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| {{SI}} | | {{Saphenous vein graft}} |
| {{CMG}} | | {{CMG}}; '''Associate Editor(s)-In-Chief:''' {{CZ}}; Jason C. Choi, M.D.; Xin Yang, M.D. |
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| '''Associate Editors-In-Chief:''' {{CZ}}, Jason C. Choi, M.D., Xin Yang, M.D.
| | ==[[Overview]]== |
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| {{Editor Join}}
| | ==[[Saphenous vein graft anatomy|Anatomy]]== |
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| ==Overview== | | ==[[Saphenous Vein Graft Harvesting|Harvesting]]== |
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| Since Rene Favaloro first described it in 1967, coronary artery revascularization with [[saphenous vein]]s (saphenous vein grafts or SVGs) has become a surgical standard for treatment of [[coronary artery disease]]. When a native [[coronary artery]] is obstructed, the sutured graft provides a connection between the [[aorta]] and the [[coronary artery]] beyond the area of obstruction. The procedure is repeated on all the [[coronary artery]] segments that are significantly diseased.
| | ==[[Saphenous Vein Graft Nomenclature|Nomenclature]]== |
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| The vein is often removed by [[cardiac surgeon]]s and used for [[autotransplantation]] in [[Coronary artery bypass surgery|coronary artery bypass operation]]s, when arterial grafts are not available or many grafts are required, such as in a [[triple bypass]] or [[quadruple bypass]].
| | ==[[Pathophysiology of Saphenous Vein Graft Disease|Pathophysiology]]== |
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| ==Normal Anatomy== | | ==[[Assessment of Target Vessels for Saphenous Vein Grafting]]== |
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| The [[great saphenous vein]] ([[GSV]]) originates from where the dorsal vein of the [[first digit]] (the large [[toe]]) merges with the [[dorsal venous arch of the foot]].
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| After passing anterior to the [[medial malleolus]] (where it often can be visualized and [[Palpation|palpated]]), it runs up the [[medial]] side of the leg. At the [[knee]], it runs over the posterior border of the [[medial epicondyle]] of the [[femur]] bone.
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| The [[great saphenous vein]] then courses laterally to lie on the anterior surface of the thigh before entering an opening in the [[fascia lata]] called the [[saphenous opening]]. It joins with the [[femoral vein]] in the region of the [[femoral triangle]] at the saphenofemoral junction.
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| The '''small saphenous vein''' (also '''lesser saphenous vein''') is originated where the dorsal vein from the [[fifth digit]] (smallest toe) merges with the [[dorsal venous arch of the foot]], which attaches to the [[great saphenous vein]]. It is considered a [[superficial vein]] and is [[subcutaneous]] (just under the skin). From its origin, it courses around the lateral aspect of the foot (inferior and posterior to the [[lateral malleolus]]) and runs along the posterior aspect of the leg (with the [[sural nerve]]), passes between the heads of the [[gastrocnemius muscle]], and drains into the [[popliteal vein]], approximately at or above the level of the [[knee]] joint.
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| <gallery perRow="3">
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| Image:Gray432 color.png|Cross-section through the middle of the thigh.
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| Image:Gray440_color.png|Cross-section through middle of leg.
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| Image:Great_saphenous_vein.png|The great saphenous vein and landmarks along its course
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| Image:Gray580.png|The great saphenous vein and its tributaries at the [[Saphenous opening|fossa ovalis]] in the [[groin]].
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| Image:Gray582.png|Small saphenous vein and its tributaries.
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| </gallery>
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| ==Saphenous Vein Harvesting==
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| The saphenous vein can be harvested by either direct visualization or via an endoscopic approach. The endoscopic approach has been associated with lower rates of wound infection, but higher rates of failure and adverse events such as death and MI.<ref name="pmid19605828">{{cite journal |author=Lopes RD, Hafley GE, Allen KB, Ferguson TB, Peterson ED, Harrington RA, Mehta RH, Gibson CM, Mack MJ, Kouchoukos NT, Califf RM, Alexander JH |title=Endoscopic versus open vein-graft harvesting in coronary-artery bypass surgery |journal=[[The New England Journal of Medicine]] |volume=361 |issue=3 |pages=235–44 |year=2009 |month=July |pmid=19605828 |doi=10.1056/NEJMoa0900708 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=19605828&promo=ONFLNS19 |issn= |accessdate=2010-07-12}}</ref> Veins that are used either have their valves removed or are turned around so that the valves in them do not occlude blood flow in the graft.
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| Side effects of saphenous vein harvesting include the following:
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| * [[Saphenous nerve]] injury
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| * [[Infection]] at incision sites or [[sepsis]].
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| * [[Deep vein thrombosis]] ([[DVT]])
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| * [[Keloid]] scarring
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| * [[Chronic pain]] at incision sites
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| ===Videos on Spahenous Vein Graft Harvesting===
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| <youtube v=VbdE6JWdY1s/>
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| <br clear="left"/>
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| <youtube v=QthyR0bTHzc/>
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| <br clear="left"/>
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| <youtube v=sV-qE2SIkJU/>
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| <br clear="left"/>
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| ==Saphenous Vein Graft Nomenclature==
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| The terms ''single bypass'', ''double bypass'', ''triple bypass'', ''quadruple bypass'' and ''quintuple bypass'' refer to the number of coronary arteries bypassed in the procedure.
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| In other words, a double bypass means two coronary arteries are bypassed (e.g. the [[left anterior descending|left anterior descending (LAD)]] coronary artery and [[right coronary artery|right coronary artery (RCA)]]); a triple bypass means three vessels are bypassed (e.g. LAD, RCA, [[left circumflex artery|left circumflex artery (LCX)]]); a quadruple bypass means four vessels are bypassed (e.g. LAD, RCA, LCX, first diagonal artery of the LAD) while quintuple means five. Less commonly more than four coronary arteries may be bypassed.
