Determinants of Sapheous Vein Graft Patency

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]

Graft patency is dependent on a number of factors, including the type of graft used (internal thoracic artery, radial artery, or great saphenous vein), the size or the coronary artery that the graft is anastomosed with, and, of course, the skill of the surgeon(s) performing the procedure. Arterial grafts (e.g. left internal mammary (LIMA), radial) are far more sensitive to rough handling than the saphenous veins and may go into spasm if handled improperly.

## Contents

* 1 Systemic or Patient-Based Risk Factors for SVG Failure
* 2 In-situ vs Free Grafts
* 3 Venous vs Arterial Conduits
* 4 Impact of Harvesting Method on Saphenous Vein Graft Patency
* 5 Pharmacotherapy
* 6 Impact of Initial CABG Results and Runoff
* 7 Potential for Pre-Operative SVG Failure
* 8 References

## Systemic or Patient-Based Risk Factors for SVG Failure

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Diabetes,hyperlipidemia,smoking, and to variable degrees hypertension are all risk facotrs for SVG failure [1]. There is some data to suggest that lipoprotein subfractions may be associated with SVG failure such as HDL cholesterol and plasma LDL apoprotein B. [1]

## In-situ vs Free Grafts

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Generally the best patency rates are achieved with the in-situ (the proximal end is left connected to the subclavian artery) left internal thoracic artery (a LIMA) with the distal end being anastomosed with the coronary artery (typically the left anterior descending artery or a diagonal branch artery). Lesser patency rates can be expected with radial artery grafts and "free" internal thoracic artery grafts (where the proximal end of the thoracic artery is excised from its origin from the subclavian artery and re-anastomosed with the ascending aorta).

## Venous vs Arterial Conduits

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Saphenous vein grafts have poorer patency rates than arterial grafts, but are more available, as the patients can have multiple segments of the saphenous vein used to bypass different arteries.

LITA grafts are longer-lasting than vein grafts, both because the artery is more robust than a vein and because, being already connected to the arterial tree, the LITA need only be grafted at one end. The LITA is usually grafted to the left anterior descending coronary artery (LAD) because of its superior long-term patency when compared to saphenous vein grafts.[2][3]

## Impact of Harvesting Method on Saphenous Vein Graft Patency

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The method of harvesting vein grafts may be associated with late vein graft patency at 12-18 months.[4] In a non-randomized subgroup analysis from the PREVENT IV study, harvesting of vein-grafts with the use of endoscopy (endoscopic harvesting) was associated with a higher rate of saphenous vein graft failure compared with open harvesting of the veins under direct visualization (46.7% vs. 38.0%, P<0.001 at 12-18 months). Likewise, clinical outcomes were worse at 3 years: use of endoscopy was associated with higher rates of death, myocardial infarction, or repeat revascularization (20.2% vs. 17.4%; p=0.04), death or myocardial infarction (9.3% vs. 7.6%; p=0.01), and death (7.4% vs. 5.8%; adjusted hazard ratio, 1.52; 95% CI, 1.13 to 2.04; p=0.005). Although these observational data are provocative, further randomized clinical trials would be needed to compare the safety and effectiveness of the two harvesting technique.

## Pharmacotherapy

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In a relatively modest sized study, there was a significant improvement in SVG patency to 91.6% (219/239) among patients treated with both aspirin and clopidogrel versus 85.7% (198/231) in those patients treated with aspirin alone (relative risk: 1.707; 95% confidence interval: 1.010 to 2.886; multivariat p = 0.043)[5] These results are in contrast to those of CASCADE [6]. CASCADE was a double-blind phase II trial of 113 patients undergoing coronary artery bypass grafting. Patients were randomized to treatment with either aspirin 162 mg plus clopidogrel 75 mg daily versus aspirin 162 mg daily for one year. The primary endpoint of SVG intimal area at 1 year did not differ between the 2 comparators (p=0.44). SVG patency at one year was 95.2% among patients treated with aspirin plus clopidogrel versus 95.5% among patients treated with aspirin alone (P=0.90). There was no difference at one year in freedom from major adverse cardiovascular events (MACE) at 1 year was 92.9% among patients treated with aspirin-clopidogrel and 91.1% among patients in the aspirin-placebo group (p=0.76).

## Impact of Initial CABG Results and Runoff

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Greater runoff, and higher mean graft flow have been associated with improved SVG patency, whereas the pulsatile index has been associated with worse patency[7].

## Potential for Pre-Operative SVG Failure

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It should be noted that studies of SVGs that are not implanted show that about 1% of veins are already stenosed by > 50% before implantation[8].

## References

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1. ↑ 1.0 1.1 Campeau L, Enjalbert M, Lespérance J, Bourassa MG, Kwiterovich P, Wacholder S, Sniderman A (1984). "The relation of risk factors to the development of atherosclerosis in saphenous-vein bypass grafts and the progression of disease in the native circulation. A study 10 years after aortocoronary bypass surgery". The New England Journal of Medicine. 311 (21): 1329–32. doi:10.1056/NEJM198411223112101. PMID 6333635. Retrieved 2010-11-09. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
2. ↑ Kitamura S, Kawachi K, Kawata T, Kobayashi S, Mizuguchi K, Kameda Y, Nishioka H, Hamada Y, Yoshida Y. [Ten-year survival and cardiac event-free rates in Japanese patients with the left anterior descending artery revascularized with internal thoracic artery or saphenous vein graft: a comparative study] Nippon Geka Gakkai Zasshi. 1996 Mar;97(3):202-9. PMID 8649330.
3. ↑ Arima M, Kanoh T, Suzuki T, Kuremoto K, Tanimoto K, Oigawa T, Matsuda S. Serial Angiographic Follow-up Beyond 10 Years After Coronary Artery Bypass Grafting. Circ J. 2005 Aug;69(8):896-902. PMID 16041156. [1].
4. ↑ Lopes RD, Hafley GE, Allen KB, Ferguson TB, Peterson ED, Harrington RA, Mehta RH, Gibson CM, Mack MJ, Kouchoukos NT, Califf RM, Alexander JH (2009). "Endoscopic versus open vein-graft harvesting in coronary-artery bypass surgery". The New England Journal of Medicine. 361 (3): 235–44. doi:10.1056/NEJMoa0900708. PMID 19605828. Retrieved 2010-07-12. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
5. ↑ Gao G et al. Aspirin plus clopidogrel therapy increases early venous graft patency after coronary artery bypass surgery. J Am Coll Cardiol 2010;56:1639–43.
6. ↑ Kulik A, Le May M, Wells GA, Mesana TG, Ruel M (2005). "The clopidogrel after surgery for coronary artery disease (CASCADE) randomized controlled trial: clopidogrel and aspirin versus aspirin alone after coronary bypass surgery [NCT00228423]". Curr Control Trials Cardiovasc Med. 6: 15. doi:10.1186/1468-6708-6-15. PMC 1282584. PMID 16219100. Retrieved 2010-12-07. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
7. ↑ Gao G et al. Aspirin plus clopidogrel therapy increases early venous graft patency after coronary artery bypass surgery. J Am Coll Cardiol 2010;56:1639–43.
8. ↑ Waller BF, Roberts WC (1985). "Remnant saphenous veins after aortocoronary bypass grafting: analysis of 3,394 centimeters of unused vein from 402 patients". The American Journal of Cardiology. 55 (1): 65–71. PMID 3871302. Retrieved 2010-11-09. Unknown parameter `|month=` ignored (help)

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