial elastance), RV-arterial coupling (end systolic elastance-arterial elastance), and stroke volume both at rest and during exercise. RV rest-to-exercise responses were compared before and after PEA using 2-way repeated-measures analysis of variance with Bonferroni post hoc correction. A total of 19 patients with chronic thromboembolic pulmonary hypertension completed the entire study protocol. Resting hemodynamics improved significantly after PEA. The RV exertional stroke volume response improved 6 months after PEA (79±32 at rest versus 102±28 mL during exercise; P<0.01). Although RV afterload (arterial elastance) increased during exercise, RV contractility (end systolic elastance) did not change during exercise either before (0.43 [0.32-0.58] mm Hg/mL versus 0.45 [0.22-0.65] mm Hg/mL; P=0.6) or after PEA (0.32 [0.23-0.40] mm Hg/mL versus 0.28 [0.19-0.44] mm Hg/mL; P=0.7). In addition, mean pulmonary artery pressure-cardiac output and end systolic elastance-arterial elastance slopes remained unchanged after PEA. Conclusions The exertional RV stroke volume response improves significantly after PEA for chronic thromboembolic pulmonary hypertension despite a persistently abnormal afterload and absence of an RV contractile reserve. This may suggest that at mildly elevated pulmonary pressures, stroke volume is less dependent on RV contractility and afterload and is primarily determined by venous return and conduit function.

Radial artery – perspective or fallacy?

Highlights. Radial artery is the second after internal thoracic artery by frequency of use among all of autogenous arterial conduits. Some modern studies indicate the superiority of this conduit to autogenous venous conduits; however, it remains an ongoing discussion.The article presence an analytical review regarding the use of the radial artery as one of conduits during coronary artery bypass grafting. Historical and contemporary perspectives of its use are given, examples of large-scale studies and results are provided, including the “graft-artery junction” concept.Abstract. Radial artery (RA) is the second after internal thoracic artery (ITA) by frequency of use among all of autogenous arterial conduits in coronary artery bypass grafting (CABG), however it is used in less than 13% of cases. The story of RA as a conduit starts in the 1970s, when the famous French surgeon, founder of modern mitral valve repair Alain Frédéric Carpentier proposed to use it. During the development of cardiovascular surgery, RA was actively introduced as a conduit for CABG, and nowadays there are both supporters and opponents of its application. On the one hand, long-term results of CABG with RA are superior to CABG with autogenous venous conduits, whereas the patency of RA is comparable with ITA. On the other hand, RA demonstrates worse angiographic indicators, which could be explained by a diffuse narrowing resulting in complete occlusion; such phenomenon is entitled “string-sign”. Moreover, as in case with other conduits, the site of proximal anastomosis, and harvesting method (open or endoscopic) play an important role in the long-term RA functioning and its resistance to atherosclerosis in grafted coronary arteries, thus making RA a good target for studing and predetermining new perspectives of its use.

Multiple arterial versus single arterial grafting in patients with diabetes undergoing coronary artery bypass surgery

BackgroundData on long-term outcomes in patients with diabetes receiving multiarterial grafting (MAG) versus single-artery grafting (SAG) are limited. ObjectivesThe objective of this study is to compare long-term outcomes between MAG and SAG for coronary artery bypass graft (CABG) surgery in patients with diabetes. MethodsPatients with diabetes who underwent isolated CABG surgeries between 2000 to 2016 were identified using the New Jersey mandatory state clinical registry linked with death records and hospital discharge data (last follow-up December 31, 2019). Patients who underwent CABG for single-vessel disease, with only venous conduits, patients with previous heart surgeries, or hemodynamically unstable were excluded. Patients undergoing MAG and SAG were matched by propensity score. Cox proportional hazard models were used to investigate long-term survival and competing risk analysis was used for secondary outcomes. ResultsOf 24,944 patients, 2955 underwent MAG, and 21,989 underwent SAG CABG. Patients receiving MAG were younger, predominantly men, with a lower prevalence of hypertension, peripheral vascular disease, congestive heart failure, chronic lung disease, and renal failure. MAG was associated with lower long-term mortality compared with SAG in 2882 propensity score-matched pairs (hazard ratio [HR], 0.75; 95% CI, 0.68-0.83); lower risks of repeat revascularization (subdistribution HR, 0.86; 95% CI, 0.76-0.97); and composite outcome defined as death from any cause, stroke, postoperative myocardial infarction, and/or repeat revascularization (HR, 0.76; 95% CI, 0.71-0.82). These results were confirmed in subgroup analyses of women, men, age <70 years, and age ≥70 years patients with diabetes. MAG was also associated with lower mortality compared with SAG in patients with diabetes taking insulin in the entire cohort (Video Abstract). ConclusionsPatients with diabetes benefit from receiving MAG over SAG and demonstrated improved long-term survival, and lower hazards of secondary and composite outcomes. Coordinated efforts are needed to offer MAG to patients with diabetes.

Early Saphenous Vein Graft Aneurysm Rupture: A Not So-Late Complication. Case Report and Comprehensive Literature Review.