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| A greater number of bypasses does not imply a person is "sicker," nor does a lesser number imply a person is "healthier."<ref>{{cite journal |author=Ohki S, Kaneko T, Satoh Y, ''et al'' |title=[Coronary artery bypass grafting in octogenarian] |language=Japanese |journal=Kyobu geka. The Japanese journal of thoracic surgery |volume=55 |issue=10 |pages=829–33; discussion 833–6 |year=2002 |pmid=12233100 |doi=}}</ref> A person with a large amount of [[coronary artery disease|coronary artery disease (CAD)]] may receive fewer bypass grafts owing to the lack of suitable "target" vessels.
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| ==Assessment of Target Vessels for Saphenous Vein Grafting==
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| A coronary artery may be unsuitable for bypass grafting if it is small (< 1 mm or < 1.5 mm depending on surgeon preference), heavily calcified (meaning the artery does not have a section free of CAD) or intramyocardial (the coronary artery is located within the heart muscle rather than on the surface of the heart). Similarly, a person with a single [[stenosis]] ("narrowing") of the [[Left coronary artery|left main]] coronary artery requires only two bypasses (to the LAD and the LCX). However, a left main lesion places a person at the highest risk for death from a cardiac cause.
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| Although the cardiothoracic surgeon reviews the [[coronary angiogram]] prior to surgery and identifies the lesions (or "blockages") in the coronary arteries and will estimate the number of bypass grafts prior to surgery, the final decision is made in the operating room upon examination of the heart and the suitability of the vessel for bypassing.
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| ==Pathophysiology of Saphenous Vein Graft Disease==
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| Several factors contribute to [[stenosis]] of [[saphenous vein grafts]], including [[intimal hyperplasia]], [[plaque]] formation, and graft remodeling. Additionally, arterialization of the graft accelerates [[atherosclerosis]]. Furthermore, [[atheroma]] found in [[SVGs]] are more friable (easily break into small pieces) and more prone to [[thrombus]] than [[plaques]] found in native vessels. Another reason why SVGs are more susceptible to [[thrombotic occlusion]] is that they lack side branches.
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| ==Saphenous Vein Graft Patency==
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| ===Definitions===
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| Saphenous vein graft occlusion is defined as a complete, 100% occlusion of a saphenous vein graft. <ref name="pmid16287955">{{cite journal |author=Alexander JH, Hafley G, Harrington RA, Peterson ED, Ferguson TB, Lorenz TJ, Goyal A, Gibson M, Mack MJ, Gennevois D, Califf RM, Kouchoukos NT |title=Efficacy and safety of edifoligide, an E2F transcription factor decoy, for prevention of vein graft failure following coronary artery bypass graft surgery: PREVENT IV: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=294 |issue=19 |pages=2446–54 |year=2005 |month=November |pmid=16287955 |doi=10.1001/jama.294.19.2446 |url= |issn= |accessdate=2010-07-12}}</ref>
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| Saphenous vein failure is defined as an occlusion of the vein graft or a 75% or greater stenosis.
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| The rate of occlusion or failure of saphenous vein grafts is calculated on a per graft basis and a per patient basis. The per patient basis is higher, because only one vein graft out of several must fail for the patient to be characterized as a failure. Analyses should be presented on both a per patient basis (the unit of randomization) and a per SVG basis (the unit that is associated with clinical events). Because the behavior of multiple SVGs may be correlated, and this within patient correlation may reduce the estimate of the variance in the population, an adjustment for the within patient correlation must be provided when presenting the results on a per SVG basis<ref name="pmid8462141">{{cite journal | author = Gibson CM, Kuntz RE, Nobuyoshi M, Rosner B, Baim DS | title = Lesion-to-lesion independence of restenosis after treatment by conventional angioplasty, stenting, or directional atherectomy. Validation of lesion-based restenosis analysis | journal = [[Circulation]] | volume = 87 | issue = 4 | pages = 1123–9 | year = 1993 | month = April | pmid = 8462141 | doi = | url = http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=8462141 | issn = | accessdate = 2010-10-31}}</ref>. The within patient conocrdance can be adjusted for using a General Linear Model of Intraclass Correlation (GLIMIC) <ref name="pmid8462141">{{cite journal | author = Gibson CM, Kuntz RE, Nobuyoshi M, Rosner B, Baim DS | title = Lesion-to-lesion independence of restenosis after treatment by conventional angioplasty, stenting, or directional atherectomy. Validation of lesion-based restenosis analysis | journal = [[Circulation]] | volume = 87 | issue = 4 | pages = 1123–9 | year = 1993 | month = April | pmid = 8462141 | doi = | url = http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=8462141 | issn = | accessdate = 2010-10-31}}</ref>.
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| Current rates of graft occlusion and failure are as follows:<ref name="pmid16287955">{{cite journal |author=Alexander JH, Hafley G, Harrington RA, Peterson ED, Ferguson TB, Lorenz TJ, Goyal A, Gibson M, Mack MJ, Gennevois D, Califf RM, Kouchoukos NT |title=Efficacy and safety of edifoligide, an E2F transcription factor decoy, for prevention of vein graft failure following coronary artery bypass graft surgery: PREVENT IV: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=294 |issue=19 |pages=2446–54 |year=2005 |month=November |pmid=16287955 |doi=10.1001/jama.294.19.2446 |url= |issn= |accessdate=2010-07-12}}</ref>
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| The rate of '''per patient vein graft occlusion''' at 12-18 months is about 42%
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| The rate of '''per patient vein graft failure''' at 12-18 months is about 46%
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| The rate of '''per graft vein graft occlusion''' at 12-18 months is about 26%
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| The rate of '''per graft vein graft failure''' at 12-18 months is about 29%
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| As a comparison, the rate of [[internal mammary artery]] failure at 12-18 months was only 8%.
