[HSF] be kind to SVG
David Harris
drdharris at yahoo.co.uk
Wed May 21 23:45:38 EDT 2008
I have a very good suggestion: do`nt use the SVG as a first option, ise the right IMA as a y-graft off the LIMA
Dr. David G. Harris, FCS, MMED,
Cardiothoracic Surgeon
Suite 207
Kuils River Private Hospital,
PO Box 1200, Kuils River, 7579, Cape Town, South Africa.
Tel +27-21-9006411
Fax +27-21-9006412 Mobile +27-83-3309587
--- On Tue, 20/5/08, Donald Ross <donross at bigpond.com> wrote:
> From: Donald Ross <donross at bigpond.com>
> Subject: Re: [HSF] be kind to SVG
> To: OpenHeart-L at lists.hsforum.com
> Date: Tuesday, 20 May, 2008, 3:51 AM
> 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)>
> >
> >>>
> _______________________________________________> >
> 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
> >> -----------------------------------------
> >
> > _______________________________________________
> > 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
> > -----------------------------------------
> >
> >
> > --
> > No virus found in this incoming message.
> > Checked by AVG.
> > Version: 7.5.524 / Virus Database: 269.23.21/1454 -
> Release Date:
> > 5/19/2008 7:44 AM
> >
> >
> > _______________________________________________
> > 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
> -----------------------------------------
More information about the OpenHeart-L
mailing list