Saphenous vein graft (SVG) is a cardiac surgical practice used to create a cardiac bypass in cases of coronary artery obstruction. It consists of a surgical procedure that involves the creation of an aorto-coronary communication by a venous conduit (saphenous vein) to bypass coronary stenosis and allow cardiac revascularization. This practice can be affected by early and late complications. The most feared complication is graft aneurysm or pseudoaneurysm degeneration and rupture which are considered late complications. This paper presents a rare case of SVG aneurysmal rupture that occurred 24 h after surgery and a review of the literature to provide a general look at the state of knowledge. The systematic review was carried out using the guidelines according to the PRISMA method. Cases of aneurysmal rupture have never been described prior to one month after surgery. The male sex and subjects under 45 are the most affected by this complication. Death occurs in less than half of the cases, being more frequent in young people. Performing a CT or angio-CT examination led to the diagnosis. It is impossible to estimate the implanted vessel's quality, so postoperative follow-up is fundamental. Transesophageal ultrasound can be useful, and hematochemical tests are valuable early diagnostic tools, whrease CT and angio-CT can be useful even months after surgery. Forensic analysis should always perform an autopsy and graft histological examination.

Rivaroxaban in patients with symptomatic peripheral artery disease after lower extremity bypass surgery with venous and prosthetic conduits

BackgroundPatients with peripheral artery disease (PAD) requiring lower extremity revascularization (LER) have a high risk of adverse limb and cardiovascular events. The results from the VOYAGER PAD (efficacy and safety of rivaroxaban in reducing the risk of major thrombotic vascular events in subjects with symptomatic peripheral artery disease undergoing peripheral revascularization procedures of the lower extremities) trial have demonstrated that rivaroxaban significantly reduced this risk with an overall favorable net benefit for patients undergoing surgical revascularization. However, the efficacy and safety for those treated by surgical bypass, including stratification by bypass conduit (venous or prosthetic), has not yet been described. MethodsIn the VOYAGER PAD trial, patients who had undergone surgical and endovascular infrainguinal LER to treat PAD were randomized to rivaroxaban 2.5 mg twice daily or placebo on top of background antiplatelet therapy (aspirin 100 mg to be used in all and clopidogrel in some at the treating physician’s discretion) and followed up for a median of 28 months. The primary end point was a composite of acute limb ischemia, major amputation of vascular etiology, myocardial infarction, ischemic stroke, and cardiovascular death. The principal safety outcome was major bleeding using the TIMI (thrombolysis in myocardial infarction) scale. The index procedure details, including conduit type (venous vs prosthetic), were collected at baseline. ResultsAmong 6564 randomized patients, 2185 (33%) had undergone surgical LER. Of these 2185 patients, surgical bypass had been performed for 1448 (66%), using a prosthetic conduit for 773 patients (53%) and venous conduit for 646 patients (45%). Adjusting for the baseline differences and anatomic factors, the risk of unplanned limb revascularization in the placebo arm was 2.5-fold higher for those receiving a prosthetic conduit vs a venous conduit (adjusted hazard ratio [HR], 2.53; 95% confidence interval [CI], 1.65-3.90; P < .001), and the risk of acute limb ischemia was three times greater (adjusted HR, 3.07; 95% CI, 1.84-5.11; P < .001). The use of rivaroxaban reduced the primary outcome for the patients treated with bypass surgery (HR, 0.78; 95% CI, 0.62-0.98), with consistent benefits for those receiving venous (HR, 0.66; 95% CI, 0.49-0.96) and prosthetic (HR, 0.87; 95% CI, 0.66-1.15) conduits (Pinteraction = .254). In the overall trial, major bleeding using the TIMI scale was increased with rivaroxaban. However, the numbers for those treated with bypass surgery were low (five with rivaroxaban vs nine with placebo; HR, 0.55; 95% CI, 0.18-1.65) and not powered to show statistical significance. ConclusionsSurgical bypass with a prosthetic conduit was associated with significantly higher rates of major adverse limb events relative to venous conduits even after adjustment for patient and anatomic characteristics. Adding rivaroxaban 2.5 mg twice daily to aspirin or dual antiplatelet therapy significantly reduced this risk, with an increase in the bleeding risk, but had a favorable benefit risk for patients treated with bypass surgery, regardless of conduit type. Rivaroxaban should be considered after lower extremity bypass for symptomatic PAD to reduce ischemic complications of the heart, limb, and brain.

Quantification of the internal mammary artery size in Aboriginal and Torres Strait islanders.

Variation in size of the internal mammary artery has been demonstrated in ethnic groups, but not reported in Aboriginal patients. We hypothesised that the left internal mammary artery is smaller in Aboriginal patients compared to non-Aboriginal patients and aimed to determine the impact on survival following coronary artery bypass graft (CABG) surgery. Left internal mammary artery size was compared between Aboriginal (n= 345) and non-Aboriginal (n= 1819) in 2343 patients undergoing CABG at Flinders Medical Centre from January 2010 to June 2021. To determine the association with-survival we used Kaplan-Meier survival analysis and Cox proportional hazard models adjusted for preoperative variables. There was a significant difference in left internal mammary artery (LIMA) size-Aboriginal 1.8± 0.4 mm; non-Aboriginal 2.1± 0.4 mm (P< 0.001)-and left anterior descending (LAD) artery size-Aboriginal 1.7± 0.3 mm; non-Aboriginal 1.9± 0.3 mm (P< 0.001). Aboriginal patients were more likely to have the LIMA discarded (9.3% vs. 0.4%) and to receive a LAD vein graft (17% versus 3%) (P< 0.001). There was no difference in 30-day mortality or survival <5 years. This study supports the hypothesis that the left internal mammary artery is smaller in Aboriginal patients compared to non-Aboriginal patients. Although Aboriginal patients were more likely to receive a venous conduit to the LAD, we observed no difference in survival up to 5 years. This data contrasts with reported outcomes of other ethnic groups.