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| ===Determinants of Sapheous Vein Graft Patency===
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| 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 vein]]s and may go into spasm if handled improperly.
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| ====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]]).
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| ====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.
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| 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.<ref>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.</ref><ref>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. [http://www.jstage.jst.go.jp/article/circj/69/8/896/_pdf].</ref>
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| ====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.<ref name="pmid19605828">{{cite journal |author=Lopes RD, Hafley GE, Allen KB, Ferguson TB, Peterson ED, Harrington RA, Mehta RH, Gibson CM, Mack MJ, Kouchoukos NT, Califf RM, Alexander JH |title=Endoscopic versus open vein-graft harvesting in coronary-artery bypass surgery |journal=[[The New England Journal of Medicine]] |volume=361 |issue=3 |pages=235–44 |year=2009 |month=July |pmid=19605828 |doi=10.1056/NEJMoa0900708 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=19605828&promo=ONFLNS19 |issn= |accessdate=2010-07-12}}</ref> 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.
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| ==Saphenous Vein Graft Diseases==
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| ===Saphenous Vein Graft Aneurysms===
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| It is also known as SVGA, aortocoronary saphenous vein graft aneurysms, saphenous vein graft aneurysm disease and saphenous vein graft aneurysmal dilatation.
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| =====Causes of Saphenous Vein Graft Aneurysms=====
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| * [[Atherosclerosis]]
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| * [[Hypertension]]
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| * Mycotic
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| * Postoperative [[mediastinitis]]
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| * Previous aneurysms
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| * Torn sutures
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| ===Amyloidosis of Saphenous Coronary Bypass Grafts===
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| Amyloid has been associated with accelarated disease in saphenous vein grafts.<ref>Marti MC, Bouchardy B, Cox JN. Aortocoronary bypass with autogenous saphenous vein grafts: histopathological aspects. Virchows Arch Abt A Path Anat 1971; 352: 255–66.</ref> <ref>Garrett HE, Dennis EW, DeBakey ME. Aortocoronary bypass with saphenous vein graft. JAMA 1973; 223: 792–4.</ref> <ref>Zemva A, Ferluga D, Zorc M, Popovic M, Porenta OV, Radovanovic N. Amyloidosis in saphenous vein aortocoronary bypass grafts. J Cardiovasc Surg 1990; 31: 441–4.</ref> <ref>Salerno TA, Wasan SM, Charrette EJ. Prospective analysis of heart biopsies in coronary artery surgery. Ann Thorac Surg 1979; 28: 436–9.</ref> <ref>Pelosi F, Capehart J, Roberts WC. Effectiveness of cardiac transplantation for primary (AL) cardiac amyloidosis. Am J Cardiol 1997; 79: 532–5.</ref>
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| ===Rupture of the Saphenous Vein Coronary Artery Bypass Grafts===
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| Aspergillus species causing a necrotizing [[vasculitis]] have been associated with rupture of a saphenous vein grafts.
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| ==Diagnosis and Evaluation of SVG Disease== | | ==Diagnosis and Evaluation of SVG Disease== |
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| ===Chest X-Ray=== | | =====[[Symptoms of SVG Occlusion|Symptoms]]===== |
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| In a patient who has undergone CABG, a [[chest X-ray]] will demonstrate multiple small clips near the heart and coronary arteries. Large circular sternal wires will also be seen. Examples are shown in the images below.
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| [http://www.radswiki.net Images courtesy of RadsWiki] | |
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| <gallery>
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| Image:CABG-clips-001.jpg|Median sternotomy wires and CABG clips
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| Image:CABG-clips-002.jpg|Lateral graphy: Median sternotomy wires and CABG clips
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| </gallery>
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| ===Coronary Angiography===
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| Coronary angiography is often used to ascertain the patency and percent stenoses of saphenous vein grafts.
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| ====Technique====
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| Most often a Judkin's Right 4 catheter (JR 4) catheter is used to engage the saphenous vein grafts. If this diagnostic catheter has insufficient "reach" to engage the SVG ostium, then an Amplatz catheter can be used. The optimal view to engage the ostium of the SVG varies from operator to operator. The most popular views to engage the ostium are the left anterior oblique 45 degrees view (LAO 45) with no cranial angulation. Some operator will use the right anterior oblique view (RAO) with 45 degrees of angulation and no cranial angulation. It should be noted that the SVGs supplying the left coronary arteries will come off of the left hand side of the screen and those supplying the right coronary artery will come off of the right hand side of the screen.
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| If an SVG is known from the operative report to exist, but cannot be selectively engaged, then a non-selective aortogram can be performed to aid in identifying the presence and location of patent SVGs. The aortogram is performed with an injection through an angled pigtail catheter with the camera gantry located in the 45 degree left anterior oblique (LAO) position with no cranial angulation.
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| In order to engage the [[left internal mammary artery]] (which is not a saphenous vein graft but is often interrogated during the process of evaluating SVGs), a view with slight cranial, and slight left anterior oblique (LAO) angulation is used. a Judkin's Right 4 catheter (JR 4) catheter is used to engage the ostium of the [[subclavian artery]]. With the catheter near the anticipated origin of the [[subclavian artery]], a counterclockwise motion of the catheter is needed to engage the ostium. Once the ostium is engaged, an '''''exchange length''''' 0.038 J tipped wire is then advance into the [[subclavian artery]]. A [[left internal mammary artery]] ([[LIMA]]) catheter is then exchanged to engage the origin of the [[left internal mammary artery]]. Again, this engagement is accomplished with counterclockwise motion of the catheter. An injection with the camera in this angulation is a suitable first view of the [[LIMA]], with careful attention in this view paid to the ostium of the [[LIMA]]. the next view is often a left anterior oblique (LAO) view with 90 degrees of angulation (LAO 90). This allows for accurate assessment of the [[LIMA]] anastomosis to the [[left anterior descending artery]].
