[HSF] be kind to SVG

Tue May 20 11:51:05 EDT 2008

Gustavo,
Try a simple flush and soak with Verapamil as soon as the vein is  
harvested.
On 20/05/2008, at 7:21 AM, gustavo abuin wrote:

> Ok, Today I perform a mammary to lad and SVG to OM.
> I dissect the saphenous vein.
> I don`t distended the graft.
> when I connected the vein to the cardioplegia line, that was at the  
> same time connected to the ascending aorta (90mm Hg of systolic  
> pressure), NO BLOOD EXIT FROM THE OTHER SIDE OF THE VEIN.
> So, I have to distend the vein "gently".with a siringe.
> The vein distended and a new attempt was performed.
> BLOOD EXIT FROM THE OTHER SIDE OF THE VEIN.
> So.
> The next " with saphenous" surgery I will try to distend the vein  
> controlling the pressure of the graft no trespassing 100mm of Hg.
> Any comments, tips?
> gustavo.
> ----- Original Message ----- From: "Dan Waters" <DWATERS at mcclinic.com>
> To: <OpenHeart-L at lists.hsforum.com>
> Sent: Monday, May 19, 2008 9:54 AM
> Subject: Re: [HSF] be kind to SVG
>
>
> 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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