[HSF] AATS

Sun May 18 18:18:06 EDT 2008

Ani,

The patentcy of vein grafts has a lot to do with their inconsistency. If we can rank the vein graft quality and check their patency rate, we may find some relationship. In my practice, some surgeons will use any vein for graft and some are very picky. 

If you put good quality veins or arterial grafts on those important targets (usually 2-3), patient usually do well. 

If I do not have a good graft on everyone of those important vessels, I will not hesitate to take a RIMA or radial even on bypass or with aorta clamped.

Zhandong Zhou

Sent via BlackBerry by AT&T

-----Original Message-----
From: Ani Anyanwu <anianyanwu at hotmail.com>

Date: Sun, 18 May 2008 13:26:59 
To:<openheart-l at lists.hsforum.com>
Subject: RE: [HSF] AATS

Don, Hal, Michael et al

We are influenced by preconceptions - that is the essence of decision making. What differs is what that preconception is and how much weight we add to it. I must agree that my preconception here is that all veins are bad so that is my bias.

My suggestion of low vein graft patency is not however a preconception but based on fact. If you were to study data from the 1980s and 1990s, most studies you will come across found a vein graft patency of 85 to 90%. However, if you look at contemporary multicentre US studies published in last 5 years that included graft patency as an outcome, the story is different with patency of 70%.

Hal - you may *think* your vein graft patency has remained constant over the years, but I seriously doubt that is the case and that if you performed angiograms you would surprised at how many of your patients are walking around, many asymptomatic, with blocked grafts. Before I go into any data, think back Hal on those patients you operate on (done elsewhere or by you) for ischemic MR following previous CABG - have you not come across several with grafts down to circumflex or RCA within a year or two of surgery? We certainly have. 

For anyone who wants data, a good starting point is the recent analysis from Prevent IV trial published recently in annals. Magee et al Annals of Thoracic SurgeryVolume 85, Issue 2, February 2008, Pages 494-500. This included data from over 3000 CABGs done 2002-3 in 107 US centers so I find it hard to believe this will not be generalizable to the most of the US. About 2,000 (over 4,000) had one-year angiograms as per study protocol. The results? A stunning 46% of patients on-pump and 45% off-pump had at least one vein graft stenosed within a year of surgery. Analysis by graft, rather than patient, showed 25% of veins, both on or off-pump, were stenosed within a year of surgery (IMA failure rate 8%). The authors looked for predictors of vein graft stenosis and guess what? Endoscopic harvest was a predictor of early failure of vein graft, more so with off-pump (odds-ratio 1.8) than on-pump (odss ratio 1.3). This is very believable and I suspect is the case in all our centers.

Michael - while quality of targets may have a role, do not for one second think US patients have the worst quality in terms of conduit or distals. Speak to Prasanna and he might give you a different perspective. Indeed one of the things that struck me on moving from the UK to the US was the abundance of good quality distals to graft here, as opposed to the tiny indian vessels typical of west london. I doubt one could explain decreasing vein graft patency on quality of conduits and targets alone.

Biologically too there are reasons to believe endoscopic harvest is inferior and that initial intimal disruption does predispose to vein graft thrombosis. Unfortunately the early trials of endoscopic harvest were introduced without trials that included the true outcome (angio patency) so we may never know for sure.

Don I hear you regarding anaortic grafts. I operated 2 days ago OBCAB*3 on an 80 year old with 90% Left main stenosis on corticosteroids for rheumatoid arthritis - would you do bilateral IMA OPCAB in him? Odd I placed a vein graft and quoted you as justification because I thought you taught me not to rely on a single IMA inflow for a tight left main? Or have you ditched the vein entirely

Ani

> From: donross at bigpond.com> Subject: Re: [HSF] AATS> Date: Sun, 18 May 2008 14:15:12 +1000> To: OpenHeart-L at lists.hsforum.com> CC: > > I agree, Hal.> Ani has shown himself to be influenced by preconceived ideas like the > rest of us.> Just because he has seen an odd SVG acutely occluded the cause must > be traumatic harvest. Ani, welcome to anecdote land!> SVGs start to fall off the perch at ten years so why is a good eight > year patency so special?> I can't understand why anyone would want to use them for a > significant stenosis anyway, but that is just my unsubstantiated view.> So, if you need a CABG Ani, Martin Misfeld can now fix you up with an > anaortic arterial opcab.> Don> > On 18/05/2008, at 8:24 AM, Hgrmd at aol.com wrote:> > > Ani,> > For such an analytical fellow, I'm surprised at the conclusions > > you've> > drawn about endoscopically harvested veins. As far as I know, > > there's never> > been a head to head study comparing open versus closed harvesting > > of the veins> > in regards to patency. I have the clinical experience of having > > done CABG's> > for at least 10 to 12 years of open veins and around 6-8 years of > > endoveins.> > I certainly haven't perceived a difference in patency. In other > > words, I> > can't tell that a lot more cases are coming to cath with closed > > grafts as> > compared to open harvested veins. Indeed, there may be a > > difference, but it has> > been imperceptible to us.> > Our P.A.'s are extremely skilled at rapidly delivering an > > endoscopic vein> > through a 2 cm stab wound (usually no incision in groin at all) > > that rarely> > has avulsed branches requiring repair with 7-0. Quite frankly, I > > can't tell> > the difference in appearance between open and closed harvested > > veins. Your> > point about dilating with blood and papaverine is well taken. > > That preparation> > may be less stressful to the vein's endothelium. However, in the > > end, no> > matter how you prep them, the veins die no matter what you do to > > them. That's> > why it is imperative that we spend more time harvesting arterial > > conduits and> > not letting concerns about time supervene.> >> > Hal> >> >> >> > **************Wondering what's for Dinner Tonight? Get new twists > > on family> > favorites at AOL Food.> > (http://food.aol.com/dinner-tonight?NCID=aolfod00030000000001)> >_______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L at lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the > > policies and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> >_______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------
_________________________________________________________________

http://clk.atdmt.com/UKM/go/msnnkmgl0010000002ukm/direct/01/_______________________________________________
OpenHeart-L mailing list

Send postings to:
 OpenHeart-L at lists.hsforum.com

To UNSUBSCRIBE, to CHANGE email address, or to view archives:
http://mmp.cjp.com/mailman/listinfo/openheart-l

All messages transmitted by the OpenHeart-L are subject to the policies and
disclaimers posted at:
http://www.hsforum.com/listdisclaim
-----------------------------------------