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| ====Impact of saphenous vein graft radiographic markers on clinical events and angiographic parameters====
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| One technique that has been used to improve the ascertainment of SVG patency and stenosis is the placement of radio-opaque markers. Use of such markers has been associated with shorter cardiac catheterization procedure times and reduced contrast agent volume for postoperative coronary artery bypass graft (CABG) catheterizations. In the large PREVENT 4 study <ref name="pmid16287955">{{cite journal |author=Alexander JH, Hafley G, Harrington RA, Peterson ED, Ferguson TB, Lorenz TJ, Goyal A, Gibson M, Mack MJ, Gennevois D, Califf RM, Kouchoukos NT |title=Efficacy and safety of edifoligide, an E2F transcription factor decoy, for prevention of vein graft failure following coronary artery bypass graft surgery: PREVENT IV: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=294 |issue=19 |pages=2446–54 |year=2005 |month=November |pmid=16287955 |doi=10.1001/jama.294.19.2446 |url= |issn= |accessdate=2010-07-12}}</ref><ref name="pmid18222256">{{cite journal | author = Olenchock SA, Karmpaliotis D, Gibson WJ, Murphy SA, Southard MC, Ciaglo L, Buros J, Mack MJ, Alexander JH, Harrington RA, Califf RM, Kouchoukos NT, Ferguson TB, Gibson CM | title = Impact of saphenous vein graft radiographic markers on clinical events and angiographic parameters | journal = [[The Annals of Thoracic Surgery]] | volume = 85 | issue = 2 | pages = 520–4 | year = 2008 | month = February | pmid = 18222256 | doi = 10.1016/j.athoracsur.2007.10.061 | url = http://linkinghub.elsevier.com/retrieve/pii/S0003-4975(07)02191-1 | issn = | accessdate = 2010-10-31}}</ref>, approximately half the patients had SVG markers present (51.2% or 910 of 1,778 patients) and half the SVGs (52.3% of SVGs or 2,228 of 4,240). If the patient had a totally occluded SVG (n = 911), visual identification of the occluded SVG was obtained more frequently among those patients who had an SVG marker (90.7% vs 72.1%, p < 0.001). The identification of SVG stenosis which were <u>></u> 70% did not differ by the use of SVG markers (25.8% with marker vs 24.4% without marker, p = not significant). These findings were also consistent in ostial lesions (n = 942). The use of an SVG marker was not associated with a difference in the long-term risk of death or myocardial infarction (MI). However, it was noted that the rate of perioperative CABG MI was higher among patients who had an SVG marker (10.1% vs 5.5%, odds ratio adjusted 1.86, p = 0.021).
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| ====Use of Coronary Angiography of Saphenous Vein Graft Disease as Endpoint in Clinical Trials Evaluating Pharmacotherapy and Device Based Therapies==== | |
| =====SVG Patency and SVG Narrowing as a Surrogate Endpoint for Clinical Events=====
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| One issue that arises is the suitability of SVG patency, and SVG narrowing as a [[surrogate endpoint]] for clinical events.
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| =====Potential for Ascertainment Bias=====
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| There are several issues that arise with respect to ascertainment bias in the use of coronary angiograms as an endpoint.
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| #'''The patient may not return for follow-up angiography.''' Maybe the patient is feeling so well they don't feel compelled to return for repeat angiography (you missed a positive treatment effect), or maybe they are so sick they can't show up (you missed a negative treatment effect). If patients died, traditionally they are counted or imputed as having SVG failure on both a per patient and a per SVG conduit basis. The percent of patients who returned for follow-up angiography was 80% in the PREVENT 4 study <ref name="pmid16287955">{{cite journal |author=Alexander JH, Hafley G, Harrington RA, Peterson ED, Ferguson TB, Lorenz TJ, Goyal A, Gibson M, Mack MJ, Gennevois D, Califf RM, Kouchoukos NT |title=Efficacy and safety of edifoligide, an E2F transcription factor decoy, for prevention of vein graft failure following coronary artery bypass graft surgery: PREVENT IV: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=294 |issue=19 |pages=2446–54 |year=2005 |month=November |pmid=16287955 |doi=10.1001/jama.294.19.2446 |url= |issn= |accessdate=2010-07-12}}</ref>
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| # '''The patient may return for follow-up angiography, but one or more of the SVGs cannot be engaged and selectively injected.''' As stated above, in the PREVENT 4 study, the use of saphenous vein graft markers improved the odds of finding SVGs in particular occluded SVGs <ref name="pmid18222256">{{cite journal | author = Olenchock SA, Karmpaliotis D, Gibson WJ, Murphy SA, Southard MC, Ciaglo L, Buros J, Mack MJ, Alexander JH, Harrington RA, Califf RM, Kouchoukos NT, Ferguson TB, Gibson CM | title = Impact of saphenous vein graft radiographic markers on clinical events and angiographic parameters | journal = [[The Annals of Thoracic Surgery]] | volume = 85 | issue = 2 | pages = 520–4 | year = 2008 | month = February | pmid = 18222256 | doi = 10.1016/j.athoracsur.2007.10.061 | url = http://linkinghub.elsevier.com/retrieve/pii/S0003-4975(07)02191-1 | issn = | accessdate = 2010-10-31}}</ref>. However, the SVG stenosis 70% or greater at follow-up did not differ by use of markers (25.8% with marker vs 24.4% without marker, p = not significant). In other words, there does not seem to be ascertainment bias whereby failure to find the SVG results in a different outcome (the outcomes in patients with SVG markers with a greater degree of ascertainment of the endpoint were no different).
