[HSF] be kind to SVG

Dan Waters DWATERS at mcclinic.com
Mon May 19 08:54:55 EDT 2008 

For preparing a SV conduit using heparinized blood at physiologic pressure, see Annals of Thoracic Surgery  56:385-6, 1993.  Although described at the time for on-pump cases, this technique works just as well for off-pump.

DJW

>>> Donald Ross <donross at bigpond.com> 5/19/2008 12:22:16 am >>>
Ani,
You are correct regarding my fear of single ima inflow for tight LM  
especially if it is  dominant.
I am not sure I would have baulked at bilateral ima unless she was  
diabetic and obese as well as on steroids.
If you used a vein as I did today ( radial not available ) I hope you  
used a no-clamp proximal technique.
Incidentally, my case was a little old lady with a rapidly tapering  
SVG from her thigh and I lysed it's valves to enable it to be non- 
reversed because the distal vein was too small for a proximal  
anastomosis.
Furthermore, for those who don't want to distend the SVG  
hydrostatically ( which should be all of you ) a simple flush with  
verapamil followed by a soak in the same stuff releases spasm as it  
does for the radial artery.
Don
On 18/05/2008, at 11:26 PM, Ani Anyanwu wrote:

> 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)> >  
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