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| =====Per Patient versus Per SVG as the Unit of Analysis=====
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| Analyses should be presented on both a per patient basis (the unit of randomization) and a per SVG basis (the unit that is associated with clinical events). Because the behavior of multiple SVGs may be correlated, and this within patient correlation may reduce the estimate of the variance in the population, an adjustment for the within patient correlation must be provided when presenting the results on a per SVG basis<ref name="pmid8462141">{{cite journal | author = Gibson CM, Kuntz RE, Nobuyoshi M, Rosner B, Baim DS | title = Lesion-to-lesion independence of restenosis after treatment by conventional angioplasty, stenting, or directional atherectomy. Validation of lesion-based restenosis analysis | journal = [[Circulation]] | volume = 87 | issue = 4 | pages = 1123–9 | year = 1993 | month = April | pmid = 8462141 | doi = | url = http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=8462141 | issn = | accessdate = 2010-10-31}}</ref>. The within patient conocrdance can be adjusted for using a General Linear Model of Intraclass Correlation (GLIMIC) <ref name="pmid8462141">{{cite journal | author = Gibson CM, Kuntz RE, Nobuyoshi M, Rosner B, Baim DS | title = Lesion-to-lesion independence of restenosis after treatment by conventional angioplasty, stenting, or directional atherectomy. Validation of lesion-based restenosis analysis | journal = [[Circulation]] | volume = 87 | issue = 4 | pages = 1123–9 | year = 1993 | month = April | pmid = 8462141 | doi = | url = http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=8462141 | issn = | accessdate = 2010-10-31}}</ref>.
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| ===CT Angiography===
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| ===MR Angiography===
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| ===Postmortem Angiography===
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| [http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]
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| <gallery>
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| Image:Postmortem angiography saphenous vein graft 001.jpg
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| Image:Postmortem angiography saphenous vein graft 002.jpg
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| </gallery>
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| ===Pathological Findings=== | | =====[[Chest X-Ray in the Patient with Saphenous Vein Grafts|Chest X-Ray]]===== |
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| [http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology] | | =====[[CT Angiography in the Assessment of Saphenous Vein Graft Disease|CT]]===== |
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| <gallery perRow="3">
| | =====[[Cardiac Catheterization]]===== |
| Image:Saphenous vein graft 001.jpg|Saphenous vein coronary bypass graft: Gross, natural color, external view of heart with thrombosed veins
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| Image:Saphenous vein graft 002.jpg|Saphenous vein coronary bypass graft: Thrombosis, Acute: Gross, fixed tissue but well shown cross sections of bypass graft and anastomotic site with thrombosis. 61 yo male, with and acute infarct treated with streptokinase and two days later had bypass. Died 5 days post op. Two veins are thrombosed
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| Image:Saphenous vein graft 003.jpg|Myocardial Infarct Acute Reflow Type: Gross, fixed tissue but good color. A very enlarged heart with moderate LV dilation and high anterior wall hemorrhagic infarct. Initially treated with streptokinase and two days later had saphenous vein grafts. Both grafts are thrombosed. He died after 5 days
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| </gallery>
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| ==Treatment== | | =====[[Saphenous Vein Graft Pathology|Pathology]]===== |
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| | ==Saphenous Vein Graft Failure and Patency== |
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| | =====[[Definition of Saphenous Vein Graft Failure]]===== |
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| ==Goals of Treatment== | | =====[[Historical Rates of Saphenous Vein Graft Failure]]===== |
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| Primarily, the goal should be to detect and treat a [[SVG]] [[stenosis]] early in the development of [[ischemia]] while the [[SVG]] is still [[patency|patent]]. Although intervention on a chronic total occlusion of a [[SVG]] may seem like an effective treatment strategy, it is best avoided. As long as the [[SVG]] is not completely [[occlusion|occluded]], intervention can be performed.
| | =====[[Determinants of Sapheous Vein Graft Patency]]===== |
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| Two additional overall goals of treating [[SVG]] [[stenosis]] include the resolution of symptomatic [[ischemia]] and the prevention/treatment of [[embolism|distal embolization]].
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| ==Treatment Options==
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| There are many different choices to consider when deciding the most appropriate treatment for [[SVG]] [[stenosis]], including [[PTCA]], [[PCI]] with [[bare metal stent|bare metal]] or [[drug-eluting stents]], [[PCI]] with covered [[stents]], embolic protection devices, [[debulking]]/[[thrombus]] removal, and surgical [[revascularization]].
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| ===Percutaneous Transluminal Coronary Angioplasty (PTCA)=== | |
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| [[PTCA]] has high initial [[revascularization]] success rates in the treatment of SVG [[stenosis]]. However, it is also associated with high rates of periprocedural complications, including acute vessel closure secondary to [[dissection]] and in-situ [[thrombosis]]. Additional complications include [[embolism|distal embolization]] and [[no reflow]], which can lead to periprocedural [[infarction]]. | |
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| In modern [[interventional cardiology]], [[PTCA]] is not often used as the sole means of treatment for SVG [[stenosis]]. Instead, [[stenting]] has become the cornerstone of treatment, while the use of [[PTCA]] has been limited to pre-dilation and post-dilation.
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| ===PCI with Bare Metal Stents (BMS) or Drug-eluting Stents (DES)===
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| Most current vein graft treatment strategies utilize PCI with stents ([[BMS]] or [[DES]]), since stenting is a superior treatment when compared to [[PTCA]] alone. As demonstrated in the SAVED (Saphenous Vein De Novo) Trial<ref name="pmid9287229">{{cite journal |author=Savage MP, Douglas JS, Fischman DL, ''et al.'' |title=Stent placement compared with balloon angioplasty for obstructed coronary bypass grafts. Saphenous Vein De Novo Trial Investigators |journal=N. Engl. J. Med. |volume=337 |issue=11 |pages=740–7 |year=1997 |month=September |pmid=9287229 |doi= |url=}}</ref>, the use of [[stents]] is associated with higher [[revascularization]] success rates, decreased [[restenosis]] rates, and improved clinical outcomes when compared to [[PTCA]]. Generally, [[DES]] are preferred over [[BMS]], since [[DES]] are associated with reduced rates of [[restenosis]] and target vessel [[revascularization]].
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| Despite their higher success rates, stents are not immune to [[restenosis]]. Predictors for [[restenosis]] include long [[stent]] length, multiple [[stents]], overlapping [[stents]], smaller vessel size, [[diabetes mellitus]], and [[stenosis]] at the coronary or aortic [[anastomosis]].
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| ===PCI with Covered Stents===
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| Theoretically, [[stents]] covered with a polymer membrane would have higher success rates than standard [[BMS]] and [[DES]]. One would expect covered stents to effectively trap friable [[atheroma]] and isolate the graft [[Lumen (anatomy)|lumen]] from the diseased wall, thereby reducing incidence of [[restenosis]], distal [[embolization]], and [[no reflow]] in comparison to traditional [[stents]]. However, the RECOVERS (The Randomized Evaluation of polytetrafluoroethylene COVERed stent in Saphenous vein grafts)<ref name="pmid12821546">{{cite journal |author=Stankovic G, Colombo A, Presbitero P, ''et al.'' |title=Randomized evaluation of polytetrafluoroethylene-covered stent in saphenous vein grafts: the Randomized Evaluation of polytetrafluoroethylene COVERed stent in Saphenous vein grafts (RECOVERS) Trial |journal=Circulation |volume=108 |issue=1 |pages=37–42 |year=2003 |month=July |pmid=12821546 |doi=10.1161/01.CIR.0000079106.71097.1C |url=}}</ref> and STING (STents IN Grafts)<ref name="pmid14563575">{{cite journal |author=Schächinger V, Hamm CW, Münzel T, ''et al.'' |title=A randomized trial of polytetrafluoroethylene-membrane-covered stents compared with conventional stents in aortocoronary saphenous vein grafts |journal=J. Am. Coll. Cardiol. |volume=42 |issue=8 |pages=1360–9 |year=2003 |month=October |pmid=14563575 |doi= |url=}}</ref> trials did not show any advantage in using covered [[stents]] when compared to [[bare metal stents]] for [[SVG lesions]].
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| ===Embolic Protection Devices===
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| During [[PCI]] of [[SVGs]], [[Atheroembolism|atheroembolic]] debris can be liberated. This debris contains [[vasoactive]] substances that can contribute to [[no reflow]], which can in turn considerably increase the risk of major adverse clinical events (MACE)<ref name="pmid16264199">{{cite journal |author=Salloum J, Tharpe C, Vaughan D, Zhao DX |title=Release and elimination of soluble vasoactive factors during percutaneous coronary intervention of saphenous vein grafts: analysis using the PercuSurge GuardWire distal protection device |journal=J Invasive Cardiol |volume=17 |issue=11 |pages=575–9 |year=2005 |month=November |pmid=16264199 |doi= |url=}}</ref>. Fortunately, embolic protection devices help capture this debris and improve outcomes in [[PCI]] for [[SVG]] [[stenosis]]. Therefore, it is recommended that these devices should be utilized in the intervention of most [[SVG]] lesions.
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| Currently, the [[FDA]] has approved five embolic protection devices in the United States. Specifically, these devices include one distal occlusion device, three filters, and one proximal occlusion device.
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| The FDA-approved distal occlusion device is called the PercuSurge Guardwire®, which involves inflating a balloon distal to the [[stenosis]] to occlude flow, thereby trapping the debris and [[vasoactive]] substances and preventing them from flowing downstream. Due to its small size, it requires little landing zone to deploy. The SAFER (Saphenous vein graft Angioplasty Free of Emboli Randomized) trial<ref name="pmid11901037">{{cite journal |author=Baim DS, Wahr D, George B, ''et al.'' |title=Randomized trial of a distal embolic protection device during percutaneous intervention of saphenous vein aorto-coronary bypass grafts |journal=Circulation |volume=105 |issue=11 |pages=1285–90 |year=2002 |month=March |pmid=11901037 |doi= |url=}}</ref> showed that when compared to conventional guidewires, balloon occlusion devices (PercuSurge Guardwire®) reduced the rates of infarction and [[no-reflow]] after intervention. Despite these advantages, the PercuSurge Guardwire® may not be the best option for all, as some patients may not tolerate the necessary 3-5 minutes of [[ischemic]] time associated with this device. Additionally, it is known to cause both [[hemodynamic]] and arrhythmic complications.
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| Filter devices allow continual distal perfusion while macroscopic [[emboli]] are trapped in the filter. The FIRE (FilterWire EX During Transluminal Intervention of Saphenous Vein Grafts) trial<ref name="pmid12874191">{{cite journal |author=Stone GW, Rogers C, Hermiller J, ''et al.'' |title=Randomized comparison of distal protection with a filter-based catheter and a balloon occlusion and aspiration system during percutaneous intervention of diseased saphenous vein aorto-coronary bypass grafts |journal=Circulation |volume=108 |issue=5 |pages=548–53 |year=2003 |month=August |pmid=12874191 |doi=10.1161/01.CIR.0000080894.51311.0A |url=}}</ref><ref name="pmid16569562">{{cite journal |author=Halkin A, Masud AZ, Rogers C, ''et al.'' |title=Six-month outcomes after percutaneous intervention for lesions in aortocoronary saphenous vein grafts using distal protection devices: results from the FIRE trial |journal=Am. Heart J. |volume=151 |issue=4 |pages=915.e1–7 |year=2006 |month=April |pmid=16569562 |doi=10.1016/j.ahj.2005.09.018 |url=}}</ref> showed that FilterWire may be preferred over PercuSurge Guardwire® due to improved clinical outcomes. While they may reduce [[ischemic]] time, filter devices are associated with their own set of potential complications. They are more difficult to deliver than balloon [[occlusion]] devices, so their own delivery may lead to distal [[embolization]], and they may not trap microscopic mediators of [[no reflow]]. Additionally, they require a significant landing zone distal to the [[lesion]] for the filter placement, which can be problematic for certain distal lesions that do not have enough room. There have also been case reports of filter entrapment in the [[Great saphenous vein#Use in cardiovascular procedures|graft]] after the completion of the [[PCI]].
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| The FDA-approved proximal occlusion device is called the Proxis® device. Some advantages of this decide are that its deployment does not require crossing the [[stenosis]], it provides superior support that is helpful where balloon or [[stent]] delivery is difficult, and it provides protected crossing of the [[lesion]], if required. However, as shown by the PROXIMAL (Proximal Protection During Saphenous Vein Graft Intervention Using the Proxis Embolic Protection System) trial<ref name="pmid17919563">{{cite journal |author=Mauri L, Cox D, Hermiller J, ''et al.'' |title=The PROXIMAL trial: proximal protection during saphenous vein graft intervention using the Proxis Embolic Protection System: a randomized, prospective, multicenter clinical trial |journal=J. Am. Coll. Cardiol. |volume=50 |issue=15 |pages=1442–9 |year=2007 |month=October |pmid=17919563 |doi=10.1016/j.jacc.2007.06.039 |url=}}</ref>, in terms of overall outcomes, there is no significant difference in death, [[MI]], or target vessel [[revascularization]] (TVR) between distal and proximal [[embolic]] protection devices.
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| ===Debulking/Thrombus Removal===
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| Data has not demonstrated a durable clinical benefit associated with [[debulking]]/[[thrombus]] removal. However, there are certain situations in which [[debulking]] techniques may be useful when treating [[saphenous vein grafts]]. For instance, severely [[calcified]] and [[stenotic]] [[lesions]] can make regular [[stent]] insertion especially difficult. When [[SVG]] [[lesions]] are too [[calcified]] to be crossed by a balloon or adequately dilated prior to [[stent]] placement, [[debulking]] and [[thrombus removal]] can change the compliance of the vessel wall. In addition, this technique is also useful if a [[lesion]] is at the aorto-ostial junction. Adjunctive stenting leads to better short and long term results.
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| There are several [[debulking]]/[[thrombus]] removal techniques, including directional coronary atherectomy, transluminal extraction catheter thrombectomy, rotational atherectomy, and laser atherectomy.
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| * Directional coronary atherectomy (DCA) uses a circular cutting blade that excises [[atheroma]] into a chamber for removal. It is useful for aorto-ostial [[lesions]] and focal [[lesions]] in large vessels. However, due to its bulky nature, it is generally not used in vessels with [[angulation]], [[tortuosity]], or heavy [[calcification]]. CAVEAT II (Coronary Angioplasty Versus Excisional Atherectomy Trial)<ref name="pmid7895354">{{cite journal |author=Holmes DR, Topol EJ, Califf RM, ''et al.'' |title=A multicenter, randomized trial of coronary angioplasty versus directional atherectomy for patients with saphenous vein bypass graft lesions. CAVEAT-II Investigators |journal=Circulation |volume=91 |issue=7 |pages=1966–74 |year=1995 |month=April |pmid=7895354 |doi= |url=}}</ref> examined how PTCA and DCA compared in the treatment of patients with coronary artery bypass graft stenoses. This study demonstrated that DCA was associated with higher initial angiographic success rates and larger acute luminal dimensions in comparison to PTCA. However, despite these successes, DCA also displayed an increased rate of non-Q wave myocardial infusion and distal embolization than PTCA. Furthermore, both techniques displayed similar [[restenosis]] rates.
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| :Additionally, a retrospective study compared DCA vs. [[PTCA]] alone vs. [[PCI]] with stenting in [[SVG]] lesions. It showed no differences in [[mortality]], [[angina]], [[infarction]], or repeat [[revascularization]] among the different methods. However, this study displayed increased angiographic complications with DCA use.
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| * Transluminal extraction catheter (TEC) thrombectomy is designed to remove [[thrombus]] from [[SVGs]] prior to stenting. It operates through the use of cutting blades with a rotating catheter and an external suction device. However, because the TEC Best trial showed no benefit of TEC prior to the stenting of [[SVGs]], this technique has fallen out of favor. Furthermore, TEC is also associated with a significant incidence of distal [[embolization]] and [[no reflow]].
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| * Rotational atherectomy (RA) uses a rotating cutting blade to grind [[calcified]] [[atheroma]]. Despite its ability to grind [[calcification]], this method is associated with high rates of [[no reflow]], distal [[embolization]], [[perforation]], and [[dissection]]. Furthermore, this method is [[contraindicated]] for [[lesions]] located in the body of [[SVGs]] or in degenerated vein grafts.
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| * Laser atherectomy uses [[monochromatic]] light energy to disrupt [[plaques]]. Despite this approach's innovation, there is no evidence that this strategy improves outcomes in lesions, and it has been complicated by high rates of [[dissection]] and [[perforation]].
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| ===Surgical Revascularization===
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| Given increased perioperative [[mortality]], surgical revascularization is not an optimal treatment strategy, as many patients with [[graft disease]] are poor surgical candidates. However, surgery may be required in patients with multi-vessel disease and when [[PCI]] fails.
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| Additionally, reoperation is not strongly encouraged, as it does not provide the same level of [[revascularization]] and resolution of [[angina]] as the initial procedure. Furthermore, a [[LIMA]] may be jeopardized in a reoperation.
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| ==Making a Selection==
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| At the earliest signs of recurrent [[ischemia]], it is important to strongly consider the possibility of a patent but [[stenosed]] [[SVG]], so that the graft [[lesion]] can be treated before the graft becomes completely [[occluded]]. Prompt treatment is essential, since a graft is lost once it becomes completely occluded.
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| Regardless of treatment choice, all patients should be given [[statins]] and [[aspirin]] (begun immediately following [[CABG]]), which are effective in the secondary prevention of [[SVG]] [[stenosis]].
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| For most [[SVG]] [[lesions]], [[PCI]] with [[stenting]] appears to be the therapy of choice. [[DES]] are associated with a decreased [[restenosis]] rate over [[BMS]], and should be used preferentially if the patient is able to tolerate dual platelet therapy for a minimum of a year. Furthermore, [[embolic]] protection devices should be strongly considered for all [[SVG]] [[lesions]], especially those with high risks for distal [[embolization]].
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| In cases in which [[stent]] delivery and expansion may be difficult due to heavily [[calcified]] and [[stenotic]] [[lesions]], [[atherectomy]] devices, used with stenting, may be considered. Furthermore, these devices can be useful in [[lesions]] that are aorto-ostial.
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| Zoghbi et al. conducted a study to investigate the role of pretreatment with [[nitroprusside]] before [[SVG]] intervention<ref name="pmid19182287">{{cite journal |author=Zoghbi GJ, Goyal M, Hage F, ''et al.'' |title=Pretreatment with nitroprusside for microcirculatory protection in saphenous vein graft interventions |journal=J Invasive Cardiol |volume=21 |issue=2 |pages=34–9 |year=2009 |month=February |pmid=19182287 |doi= |url=}}</ref>. They studied sixty-four consecutive patients with normal preprocedural cardiac [[enzymes]] that underwent [[SVG]] [[PCI]], without the use of [[embolic]] protection devices. They found that pretreatment with [[nitroprusside]] results in a lower magnitude and frequency of post-procedural cardiac [[enzyme]] elevation. Thus, it is important to consider [[nitroprusside]] use.
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| Finally, while [[Glycoprotein IIb/IIIa inhibitors|GP IIb/IIIa inhibitors]] are frequently used in the setting of [[SVG]] intervention, their benefit has not been fully evaluated in randomized trials of this lesion subset.
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| ==Other Concerns== | |
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| As with all medical procedures, complications for [[SVG]] intervention can occur. Risk factors for complications include: older [[graft]] age (>3-5 years), the presence of [[thrombus]], and diffuse disease.
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| Although [[PCI]] with [[stenting]] is effective for focal lesions, there is uncertainty regarding the best treatment for diffusely degenerated [[SVGs]]. In these cases, it is often a better choice to abandon the [[graft]] and intervene on the native vessel instead.
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| As mentioned above, prevention of [[no reflow]] should be attempted with [[embolic]] protection devices, pretreatment using [[nitroprusside]] and the avoidance of high-pressure inflations and unnecessary pre/post-dilation and oversizing. However, in the event that [[no reflow]] develops, it should be aggressively managed with intracoronary [[vasodilators]] (i.e. [[diltiazem]], [[nicardipine]], [[adenosine]], and [[nitroprusside]]).
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| | =====[[Saphenous vein graft failure as a Surrogate Endpoint in Clinical Trials]]===== |
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| | ==[[Saphenous vein graft disease treatment|Treatment]]== |
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| | ====[[Saphenous vein graft disease treatment#2011 ACCF/AHA/SCAI Guideline Recommendations: Saphenous vein grafts|2011 ACCF/AHA/SCAI Guideline Recommendations]]==== |
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| ==Clinical Trials== | | ==Clinical Trials== |
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| * [http://clinicaltrials.gov/ct2/show/NCT00777777 The eSVS (TM) Mesh External Saphenous Vein Support Trial] | | * [http://clinicaltrials.gov/ct2/show/NCT00777777 The eSVS (TM) Mesh External Saphenous Vein Support Trial] |
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| ==References== | | ==Related Chapters== |
| {{Reflist|2}} | | * [[Percutaneous Coronary Intervention (PCI): Basic Principles and Guidelines]] |
| | * [[CABG]] |
| | * [[Hybrid bypass]] |
| | * [[Off-pump coronary artery bypass surgery|Off-pump coronary artery bypass surgery (OPCAB)]] |
| | * [[Minimally invasive direct coronary artery bypass surgery]] ([[MIDCAB]]) |
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| | ==Guideline Resources== |
| | *[http://content.onlinejacc.org/cgi/reprint/58/24/2550.pdf 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions]<ref name="pmid22070837">{{cite journal |author=Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH |title=2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions |journal=[[Journal of the American College of Cardiology]] |volume=58 |issue=24 |pages=2550–83 |year=2011 |month=December |pmid=22070837 |doi=10.1016/j.jacc.2011.08.006 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)02875-0 |accessdate=2011-12-08}}</ref> |
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| ==Additional Resources== | | ==Additional Resources== |
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| {{refend}} | | {{refend}} |
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| ==See Also== | | ==References== |
| | | {{Reflist|2}} |
| * [[CABG]]
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| * [[Hybrid bypass]]
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| * [[Off-pump coronary artery bypass surgery|Off-pump coronary artery bypass surgery (OPCAB)]]
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| * [[Minimally invasive direct coronary artery bypass surgery]] ([[MIDCAB]])
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| ==External Links==
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| *[http://www.texheartsurgeons.com/ Advances in Cardiovascular Surgery and Cardiothoracic Surgical Procedures]
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| *[http://www.ctsnet.org/ CTSNet: The Cardiothoracic Surgery Network]
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| *[http://info.med.yale.edu/intmed/cardio/imaging/ Yale: Introduction to Cardiothoracic Imaging]
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| {{SIB}} | |
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| [[Category:Cardiology]] | | [[Category:Cardiology]] |
